The over-medicalisation of male sexual dysfunction

by Andrew Barnes

[ Andrew Barnes is the co-author of the book Heart of the Flower. ]

Until recently, male sexual problems like Premature Ejaculation (PE) were seen as a psychological problem and treatment plans were therefore centred on behavioural and cognitive therapies (Masters et al., 1970. In Barnes & Eardley, 2007). Over the past decade or so, with the rise of pharmacological therapies, the definition of male sexual dysfunction (MSD) has taken a new 'neurobiological' (Waldinger, 2002. In Barnes & Eardley, 2007, p. 152) direction.

In Angus McLaren’s book Impotence: A Cultural History, McLaren explains "the main tendencies that have historically structured representations of masculine sexual inadequacy" (Marshall, 2007, p. 1164) and how this relates to how Erectile Dysfunction (ED) is defined. He shows that what constitutes impotence is relevant to a particular time and place rather than merely being an issue of biology. Therefore, dysfunction can be seen as socially created and defined along with the treatment methods that are also social practices which often serve to support the dominant groups of that society (Burr, 2005).

The medical/drug companies were able to establish what Larson (1977, p. 38) calls a “public monopoly of credibility” during the early part of the 20th century. Biomedicine, with its scientific foundation, has been able to redefine illness/sexuality and then present itself as the solution by gaining the support and power of the state. According to Friedson (1970), the clash between patient and doctor viewpoint is seen to involve patient obedience and submission of their concerns about illness/sexuality to a scientific and technical explanation of disease. This explanation brought forth "the creation of a realm of cognitive exclusiveness" (Johnson et al, 1995) that has been essential in gaining market control. By proclaiming themselves as the pinnacle of professions to which all others needed to be judged by, they were able to create 'disciplinary power relationships', make stereotypical assumptions about the inferior knowledge of 'semi professions' and regulate codes of conduct, training, clinical practice and who works in the field (Salvage, 2003).

Marketers riding on the wave of biomedicine's 'social credibility' have been able to hail sildenafil and other drugs as scientific breakthroughs. However, Loe, for example, feels that the "unprecedented success of Viagra in America is not the result of an exciting scientific breakthrough bringing relief to the desperate or dying. Rather, commercial interests have created a socially desirable but medically limited product - ironically, by denying the fundamentally social nature of sex” (Loe 2004. In Marshall, 2004, p. 2776).

Drugs for MSD can be seen as a growing phenomenon that Loe calls the "medicalising of discontent" (Loe 2004. In Marshall, 2004, p. 2776). This medicalisation has involved the reinventing of sociopsychological problems into medical conditions. Loe uses the example of creating the market for Viagra: "impotence is reinvented as erectile dysfunction and frigidity as female sexual dysfunction. In each case, the identified problem is shorn of its social, cultural, emotional, and psychological elements, leaving a core physiological dysfunction that is intrinsic to the individual and independent of society. This can be “cured” with a specific medical treatment. In short, the problem is designed to fit the treatment, not the reverse" (Loe 2004. In Marshall, 2004, p. 2776).

By labelling and classifying people and illness into normal or abnormal, mad or sane, moral or immoral, the medical profession can control and manipulate the populace and predict future trends in work/home life, sexuality and politics (Foucault, 1976). From a big picture perspective, drugs like Viagra can then be seen to be exacerbating the problem and concretising the new neurobiological definition, thus "ensuring the continued growth of the condition, the treatment and the profits from drugs sales" (Marshall, 2004, p. 2776). Loe clearly shows how in America this medicalising of discontent has been facilitated by the legislation that has enabled "direct-to-consumer drug advertising, online drug sales, and the entanglement (even merger) of health professionals and drug marketers" (Loe 2004. In Marshall, 2004, p. 2776).

Physicians often find they have limited time and a limited psychological shelf space, so when they are presented with a particular drug that ‘fits’ easily with a perceived MSD they will tend to use it unless otherwise directed (Lee, 2004). Studies have shown "[p]harmaceutical manufacturers that physicians and patients are usually reluctant to switch from a medication that is working" (Lee, 2004, p. 212). Therefore it is in their best interests to continue using marketing strategies that focus on a neurobiological definition of MSD as they know it will maximise profits and ensure long term usage of their products by doctors and patients alike, regardless of the high retail sale prices. By reducing sex to penile performance, then associating this with masculinity, a man's self worth and social worth are diminished to his ability to maintain hard erections.

Rosie King, in the Handbook of Erectile Dysfunction (ED): a simple 4-step plan for managing ED, explains that the "predominant cause of ED in a patient can usually be distinguished through taking a history" (King 2007, p. 20). She has developed a guide that suggests the cause of the ED:

Organic ED is suggested when	Psychogenic ED is suggested when
Man is over 50 years	Man is under 40 years
ED came on gradually	ED came on suddenly
ED is getting worse over time	Severity of ED varies
ED is total – erection is impaired in all situations	Firm erections in some situations but not in others
NPT and waking erections are reduced or absent	NPT and waking erections are retained

(King, 2007, p. 20)

When we consider the causes of ED as being due to organic or psychogenic causes, it is clear that what is needed is a multidisciplinary, holistic approach. Multidisciplinary, holistic approaches are developed to suit the individual's health needs by incorporating their lifestyle, psychological and physiological characteristics when developing and managing their treatment plan.

In organic cases of MSD, the use of drugs to enable the man to continue having erections is definitely a wonderful thing. However, I believe that the campaign strategies used by drugs companies are continuing to target market men with non-organic MSD also, giving an impression that the one little pill will fix it all, when clearly there are of course social, intrapersonal issues that may be causing the problem: for example, the situational loss of an erection. For this reason, I believe that the management of MSD has become too medicalised, as it has brought forth a very narrow view of MSD and the treatment options available.

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References

Barnes, T., & Eardley, I. (2007): "Premature Ejaculation: The Scope of The Problem." St. James Hospital, Leeds, United Kingdom. Routledge. Journal of Sex & Marital Therapy, 33:2, 151 – 170. Downloaded on 15th April 2008 http://dx.doi.org/10.1080/00926230601098472

Burr, V. (2003): Social Constructionism. Routledge.

Foucault, M. (1976): The History of Sexuality: An Introduction. Penguin: Harmondsworth.

Friedson, E. (1970): Profession of Medicine: a study of the sociology of applied knowledge. University of Chicago Press.

Johnson, T., Larkin, G., & Saks, M. (1995): Governmentality and the institutionalisation of expertise: Health Professions and the State in Europe. Routledge: London

King, R. (2007): Handbook of Erectile Dysfunction: a simple 4-step plan for managing ED. Intimate Solutions, NSW.

Larson, M. (1977): The Rise of Professionalism: a sociological analysis. University of California Press: Berkeley.

Lee, T. (2004): "Me Too Products – Friend or Foe?", Massachusetts Medical Society, New England Journal of Medicine, 350;3

Marshall, Y (2004): "The Rise of Viagra: How the Little Blue Pill Changed Sex in America", New England Journal of Medicine, 351;26

Marshall, Y. (2007): "Impotence: A Cultural History", New England Journal of Medicine, 357:11

Salvage, J. (2003): Rethinking Professionalism: the first step for patient focused care? University of Sheffield, UK.

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