Two facets of the medicalization of sexuality in the late 20th century: AIDS & Viagra

Alain Giami is associated with Institut national de la santé et de la recherche médicale, U822, Le Kremlin Bicêtre, F-94276, France; INED, Le Kremlin Bicêtre, F-94276, France; og Université Paris-Sud 11, Faculté de médecine, IFR69, Le Kremlin Bicêtre, F-94276, France. Email: giami@vjf.inserm.fr. This paper has been translated from the French by Noal Mellot and edited with the help of Stuart Michaels.

Sexuality has become a compartmentalized field divided into research, educational programs, counseling, clinical work and political activism. The professionals who operate in areas as different as campaigns against HIV/AIDS, reproductive health, sexual dysfunction or the prevention and treatment of sexual abuse do not share the same definition of sexuality and do not assign the same meanings to sexual activities. Nor do they work with the same groups in terms of age, gender, sexual orientation, marital or socioeconomic status, and health status. Outside the domain of health, activists face still other problems when trying to obtain recognition of the human and sexual rights of dominated, if not oppressed and stigmatized groups. In brief, these professionals move in quite different spheres, seldom have the chance to meet each other and do not deal with the same issues.

The number and diversity of academic journals in sexual research provide a measure of this compartmentalization. Among the few journals that existed in the early 1970s were Archives of Sexual Behavior and Journal of Sex Research. More recently, Ken Zucker (2002) listed 76 scientific journals in this field. We must, therefore, reckon with a quantitative change in the interest shown in sexuality, as evidenced by the diversification, separation, specialization and growing autonomy of areas of research.

This editorial is drawn from the experiences of a «scientific flaneur» who has sauntered from conference to symposium devoted to sexuality in the broadest sense. My comments will focus on two topics: the prevention of HIV/AIDS and the treatment of erectile dysfunction with the help of drugs such as Viagra. Each topic illustrates how human sexuality is undergoing a process of medicalization. This process of medicalization consists in: defining problems in medical terms, describing them with a medical language, adopting a medical framework for understanding them, having recourse to medical interventions to «treat» them, and mandating or licensing the medical profession to provide treatment (Conrad, 1992). It developed throughout the 19th and 20th century including the invention of sexual perversion, homosexuality, eugenics, the sterilization of the unfit and the weak, birth-control and abortion, the prevention of sexually transmissible diseases, pedophilia, treatments for transsexuals, etc. In a more general way, this process of medicalization of sexuality is a permanent process of construction, deconstruction and reconstruction of the meanings attached to sexual experience and sexual conduct. The latest expression of the medicalization of sexuality is evident in the concept of sexual health, which tends to be applied to most of sexual experience in the field of health and disease (Giami, 2002). Moreover, the process of medicalization is not limited to medical approaches to sexuality: it includes psychological and educational interventions applied in similar contexts. Thus «psychologization» can be considered a part of medicalization since it interprets conducts, relations and representations in terms of health and treatment.

Critiques of the medicalization of sexuality have mostly focused on sexual disorders and perversions (paraphilias); and have challenged the influence wielded by the pharmaceutical industry and the normalization of sexual behavior along the lines of a «bio-psycho-social model» with little room for the cultural, social dimensions that shape the meaning of sexual activities (Hart & Wellings, 2002; Tiefer, 1996). But these critics of the process of medicalization have not included HIV/AIDS prevention, which also exemplifies this medicalization of sexuality. Let us compare the differences between the medicalization of HIV/AIDS and of erectile dysfunction in order to illustrate the various aspects of the process of medicalization of sexuality.

Sexuality and HIV/AIDS

The various techniques developed for preventing HIV-infection provide us with one of the most important examples worldwide of the medicalization of sexuality during the 20th century. The major aim of the fight against HIV-infection has been, and still is, to «modify sexual behavior» by convincing people to adopt «protective» measures so as to avoid transmission of the virus. This attempt to change behavior patterns is underlaid by a scientific and medical rationale and by an understanding of public health. From the viewpoint of public health, campaigns against AIDS have been undertaken by working with «risk groups» and using methods based on communication, education and counseling.

Sexual practices have been re-assessed in terms of their potential risk of infecting others with HIV, with distinctions being made between «safer» and «risky» or even «high-risk» behaviors. This ranking by risk is based on sexual practices, whether genital, oral or anal, and the number of sexual partners. The meaning of sexual activities and relationships has evolved to the point of considering love to be a major risk factor for HIV infection (Henrikson, 1995) insofar as most people do not feel that it is necessary to adopt protective measures in a relationship with someone whom they love. «Promiscuity» used to be a moral problem having to do with infidelity; nowadays, «multi-partner» sexual relations are said to be a risk factor. Attention has been devoted to gay men but not at all to Lesbians, since they supposedly run few risks of HIV-infection. This perspective has led to a concentration on «insertive/receptive» anal practices, which are classified as very risky. This stigmatization of anal penetration and the attempt to restrain such practices contrasts with the decriminalization of sodomy by the US Supreme Court in 2003. Even as efforts were being made to limit anal practices for the sake of health, legal actions against those accused of sodomy were halted. The rationale of public health does not coincide with legal or moral norms. Sexual behaviors that are not mainstream — intercourse with prostitutes or group sex — have also become public health problems, rather than legal and/or moral issues.

The approaches to fighting against HIV/AIDS have targeted young people and persons with multiple sexual partners while overlooking the aged, the monogamous and heterosexual married couples, all of whom are thought to run few risks of exposure to HIV (Giami & Schiltz, 1996). As we see, boundaries have been drawn around a set of «risky sexual behaviors». Public health actions have targeted the latter while taking for granted that «ordinary» sexuality, since it is not a risky practice, does not fall in the scope of public health interventions and recommendations.

Erectile dysfunction and Viagra

Brought on the market in 1998, Viagra has been promoted through major «marketing campaigns» in the media of developed and emerging countries. Viagra — understood here as a rhetorical figure of speech and not necessarily as the drug itself — was presented as the symbol of a new sexual revolution at a time when sexual pessimism in the West was starting to wane after years of AIDS. This script presented Viagra as a way to «restore natural, normal sexuality» rather than to increase sexual performance. It targeted a different public than HIV/AIDS prevention work: men over forty years of age and stable heterosexual couples. It focused on genital intercourse, which was to be stimulated in couples. This has led to a rediscovery of the sexuality of senior citizens and of marital sex, which had been overlooked during the fight against AIDS (Giami, 2000).

Viagra has been presented as a drug that a doctor has to prescribe for an illness: erectile dysfunction. This clinical model of doctor-patient interaction still prevails even though Viagra is being promoted through major advertising campaigns in mainstream media. These campaigns are double-edged: drug-makers appeal directly to consumers while also soliciting doctors via professional channels of communication. Given the public dimension of advertisements, we can infer that the drug has been understood to have an appeal reaching far beyond the population for whom it is supposedly intended. The supposed intent of limiting the use of Viagra and other molecules to the treatment of erectile dysfunction, did not prevent its use as an aphrodisiac, bought over the counter or on the Internet, without a medical prescription, and its use in public sex venues for enhancing sexual performance.

The two facets of the medicalization of sexuality

AIDS and erectile dysfunction drugs such as Viagra involve two complementary approaches to the medicalization of sexuality. On the one hand, AIDS has led to an approach of limiting forms of sexuality (anal practices, homosexuality, group sex, multi-parnership) that are deemed to represent major health risks. HIV-prevention campaigns have mainly sought to reduce what is thought to be excessive in relation to heteronormative values (heterosexuality, marital relations, monogamy and genital intercourse). In the case of Viagra, the objective is to restore, even stimulate, forms of sexuality that are thought to be normal, though inhibited, and to reinforce normative heterosexuality. Despite the different means used — prevention and education in the one case, drug prescriptions and clinical interaction in the other — the intention is to re-establish a normal functioning of sexuality by restraining it when it is deemed «excessive» or by stimulating it when it is deemed insufficient.

The process of medicalization of sexuality goes far beyond the domain of medical and psychological therapeutic intervention: it takes places in a wider context of redefining the meaning of sexual experience by redefining what is normal and what is not normal by relating it to the notion of health. In this perspective, it is quite interesting to note that those who have criticized the process of medicalization in relation to Viagra did not use the same intellectual tools to understand the development of HIV/AIDS prevention, which is almost never interpreted as an enterprise of medicalization. As if the dramatic situation related to the HIV/AIDS world epidemic gave more legitimity to professional interventions in sexual behavior modification.