Discussions about sexuality permeate all fields of medicine and yet are still taboo.1 If medical professionals were to promote a liberated dialogue about sex, we could encourage a societal shift towards acceptance. This could benefit not only individual patients, but also public health outcomes.2 Hafferty and Franks found that prevailing ethics and the study of the development, structure, and functioning of human society, that is, sociology, are often embedded in medical education,3 but this alone does not guarantee patient-centred care. Reflecting on past popular culture might better cultivate best practice as it allows us to consider historical narratives around medicine, and how these influence our patients’ perceptions of the field. William Hogarth’s series Marriage A-la-Mode (c. 1743) offers a deeply satirical commentary on the sexual hedonism of a young couple married not for love, but for social and financial gain. Such artefacts can aid our understanding of the evolution of social norms.
WOMEN’S SEXUALITY
In The Tête à Tête (image, above right), we encounter a Viscount and Viscountess having both returned from wayward evenings with other sexual partners. The woman’s mischievous expression and languorous posture suggest that she has been disturbed by her husband’s arrival.4 The virginal colours of her dress contrast with her highly sexual (and modern) manner: she is a woman carving out a satisfying sexual identity for herself within the patriarchy. Conversely, the pink of her dress could imply that her carnal desires are an inherently masculine trait (‘diminutive of the warlike red’).5 The patriarchy stipulates that to engage in recreational sex one must be male, echoed today by the concept of ‘slut shaming’6 and particularly amplified by social media.
The Viscountess highlights the diversity of female sexuality, something a contemporary doctor must acknowledge when offering guidance in women’s health. Imagery such as the broken nose on the bust (used to signify adultery) highlights the open-mindedness required of a clinician working in a time when more progressive sexual practices are a cultural norm. The semen staining the Viscountess’s dress symbolises ignorance towards contraception; the professional duty of a clinician dictates that this should never be met with indignation. Compassion is paramount in a contemporary setting where clinicians are licensed to administer drugs such as Levonelle® and EllaOne®. Doctors ought to commend patients for making the complex, often troubling, decisions to use such medications. Cooperative discussion between a doctor and their patient is essential to prevent contraceptive medications acting as a substitute for safe, protected sex. Tolerance here is critical, and support must be offered for the benefit of the patient’s health and wellbeing without the influence of one’s personal ideologies.
HYSTERIA AND THE CONTINUING SEXUAL DOUBLE STANDARD
Female sexuality became itself a diagnosis of sorts through the prevalence of hysteria in the 19th century. This dichotomous ‘demonological-scientific’7 term allowed for the institutionalisation of women whose desires did not conform to Victorian ideals. The phrase waned through the 20th century as its medical validity was questioned, but the principle that female libido should be deprecated and controlled has lingered on. In The Bagnio (image, left), the Viscount has fought a duel with the Viscountess’s lover on learning of her promiscuity. She is hypocritically berated for the morbid fate of their marriage, as the Viscount has behaved just as promiscuously. Once again there is a ‘sexual double standard’8 whereby there are different moral criteria for men and women. This is something we must be continually aware of as we shift towards a more gender-fluid society: doctors must ensure that, regardless of the sexual practice of the patient, the same duty of care is upheld. Doctors must help to empower patients to engage safely with sex, particularly in the case of sexually transmitted diseases such as HIV, which can be well managed with clear, unbiased advice.
IMPOTENCE AND MALE SEXUAL HEALTH
Hogarth uses derogatory imagery such as the broken sword to indicate that the Viscount has experienced impotence. This emasculating stigma around male sexual health still pervades: statistics suggest that erectile dysfunction is massively under-reported in the UK, with only 33% of men experiencing it actively seeking medical assistance.9 Research shows that people and their partners report an absence of conversational cues from doctors that lead to the discussion of erectile dysfunction,10 demonstrating how male sexual health is not embedded in our social discourse. This highlights the significance of open discussion in allowing patients to feel comfortable sharing their problems, leading to a greater incidence of reporting and better health outcomes.
Through The Inspection (image, below), we appreciate the role of the clinical environment in facilitating this discussion. The darkness and sexually implicit imagery stigmatises the Viscount for his syphilis; the stark, clinical glare of contemporary hospitals can make consultations, particularly around intimate subjects, feel interrogatory. It is not just the clinicians but also the spaces in which they work that promote freedom of discussion, or otherwise. Public perception of a health condition undeniably influences how it is approached by the individual, and, if sexual dysfunction is publicly shamed and shaming, as insinuated here, it is understandable that modern men may be reluctant to report their symptoms.
The parallel between sexuality in Hogarth’s Marriage A-la-Mode and our modern ideals is clear, as in both eras there is still much work to be done for freedom of expression to be truly achieved. Medicine should not lag behind the development of cultural norms, but, rather, should be at the forefront of pioneering positive change in society.
- © British Journal of General Practice 2019