EDITORIAL

A plea for ordinary sexuality

If you want to play a musical instrument harmoniously, you
not only need the right instrument in good working condi-
tion, but also some talent, lots of practice and a bit of crea-
tivity. If you want to play a duo, you not only need rhythm
but also synchronization, tuned instruments, and harmo-
nious tones. For a successful sexual encounter, the
requirements are the same, or even greaterthe perfor-
mer also needs to be instilled with desire and the duo
need to share the same motivation All this could happen
naturally had the sexual domain not been so patholo-
gized, with resulting confusion in its tones. Sexual medi-
cine focuses on having the right instrument and keeping the
performer in a good state of health, but has used this to
define norms of sexual functioning as if the dexterity
and the know-how of the subject, his sexual desire and his
educational and relational limitations were of no conse-
quence. And yet, for the listener who has to sit through
the cacophony of a poor performance because the musician
or musicians lack talent, this is worse than if their instru-
ments were worn or damaged, since a true artist will always
find the means to produce pleasant sounds, regardless of
the condition of his instrument. In the same spirit, Pryce
and Steggall (2006) wrote that sexual activity had migrated
from an Art to being a Science, where reproducible
evidence was the only basis for sexual normality. Although
evidence is useful (or is at least easy to measure and inte-
grate into a protocol) for understanding sexual functions
and biology for defining a treatment, when it comes down
to emotions, motivation, relations and psychologythe
motors of the sexual instrumentother types of evidence
are needed in order to understand the etiology, and here
we need evidence focusing much more on quality than
quantity. One must not forget that the realms of reality
and symbolism are on two totally different planes, and the
interface between themgiving them meaningis the
image we create of the body and its representations. Con-
sequently, depending on the symbols we like to use, we may
see our body as a machine tool, as a means to create and
maintain relationships, or even as a gift from God, and
assign to it many other meanings of varying levels of com-
plexity, whereas evidenced-based medicine in the field of
sexuality sees it principally as a body-machine.
Looking at this from another angle, historically speaking
the term sexual health as coined and advocated back in
1974 by the WHO, lead to recommendations for multidisci-
plinary teaching of sexology in faculties of medicine. Not
without some reticence, one might add, since the faculties
that followed these recommendations were few and far
between, limited to those run by the few local pioneers
who had been working towards this change for some time.
With the arrival of sex-activating drugs in the 1990s, the
amount of interest in sexual health took a quantum leap
forward both in terms of the progress made in treating dif-
ferent sexual afflictions (erectile dysfunction in particular,
and more recently premature ejaculation), and in the
development of multidisciplinary research and the dissemi-
nation of scientific findings. It is true that funding from the
pharmaceuticals industry has been decisive in this process,
but research into other areas of sexuality still struggles to
find funding (and when it exists at all, it requires mountains
of complex paperwork), leaving these areas less explored
and understood. The result is that we have research find-
ings and treatments based on much more extensive and
conclusive evidence in the study of comorbidities fostering
sexual difficulties than in areas concerning clinical and qua-
litative empirical research, which are neglected and under-
mined (Rosen and Leiblum, 1995). Some work has neverthe-
less been published showing that the efficacy of treatments
in the daily lives of patients is significantly different from
the therapeutic efficacy evidenced in clinical trials. This is
not really surprising when one considers that the protocols
for these trials are designed to carefully avoid anything that
might interfere with the measurable efficacy of a drug;
instability within the couple, the vagaries of life, variations
in desire, to mention just a few. Experts from the pharma-
ceuticals industry thereby know the limitations and the
associated conditions of the treatments developed from a
clinical point of view, and their marketing focuses on the
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factors facilitating medical preferences. This situation has
already been described by Leonore Tiefer as one of social
constructions of illness by the pharmaceuticals industry
(Tiefer, 1996), but we still need to emphasize that if you
only present this aspect of the situation, there is a risk of
confusion in roles; the pharmaceuticals industry is clearly
playing solely its own music score which is to assess the
effects of a drug outside any factors of variation related
to the relational or psychological context. However, the
medical world is not always able to put the challenge into
perspective, and we now find ourselves with huge deficien-
cies in our knowledge base concerning the role of context
and personality in the course of the illness. By means of
sponsoring, the knowledge selected for dissemination in
congresses and conventions and to be published in scientific
literature full of comparative studies and evidence of mole-
cule efficacy, has become the main reservoir of knowledge
circulated by the experts. With the dismissal of psycho-
dynamic theories used by non-theoretical classifications
such as DSM and CIM 10, cognitive behavior therapy,
although considered to be an alternative medicine has
tried, with some success, to become evidenced-based.
Sexuality should be an integral part of medical psychology
so as to be included in a global approach that takes account
of the relationship between the physician and the patient.
Medical psychology is starting to show the need to take
account of the functions of personality and how they can
be modified by contextual interactions. All these factors
will have an effect on the efficacy of the patients treat-
ment on a daily basis and we need now to direct our atten-
tion in that direction: i.e. study the software, and not just
the hardware.
There are some pretty obvious pointers to the current
imbalance:
a multitude of dodgy treatments sold on the internet
where patients are perhaps looking for solutions they
cannot find elsewhere;
a lack of understanding of the significant importance of
placebo effects in drug-based treatments for sexual dis-
orders;
the all-genetic theory taking over the field of etiology,
often to the detriment of other explanations, reminding
us strangely of Alexander (1946) x vulnerability factor
in his theory of psychosomatic illness.
One might also challenge the validity of evidence pro-
duced by self-assessment questionnaires in clinical studies,
filled in by patients selected according to their desire to
take part in the study and to believe that they are going
to get something out of it. How can self-assessment ques-
tionnaires drafted by people who lack working terminology
be expected to assess things that the patient is not even
aware of and which confer on the doctor of the art the
key to suffering? What is normal and what is pathological?
And how are we to tell the difference (Canguilhem, 1990)?
The pharmaceuticals industry has become more forward-
thinking in initiating sponsorship, thereby providing the
medical profession with the means to broaden their knowl-
edge; when a drug is prescribed, the patient wants to be
informed of its therapeutic efficacy for him. The more
knowledge the physician has, the more effective the treat-
ment will be.
Concerning the time spent listening to the patient, it is
important to know what you are listening for, and as far as
this is concerned, the situation will not improve with the
restrictions placed on freedom to prescribe and the limited
time available on the part of the practitioner. It is essential
that we refocus our attention on clinical examination and
set sexuality within an art form supported by science if we
want to differentiate ourselves from a simple artificial
intelligence diagnosis; but for this to be the case, medi-
cine must remain an art; we must stop shooting the pianist,
and society must continue to produce artists.
References
Alexander F. La Mdecine Psychosomatique. Payot, 1946.
Canguilhem G. La sant, concept vulgaire et question philosophi-
que (1988). Pin-Balma: Sables, 1990.
Pryce A, Steggall MJ. Responses to Waldinger et al. JMJG 2006;
3(2): 178-9.
Rosen R, Leiblum S. The changing focus of sex therapy. In: Rosen R,
Leiblum R, eds. Case Studies in Sex Therapy. New York: Guilford
Press, 1995: 3-18.
Tiefer L. The medicalization of sexuality: conceptual, normative
and professional issues. Annu Rev Sex Res 1996; 7: 252-82.
M. Bonierbale, MD
Head of the Sexology Department of Marseille
and Montpellier Faculties of Medicine. Coordinator
of the Functional Unit of Sexology and Gender Dysphoria
Service du Professeur-C.-Lanon, CHU Sainte-Marguerite,
13274 Marseille cedex 09, France
E-mail address: mireille.bonierbale@wanadoo.fr
(M. Bonierbale).
Available online 16 November 2006
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