BASIC ISSUES IN SEX THERAPY
Sex therapy, and even medical sex education, have recently come under attack in our society. These attacks come not only from conservative "authoritarian personalities" but also from radical libertarians. Various moralistic religious fanatics as well as some humanistic champions of individualism are accusing sex therapy of being a dangerous fraud perpetrated by power-hungry and phony "experts" upon a gullible public.
How is such animosity to be explained? What is the motive behind these strange accusations? Could they possibly be justified? If so, to what extent? Has sex therapy perhaps overreached itself? Does it have, and indeed deserve, a future? The answers will emerge only from an examination of some hitherto silent assumptions of the present therapeutic practice.
Most of the time, of course, therapists do not worry about their assumptions but try to respond to acute needs and miseries as they see these; and this approach needs no justification as long as it is supported by the general public. However, today this support is no longer unanimous or certain in any therapeutic field—neither in sex therapy, nor in psychiatry, nor even in traditional somatic medicine. It has therefore become necessary even for "simple" practitioners to develop some interest in theory. This means, above anything else, that they need a critical understanding of the social-historical context in which their work is embedded. Unfortunately, a history of sex therapy still waits to be written, as does a history of sex research. Such fundamental and, in the long run, indispensible studies simply do not exist at this time in either field. Nevertheless, one can say this much: From Hippocrates to Masters and Johnson, therapists have dealt not only with sexual dysfunction, but also with sexual deviance. They have tried not only to restore, increase, or reduce sexual vigor, but also to channel it into socially acceptable outlets, and they have done so on the assumption that they were "handmaidens of nature", i.e., that they simply helped people to achieve what should have "come naturally'' in the first place.
Thus, the first and greatest silent assumption of all sex therapy has been the belief in a "naturally" given, healthy sexuality which becomes dysfunctional or deviant only as a result of interference. Conversely, once this interference has been stopped, and its ill effects have been eliminated, the human "natural sexuality" is automatically restored.
Apart from this belief, the various therapeutic interventions did not necessarily have very much in common. Indeed, over the centuries they often pursued opposite strategies. What was promoted as a natural function at one time was denigrated as an unnatural excess at another time, and behavior that was recommended as healthy by one physician was denounced as pathological by another. For example, physicians in ancient Rome recommended that therapists masturbate their female patients in the interest of natural health. In the 19th century, women were treated, often by means of a clitoridectomy, against the unnatural habit of masturbation. In the early 20th century, Wilhelm Reich again prescribed masturbation for the purpose of regaining the natural sexual function and, as he reports, some of his psychoanalytic colleagues in Vienna even secretly followed Galen's advice and masturbated their female patients in therapeutic sessions. At present, this kind of therapy is prohibited in the Code of Ethics of the American Association of Sex Educators, Counselors and Therapists. (1980, III, 7). Therefore, it is obvious that not only the therapeutic techniques, but also their goals have changed rather drastically in the course of time. Yet their underlying assumption always remained the same: Both the encouragement and the suppression of masturbation merely served to restore the "natural" sexual response which, in turn, was essential to the patient's health.
The fact that this kind of reasoning can lead to such different and even contradictory therapies gives us a first hint of some serious flaw in its premise. This flaw is the questionable character of the concept of "naturalness" as employed here. What the various therapists called "natural" was actually a moral value in medical disguise. In reality, therefore, they did not follow "nature" but their own moral convictions. After all, objectively speaking, any dysfunction is just as natural as any function; both order and disorder, health and disease are natural. This means that the belief in a "natural sexuality" is not and cannot be based on scientific insight, but is essentially and unavoidably ideological.
What is true of the treatment of sexual dysfunction, of course, also applies to the treatment of sexual deviance although, at first glance, it now appears much more sophisticated than in the past. For example, in the most recent "progressive" therapeutic literature the old-fashioned epithets "perversion", "aberration", and "deviation", whose moralistic, indeed religious, origin was fairly obvious, have been replaced with the seemingly more objective term "paraphilia". Yet, upon closer inspection, this term is no less ideological than the others. It still assumes the existence of a "naturally" given norm, a correct "philia", which can have less admirable relatives. In fact, the relationship of this "philia" to the "paraphilias" is the same as that of the true professional or true physician to the various paraprofessionals and paramedics. The latter definitely belong to the second rank. They stand slightly below and beside the former, and do not command the same respect.
The bias at work here is quite apparent in some current definitions. Thus, the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM III, 1980) defines paraphilias as involving sexual responses to "objects and situations that are not part of normative arousal-activity patterns and that . . .interfere with . . . affectionate sexual activity." The "normative patterns" invoked in this passage are, of course, nothing but disguised value projections emanating from the authors who feel that sex, in order to be good, must be affectionate. Indeed, in another recent book, a prominent author is even more outspoken. He flatly states that a paraphilia is "an erotosexual condition of being recurrently responsive to, and obsessively dependent on, an unusual or unacceptable stimulus." He then explains that he does not list homosexuality among the paraphilias, because it does not "interfere with .. .falling in love."
However, "sex with love" is not a natural given, but a cultural ideal and, historically speaking, a fairly recent one. Moreover, the "unacceptable stimulus" is obviously not unacceptable to the "paraphiliac", but to those who disapprove of his choice and would rather recommend something more "usual". In short, all these new terminological stratagems notwithstanding, there are no sexual norms to be found in nature. This means, among other things, that the current terms "psychosexual disorder" and "paraphilia" will have to be abandoned, because there is no scientific way of determining "psychosexual order" or a correct "philia." Where sexual behaviors are individually or socially unacceptable, they will have to be defined and classified on entirely different, openly stated grounds.
What all of this means in practice is exemplified by a current controversy whose ultimate resolution remains in doubt. This is the question of whether homosexuality is or is not a disease. We have just quoted one prominent sexologist who does not list homosexuality under the paraphilias, because it does not, in itself, "interfere with falling in love". Furthermore, the Diagnostic and Statistical Manual (DSM 111) no longer lists homosexuality anywhere, except indirectly when it describes a new disorder called "ego-dystonic homosexuality", i.e., homosexual tendencies that are clearly felt, but unwanted by an individual. On the other hand, there are still many psychiatrists who believe that homosexuality as such is a pathological condition and who refuse to accept its removal from the manual. They denounce the decision as unscientific and one that is blatantly political and would therefore like to see it reversed.
Curiously enough, neither side in this controversy seems to have cared very much about the unscientific and blatantly political decision to include homosexuality in psychiatric manuals in the first place. Yet, as a critical historical examination shows, science and objectivity never had anything to do with it one way or the other. Indeed, the whole notion of homosexuality as a special condition is a product of the 19th century. Surprising as this may seem to many people today, not only the word, which was coined in a legal (not medical) context by a "gay rights" crusader in 1869, but the very concept of homosexuality did not exist before the Industrial Revolution. The question is therefore not only whether we are dealing with a healthy or pathological condition, but whether we are dealing with any condition at all.
Recent historical studies have shown that the ancient Greeks and Romans did not and could not conceptualize sexual behavior in this way. In spite, or perhaps because, of their open acceptance of same-sex eroticism, the modern concept of homosexuality would have been incomprehensible to them. It also remained inconceivable to others well through the Middle Ages. This becomes especially clear in medical writings that recommended homosexual behavior for therapeutic reasons. For example, the voluminous sexological literature of medieval Islamic scholars never mentions anything resembling modern homosexuality. However, it does contain some related and, to modern readers, rather startling observations. Thus, in the 12th century, Abu Nasr al Israeli, a Jewish scholar, who was born in Baghdad and who had converted to Islam, reports in a great sexological study that many physicians recommend homosexual intercourse to their male patients for the purpose of preserving their health and youthful appearance. The reasons are listed in great detail and are perfectly logical from a medical point of view, if the basic assumption is accepted. This assumption, needless to say, is that sexual activity must always be "natural" in order to be healthy.
Since the text is not very well known and is, in fact, unavailable in English, a brief summary may be appropriate: Nature demands that men should have intercourse only when their bodies are truly ready for it, as evidenced by a very hard erection. It follows further that anal intercourse with boys is always healthy, because it is physically impossible if this condition has not been met. In contrast, vaginal intercourse, which, at the insistence of women, is often performed in a semi-erect state, is just as often unhealthy, because it demands from the male body what it is obviously not ready to give. Therefore, those men who, at least after a certain age, restrict their sexual activity to boys live a longer, healthier, and more natural life than those who continue to have intercourse with women.
This passage proves again, if any further proof was needed, that the invocation of "nature" can justify or denigrate any conceivable form of sexual activity. However, more interesting in the present context is another implication: Quite clearly, homosexual behavior, indeed a very specific kind of homosexual behavior, appears here as a simple medical option open to any reasonable man. There is no mention of any "sexual orientation", or any "conversion" or "reversion" from one orientation to another. Instead, it is merely a matter of being practical. Once heterosexuality has become pathogenic and therefore ego-dystonic, i.e., when a man begins to worry about his failing health and his ebbing strength as a result of coitus, he simply takes the advice of his therapist and switches to homosexual practices.
The very fact that such advice could be given and approvingly cited in a learned text demonstrates that the Middle-Eastern patients of that historical period had not yet internalized the modern strict dichotomy of hetero- and homosexuality, but had retained some measure of erotic responsiveness to both sexes. Thus, no radical "reorientation" was required. Indeed, even in medieval Christian Europe, where homosexual behavior was condemned as "sodomy", it was considered a sin that could be committed by anyone. No presumption was made of a particular character which found expression in such behavior. Sodomy, like adultery, was not a condition but an act. As long as no such act had been committed, no one could be called an adulterer or a sodomite. It was only in the 19th century that, in the interest of legal reform, certain "gay rights" advocates advanced the concept of an inborn, unchangeable, healthy condition called "Uranism" or "homosexuality". This concept, firmly rejected by the medical establishment of the time, was finally taken up by younger psychiatrists like Westphal and Krafft-Ebing, who renamed it "contrary sexual feeling" and declared it to be pathological. It took several more decades before psychiatry also adopted the legal propaganda term "homosexuality" and suggested the possibility of a "cure". Since that time all sorts of therapies have been tried to turn "homosexuals" into "heterosexuals". It was only in 1973 that growing protest from "gay liberation" groups prompted the American Psychiatric Association to remove homosexuality from its list of mental diseases. However, as we have seen, even today psychiatry still provides for the treatment of "ego-dystonic homosexuality", and some nonpsychiatric sex therapists are also conducting such programs. On the other hand, it is noteworthy that there has not yet been a return to the medieval Middle-Eastern treatment of ego-dystonic heterosexuality.
Needless to say, on either side of the issue, therapists act on the assumption that the interests of society and those of their clients are identical. They simply see themselves as honest double agents who help to restore the lost harmony between individual and social happiness. In short, sex therapy persists in trying to play the role of a servant of two masters and hopes to do justice to both.
However, like the belief in a "natural sexuality", this second silent assumption also cannot stand up to rational scrutiny. It is simply another self-serving delusion. To begin with, the two beliefs are mutually exclusive. Critical therapists like Freud and Reich knew this and, in their different ways, drew the intellectual consequences. After all, if society really had an interest in individual sexual fulfillment, the dysfunctions and disorders would not, and indeed could not, arise, and sex therapy would be superfluous. The fact that it is necessary, therefore, puts the therapist in conflict with certain prevailing sexual values. By the same token, those who merely help an individual conform to society are not engaged in true therapy but in adjustment training. This is what happened to psychoanalysis in the hands of the socially conformist Neo-Freudians, and is also the case in the present treatment of "ego-dystonic homosexuality".
It is this function of sex therapists as unwitting agents of social control which disturbs the libertarians. On the other hand, the recent attacks on sex education and therapy from the authoritarian side show that these fears are exaggerated. In fact, when critics lash out against therapists like Masters and Johnson, they are picking the wrong target. If Masters and Johnson have done anything, they have taken sex therapy out of the traditionally prejudiced psychiatric context and opened it up as never before to scrutiny and dispute. To denounce their cautious, limited, and commonsensical assistance to fully autonomous clients as a medical power-grab is simply absurd.
Still, the basic concern deserves to be taken seriously. In the past, sexual therapies of various kinds have been used to enforce allegedly "natural" norms on reluctant and even unwilling "patients", and it is useful for us to be aware of this embarrassing aspect of our past. Yet, this past is not entirely dead, as we learn from certain misleading terms, unquestioned assumptions, mindless traditions, and other ideological remnants that continue to plague our field. On the other hand, when we look at the actual practice of sex therapy today, we have little reason to be embarrassed. It is precisely the new, behavioral approach of Masters and Johnson that has pointed sex therapy in a more rationally defensible direction. Most sex therapists know this and are very grateful for it. They may be less ambitious than before, and they certainly do not see sexuality as the beginning and end of human happiness. Neither do they make universal claims for the ultimate effect of their work. Still, in a practical sense, sex therapy is enriching many lives on a sensual and emotional level. Moreover, it does so without dogmatism and arrogance. All that is needed now is a theoretical framework that reflects these recent developments. As theory catches up with practice, and as sex therapy becomes aware of its silent assumptions, a new articulation of its premises will have the support of every rational person.