Second Opinion: Sex in the surgery
Doctors at our health centre have recently been bombarded with invitations to attend a 'sexuality training day' on the subject of 'sex in primary care'. As this sounded like a good day out, I requested details of the agenda which promised 'an opportunity to discuss [my] experience of sexual history- taking, explore associated issues and develop and enhance [my] skills and confidence to discuss sex with a diverse range of patients'.
Highlights of a day featuring games and role play include an 'orgasm exercise': 'pairs to practice communications skills to talk about experience of or understanding of an orgasm.' Another exercise tackles 'sexual language': 'small groups to brainstorm words for male and female sexual organs and homosexual/homosexuality.' The course includes 'a nice lunch and all course materials'(!).
Our first response was to have a good chuckle at the sheer silliness and self-indulgence of this course. As one of my colleagues observed, 'if GPs want to get off on talking dirty why don't they do it in their own time instead of dressing it up as a "study day"?'. Somebody else commented on another example of the 'dumbing down' of postgraduate education: this day of 'facilitated' play-acting is organised under the auspices of a prestigious university department and GPs are paid to attend.
But if we ask the question - how is the sexuality training day for GPs supposed to relate to their work with patients? - we raise a much deeper problem. It is clear that the aim of the course is to overcome doctors' own inhibitions in talking about sex (and doctors are a notoriously straitlaced profession) so that they can in turn break through their patients' reserve in these matters. Challenging doctors' personal reticence is the key to opening up the intimate personal areas of ordinary people's lives to professional scrutiny and interference.
The 'Sex and the GP' conference made me remember a book entitled Sexual Health Promotion in General Practice (retail price £15) that was sent free of charge to every GP in London in 1995. The main justification offered for this well-resourced drive to recruit GPs to the safe sex crusade was the campaign to reduce the incidence of HIV and other sexually transmitted diseases. This did not make much sense, as both HIV and STDs are fairly uncommon in general practice and also because there is a flourishing network of clinics already dealing with these problems. Indeed, after prevaricating for more than a decade over providing a psychiatric unit, our local hospital promptly opened a grand, lavishly equipped and highly staffed 'department of sexual health' - a speciality unheard of 10 years ago.
So why target general practice? The book (which is largely written in bullet points to make it accessible to the limited intellect of the GP) provides a long list of the 'advantages' of general practice as 'a setting for promoting sexual health', of which the first three are:
- Reaches large numbers of people on a one-to-one basis
- Relationship with patient already exists
- Opportunities to discuss sexual health arise during relevant consultations, for example, for smears or contraception
The importance of general practice is that it provides access to the mass of the population through an individual who has a relationship with people that reaches deep into their personal, private space.
The central concern of sexual health promotion is not to prevent disease but to preach a new form of sexual morality. This moral code not only rejects traditional mores based in religious faith, but it also explicitly proclaims its 'non-judgemental' character. Yet the new framework simply replaces 'good' with 'safe', and 'evil' with 'unsafe', and proceeds to construct a code as dogmatic and authoritarian as any to be found in the Bible or the Koran. Sexual Health Promotion in General Practice provides a table of around 30 forms of sexual activity which are classified, fairly arbitrarily, as 'safe/low risk; possibly safe/ medium risk; unsafe/high risk'. Like scholars of the Talmud, the rabbinate of the sexual health establishment finds fruitful employment in tutoring the faithful in the subtleties of the classification and in offering endless interpretations and reinterpretations of the sacred text. Those who stray from the path of righteousness - such as the HIV-positive woman recently discovered to be breastfeeding her baby (a behaviour of indeterminate risk) - are likely to find themselves smitten with the full force of the law, not to mention the wrath of the Guardian.
It is interesting to contrast the medicalisation of sex in the late nineteenth century and today. One of the few insights of the opaque French philosopher Michel Foucault was that the apparent liberalisation associated with the sexual reformers of the late Victorian period was illusory: by identifying and classifying diverse forms of sexual experience they merely replaced a traditional mode of moral regulation with a modern, rational, professionally mediated form of surveillance and control. The 'repeal of reticence' led to the displacement of the priest by the doctor, whose supervision was more thorough.
Yet the resulting 'revolution in manners and morals' remained largely confined to the elite of society, in Britain scarcely extending beyond the Bloomsbury set. The distinctive feature of the current phase of medicalisation is that it reaches out to the whole of society and penetrates more deeply into the individual personality. When Foucault commented on the replacement of 'silence' with 'volubility' about sex in the 1890s, he can scarcely have anticipated the combined effect of Denise van Outen on TV and your family GP after a 'sexuality training day'.
Reticence may be in shreds, but this has been achieved at the cost of the intrusion of the doctor into the bedroom and the transformation of the doctor's surgery into a confessional. Sexuality training? No thanks!
Dr Michael Fitzpatrick
Reproduced from LM issue 125, November 1999