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Selected M.E. Grenander Materials:
The fourfold way: Determinism, moral responsibility, and Aristotelean causation.
[Note: This review was donated to the Szasz Site by M.E. Grenander shortly before her death. Copyright Journal for the Humanities & Technology, 1981.]
Thomas Szasz, Sex by Prescription
This book adds yet another chapter to Professor Szasz developing oeuvre: an analysis of and an attack on the continuing attempt to insinuate moral values and social policies into the body politic under the guise of medical diagnoses and treatments. His particular focus here is on sex, which he himself regards as a profound personal interaction between two people that satisfies a, basic human need and that involves a deep commitment on both their parts. Celebrated as love throughout human history, it can and does reach spiritual heights which may transcend the mere release of physiological tension. But the sexologists he describes as peopling the contemporary scene discuss it in the vocabulary of medicine. Epithets like impotence, premature ejaculation, and anorgasmia (the modish term for what used to be called frigidity) convey an aura of pathology. Such a judgment, however, is culturally conditioned. Particular kinds of sexual behavior, whether undertaken alone or with someone else, may be pleasant or unpleasant, good or bad, reflecting the individual's tastes, attitudes, morals, and ethical standards. But they are neither diseases nor treatments. As a quasi-theological social enterprise, medicine throughout its history has swayed like a pendulum with regard to sex. Accordingly, in Szasz¹s view we should "erect a wall between medicine and the state maximally impervious to the rhetorical incantations and financial temptations of each directed toward the other." Under the rubrics of "sexual medicine" and "sex education," he therefore takes apart the new-fangled discipline of "sexology." His concern with "sexual medicine" has nothing to do with venereal diseases like gonorrhea, which are indeed legitimate grounds for medical interventions, but rather with sexual dysfunctions expressing someone's life-style, with the individual participating actively in both their diagnosis and their treatment "Sex therapy" therefore resembles learning more than medicine. Szasz describes how the modern concern with sexual medicine fails to relate sex to the self, then with a broad brush sketches the ways in which physicians, with the rise of science in the seventeenth century, began to displace priests as the experts on sexual behavior, wielding disease instead of sin as their symbol of control. He traces the medicalization of sex through such historical figures as Benjamin Rush, Jean-Etienne Esquirol, Richard von Krafft-Ebing, and Sigmund Freud (who considered squeezing blackheads to be a form of masturbation). In Szasz's view, psychoanalysts even today regard unconventional sexual behavior as an illness which they are especially adept at diagnosing and treating, with Karl Menninger still claiming that masturbation is psychologically harmful, and Charles Socarides defending the disease concept of homosexuality, despite its deletion in 1973 from the American Psychiatric Association's official list of mental illnesses. For the most part, however, physicians now regard sex not as disease but as medical treatment, bestowing their approval on behaviors like female sexuality and masturbation that were formerly considered pathological. For Szasz, the paradigm theorists of sexual medicine are Masters and Johnson, naive moralists who pretend to be value-free scientists. They reinvented the wheel by observing in impersonal, bureaucratic, and pompous prose that sexual arousal causes erection in the male and vaginal lubrication in the female; interaction in this condition results in a pleasurable release of tension. The ecstatic media response to such banalities can be attributed to pornography's enduring appeal, especially when it is respectably medicalized. While posing as sexual egalitarians, Masters and Johnson in fact use different standards for treating men and women, and for treating homosexual and heterosexual couples. As described in Szasz¹s mordant prose, their clinic seems to differ little from a high-class bordello. Hence it is not surprising that prostitutes, wanting to get in on the "sex therapy" act, have updated their ancient profession to a remarkable degree, with their services even subsidized occasionally by the taxpayer in America, England, and Germany. Since the Masters and Johnson clinic and its numerous epigones are very very expensive, costing seven or eight times as much as psychoanalysis, the taxpayer could even be getting a bargain by underwriting the relatively cheap fees of the hooker. The real problem, of course, is that the state has no business intervening in the sexual lives of its citizens. But regardless of who foots the bill, since most sex therapy clinics are at universities and hospitals, the academics may be on to something almost as good as a winning football team to far as balancing the budget is concerned. Sexual surgery, like prostitution, goes far back in time, beginning with circumcision of the Jews (who copied it from the Egyptians). Throughout the nineteenth century, brutal operations on both male and female genitalia were imposed in order to cure the dread disease of masturbatory insanity. But today's sexual surgeon is handier than ever with his knife, turning men into imitation women with artificial female genitalia; and, to a lesser extent, turning women into *imitation men with artificial male genitalia. The zaniness of even these operations, however, is exceeded by those now being performed on impotent men in order to give them artificial erections, either permanent or temporary. The patient could have silicone rods implanted in his penis, with the result that he has to wear a jock strap to hide his condition when he does not want to use it. Or he might opt for a "hydraulic prosthesis," consisting of two cylinders in his penis connected to a little reservoir in his abdomen; he squeezes a pump in his scrotum to create an erection. Women are not supposed to know about this gimmickry, whose therapeutic effect is apparently based on deceiving the female. The reader who recalls Faulkner's Sanctuary can only share Szasz's wonder at this surgical updating of Popeye's corncob. Sex education, like sexual medicine, is a vast meadow in cloud-cuckoo land. It, too, has ancient historical roots, in the Jewish, Christian, and Moslem religions, each having promoted its own sexual ethic. Modern sex education, however, is in the hands of the medical profession. Mary Calderone, M.D. (who was furious when this book appeared), is the guru of sex education for children and youths, operating through her Sex Information and Education Council of the United States (SIECUS). Sex education in the public schools is now omnipresent; despite 'its pretensions to medical objectivity, it has replaced biology and ethics with a sexual ideology many people find offensive, and illegitimate pregnancies among teenage girls are on the increase. In the medical schools, however, sex education becomes low comedy, if not farce: pornographic movies are shown with multi- media pizzazz to groups of students in conjunction with their sexual partners. Once they get their degrees, the physicians continue with tax-deductible postgraduate sex education, which consists either of Masters and Johnson methods cloned at various universities or, alternatively, cruises and resort vacations laced with pornography and casual sex. Szasz criticizes such practices not only for their dubious educational value, but because they tend to loosen the physician's sexual morality. He characterizes as "intellectual bankruptcy compounded by moral paralysis" the rationalizations of those medical sex- educators, - including clinical psychologists, who justify their sexual abuse of both female patients and female students as therapy The general thrust of Szasz¹s argument is clear. Yet he has little to say about the obvious topics of birth control and abortion. For example, he fails to engage the question of whether the popularity in the nineteenth century of a surgically induced menopause among women whose average age was only thirty may not have been due to its having been a form of permanent birth control. Moreover, although he opposes compulsory sterilization and compulsory abortion, he does not indicate whether he is also against compulsory pregnancy, even when it results from rape or, incest. Given America's current social ambience, this seems to be a far greater danger. On the other hand, he has certainly given us the-relevant principle concerning the individual's right to express personal sexual values. Freedom, he says, implies the responsibility of everyone "to confront his own sexual nature; to relate it to his vision of himself; and to construct and conduct ... a sexual life that is genuinely his own." The 'obvious biological and cultural" conditions of women's lives make such choices for them even harder than for men. Judging various types of human sexual acts (apparently including those which involve attempts to avert or terminate pregnancy, although he does not say so) to be "legitimate or illegitimate, much less prohibiting them by means of criminal (or mental health) laws, falls outside the proper scope of government." This passionate commitment to the individual's own deeply internalized values informs the entire book. It is perhaps quibbling, then, to wish that Szasz had confronted more squarely the spectre of compulsory pregnancy which looms on the American horizon. Be that as it may, he believes that the issues he has discussed are problems of political philosophy, not of medicine, and that the answers depend on whether one supports a paternalistic society or a libertarian one. The libertarian stance stipulates that the only aspect of sexual conduct the law should be concerned with is that which might entail the use of force or fraud. Such coercion justifies and indeed requires that the law protect the individual who is imposed upon. (This would seem to take care of rape, although that, too, is a topic he does not discuss.) Thus, whatever one may think of the foolish practices Szasz does describe, he himself believes that, so long as they are undertaken by adults and are not subsidized by the state, one can interpose no objection to them. Unfortunately, however, most sexologists seek to impose their views on others through the machinery of government. His basic concern is that the consequent transformation of sex from a private into a public act entails "the end of individual freedom and dignity." He certainly does not deny the existence or reality of sexual problems. But since they are basic human problems, the individual must learn to handle them for himself; this view is the antithesis of saying that their solutions should be formally taught. Szasz not only opposes government- sponsored and tax-funded sex education and sex therapy; he supports "an economic, legal, and political order that allows the individual a maximum amount of freedom to learn about and engage in sexual activities." And he concludes his book on a sombre note which is quite at -odds with the cheerful insouciance of those sexologists who forget that -the ultimate organ of human sexuality is not the genital but the mind." Szasz reminds us of that basic fact. Reading the right sex manual, being counselled by the right sex therapist, finding the right partner, does not mean that people "will enjoy unremitting sexual satisfaction, in a loving encounter with another, with integrity and dignity, day after day, year after year, for forty, fifty, or more years. The absurdity of this image is a measure of the absurdity of modern sex education and sex therapy." M. E. GRENANDER The Institute for Humanistic Studies State University of New York at Albany