Accessed through sex: the medicalization of male sexuality at two different moments
Capturados pelo sexo: a medicalização da sexualidade masculina em dois momentos
Departamento de Antropologia, Instituto de Filosofia e Ciências Humanas, Universidade Federal do Rio Grande do Sul. Av. Bento Gonçalves 9500, Campus do Vale. 91509-900 Porto Alegre RS. email@example.com
O objetivo deste artigo é refletir sobre a medicalização da sexualidade masculina a partir do contraponto entre dois processos históricos distintos. O primeiro deles se refere ao grande movimento de intervenção na sexualidade masculina ocorrido no início do século XX no Brasil em torno da sífilis e do combate mais geral das doenças venéreas. O segundo diz respeito à medicalização da sexualidade via o foco na disfunção erétil e na chamada andropausa e a criação de uma nova farmacologia do sexo que se torna incontornável na passagem para o século XXI. Esse contraste permite perceber certas diferenças importantes. Destaca-se a nova ênfase na noção de saúde sexual baseada no aprimoramento individual e uso de medicamentos além da promoção do interesse masculino no desempenho sexual como porta de entrada para se chegar ao tratamento da saúde do homem.
Palavras-chave: Sexualidade masculina, Medicalização, Saúde sexual, Disfunção erétil
The scope of this article is to reflect upon the medicalization of male sexuality based on the counterpoint between two distinct historical processes. The first of these is the major trend towards intervention in male sexuality which occurred in the early twentieth century in Brazil as a result of syphilis and the broader campaign against venereal disease. The second concerns the medicalization of sexuality through the focus on erectile dysfunction and the creation of a new pharmacology of sex which has become inevitable with the transition to the twenty-first century. This contrast enables us to see some important differences. The study highlights the new emphasis on the notion of sexual health based on individual improvement and use of medications. It also demonstrates that the promotion of male interest in sexual performance serves as a gateway to approach the treatment of male health.
Key words: Male sexuality, Medicalization, Sexual health, Erectile dysfunction
The aim of this article is to reflect upon the medicalization of male sexuality based on the counterpoint between two distinct historical processes. The first of these was the great trend towards intervention in male sexuality which occurred at the beginning of the 20th century in Brazil as a result of syphilis and the more general fight against venereal disease. The second concerns the medicalization of sexuality through the focus on erectile dysfunction and the creation of a new pharmacology of sex which has become unavoidable with the transition to the 21st century. The choice of these two processes is obviously not intended to imply that the phenomena are analogous, bearing in mind all the differences imposed by the historical and contextual distance. But the analysis allows us to show the emergence of certain discursive structures which may be contrasted in a productive way. I propose that a discussion of these analytical factors allows us to examine in some depth the processes of male medicalization which link sex and health through very precise terms of reference insofar as they concern certain implicit normative conceptions.
This work is the result of a research project entitled Gender differences in the recent medicalization of aging and sexuality: the creation of the categories of menopause, andropause and sexual dysfunction (supported by CNPq - theNational Council for Scientific and Technological Development), which sought to outline the creation and development of diagnostics relating to the aging process in men and women and the interrelationship with symptoms associated with sexuality, in which the dimension of gender relationships is a benchmark. In this context, it investigated how these new diagnostics have appeared in the Brazilian medical field in recent decades. This research, which was of a socio-anthropological nature, emphasized the interplay between different qualitative research techniques, such as participatory observation, interviews and documentary research. It had recourse to the examination of articles from scientific periodicals, the websites of medical societies, news reports, television programs and publicity material in the press, as well as ethnography from medical conventions and campaigns and the conducting of interviews with professionals in the areas involved. The diverse nature of the sources was indispensable in order to show the scope of the processes studied and the interlocking nature of the networks involved.
It is important to stress that it is only recently that we have been able to rely on studies which are specifically intended to give a historical outline to the differentiated interests of medicine, in theory and in daily practice, in relation to men and women. In a preliminary survey it may be noted how medical knowledge has been much more focused on women, in contrast to men who in recent decades have merited specific attention through the creation of new diagnostics and pathologies1-4.
Syphilis and the medicalization of male sexuality at the beginning of the 20th century
To begin the discussion, I will make use of the valuable work of Sergio Carrara5, Homage to Venus the fight against syphilis in Brazil, from the turn of the century to the 1940s. From this study we learn how the male body and male sexuality became the object of great concern as a result of syphilis and other venereal diseases. In his examination of the fight against syphilis in Brazil, the author describes the massive efforts made by doctors and public authorities against this disease which, because of its association with the degeneration and weakening of the race, became a threat to the establishment of a healthy population and to the social order.
Carrara places the efforts in relation to syphilis in the context of a process of the regulation of sexuality and fears for the future of the population in the face of the aspirations of the government. He calls attention to how the social pattern of syphilis was reflected in the process of the social configuration of the nation in the first decades of the 20th century on the basis of the central idea of racial degeneration. He also stresses how the fight against syphilis gave impetus to the construction of a new individual, capable of exercising self-control, which was a necessary quality for the new political institutions which were being formed. He suggests that the formation and expansion of the states and the development of an individual with built-in social control are complementary phenomena. In this sense, syphilis is seen as "a strategic point for observing and understanding the way in which this simultaneous social transformation was in practice directed towards a demand for greater self-control and towards the actual formation of the nation state"5.
Carrara emphasizes that this individual self-control related particularly to men and to male sexual behavior. By means of measures relating to syphilis, doctors and public authorities, were attempting to deal a blow to oligarchic and patriarchal power by challenging traditional male prerogatives through the possible control of their access to women, and therefore to sexual pleasure and matrimonial alliances. It was then that men's bodies, up till that time more inaccessible than the bodies of women, children or sexual perverts, were finally submitted to medicalization. The author writes:
"It was the power of men over their own bodies that was in question, and nothing less than an unqualified, apocalyptic evil, such as syphilis was considered at the time, appears to have been necessary in order to affect it. It does not seem to me fortuitous that it was precisely the context of a struggle against venereal disease that saw the birth of andrology, the science of male 'sexual problems.' It seems to have been precisely because of venereal disease that men made the transition to being patients more easily, with their masculinity becoming an area where intervention was possible". (Author's italics) 5
Sex no longer belonged to men, suggests Carrara, as for some time it had not belonged to women. In the context of the debates over syphilis, sexual function and the reproductive organs themselves would be seen less as individual, more as collective, property. In the final analysis, the first priority was the biological responsibility to produce offspring. What is interesting is that men were viewed from the standpoint of an illness which threatened their descendants, but which more immediately led to their own degradation as individuals. The science of male sexual problems is related to a disease which has an exterior cause or which is the result of sexual excess.
An interesting chapter in this process of the medicalization of sexuality, or to a certain extent the resistance to it, revolves around the efforts of Doctor José de Albuquerque to promote sexual education and in the creation of andrology in the 1930s. According to Carrara, Albuquerque was responsible for initiatives such as the foundation of the Brazilian Circle for Sex Education in 1933 and the issue of the Bulletin of Sex Education, which was published every two months between 1933 and 1939 and distributed free nationally, and which reached a print run of 100,000 copies per issue. Among other activities, such as lectures and radio discussions, the Circle sponsored Sex Education Week in 1934 and Sex Day on 20 November 1935, arguing that sex should be subject to "scientific morals" 5.
Doctor Albuquerque, who was a self-proclaimed sexologist, also made efforts towards the establishment of andrology, a discipline which would be dedicated exclusively to the problems of "sexual function" and of the "male reproductive apparatus." Towards this end, Albuquerque founded the Journal of Andrology in 1932, which he edited until 1938. It was also distributed free and reached a print run of 30,000 copies in 1935, the year in which it began to be published in five languages. The efforts of the doctor also led to the creation of the chair of clinical andrology at the University of the Federal District, which he occupied between 1936 and 1938, when he resigned due to the problems he faced with the appointment of the Catholic Alceu Amoroso Lima as rector. Actually, confrontations with Catholics and fundamentalists were a notable feature in the career of Albuquerque and his movement. In a different context, representing a dispute between medical specialties, he also took on the urologists. He believed that they had an undue monopoly over problems such as impotence, sterility, premature ejaculation and venereal diseases, amongst others which should be more properly treated by andrology5.
The erectile function and the medicalization of male sexuality at the beginning of the 21st century
The picture of intensive efforts with regard to syphilis, connected with the promotion of scientific sexual morals and linked to an emphasis on male self-control, remains a singular phenomenon. Despite the attempts to establish andrology, Carrara et al.6 argue in this context for example that the efforts were not enough to formulate public policies specifically directed towards the male population, in contrast to the large projects undertaken over the course of time which were directed towards women4. This picture appears to have fundamentally changed at the turn of the 21st century, as demonstrated for example by the formation of the Brazilian National Men's Health Policy (PNAISH), launched in August 2009.
Beyond a discussion in greater depth with regard to PNAISH6-9 and contemporary trends towards developing special attention to male health, which has been the focus of a series of studies10-14, the aim here is to give priority to the associations between sexuality and medicalization15. For this purpose, I take a quotation which has become more and more repeated and which has characterized recent steps in the medicalization of male health, at least as far as the appeals made by urologists and their professional associations are concerned. This is the slogan: "Sexual health as the gateway to male health." We are not concerned here to seek the origin, the authorship or the primary intentions behind the slogan, but to note how it is used again and again to set a specific tone as regards the links between sex, health and medicalization.
In 2008 it was common to witness the propagation of this idea in various areas, from reports in the press to material produced by pharmaceutical laboratories, medical conventions and public events. In Veja magazine, for example, the theme appears in at least two important features. The first is the Interview Section in the edition of January 9, 2008, the title of which is "Sex, Medicines and happiness. For the American doctor, there is nothing wrong in a man having recourse to chemicals in order to improve his performance in bed. It's even good for women. It simply needs judgment"16. The person concerned is John P. Mulhall, a well known urologist in the United States, who is the director of the department of urology at the Memorial Sloan-Kettering Cancer Center, in New York, and is a professor at the Weill Medical College of Cornell University, where he directs the laboratory for research in sexual medicine. In the interview, he talks about the importance of sex in maintaining the quality of life, problems which affect men and women in this area and the role of medicines in the quality of sex. He even claims that it is not possible to achieve quality of life without a regular and satisfactory sex life, and that this contributes towards a reduction in the risk of cardiovascular, mental and immunological illness. He points to the low level of sexual satisfaction among men and women and defends the use of anti-impotence medicines, even by young people, as a way of dealing with insecurity, provided that they do not lead to dependence. In a Special Section published on March 19, 2008 entitled "The Blue Revolution: Ten years after the launch of Viagra, impotence has ceased to be a male specter," it is argued that among the principal benefits introduced by Viagra is a greater ability to diagnose hypertension and diabetes, problems whose symptoms can include erectile dysfunction. The article highlights the publicity given to the subject of erectile dysfunction and the use of Viagra as a gateway to male health17. In Isto É magazine of July 9, 2008 there is a discussion of the formation of the Brazilian National Men's Health Policy (PNAISH), highlighting the argument that erectile dysfunction can lead to upsets in men's lives and can also indicate the presence of other illnesses, such as cardiovascular disease18. In a report in the O Globo newspaper of August 17, 2008, the tone is the same, as evidenced by the claims of the urologist José Carlos de Almeida, then president of the Brazilian Urology Society (SBU), when stating that erectile dysfunction is often not the cause of a problem but basically the consequence of other illnesses19.
At medical conventions the topic was also to the fore, not only in the speeches but also in the material prepared by the pharmaceutical laboratories20. At the International Urology Conference in Rio de Janeiro in 2008 and the 10th Conference of the Latin American Society for Sexual Medicine in Florianópolis, the Bayer Schering Pharma company, which was particularly concerned to promote itself as "the first laboratory with a portfolio directed towards male health," distributed the same document entitled "Sexual health as the gateway to male health" 21. It was in fact a collection of three articles: "Sexual health as the gateway to male health" by Ricardo Meirelles (professor of endocrinology at PUC-Rio and president of the Department of Female Endocrinology and Andrology of the Brazilian Society of Metabolic Endocrinology); "Testosterone deficiency and erectile dysfunction as components of metabolic syndrome," by Farid Saad (honorary professor at Hang Tuah University, Indonesia); and "The role of testosterone replacement therapy in the bodily and sexual health of males," by Svetlana Kalichencko (President of the Department of Andrology and Urology at the Scientific Research Center for Innovations and director of the Russian branch of the International Society for the Study of Aging Males). The document, "exclusive to the medical profession," underlined the association between sexual performance, youth and male health, and had an inside cover showing an advertisement for Nebido, a three monthly injection of testosterone indicated for the treatment of Androgen Deficiency in the Adult Male (ADAM).
In the National Campaign for the Advancement of Male Health sponsored by the Brazilian Urology Society (SBU) starting in August 2008, prominence was again given to erectile dysfunction, on the grounds that it was an important sign of illness, as it could be related to heart disease, hypertension and diabetes. The SBU website contained the message that "Erectile dysfunction is a matter for action because it is a sign of illness. The problem affects around 50% of men over the age of 40. Less than 10% see their doctor. The society wishes to discourage self-medication"22. This was also the message of the videos produced by the SBU during the period. It was the topic chosen for the first SBU TV program, consisting of a talk on erectile dysfunction given by Sidney Glina who, among other aspects, stressed how behind erectile dysfunction there were other illnesses. In the series of programs entitled Healthy Citizen, the link between erectile dysfunction and other illnesses was again touched on, this time by Antônio Barbosa de Oliveira22.
Moreover, it is noteworthy how this idea was present in the events connected with the launch of the Brazilian National Men's Health Policy (PNAISH). It was the case with the 4th Public Political Forum and Male Health organized by the Social Security and Family Commission of the Chamber of Deputies on August 7, 2008. The topic for public debate was "Male health, urological aspects and the National Health System (SUS), the current situation and future prospects." Once more, a prominent figure in the discussions was Sidney Glina, who presented a paper, "Erectile Dysfunction Approach and Treatment. Should the National Health Service (SUS) distribute medication free of charge?" The urologist emphasized erectile dysfunction as a question of public health and as a sign of illness through the use of a series of references to medical literature, epidemiological data and international documents and stressed that the "Treatment of Erectile Dysfunction could be the gateway for men into the Health System!23.
In the years that followed, the same attitude continued to maintain a significant presence in public programs by urologists, as in the 5th Public Political Forum and Male Health organized by the Social Security and Family Commission of the Chamber of Deputies on August 20, 2009. In an interview about the event with the Câmara de Notícias Agency, Sidney Glina stated that urology "is a gateway into SUS and the patient can then see doctors in other areas, such as cardiologists"23. The doctor also underlined the importance of SUS employing a larger number of urologists.
This emphasis was also to be seen among urologists linked to the Brazilian Association for the Study of Sexual Inadequacies (ABEIS), an important body in the promotion of sexual medicine in Brazil24. The interview between the journalist Lilian Ribeiro and Paulo Brito Cunha, then the president of ABEIS and a member of the Brazilian Urology Society, on CBN Radio on May 15, 2010 is a good example of this. The focus of the interview was the relationship between erectile dysfunction and pre-existing illnesses. In the first part, Dr. Cunha dealt with separating any possible connection between remedies for erectile dysfunction and cardiovascular problems. More than this, he even claimed that the use of Viagra helped to avoid difficulties of this kind:
We now use it (Viagra) on a daily basis to protect against cardiovascular disease. It benefits the cardiovascular system, it benefits the arteries, the erection is a cardiovascular phenomenon [ ] The illnesses which kill people who use Viagra are the illnesses which makes it necessary to use Viagra: serious hypertension, serious diabetes, extremely high levels of cholesterol, but not Viagra. The use of Viagra protects against these illnesses25.
Further on, Cunha explained that the first symptom to appear before heart disease, diabetes or hypertension is "impaired erectile function." And he goes back to the idea, now redefined more precisely as erectile function, and no longer as the wider notion of "sexual health," as the "gateway" to the diagnosis and treatment of other illnesses:
Do you want to know if you have hypertension? Ask yourself how you are in terms of erectile function. Do you want to know if you have high cholesterol? Ask yourself about your erectile function. The erectile function is a gateway to these things [ ] We have the Brazilian Association for the Study of Sexual Inadequacy, our website is at www.abeis.org.br, if you enter this site you will find there a list of many of the professionals who deal with this subject [ ] You will find people there of the highest professional competence in dealing with it, because, according to the World Health Organization, the thing which most affects people's quality of life is sexual activity [ ]25.
It will be noted from the above passage that connections are made between a diagnosis of hypertension and erectile dysfunction, the existence of ABEIS and the promotion of its members as the proper professionals for diagnosis and treatment, and reference is made to the WHO and the idea of sexual activity, no longer to "sexual health," as the best indication of quality of life. Based on international medical literature, the president of ABEIS adds that only 10% of men who have erection difficulties seek help and that doctors are not accustomed to ask their patients about their sexual activity. These facts support the idea that it is therefore necessary to call attention to the problem and encourage initiatives both with regard to possible patients and with regard to doctors themselves and the health sector in general. The precision with which Dr Cunha sets out these considerations is made even more explicit in another notable passage dealing with erectile dysfunction, the role of the penis and systemic or peripheral diseases, or what should really be the target of urologists:
When you think about erectile dysfunction, the last thing you look at is the penis. The disease is not there, the disease is peripheral, the disease is systemic. The penis is simply saying that something is wrong in your life, let's investigate. This is the way we work25.
The various ideas cited above show that the emphasis on sexual health as a gateway or a means of access in order to deal with male health is bound up with a series of factors and recurrent references. A frequent argument is the idea that men do not customarily concern themselves with their own health, a task which is often described as a female responsibility. But, on the other hand, they are always concerned with their sexual performance, looked at in terms of erectile function. In proposing to treat this condition, urologists are opening the door to the possibility of accessing men for the treatment of other diseases. In order for this strategy to be effective, it would therefore be of fundamental importance to ensure a more representative and wider presence of urologists in health services.
Another frequent point is a restricted use of the notion of sexual health. It cannot be overlooked how important this concept has become, to the point where it is officially promoted by the World Health Organisation itself26. But beyond this and the whole context of the discussions about sexual rights, it is right to be aware of how it has become a formula often associated with other interests. It will be noted that in addition to a dilution of the notion of sexual health, we also find its reduction, in the case of men, to erectile dysfunction, thereby lending support to the idea of male sexuality as restricted to erection, which is almost exclusively conceived, in this context, in heterosexual terms. Thus, any other ways of seeing things with regard to male sexuality are ignored.
The promotion of new diagnoses: erectile dysfunction and Androgen Deficiency in the Adult Male (ADAM)
In accordance with the picture described above, it can be argued that a new wave of medicalization of male sexuality is particularly observable in the increase in diagnoses of sexual dysfunction27 of andropause or of Androgen Deficiency in the Adult Male (ADAM)28. Barbara Marsall and Stephen Katz1 point out that in the 20th century the medicalization of sexuality took place because of a focus on men and the reduction of male sexuality to erectile dysfunction. Through a more general approach to the problem which views sexuality and age as fundamental aspects of modern humanity, stress is placed on the importance of life style cultures at the end of the last century, with the emphasis on health, on activity and on non-aging for a process that results in a huge field of studies and interventions with regard to the penetrative capacity of the male sexual organ. According to the authors, the great novelty was the transition from a view which accepted the decline in sexual powers over the course of time and which even looked askance at sexual activity in old age to another view in which good sexual performance throughout life became mandatory. More than this, it is taught that sexual activity is a necessary precondition for a healthy life and that erectile capacity defines virility throughout the life of a man. It is precisely in this context that we have witnessed the rise of Viagra (sildenafil citrate), a medication from the Pfizer laboratory which is intended to facilitate and maintain erection, thereby illustrating the development of a molecular science of sexuality1,29.
To ensure the success of the new medication, it was necessary, on the one hand, to portray erectile dysfunction as a problem capable of affecting any man, at any stage of his life, and that a drug was now available which was capable of solving or preventing this difficulty. In this sense, Viagra formed part of a much wider group of so-called lifestyle drugs or comfort medications, intended to improve individual performance, which was clearly an expanding market. On the other hand, Pfizer also made every effort to promote the idea of erectile dysfunction as an acceptable topic for public discussion, which would lead to a greater demand for treatment30.
This was only possible thanks to the spread of the idea of masculinity in crisis, illustrated above all by the metaphor of erection. The idea that erection, the symbol of virility and male identity, is fundamentally unstable and subject to various kinds of disturbance seems to achieve greater and greater notoriety. And it is precisely in order to combat this lack of control or unpredictability of the male body that the pharmaceutical industry offers an aid such as Viagra, with the capacity to ensure expectations for ever better performance3,31,32.
One important factor in this process was the increasing presence of urologists and their fundamental role in institutionalizing the field of sexual medicine, through the setting up of organizations, conferences, training centers, scientific journals, clinics and medical departments33,34. The "success" of these professionals in promoting the new possibilities for medicalizing male sexuality also extended to the diagnosis of the andropause or ADAM. Defined as an "illness" affecting men from the age of 35-40, it is characterized by loss of libido or sexual desire, decrease in muscle tissue, loss of energy, depression and erectile dysfunction, among other symptoms, and its cause is a fall in the production of testosterone. Known as a treatable organic disease since the 1930s, it was only in the 1960s that the treatment for it came to emphasize problems of a sexual nature35.In the 1990s the use of testosterone became widespread, and emphasis was increasingly placed on the restoration of sexual performance, in harmony with the treatments for erectile dysfunction.
In Brazil, the urologists, represented by the SBU, made a particular contribution towards the focusing of special attention on the andropause and erectile dysfunction. As shown by Carrara et al.6, since at least 2004 the SBU had been putting pressure on government departments, members of Congress, health councils and other medical societies to develop a policy for catering to male health. At the same time the Society devoted itself to carrying out a series of campaigns and other events, along the lines of the so-called Movement for Male Health in 2010. It was an initiative which aimed to increase public awareness of the need for prevention and treatment of illnesses such as erectile dysfunction, the andropause and prostate problems. The Movement's Mobile Unit (a trailer equipped with medical facilities and a team of three urologists and other health professionals), sponsored by the Eli Lilly laboratory, toured the major cities of the country making free medical advice available.
The promotion of this type of campaign and the public attention focused on ADAM and erectile dysfunction illustrates how the last two decades have seen the creation of a new focus on masculinity, through the pharmacologization of sexuality. This has occurred both through the use of drugs to facilitate erection and through the prescription of testosterone. Although there are signs of a certain critical perspective, in particular with the publication of data which has placed a question mark against the efficacy and safety of such therapies, it may be assumed that medicalization has prevailed, both in medical practice and in those lay perceptions which have been supporting it. In the specific case of the linking of aging and sexuality, it should be noted that the promotion of new drugs and resources goes hand in hand with the promotion of behavioral models centered on the value attributed to a young, healthy and sexually active body.
New and old access
The recent medicalization of male sexuality, centered on the rise of erectile dysfunction and ADAM diagnoses, shows a series of interesting contrasts with the kind of medicalization which characterized the reaction to syphilis in the first decades of the 20th century. It should of course be noted that the two situations involve very distinct social contexts, which manifest themselves, for example, in very different expectations of life and in public policies with very different aims. In general terms, in the earlier epoch the question of health was framed in more collectivist terms, as a concern for the nation, whilst in the later epoch it was bound up with a more individualist ideology, often running in the opposite direction to the discussions concerning the promotion of health from a perspective of rights and citizenship.
It is possible to point out certain "permanent" characteristics or points in common, such as the idea that men are very concerned with sex, which would demand certain definite policies. However, even here there are significant differences. Whilst in the campaigns in relation to syphilis, the question was framed in terms of the self-control of sexual "excesses" for the good of society or the nation, the central focus currently appears to be the promotion of self-care, as a way of achieving a projected individual improvement. In addition, syphilis was viewed as an external and wasting disease which could affect men. The current medicalization through the recognition of functional and biochemical problems is based on the difficulties which are inherent in the individual body and its functioning. If the discussions with regard to syphilis stressed the dangers of collective degeneration, the discussions surrounding sexual health in the context of today emphasize above all a regeneration of individual sexual potency.
The predominance of this more individualist trend, modeled on an improvement in performance and functionality and on pharmacological solutions, brings us to the recent discussions on biomedicalization procedures, associated with the emergence of a new culture or "truth regime," centered on individual responsibility. In this context, a concern with health becomes a moral attribute of the individual, who needs to be informed with regard to new medical knowledge, the practices for caring for one's own health, and the prevention and treatment of diseases, and being prepared to consume the resources now available36.
This line of argument gains prominence in the work of Nikolas Rose37, which questions the role of life sciences in the production of contemporary truths and subjectivities. His discussion of the concepts of molecularization, optimization, subjectification, expertise and bio-economy is relevant for our understanding of the dynamics of transformations which involve the notion of a healthy body centered on individual self-management. By molecularization, Rose emphasizes the transition between the concept of biomedicine centered on the body to one which is now specialized at the molecular level, which could be described in terms of a new bio-politics. Optimization is presented as the use of contemporary medical technologies no longer simply to cure pathologies but to control the vital processes of body and mind. These optimization technologies are associated with the idea of improvement as something directed towards the future and the possibility of creating individual consumers of these new desires and possibilities for controlling life. The concept of subjectification describes the process by which the subject is led to believe that the promotion of health is a personal question, involving self-management and responsibility.
This is associated with the establishment of health as an important ethical value in western society, starting in the second half of the 20th century, and in more recent times with the creation of a new ethic. It amounts to "etho-politics," i.e. an attempt to mould the conduct of human beings by acting on their feelings, beliefs and values as to how they should judge and act in relation to themselves and their bodies with a view to the future. Expertise is now becoming important because the emerging bio-power practices are related to new forms of authority. The current "experts in life itself" no longer become prominent through the cure of illnesses but through a capacity to perfect the art of self-government. Not only doctors but other health professionals make up this field of "body experts," with the capacity to give guidance to individuals in their search for the perfection or optimization of their potential37.
In the case of the medicalization of male sexuality, it is possible to suggest that these more general phenomena might be linked to certain important transformations, or at least that they permit a deeper analytical approach. As regards the development of new specialties and "experts," we could begin by pointing to the contrast between the lack of success in institutionalizing andrology, when it was proposed by José de Albuquerque, and the rise of urology when it was transformed, at least partly, into sexual medicine24. Although the Brazilian Urology Society currently has a department of andrology, the most important development is that urology itself has become prominent as a legitimate specialty in the care of male sexuality. If proposals for a science of male sex, outlined in moral and scientific terms, have not advanced since the 1930s, the new sexual pharmacology has made its presence increasingly felt.
Whereas in the process of medicalization and control through syphilis, men were accessed through a disease which was external, contagious and wasting, and which even harmed the nation, currently medicalization operates on the basis of the threat of low sexual performance and the need to improve functioning, linked to molecular factors. It is no longer a question of the self-control needed by citizens of emerging states, but of the self-care which is indispensable for individuals who have become responsible for their health, well-being and improvement. One might speak of a medicalization "inside" and "towards improvement," linked to the promotion of health as a cultural value and a consumer item.
This aspect leads to a final point. It is only when health, especially sexual health, becomes an asset which is prized in contrast with the medicalization which emphasized the illness that the public pronouncements of the urologists appear to meet with more success. It is possible to defend the thesis that perhaps a concern for health, through stressing the threat of disease, remains behind the perception of Brazilian urologists as still being insistently linked to women. One might suppose that, in view of this, in order to get men to the doctors and health services it is necessary to employ the strategy of not talking of illness but instead promoting the maintenance or improvement of erection in other words, of accessing them through sex.
Pedro G. Cassel, who collaborated providing technical support for this work.
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