Medicalization of Sexuality and Trans Situations: Evolutions and Transformations

Round 1

Reviewer 1 Report

This paper provides an interesting analysis of the concept of medicalisation of sexuality in the field of  ‘sexual dysfunction’, HIV treatment, demedicalisation of homosexuality and provision of gender-affirming care for trans and gender diverse people. It will make a valuable addition to the literature, but I have a number of recommendations for revision.

1.       The introduction needs some tightening. The authors don’t provide a definition of medicalisation, but there is an opportunity to do so at lines 61-71 – to provide the ‘common sense’ one, which they suggest is adopted by medical professionals. Then it is important to say why no definition is provided by what is meant by the term in this article (e.g. that  the various ways in which is it deployed in a range of discourses will be discussed in the paper).

2.       Why use the term ‘sexual disorders’ that seems to be buying into a pathologized model early on – why not ‘sexual function’? e.g. line 36.

3.       Line 40-42 The assertion that it is the controversial nature of sexual medicalisation that makes it interesting seems to me deficient – I’d argue that it is because these discourses are concerned with matters of high importance for people’s lives and for the social and moral fabric of society – that, to me, is both why the issues are interesting AND polarising.

4.       Line 192. While there may not be a great deal of discussion about HIV treatment as being a medicalisation of sexuality, there was a great deal of discussion about the medicalisation of AIDS, and the medicalisation of people with HIV in the late 1990s when the new paradigm of combination ART came into clinical practice.

5.       Line 261 The assertion that pharmaceutical companies were ‘confronted’ with regulatory bodies of drug distribution is not credible – this is the model in which such companies work, and there are many examples of them having to reframe conditions within a disease model to sell products earlier – such as Valium, for example.

6.       Line 266 – what does ‘sexuality staged int eh rhetoric of AIDS’ mean?

7.       Line 281 – would be good to cite an example here, such a Hammoud et al’s  2018 paper, The new MTV generation: Using methamphetamine, Truvada™, and Viagra™ to enhance sex and stay safe

8.       Line 283 – need to state in which culture/time period homosexuality ‘began as unnatural’. Also need to state that homosexuality was listed as a mental illness – this is implied in the text but not stated and might confuse some readers.

9.       In the section of HIV, it is worth noting the phenomenon of the moralisation of risk – see for example Haire et al 2021 https://doi.org/10.1371/journal.pone.0255731

10.   Lines 228-332 I disagree that there is little attention paid to the complexities of heterosexual sex in the ‘fight against AIDS’ The whole microbicides movement aimed to address the social and political context of women’s risk in heterosexual relationships. See for example MEGAN GOTTEMOELLER, 2000

11.   Line 338 Pre-exposure prophylaxis (PrEP has been licensed in the US for 10 years now – it is not in the future.

12.   Line 356 surveillance, self-examination and early response are bio-behavioural interventions.

13.   Line 363 Typo – should be ‘behaviours’

14.   Line 365 There is a really important issue here – preexposure prophylaxis and treatment as prevention are two different strategies for HIV prevention, and the authors are conflating and confusing them.  PrEP involves the use of ARV in people without HIV to prevent infection. TasP involves the ARV in people with HIV to control HIV replication and render the person with HIV non-infectious. In PrEP, the person without HIV has the agency to control the prevention (indeed, in the case of receptive sex partners, far greater control than they would have over condom use). With TasP, the efficacy is dependent upon the adherence of the person with HIV. This section needs to be revised to ensure that this is clear.

15.   Line 371 -the advent of biomedical prevention has need stopped HIV health promotion and education, if has shifted its focus.

16.   Line 372 – Note the PrEP is significantly more effective than condom use in preventing HIV, so the claim that these interventions don’t generate certainty needs to be reconsidered.

17.   Use ‘transgenderism’ rather than ‘transexualism’

18.   In the discussion about ‘gender dysphoria’ it would be good to also mention that for TGD people seeking treatment, some recognise a requirement to ‘perform gender dysphoria’  to clinicians to receive hormone treatment.

19.   Line 475 – don’t use etc.

Author Response

I wish to thanks Reviewer 1 for the time taken for reading my manuscript and interesting and useful comments and suggestions. My replies to the queries are following in  the text

This paper provides an interesting analysis of the concept of medicalisation of sexuality in the field of  ‘sexual dysfunction’, HIV treatment, demedicalisation of homosexuality and provision of gender-affirming care for trans and gender diverse people. It will make a valuable addition to the literature, but I have a number of recommendations for revision.

1. The introduction needs some tightening. The authors don’t provide a definition of medicalisation, but there is an opportunity to do so at lines 61-71 – to provide the ‘common sense’ one, which they suggest is adopted by medical professionals. Then it is important to say why no definition is provided by what is meant by the term in this article (e.g. that the various ways in which is it deployed in a range of discourses will be discussed in the paper).

The definition and discussion of medicalization is presented from page 3 to 6 in a quite extensive and comprehensive manner

2. Why use the term ‘sexual disorders’ that seems to be buying into a pathologized model early on – why not ‘sexual function’? e.g. line 36. The terme “sexual disorder” is used in sexual medicine : I am not buying this expression but only use it as it used in the field. For more clarity, I will include it into ‘sexual disorders’ in the text.
3. Line 40-42 The assertion that it is the controversial nature of sexual medicalisation that makes it interesting seems to me deficient – I’d argue that it is because these discourses are concerned with matters of high importance for people’s lives and for the social and moral fabric of society – that, to me, is both why the issues are interesting AND polarising.

I agree with this remark but I wish to focus on the controversial nature of the idea / concept itself, beyond the controversial nature of the situations which are the objects of “medicalization”. Of course one reinforces the other.

4. Line 192. While there may not be a great deal of discussion about HIV treatment as being a medicalisation of sexuality, there was a great deal of discussion about the medicalisation of AIDS, and the medicalisation of people with HIV in the late 1990s when the new paradigm of combination ART came into clinical practice. OK but my topics here is the transformation of medicalization considering that psycho-social / behavioral prevention of HIV is also a form of normative medicalization of sexuality.
5. Line 261 The assertion that pharmaceutical companies were ‘confronted’ with regulatory bodies of drug distribution is not credible – this is the model in which such companies work, and there are many examples of them having to reframe conditions within a disease model to sell products earlier – such as Valium, for example. I removed “confronted” into 'facing’. Of course Viagra / Erectile dysfunction is not the first model of such a process.  
6. Line 266 – what does ‘sexuality staged in the rhetoric of AIDS’ mean?

The paragraph was rewritten as : Viagra represents a sexual world much different from the world that was constructed in the rhetoric of AIDS (Gagnon, 1988), in which it is a matter of "restoring a natural and normal sexuality" [25] instead of trying to reduce anal sexual practices, promiscuity and multiple partnership . From this perspective, the Viagra discourse is aimed at a different segment of population: men over forty, the stable heterosexual couple and penile – vaginal  penetration, and aims at the "restoration" of this practice within the context of the married different gender couple.

7. Line 281 – would be good to cite an example here, such a Hammoud et al’s 2018 paper, The new MTV generation: Using methamphetamine, Truvada™, and Viagra™ to enhance sex and stay safe
8. Line 283 – need to state in which culture/time period homosexuality ‘began as unnatural’. Also need to state that homosexuality was listed as a mental illness – this is implied in the text but not stated and might confuse some readers. Thank you : done
9. In the section of HIV, it is worth noting the phenomenon of the moralisation of risk – see for example Haire et al 2021 https://doi.org/10.1371/journal.pone.0255731
10. Lines 228-332 I disagree that there is little attention paid to the complexities of heterosexual sex in the ‘fight against AIDS’ The whole microbicides movement aimed to address the social and political context of women’s risk in heterosexual relationships. See for example MEGAN GOTTEMOELLER, 2000. I have included the contrast between the Global North and Global South and gave an example about Brasil.
11. Line 338 Pre-exposure prophylaxis (PrEP has been licensed in the US for 10 years now – it is not in the future. OK changed
12. Line 356 surveillance, self-examination and early response are bio-behavioural interventions.
13. Line 363 Typo – should be ‘behaviours’
14. Line 365 There is a really important issue here – preexposure prophylaxis and treatment as prevention are two different strategies for HIV prevention, and the authors are conflating and confusing them. PrEP involves the use of ARV in people without HIV to prevent infection. TasP involves the ARV in people with HIV to control HIV replication and render the person with HIV non-infectious. In PrEP, the person without HIV has the agency to control the prevention (indeed, in the case of receptive sex partners, far greater control than they would have over condom use). With TasP, the efficacy is dependent upon the adherence of the person with HIV. This section needs to be revised to ensure that this is clear. OK made some changes.
15. Line 371 -the advent of biomedical prevention has need stopped HIV health promotion and education, if has shifted its focus. I wrote reduced health promotion and behavioral change
16. Line 372 – Note the PrEP is significantly more effective than condom use in preventing HIV, so the claim that these interventions don’t generate certainty needs to be reconsidered. I have removed this sentence
17. Use ‘transgenderism’ rather than ‘transexualism’
18. In the discussion about ‘gender dysphoria’ it would be good to also mention that for TGD people seeking treatment, some recognise a requirement to ‘perform gender dysphoria’ to clinicians to receive hormone treatment.
19. Line 475 – don’t use etc.

Reviewer 2 Report

`Although an interesting onject of inquiry, this paper is limited by lack of clarity and lack of engagement with recent innovations in terms of both gender identity and HIV care.  

I have specific concerns:

1. The discussion is not situated in macro-level forces for instance neoliberalism, which is an important determinant of medicalisation

2. The argument is at times dated - PrEP is now wisely available and has revolutionised HIV prevention,  Treatment as prevention dioes nto relate to PrEP but to people with HIV taking ART and not being able to pass it on (knwon as U=U, of which there is no mention), combination HIV prevention is the cornerstone of HIV prevention - it takes into account pharmaceutical and behavioural approaches, there is no mention of sexual wellbeing and pleasure and how PrEP may support this, and it is almost 100% effective. I do not think HIV prevention has focused on prevention anal sex for many years.

2. This is a very eurocentric paper - this is not a problem but should be acknowledged. For instance work on HIV prevention in sub Saharan Africa has engaged with the epidemic in heterosexual couples.

3. I am greatly concerned about the inclusion of gender identity in this paoer - I do not believe it falls under sexuality and to conflate gender identity with sexuality is mistaken.

4. Material and methods are unclear

5. There are some instances of potentially stigmatising language e.g. AIDS (rather than HIV or HIV/AIDS, disorder, infected, transexualism, deviant, banal sexuality, compliance (we use the term adherence) and deficient.

These points will need to be addressed prior to submission elsewhere - the paper has merit and would benefit from taking these points on. 

Author Response

Thanks for your careful review. I have included some of your comments but discussed some other ones.

Although an interesting object of inquiry, this paper is limited by lack of clarity and lack of engagement with recent innovations in terms of both gender identity and HIV care.  

I have specific concerns:

1. The discussion is not situated in macro-level forces for instance neoliberalism, which is an important determinant of medicalization. This is not the topic of the paper
2. The argument is at times dated - PrEP is now wisely available and has revolutionised HIV prevention,  Treatment as prevention dioes nto relate to PrEP but to people with HIV taking ART and not being able to pass it on (knwon as U=U, of which there is no mention), combination HIV prevention is the cornerstone of HIV prevention - it takes into account pharmaceutical and behavioural approaches, there is no mention of sexual wellbeing and pleasure and how PrEP may support this, and it is almost 100% effective. I do not think HIV prevention has focused on prevention anal sex for many years. This has been changed in the text
3. This is a very eurocentric paper - this is not a problem but should be acknowledged. For instance work on HIV prevention in sub Saharan Africa has engaged with the epidemic in heterosexual couples. OK I have specified that it is mostly about Global North and included some examples about Brasil.
4. I am greatly concerned about the inclusion of gender identity in this paper - I do not believe it falls under sexuality and to conflate gender identity with sexuality is mistaken. I have included Sexuality and gender but the reviewer should be aware that the WHO itself created a new category of “Conditions related to sexual health” for the inclusion of Gender Incongruence. This has to do with the sexualization of gender situations and enter inside the discussion about the medicalization of sexuality.
5. Material and methods are unclear
6. There are some instances of potentially stigmatising language e.g. AIDS (rather than HIV or HIV/AIDS, disorder, infected, transexualism, deviant, banal sexuality, compliance (we use the term adherence) and deficient. These have been changed when necessary.

These points will need to be addressed prior to submission elsewhere - the paper has merit and would benefit from taking these points on. 

The argument in this paper is strong, but it is out of date, especially with regard to trans/gender identity. The references to ICD-10 are appropriate, but ICD-11 is already published and the section on "Sexual Health" must be incorporated. Changed. But the discussion is about the process of revision of the ICD 10 into ICD 11.

The final sentence of the paper alludes to "health" becoming the foundation of moral values - but there is no reference cited. In fact, Steven Epstein's 2022 book, "The Quest for Sexual Health" is now a foundational text for the arguments made in this paper. Epstein also has relevant articles published. As a sociologist, he needs to be in this paper. OK

Reviewer 3 Report

The argument in this paper is strong, but it is out of date, especially with regard to trans/gender identity. The references to ICD-10 are appropriate, but ICD-11 is already published and the section on "Sexual Health" must be incorporated. The final sentence of the paper alludes to "health" becoming the foundation of moral values - but there is no reference cited. In fact, Steven Epstein's 2022 book, "The Quest for Sexual Health" is now a foundational text for the arguments made in this paper. Epstein also has relevant articles published. As a sociologist, he needs to be in this paper. 
Also, I thought reference to Covid-19 and vaccines belonged in the section around line 365.

I think the terminology "gender affirmation" is misused in line 9, line 37 and section 8. "Gender affirmation" refers to a specific approach to gender identity theory and treatment. The phrase "the treatment of gender affirmation pathways" is without meaning (line 9). 

The claim that "Viagra was constructed as a symbol of a new sexual revolution which countered the pessimism developed all along the AIDS years" (line 266) is a novel argument which needs to be explained not just asserted.

"Denaturation" in Line 211 is misused.

There is way too much jargon in this paper and too much use of passive voice and too much technical terminology. I had to read many sentences over and over to figure them out. This would be a better paper if it were more carefully edited. 

Author Response

Thanks for your important comments.

Also, I thought reference to Covid-19 and vaccines belonged in the section around line 365.

I think the terminology "gender affirmation" is misused in line 9, line 37 and section 8. "Gender affirmation" refers to a specific approach to gender identity theory and treatment. The phrase "the treatment of gender affirmation pathways" is without meaning (line 9). 

The claim that "Viagra was constructed as a symbol of a new sexual revolution which countered the pessimism developed all along the AIDS years" (line 266) is a novel argument which needs to be explained not just asserted. Included some references from Tiefer and Viagra culture

"Denaturation" in Line 211 is misused. no

There is way too much jargon in this paper and too much use of passive voice and too much technical terminology. I had to read many sentences over and over to figure them out. This would be a better paper if it were more carefully edited. OK