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Sexual and Relationship TherapyVol. 25, No. 2, May 2010, 189–196 Still resisting after all these years: an update on sexuo-medicalization and on the New View Campaign to challenge the medicalization of New York University School of Medicine, New York, USA In 2002, Sexual and Relationship Therapy published my leading comment, ‘‘Beyondthe medical model of women’s sexual problems: A campaign to resist the promotionof ‘female sexual dysfunction’’’. I wrote that comment not long after convening ‘‘TheNew View Campaign’’ as an educational initiative to deal with the Viagra-inspiredjuggernaut of medicalized thinking about sex that threatened, at least in my mind, tobias and distort sex research, sex education and sex therapy for the next generation. Ivery much appreciate the recognition the article has received and welcome thisopportunity to review and update my thinking on its 2002 theme. Here is the bottomline: it’s all come true, and more so, but there are numerous pockets of resistance,unexpected things do happen, and hope remains alive! When I wrote the 2002 essay (sometime in 2001), Viagra had been available for threeyears. My involvement as a critic of the sexuo-pharmaceutical revolution had begunwithin days of the US Food and Drug Administration’s (FDA’s) approval of Viagrain March, 1998, when journalists began to ask, ‘‘And where is the Viagra forwomen?’’ As a feminist sexologist working in a hospital urology department, I gotworried! I had written about the dangers of medicalization when I first observed howurologists managed men’s sexual problems (Tiefer, 1986) and had continued in thisvein for years, including a review essay on medicalization 10 years later (Tiefer,1996).
Long before Viagra appeared I had expressed concern that the ‘‘medical model’’ of mind-body dualism, ‘‘objective’’ research, universal bodies, essentialism, narrowfunction-oriented definitions, biological reductionism and reified diseases was not agood match for the socially constructed domain of sexuality. I feared that medicalthinking was too enmeshed with norms of health and disorder to allow a fullembrace of sexual diversity in education, research or treatment. I was concernedabout the normative aspect of medical thinking and I was concerned that too muchcoziness ISSN 1468-1994 print/ISSN 1468-1749 onlineÓ 2010 British Association for Sexual and Relationship TherapyDOI: 10.1080/14681991003649495http://www.informaworld.com determinants of sexual conduct and problems at the expense of psychosocial andcontext-related factors.
The deluge of publicity surrounding the approval of Viagra both indicated and promoted substantial interest in a medical approach to sexuality. There was theeconomic ka-ching, of course, for the drugs industry. But there were otherconvergent trends. The discourse of ‘‘sexual health’’ was becoming a popular way toframe public health discussions about sexuality in the era of herpes and AIDS and italso provided a positive sexual spin to counteract right-wing fear-mongering aboutsex education, gay rights and reproductive freedom. And there was also the‘‘biomania’’ going on in the 1990s Human Genome Project era.
I was comfortable with a narrative of ‘‘sexual health’’ as long as it related explicitly to issues of genital health, but when ‘‘sexual health’’ expanded to includepronouncements and classifications of sexual conduct and preferences, this seemedlike a slippery slope towards medicalizing sexual desire and performance, erasingthree decades of feminist research into social and cultural variables like genderrelations, media, politics and education.
In 2000 I called for a feminist movement to examine and resist the escalating medicalization of sex and convened what came to be known (somewhatunimaginatively and even incorrectly) as ‘‘The New View Campaign to Challengethe Medicalization of Women’s Sexual Problems’’ (Tiefer, 2001). Our view of sexwasn’t really ‘‘new’’, it was the familiar psycho-bio-social model. It wasn’t really justabout women, either, but as a feminist I thought that was my most legitimate placeto start. And it wasn’t only about sexual problems, but about the broadconceptualization of sexuality that was being medicalized just as the women’s andgay and lesbian movements were re-creating and re-visioning ideas of sexuality thathad been cramped by politics and religion for centuries.
That was the point, I thought, and why I felt urgent about a plan of action.
Medicalization was actually a political process. Unfortunately, this was not at allobvious to clinicians and researchers who saw the new biomedical initiatives asexciting scientific opportunities and signs of progress and were utterly disparaging ofa political interpretation.
What I didn’t understand back then, and what has captured much of my attention inthe intervening years, was the global pharmaceutical industry culture and how itcould affect sexology and sexuality. Although there were other trends promotingmedicalization, I came to see the pharmaceutical industry as the chief ‘‘engine’’ ofmedicalization (Conrad, 2007). When I wrote the essay for Sexual and RelationshipTherapy I still didn’t know much about branding, about ghostwriting, about paidsupplements to journals, about the politics of gift-giving, about using ‘‘key opinionleaders’’ as wedges into professional circles. I didn’t know about internationalregulatory bodies or media advertising budgets or using patient advocacy groups asfront organizations or about pharma-funded ‘‘consensus development conferences’’.
I had never heard of ‘‘disease awareness campaigns’’ or the legal ins and outs of ‘‘off-label’’ prescribing. I had to learn not only about the direct ways that Big Pharmaadvances its interests (funding and supporting and promoting this or that), but theindirect ways such as political opposition to direct-to-consumer ad reform or usingthe language of ‘‘evidence-based’’ medicine to marginalize narrative and interview research. I had, in other words, to learn to read the business pages of the New YorkTimes as well as the science pages and to join sociology of science and medicalanthropology organizations in addition to psychology and sexology ones.
One unexpected development has been the growing backlash against the excesses of the drugs industry in the last few years. In 2009 an exhaustive review of the manyconflicts of interest between physicians or medical researchers and pharmaceutical,medical device and biotechnology companies was published by the US NationalAcademy of Medicine’s highly respected Institute of Medicine.1 It offered manyrecommendations for reform of the sort I have been reading and writing aboutregarding continuing medical education, medical publications and researchsponsorship.
Back in 2001 I didn’t fully foresee how the drugs industry would use sex therapists and researchers not just to further medical model research and therapy,but to distract efforts from psychosocial research and therapy by underwriting‘‘evidence-based’’ (i.e. medical-model-evidence only, please) research journals,organizations, conferences, and prizes. Here are three specific examples: (1) Sex research is now often narrowly focused on dysfunction and drug remedies.
For example, although no drug for ‘‘female sexual dysfunction’’ has yet beenapproved by the FDA, a testosterone patch has been approved in the UK andEU. Yet, as with the erectile dysfunction pills, there is practically no socialscience research on the psychosocial impact of these drugs on couples’ sexualrepertoires, attitudes and feelings or details of use. Rather, we have endlessquestionnaire projects funded by industry that focus on simplistic, single-itemmeasures of ‘‘satisfaction’’ and ‘‘effectiveness’’. How many thousands ofsexologist-hours have been devoted to generating questionnaires withcompeting definitions of sexual function and satisfaction? It makes yourhead spin until you see company scientists present these data at research orregulatory meetings and you realize that it’s not about understandingsexuality but about generating numbers to support product applications.
(2) The growth of off-label prescribing has made official approval of sexuality drugs almost unnecessary and online purchasing will likely eliminateremaining obstacles in the name of ‘‘consumer choice’’. Viagra andtestosterone preparations are routinely given to women for low desire,despite health worries and marginal benefits. ‘‘Premature ejaculation’’ is arapidly emerging example. Ignoring disputes over definitions and treatmentgoals, many medical courses and journal articles now recommend the off-label use of SSRI (acronym for certain drugs with serotonin action)antidepressants to delay ejaculation. Pre-approval studies use narrowoutcome measures and neglect concerns about suicidality and dependency.
Publicity about off-label drugs ignores the fact that this means the drugs arenot yet regarded as safe! Unfortunately, investigative reporting is far rarerthan promotional reporting.
(3) The biggest news about sex in the last few years has to do with the new forms and opportunities for sexuality that are proliferating through socialnetworking technologies, computer dating services, webcams, online shop-ping, cellphone cameras, computer games, internet chatrooms etc. I knowhalf a dozen women who have sex blogs! These media contribute to sexualdevelopment, fantasies, attitudes and conduct, but where is the research, education and training to match these challenges? The sex drugs industry thatso wants people to have great sex lives is utterly silent on the topic of sexeducation – preparation for a good sex life – and pays its billions only topromote diagnoses and treatments. What about preventing a few of thosediagnoses for a change? The public requires independent, non-commercialinformation ‘‘Sexual literacy’’ is needed to manage the complexities of contemporarylife in an ever-changing and, it seems, ever-escalating sexual environment.
Good luck.
What has the New View Campaign accomplished? As of 2001–2002, the New View Campaign (NVC) had just been launched. As of2010 we have made our website, newviewcampaign.org, into a major resource andeverything public that we have done is catalogued there in one way or another. Anoverview of New View activities was published in an open access journal (Tiefer,2006). There have been dozens of publications, about eight translations of theManifesto and scores of presentations all over the world. Many curricula includeNew View materials. There have been innumerable interviews with journalists anddocumentary-makers. Here is a brief chronological list of campaign highlights(including just a sampling of presentations): 2000. New View manifesto written. NVC kickoff with press conference in Boston 2002. One day New View conference in San Francisco 2003. Debate on female sexual dysfunction (FSD) at international sexual medicine . New View teaching manual published. Plenary, American Society of Reproductive Medicine 2004. First New View continuing education course published. Testimony before FDA Committee that rejected testosterone patch 2005. Three day New View conference in Montreal. New View listserv begins 2006. Plenary, Inaugural Conference on Disease-Mongering in Australia. Special Sexualities issue on ‘‘Viagra Culture’’ published . New View classification for men’s sexual problems published2. Plenary, British Association for Sexual and Relationship Therapy (BASRT) 2007. Keynote, British Psychology of Women conference. Website redesigned to include videos, publications, complete press coverage record, current activities, events photos, continuing education courses 2008. Special New View issue published in Feminism and Psychology. Canadian TV ‘‘Pharma-Sutra’’ documentary on FSD disease-mongering. Intergenerational street demonstration in New York against cosmetic genital surgery (cf. webpage with complete resources and background) 2009. ‘‘Second Opinion’’ public TV program on FSD in US features NVC. ‘‘Orgasm, Inc’’ documentary about race for ‘‘female Viagra’’ debuts. Front page Philadelphia Inquirer story about failed drug development for . Intergenerational gallery exhibit in Brooklyn, NY celebrates female genital The NVC has created a unique spot of feminist sexological critique, but over theyears I have realized that we are part of several current social movements.
They give us moral support and insight and we, in turn, provide an in-depthexample.
The first is the women’s health movement, with its emphasis on woman-centered health goals and standards (Morgen, 2002). We have been criticized by some whosay that the essence of the women’s health movement is freedom of choice and thatby opposing drugs for FSD we limit freedom of choice, but that is a speciousargument that I have taken up elsewhere (Tiefer, 2008) in conjunction with femalegenital cosmetic surgery and won’t consider further here. The women’s healthmovement is very concerned about many dangerous aspects of ‘‘the pushto prescribe’’ to women and we fit quite well under that umbrella (Ford & Saibil,2009).
Our second membership is in the anticorporate public health movement that emerged from the consumer rights initiatives of the 1960s (Freudenberg, 2005;Mintzes & Hodgkin, 1996). We are allies with those challenging global industriesthat promote unhealthy consumption, e.g. the tobacco and fast food industries. Thisnew public health movement shows the importance of appropriate and enforcedgovernment regulations and the dangers of saturation advertising.
Third, our challenge to sexuo-pharmaceuticals is analogous to that of dozens of other critics of the pharmaceutical industry from whom we have learned about BigPharma’s strategies as it moves into ‘‘Lifestyle’’ drugs and transforms commoncomplaints into medical disorders (Brownlee, 2007; Critser, 2005; Moynihan &Cassels, 2005). The biases introduced by drugs companies in professional education,research and publications are of special concern to the NVC.
Finally, our analysis of the obstacles confronting women’s sexual emancipation make the NVC part of the feminist ‘‘body project’’ movement, the group critiquingcultural standards of youth, beauty and thinness that contribute to body hatred,sexual dissatisfaction and destructive self-monitoring. We joined this movement in2006 when we began to study the new cosmetic genital surgery industry that waspromoting labiaplasty, laser vaginal rejuvenation and collagen injections into thevaginal ‘‘G-spot’’ to enhance sexual pleasure and response. Our responses to thisnew industry have taken the NVC into activism and out into the streets.3 Taking a hard line against a discourse of ‘‘sexual health’’ has in some ways been themost exciting and most difficult aspect of this campaign. In many public talks andconversations with journalists, I have tried to argue that the models and metaphorswe use to discuss sexuality profoundly affect our thinking about sex education,treatment and research – and our own sexual lives. Some years ago, I first titled atalk ‘‘Is sex more like dancing or digestion?’’ and that phrase continues to sum upthis perspective for me. A video of a talk along those lines is posted on the New Viewwebsite homepage.
Every once in a while a journalist will really get it. Drake Bennett, for example, the ‘‘Ideas’’ reporter for the Boston Globe had a recent piece titled ‘‘The newromantics: Should we get the doctor out of the bedroom?’’ that examined New Viewideas (Bennett, 2009). He suggested that the New View was all about criticizing‘‘crude materialists focused only on the body and in thrall to the pharmaceuticalindustry’’ which is pretty good! After giving voice to some of our critics, Bennettconcluded, ‘‘But even the scientifically minded will often acknowledge that parts ofthe New View critique have it right: when we treat sex as simply another metabolicprocess, we’re turning a matter of personal taste into a medical norm, and making iteasier to ignore the ways that sex can be a barometer of other, deeper difficulties in arelationship’’. I would add, ‘‘and in a culture’’.
The medical model can be seen as progressive and liberating, especially when contrasted with older, more restrictive norms. The trouble comes when the medicalmodel produces false expectations of diagnostics and treatments, drugs withunexpected side-effects and escalating costs, a disempowered public whose onlycoping skill for sexual problem-solving is consulting a doctor, new performanceinsecurities and a wholesale neglect of social, relationship and psychological factors.
On balance, medicalization does not deliver a better sexual world and so we findourselves continuing to resist.
http://www.iom.edu/Reports/2009/Conflict-of-Interest-in-Medical-Research-Education-and-Practice.aspx Leonore Tiefer, PhD, is an author, educator, researcher, therapist and activist who hasspecialized in many areas of sexuality. She began with a Psychology PhD on hormones andhamsters (University of California, 1969) and an academic position and animal laboratory (Colorado State University, 1969–1977). Responding to the call of feminist politics and theworld of sexology for people, she later re-specialized in clinical psychology (New YorkUniversity, 1988) with a focus on sex and gender problems. Beginning in 1977 her New YorkCity career took her to Downstate Medical Center, Beth Israel Medical Center and then toMontefiore Medical Center where she was employed in the Urology Department and co-directed the Sex and Gender Clinic from 1988 to 1996. She is currently AssociateClinical Professor of Psychiatry at both New York University School of Medicine and AlbertEinstein College of Medicine and has a private psychotherapy and sex therapy practice inManhattan.
Dr. Tiefer has written widely about the medicalization of men’s and women’s sexuality. She has been interviewed by news media around the world and appeared on many news shows asthe foremost critic of ‘‘disease-mongering’’ trends in the medical management of women’ssexual newviewcampaign.org, is a major resource on this topic for journalists, colleagues and thepublic.
Dr. Tiefer has received many professional awards, e.g. 1994 Alfred C. Kinsey Award and 2004 Distinguished Lifetime Scientific Achievement Award from the Society for the ScientificStudy of Sexuality and 2004 Lifetime Career Award from the Association for Women inPsychology. She has been elected to many professional offices within sexological and feministorganizations (e.g. 1986 National Coordinator of Association for Women in Psychology, 1993President of the International Academy of Sex Research). She serves as Vice-Chair of theBoard of Directors of the National Coalition against Censorship (ncac.org) and serves on thesteering committee of the Shelter for Homeless Men at her New York City UnitarianUniversalist Church (bjsplace.org) Dr. Tiefer’s cv contains over 175 scientific and professional publications. Her Westview Press book, Sex is not a natural act and other essays now in a 2nd edition (2004), has beentranslated into several languages. In 2001 she co-edited an important feminist sexologycollection, A new view of women’s sexual problems, which grew out of the New Vieweducational campaign (newviewcampaign.org). She also co-authored a classroom andworkshop teaching manual (2003) to accompany this text. The New View Campaign hasheld several scholar-activist conferences, testified before the FDA, provided fact sheets andbriefings for media and has generated articles and chapters that are influencing the waystudents and professionals are taught about human sexuality.
Dr. Tiefer is well known as a public speaker, having been invited to keynote scores of conferences from London to Paris to Berlin to Osaka to Istanbul to Calcutta to Lausanne toZagreb and to Auckland. She has given challenging and provocative grand rounds inPsychiatry, Urology and Obstetrics and Gynecology at numerous medical centers and spokento innumerable university and college clubs, classes and public audiences. In 2003, she was aplatform speaker at the Chautauqua Institution, speaking to an audience of over 4500,standing in the same honored spot as Susan B. Anthony, Eleanor Roosevelt, presidents andsenators and other leading intellectual figures.
Bennett, D. (2009, May 17). The new romantics: Should we get the doctor out of the bedroom? Brownlee, S. (2007). Overtreated: Why too much medicine is making us sicker and poorer.
Conrad, P. (2007). The medicalization of society: On the transformation of human conditions into treatable disorders. Baltimore, MD: Johns Hopkins Press.
Critser, G. (2005). Generation Rx: How prescription drugs are altering American lives, minds and bodies. New York: Houghton-Mifflin.
Ford, A.R. & Saibil, D., (Eds.). (2009). The push to prescribe: Women and Canadian drug Implications for health education practice and research. Health Education and Behavior,32, 1–22.
Mintzes, B., & Hodgkin, C. (1996). The consumer movement: From single-issue campaigns to long-term reform. In P. Davis (Ed.), Contested ground: Public purpose and privateinterest in the regulation of prescription drugs (pp. 76–91). New York: Oxford UniversityPress.
Morgen, S. (2002). Into our own hands: The women’s health movement in the United States, 1969–1990. New Brunswick, NJ: Rutgers University Press.
Moynihan, R., & Cassels, A. (2005). Selling sickness: How the world’s biggest pharmaceutical companies are turning us all into patients. New York: Nation Books.
Tiefer, L. (1986). In pursuit of the perfect penis: The medicalization of male sexuality.
American Behavioral Scientist, 29, 579–599.
Tiefer, L. (1996). The medicalization of sexuality: Conceptual, normative and professional issues. Annual Review of Sex Research, 7, 252–282.
Tiefer, L. (2001). Arriving at a ‘‘new view’’ of women’s sexual problems: Background, theory and activism. In L. Kaschak & L. Tiefer (Eds.), A new view of women’s sexual problems(pp. 63–98). Binghamton, NY: Haworth.
Tiefer, L. (2002). Beyond the medical model of women’s sexual problems: A campaign to resist the promotion of ‘‘female sexual dysfunction’’. Sexual and Relationship Therapy, 17(2),127–135.
Tiefer, L. (2006). Female sexual dysfunction: A case study of disease mongering and activist resistance. Public Library of Science - Medicine, 3(4), e178. Retrieved March 27, 2010,from Tiefer, L. (2008). Female cosmetic genital surgery: Freakish or inevitable? Analysis from medical marketing, bioethics, and feminist theory. Feminism & Psychology, 18, 466–479.
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