by Dr. Jem Tosh
(Content warning: Discussion of s*xual abuse in therapeutic and medical contexts, non-consensual surgeries, conversion therapies)
In my latest book I theorise that therapeutic and treatment contexts in psychology, psychiatry, and medicine have a deeply problematic foundation in relation to how the body is conceptualised, how consent is considered, and the role of sexual abuse in (and as) therapy. I draw on examples from conversion therapy and sex therapy, treatments for sexual 'dysfunction', methods for evaluating sexuality and more. I analyse telling cases from over a century ago to the present day. I describe sexually abusive therapeutic contexts for transgender and cisgender women and men, nonbinary people, and intersex folks.
Through a critical and intersectional discursive analysis, I show how marginalised groups are pathologised in a way that is used to normalise and justify troubling treatments - treatments that potentially cross the line from therapy to violence.
"Rather than using 'therapeutic culture' to refer to the 'therapisation', 'emotionalism', or the pervasiveness of psy discourse in everyday life... I add 'therapeutic' to the concept of rape culture, which argues that rape is a result of complex and interrelated social and cultural factors. This moves the concept of rape away from the individualistic theories of psychology and psychiatry that construct the problem as an internal and uncontrollable 'lust'. 'Therapeutic culture' in this context, then, refers to the complex and interrelated social and cultural 'norms' that produce a particular version of therapy and therapeutic practice within a broader psy complex... " - J. Tosh, 2020, p. 102
Below is a short slideshow outlining the 14 conditions of a therapeutic rape culture, with examples for each. I consider these conditions central to the creation of a context where the abuse of marginalised groups can thrive. Preventing violence and abuse in therapeutic contexts, then, requires addressing and dismantling these conditions.
Each chapter of the book (other than the introduction and conclusions chapters) focuses on a particular telling case. The book links those cases through a genealogical discursive analysis that illustrates the interconnectedness of research, theories, and practice regarding gender and sexuality in psychology, psychiatry, and medicine. This tracing of harmful narratives regarding consent, the body, therapy, and sexual violence concludes with the theorisation of a therapeutic rape culture in the final chapter.
1 - Introduction
In this chapter I introduce the theoretical underpinnings of the book and define key concepts, such as intersectionality theory, critical discursive psychology, and the medical gaze. Through a range of examples of medical coercion and violence, I conduct an analysis of the concept of ‘the body’ in medical discourse with a focus on the intersections of race, class, gender, sexuality, and disability. The chapter concludes with an overview of the book, as well as a reflection on my own positioning in relation to the topic under analysis.
...where does the 'self' end and the Other begin? Who decides what bacteria is 'good' and 'normal' and part of the constructed bodily boundary of the biological self, and what is constructed as 'bad' and 'pathological' like an invading and colonising Other?
2 - Intersex youth: Non-consensual surgeries and nosocomial sexual abuse
This chapter describes and critiques the concept of ‘nosocomial sexual abuse’ that was coined by John Money in his work with intersex youth. Defined as sexual abuse that occurs within medical settings, the concept was often used in discussions of ‘false’ accusations against professionals. I examine the experiences of intersex people in medical and psychological therapies designed to encourage gender conformity and ‘normalisation’. I challenge the dismissal of disclosures of abuse in this context as ‘false’ and interrogate the boundary between ‘therapy’ and violence. I argue that in defining an intervention as harmful or helpful, centering the perspectives of those experiencing the treatment and a more complex and relational concept of consent is imperative.
3 - Queer and trans youth: ‘Sexual rehearsal play’ and reparative therapies Continuing my analysis of therapies that promote gender conformity and the work of John Money, I analyse Money’s conceptualisation of gender development in childhood particularly in relation to sexuality. I critique and problematise his theory of ‘sexual rehearsal play’, that frames sexual orientation as malleable in childhood, and his attempts to manipulate children’s sexuality for a heterosexual outcome. I examine this (hetero)sexualisation of childhood through the lens of consent and sexual abuse, troubling Money’s controversial normalisation of adult-child sexual relationships and his contested concept of ‘heterophobia’. I conclude that sanitising sexual manipulation via therapy destigmatises and trivialises the actions of abusers and the discourse of ‘sexual rehearsal play’ silences survivors of childhood sexual abuse.
Queer and trans children who are survivors of sexual abuse must navigate this concept of 'childhood' where they are Othered for their experiences of abuse as well as their gender and sexuality.
4 - ‘Sex’ as treatment: Consent, coercion, and sex therapy
This chapter continues to trace the influence of Money’s work, by proceeding with Masters and Johnson’s uptake of his conceptualisation of sexuality as malleable and their therapeutic approach to ‘sexual dysfunction’. I analyse Masters and Johnson’s sex therapy as outlined in their classic text Human Sexual Inadequacy (1970), focusing on constructions of consent and coercion. I examine how this foundational approach to sex therapy shaped broader therapeutic understandings and approaches to sexual difficulties, which created a therapeutic culture where sexual abuse by therapists proliferated.
...what would consent look like in the sex therapy context, where academics removed stimulatory techniques from sex worker communities and implanted them into a pathologizing and oppressive medical system?
5 - Penetration as ‘treatment’: Pathologizing sexual avoidance and pain
I further my analysis of the concept of ‘sexual dysfunction’ and the boundary between therapy and violence through an examination of the DSM-5 (APA, 2013) diagnosis of ‘penetration disorder’. I critique its pathologization of non-penetrative sexual activity, sexual avoidance, and vaginal penetrative pain in the context of a longstanding construction of (particularly women’s) sexual ‘frigidity’ as problematic for therapists and heterosexual men alike. I analyse therapies that focus on penetration as ‘treatment’ and their implications for consent and coercion within therapeutic contexts. In addition, then, to analyses of sexual abuse within therapy, I argue that we must also consider how therapy itself can promote and produce further sexual coercion.
6 - Phallometrics: Quantifying sexual violence and sexuality
Continuing on from the analysis in the previous chapter of the problematic construction of vaginal penetration as central to sexual ‘normality’ and ‘health’, this chapter examines how the focus on penetration, and particularly the penis, is central to rape discourses within psychology and psychiatry. I analyse the use of phallometrics in research, forensic, and therapeutic settings; that is, the measurement of changes in the penis to assess for sexual arousal. I trace its history from harmful behaviourist reparative therapies with gay men and gender nonconforming people, to its current use to assess for coercive and marginalised sexualities in sexual research and forensic contexts. I analyse phallometric discourse in relation to the construction of sexuality and rape, as well as how the procedure of measuring penile responses is troubling when issues of consent and sexual abuse are considered. I conclude that framing sexuality and rape as solely embodied in the human penis, not only reifies problematic gender binaries of embodiment, but also silences cisgender men survivors of sexual violence.
7 - Conclusions: A therapeutic rape culture
Drawing on my analyses throughout the book, in this chapter I outline the process of pathologization, victimisation, and normalisation evident in psychology, psychiatry, and medicine. I describe how the psy-complex first frames particular groups of people as ‘abnormal’ to justify harmful intervention; interventions that are then normalised and sanitised as ‘treatment’. This process occurs within a broader therapeutic rape culture that draws on and contributes to multiple intersecting axes of oppression. Finally, I discuss the need for a culture of consent in therapy to counter the normalisation of abuse in psychology, psychiatry, and medicine, and the importance of believing survivors.
To cite: Tosh, J. (2020). The body and consent in psychology, psychiatry, and medicine: A therapeutic rape culture. London: Routledge.
About the Author: Dr. Jem Tosh is a Chartered Member of the British Psychological Society and a Full Member of the Canadian Psychological Association. They are the Director of Psygentra, an organisation that specialises in the psychology of gender and trauma. Jem is also the author of Perverse Psychology (2014) and Psychology and Gender Dysphoria: Feminist and Transgender Perspectives (2016).