Erwin J. Haeberle

The Manufacture of Gladness

Some Observations on Sex Therapy

First published in: The Manufacture of Gladness - Some Observations an Sex Therapy, in: Challenges
in Sexual Science, A SSSS Monograph, C. M. Davis ed., Syracuse, N.Y. 1983, pp. 8 – 15.
The text has been slightly cut for this online library.


Sex therapy, and even medical sex education, have recently found themselves under attack in our society. These attacks come not only from conservative "authoritarian personalities," but also from radical libertarians. Various religious fanatics of a moralistic would-be majority, as well as humanistic champions of individualism like Thomas S. Szasz, are accusing sex therapy of being a dangerous fraud perpetrated by power-hungry and phony "experts" upon a gullible public.

What is the reason for these strange accusations? Could they possibly be justified? If so, to what extent? Does sex therapy have, and indeed deserve, a future? I believe that the answers will emerge only from an examination of some hitherto silent assumptions of our therapeutic practice.

Most of the time, of course, therapists do not worry about their assumptions; rather, they try to respond to acute needs and miseries as they see them. This approach needs no justification as long as it is supported by the general public. However, today this support is no longer unanimous or certain in any therapeutic field - neither in sex therapy, nor in psychiatry, nor even in traditional somatic medicine. It has, therefore, become necessary, even for "simple" practitioners, to develop some interest in theory. This means, above anything else, that they need a critical understanding of the social-historical context in which their work in embedded.

Unfortunately, a history of sex therapy still waits to be written, as does a history of sex research. Such fundamental and, in the long run, indispensible studies simply do not exist at this time in either field. Thus, for all practical purposes, we belong to a profession without a past. Yet, without an awareness of our origins and traditions, a critical self-assessment is very difficult. Since we do not know where we came from, we can hardly be expected to know where we are going and why. All we can hope for under the circumstances are some preliminary conjectures.

I think we can say this much: From Hippocrates to Masters and Johnson, therapists of various kinds have dealt not only with sexual dysfunction but also with sexual deviance. They have tried not only to restore, increase, or reduce sexual vigor but also to channel it into socially acceptable outlets, and they have done so on the assumption that they were "handmaidens of nature," i.e. that they simply helped people to achieve what should have "come naturally" in the first place. Thus, the first and greatest silent assumption of all sexual therapy has been the belief in a "naturally" given, healthy sexuality which becomes dysfunctional or deviant only as a result of interference. Conversely, once this interference has been stopped, and its illeffects have been eliminated, the human "natural sexuality" is automati¬cally restored.

However, apart from this belief, the various therapeutic interventions did not necessarily have very much in common. Indeed, over the centuries they often pursued opposite strategies. What was strengthened as a natural function at one time was weakened as an unnatural excess at another time, and behavior that was recommended as healthy by one physician was denounced as pathological by another. For example, as Szasz delights in reminding us, Galen, in the second century A. D., recommended that therapists masturbate their female patients in the interest of natural health.1 In the 19th century, women were treated, often by means of a clitoridectomy, against the unnatural habit of masturbation. In the early 20th century, Wilhelm Reich again prescribed masturbation for the purpose of regaining the natural sexual function, and, as he reports, some of his psychoanalytic colleagues in Vienna secretly even followed Galen's advice and masturbated their female patients in therapeutic sessions.2 On the other hand, at present this kind of therapy is prohibited in the AASECT Code of Ethics (1980, III, 7).

Thus, it is obvious that therapeutic techniques and therapeutic goals have changed rather drastically in the course of time. Yet, their underlying assumption has always remained the same: Both the en couragement and the suppression of masturbation merely served to restore the "natural" sexual response which, in turn, was essential to the patient's health.

The fact that this kind of reasoning can lead to such different and even contradictory therapies gives us a first hint at some serious flaw in its premise. This flaw is the questionable character of the concept of "naturalness" as employed here. What the various therapists called "natural" was actually a moral value in medical disguise. In reality, therefore, they did not follow "nature" but, rather their own moral convictions. It could not have been otherwise, because the belief in a "natural sexuality" is not, and cannot be, based on scientific insight. It is essentially and unavoidably ideological.

Of course, it is understandable that sex therapists shy away from explaining their moral positions and prefer to hide, for as long as possi ble, behind seemingly objective criteria, like sexual health and sexual sickness, because this seems to protect them from direct criticism . Thus, they are always tempted to speak in the name of science, seeking protection behind some alleged laws of nature. However, in sciences that deal with human behavior, this strategy can be only of limited use. It is no coincidence that these sciences were once called the "moral sciences" in contrast to the "natural sciences" which deal with matters unaffected by human decisions. In particular sexology or Sexualwissenschaft, as it was called by its founders, is nothing if not an interdisciplinary effort, and it has always combined both the natural and the moral sciences. Moreover, sex therapy, like medicine or any other helping intervention, is never reducible to science but derives its justification from the moral appli¬cation of scientific insight. Making moral decisions is, therefore, an essential part of any therapist's work. The best anyone can hope for is that these deci¬sions are well informed. All of this also applies to the treatment of sexual deviance, although, at first glance, it now appears to be more sophisticated than in the past. For example, in the most recent "progressive" therapeutic literature, the old-fashioned epithets "perversion," "aberration," and "deviation," whose moralistic, indeed religious, origin was fairly obvious, have been replaced with the seemingly more objective term "paraphilia." Yet, upon closer inspection, this term is no less ideological than the others. It still assumes the existence of a "naturally" given norm - a correct "philia" - which can have less admirable relatives undeserving of the same respect. The bias at work here is quite apparent in the most prominent current definition. The Diagnostic and Statistical Manual of the American Psychiatrie Association (DSM I II, 1980) defines paraphilias as involving sexual responses to "objects and situations that are not part of normative arousal-activity patterns and that may interfere with the capacity for reciprocal affectionate sexual activity."3 The "normative patterns" invoked in this passage are, of course, nothing but disguised value projections emanating from the authors who feel that sex, in order to be good, must be affectionate. However, "reciprocal affectio¬nate sexual activity" is not a natural given but, instead, a cultural ideal. Whatever is "normative" here merely reflects the wishes of some American psychiatrists. Indeed, all their new terminological stratagems notwithstanding, there are no sexual norms to be found in nature. This means, among other things, that the current terms "psychosexual disorder" and "paraphilia" will have to be abandoned, because there is no scientific way of determining "psychosexual order" or a correct "philia ." Where sexual behaviors are individualy or socially unacceptable, they will have to be defined and classified on entirely different, openly stated grounds.

What all of this means, in practice, is exemplified by a perennial con troversy whose ultimate resolution is still in doubt at this time. This is the question whether homosexuality is or is not a disease. The just quoted Diagnostic and Statistical Manual (DSM I II) no longer lists homosexuality anywhere, except indirectly when it describes a new disorder called "ego-dystonic homosexuality," i.e. homosexual tendencies that are clearly felt, but unwanted by an individual.4 On the other hand, there are still many psychiatrists who believe that homosexuality as such is a pathological condition of some sort and who refuse to accept its removal from the manuual. They denounce this decision as unscientific and blatantly political and would, therefore, like to see it reversed. Ronald Bayer has chronicled the whole issue in a recent, very enlightening book.5

Curiously enough, neither side in this controversy seems to have cared very much about the unscientific and blatantly political decision to include homosexuality in psychiatric manuals in the first place, and even Bayer 's study is not very informative on this point. Yet, as a critical historical examination shows, science and objectivity had never anything to do with it one way or the other. Indeed, the whole notion of homosexuality as a special condition which people either have or do not have, is a product of the 19th century. Surprising as this may seem to many people today, not only the word, which was coined in a legal (not medical) context by a "gay rights" crusader in 1869, but the very concept of homosexuality did not exist before the industrial revolution. The question is, therefore, not only whether we are dealing with a healthy or pathological condition, but whether we are dealing with any condition at all.6

This becomes very clear, for example, in non-Western medical writings that recommend homosexual behavior for therapeutic purposes. Thus, the voluminous sexological literature of medieval Islamic scholars never mentions anything like modern homosexuality. However, it does contain some related and, to modern readers, rather startling observations. For instance, in the 12th century, Abu Nasr al Isra 'ili (a Jewish scholar, born in Baghdad, who had converted to Islam) reports in a great sexological study that many physicians recommend homosexual intercourse to their male patients for the purpose of preserving their health and youthful appearance.7 The reasons are listed in great detail, and, if the basic assumption is accepted, are perfectly logical from a medical point of view. This assumption, needless to say, is that sexual activity must always be "natural" in order to be healthy.

Since the text is not very well known and is, in fact, unavailable in English, I will offer a brief summary:

Nature demands that men should have intercourse only when their bodies are truly ready for it, as evidenced by a very hard erection. It follows logically that anal intercourse with boys is always healthy, because it is physically impossible if this condition has not been met. In contrast, vaginal intercourse, which, at the insistence of warnen, is often performed in a semi-erect state, is just as often unhealthy, because it demands from the male body what it is obviously not ready to give. Therefore, those men who, at least af ter a certain age, restrict their sexual activity to the anal penetration of boys live a longer, healthier, and more natural life than those who continue to have intercourse with women.8

This passage proves once again, if any further proof was needed, that the invocation of "nature" can justify or denigrate any conceivable form of sexual activity. However, more interesting in the present context is another implication: Quite clearly, homosexual behavior, indeed a very specific kind of homosex ual behavior, appears here as a simple medical option open to any reasonable man. There is no mention of any "sexual orientation" or "conversion" or "reversion" from one orientation to another. Instead, it is merely a matter of being practical. Once heterosexual intercourse has become pathogenic and therefore ego-dystonic, i.e. when a man begins to worry about his failing health and ebbing strength as a result of coitus, he simply takes the advice of his therapist and switches to homosexual intercourse.

The very fact that such advice could be given and approvingly cited in a learned text demonstrates that the Middle-Eastern patients of that historical period had not yet internalized the modern strict dichotomy of hetero- and homosexuality but had retained some measure of erotic responsiveness to both sexes. Thus, no radical "reorientation" was required.

This throws a very interesting light on some current American therapeutic programs. To be sure, we have not yet reverted to treating ego­ dystonic hetero-sexuality, but some therapists, newly encouraged by the Diagnostic and Statistical Manual, still try to turn "homosexual" clients into "heterosexuals" upon request. Moreover, because the therapist uncritically accepts the will of the client and professes a stance of complete neutrality, the reasons for such a request very often remain unexplored and are even considered irrelevant . However, in view of the continued wide-spread psychiatric bias, this neutrality seems insincere to many observers. Indeed, to those who have followed the whole issue as historians, a complete reversal to the previous par­ tisanship is entirely conceivable.

Needless to say, if such a reversal should occur, therapists will, as they of ten have, act on the assumption that the interests of society and those of their clients are identical. They will see themselves, as many do now, as honest double agents who help to restore the lost harmony between individual and social happiness. In short, sex therapy will persist in trying to play the role of a servant of two masters and hope to do justice to both.

However, as with the belief in a "natural sexuality," this second great silent assumption also cannot stand up to rational scrutiny. It is simply another self-serving delusion. First, the two beliefs are mutually exclusive. Critical therapists have always known this and drawn the intellectual consequences. After all, if society really had an interest in individual sexual fulfillment, the dysfunctions and disorders would not, and indeed could not, arise, and sex therapy would be superfluous. The fact that it is necessary, therefore, puts the therapist in conflict with certain prevailing sexual values. By the same token, those who merely help an individual conform to society are not engaged in true therapy but in adjustment training. However, it is this function of sex therapists as unwitting agents of social control which disturbs some libertarians. On the other hand, the recent attacks from the authoritarian side on sex education and sex therapy show that their fears are exaggerated. In fact, when a libertarian like Thomas S. Szasz lashes out against therapists like Masters and Johnson, he is picking the wrong target. In spite of their medical rhetoric, if Masters and Johnson have done anything, they have taken sex therapy out of the traditio¬nally prejudiced psychiatric context and opened it up as never before to scrutiny and dispute. To denounce their cautious, limited and commonsensical assistance to fully autonomous clients as a medical power-grab is, I dare say, rather misguided.

Still, although Szasz misses the mark in this case, his basic concern deserves to be taken seriously. In the past, sexual therapies of variou s kinds have been used to enforce allegedly "natural" norms on reluctant and even unwilling "patients ," and it is useful for us to be aware of this embarrassing aspect of our past . Indeed, this past is not yet entirely dead, as we can learn from certain misleading terms, unquestioned assumptions, mindless traditions, and other ideological rem­ nants that continue to plague our field.

On the other hand, when we look at the actual p:ractice of sex therapy today, we have no reason to be embarrassed at all. It is precisely the new, behavioral approach of Masters and Johnson that has pointed sex therapy in a more rationally defensible direction. Most sex therapists at this conference know this and are very grateful for it. They do not see sexuality as the beginning and end of human happiness. Neither do they make universal claims for the ultimate effect of their work. Still, in a practical sense, sex therapy is now enriching many lives on a sensual and emotional level. Moreover, it does so with­ out dogmatism and arrogance. All that is needed now is a theoretical framework that reflects these recent positive develop¬ments. As its theory catches up with its practice, and as it becomes aware of its untenable silent assumptions, a newly articulate sex therapy will deserve the support not only of Thomas S. Szasz, but of every rational person.


1 Szasz, T. S., Sex by prescription, Garden City, New York: Anchor Press/Doubleday, 1980, p. 61.

2 Reich, W., Reich speak s of Freud, New York: Farrar, Straus and Giroux, 1967, p. 103.

3 Diagnostic and statistical manual (DSM III), p. 261.

4 ibid. p. 281.

5 Bayer, R., Homosexuality and American psychiatry, New York : Basic Books, 1981.

6 The word "Homosexualität" (homosexuality) was coined in 1869 by the Austrian writer K. M. Kertbeny (Benkert) in an anonymous pamphlet attacking the Prussian sodomy law: Paragraph 143 des Preussischen Strafgesetzbuches vom 14. April 1851 und seine Aufrechterhaltung als Paragraph 153 im Entwurfe eines Strafgesetzbuches für den Norddeutschen Bund, reprinted in Jahrbuch fur sexuelle Zwischenstufen, Magnus Hirschfeld (Ed.), vol. VII, 1, 1905 pp. 10-66. For the lJack of a concept of homosexuality in ancient Greece and Rome see Dover, K. J ., Greek Homosexuality, Cambridge, Mass: Harvard University Press, 1978 and Boswell, John, Christianity, Social Tolerance and Homosexuality, Chicago and London: University of Chicago Press, 1980.

7 al-Isra'ili, Abu Nasr, Ki tab nuzhat al-ashab fi mu asarat al-ahbab fi ilm al-bah (Das Buch der Unterhaltung der Freunde über den vertrauten Umgang der Liebenden mit der Wissenschaft der Sexualität) Part 1, 6-8, Arabic text and German translation edited by Taher Haddad, Diss. Erlangen-Nürnberg, 1976.

8 ibid . 1.