Is The Functional Normal ?

Aging, sexuality and the bio-marking of successful living

This article was first published in "History of the Human Sciences" Vol. 17 (1) , 2004

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his article raises the question of ‘normality’ today and the fracturing of health ideals along new lines of enablement and function. In particular the study asks if ‘functional’ and ‘dysfunctional’ are displacing ‘normal’ and ‘pathological’ as master biopolitical binarisms, and if so, what distinctions can be drawn between them. The discourse of ‘function’ and ‘dysfunction’ is certainly ubiquitous in two areas of research and practice: gerontology and sexology. In the former case ‘functional health’ is linked to successful aging represented by technical tests around activities of daily living (ADLs) and risk-assessment profiles. In the latter case, sexual function and dysfunction have become all-encompassing markers of heterosexual competence, now largely detached from reproductive imperatives, but refashioned as integral to responsible and successful self-management. Presenting examples from both cases, the article concludes that functionality, circulating under the signs of ‘normal’, ‘natural’ and ‘healthy’, furnishes economic, technological, educational, professional, pharmacological and policy fields with a rich intellectual, practical and regulatory resource.

The Functional, The Dysfunctional And The Rationalities Of Biosociality

The late George Canguilhem’s influential critique of 19th-century biomedicine demonstrated that the master binary between the ‘normal’ and the ‘pathological’ was far more than a set of clinical standards. Laden with moral, cultural and technical values, the normal and the pathological re-created scientific perceptions of health and disease that ushered in a new era of therapeutic normalization (Canguilhem, 1978, 1988). Such standards not only bolstered the professional authority of empirical and statistical knowledges and the government of the social sphere, but also problematized bodily and populational life itself into a series of highly publicized risks and crises.

Canguilhem’s ingenious history of the normal and the pathological as the binary structure of the modern life sciences inspires us to think in a related way about function and dysfunction. However, today we have the formation of a new relationship between the natural and the cultural that redefines their zones of penetration and territories of meaning. Due in large part to the expanding political realm of genetic, reproductive, neurochemical, dietary, vascular and cognitive crises, and the technological responses to them fostered by pharmacological, marketing and life-style interventions, this new relationship centers on biological life itself by altering its terms of reference. Traditionally, the family of concepts clustered around the natural – life, health, fitness, normativity, the body, aging, etc. – shored up its ontological certainties by signifying nature as that which could not be changed, manufactured or reversed. Nature was ‘the real’ onto which the human veneer of culture, positioned as the opposing and often oppressing outside, was built. Despite centuries of competing philosophical, theological, anthropological and economic dogma about the nature/culture relationship, the idea that nature is beyond the limits of human modification remained constant. Until today. Today, the natural, to the extent that it still functions as a sign of ontological existence, is increasingly culturalized and open to culture’s experimental forces. Critical writers have referred to aspects of this nature/culture reversal as ‘biosociality’ (Rabinow, 1996), ‘vital politics’ (Rose, 2001), a ‘fourth nature’ (Featherstone and Hepworth, 1998), ‘posthuman’ culture (Hayles, 1999) and ‘cybernatural life’ (Waldby, 2000; see also Franklin and Lock, 2003). This new language signals a scholarly attempt to come to terms with the fluidity of conventional boundaries between the real and the artificial, the human and the instrumental, and the technoscientific forms of life which appear neither natural nor cultural, yet both at the same time.

Rabinow, for example, argues that in the future, ‘nature will become known and remade through technique and will finally become artificial, just as culture becomes natural’ (1996: 99). The expansion of pharmacological culture exemplifies this biosociality – as Mariam Fraser asks of Prozac, do such medications return the brain to ‘normal’, or do they create another state of mutable ‘normal’ where the biological and the natural do not necessarily represent each other (2001: 68)? Or are we experiencing the confluence of a number of ‘natures’? Featherstone and Hepworth suggest that ‘it makes sense to conceive not of one single nature, but of a series of natures’ (1998: 165). They contend that overlapping the biosphere, the built environment and the cybersphere is a ‘fourth nature’ – ‘the sphere of artificial life, a post-anthropogenetic domain; a domain in which the genetic structures of life-forms are reduced to an information code which can be replicated, manipulated and engineered to reproduce and make new life’ (ibid.). Fourth-nature beings have their own forms, movements, shapes and identities, forged at the edges of culture and nature where acts and actors of consumption and production are often indistinguishable. Further, as we discuss below, the rise of new biosocial rationalities is not simply based on technoscientific advancements; but they have been elevated to blueprints of life and life-course because of their commercial and political resonance with what Rose refers to as ‘the new “will to health”’ (2001: 6).

What then becomes of the normal and the pathological, its medicalization of the social sphere and its clustering of life into ‘natural’ and ‘cultural’ schemata? We argue, in the spirit of Canguilhem, that it has been absorbed and supplanted by a new binary biosocial grid – the functional/dysfunctional – that allows for the expansion of the politics of life, the cultures of enablement, the powers of expertise and the governance of everyday life across a broader horizon of human problems. We turn now to a brief history of the discourse of ‘function’ in medical and industrial sciences before elaborating the contemporary dimensions of the functional/dysfunctional binary.

A Genealogy of Function

The idea of ‘function’ has a durable history in medical science, going back to Aristotle’s treatises on natural science. Aristotle called the creative force that transforms the human body into a living person the psuchê, a vitalizing form of life constituted by a specific set of functions (Green, 1998). Later Galen also celebrated the natural design of organic bodies in his De usu partium (‘On the Usefulness of the Parts of the Body’) by arguing ‘that every structure of the human and animal body was perfectly situated to perform its function’ (Freemon, 1994: 265–6). Indeed, a significant component of the making of Western rationalist world-views from classical to early modern medico-philosophies was the focus on the performative role of function and its relationship to structure in biological entities. In the modern period an expansive conceptualization of function became intrinsic to disciplinary developments in anatomy, physiology and biology. In part this was due to advances in experimental research and microscopic technologies to study the body, but it was also a result of a shift in the medicalization of life itself. As life became more deeply probed at organic and cellular levels, function emerged as a sign of its universalism across species and orders of nature. Further, as early 19th-century debates between mechanistic and vitalistic medical epistemologies gave way to evolutionary and pathological medicines, functionality also became an empirical ideal, a calculus with which to measure the activities of all living beings.¹ Regarding later 19th-century biology William Coleman notes that ‘function, now studied increasingly on the physical and chemical level and with the aid of the conceptual and laboratory implements of those sciences, meant vital process, the day-to-day, second-to- second events whose sum total was life’ (1971: 166). Or in the words of contemporary Thomas Henry Huxley in 1875: ‘The actions of living matter are termed its functions’ (quoted in Coleman, 1971: 143).

Michel Foucault, in The Order of Things, also traces the historic gravitation towards function in medical practices and priorities. Attributing this development to the discoveries of Georges Cuvier (1769–1832) and his associates, Foucault argues:

From Cuvier onward, function, defined according to its non-perceptible form as an effect to be attained, is to serve as a constant middle term and to make it possible to relate together totalities of elements without the slightest visible identity. What to Classical eyes were merely differences juxtaposed with identities must now be ordered and conceived on the basis of a functional homogeneity which is their hidden foundation. (1973: 265)

Cuvier was part of a larger scientific and experimental movement, or epistemic shift in Foucault’s terms, which directed biological thought away from the anatomical surfaces of classical representation and grounded it in the new equation between scientific truth and organic complexity.²

As medicine wrought an empire of functions from the body throughout the modern period it also generated concerns about functional disorders. Biological research into the functions of organs was seen to be possible because such organs were visualized as permanently vulnerable to functional disturbance and crises. The modern medical project was less about discovering purely healthy or diseased bodily conditions than determining the extent to which organic performance could be expected to match ideal states of functionality.

Similarly, the concept of ‘dysfunction’ made its appearance in early 20th-century medical literature, much of it in relation to brain functioning. An example is The Human Mind: The Organ of Thought and Dysfunction by Murdo Mackenzie, a British physician and psychologist for whom and breathing the function of the lungs’ (1941: 39). By treating the mind organically and biologically, Mackenzie argues that it too can come under the domain of functionality, hence anxiety, depression or apathy are best classified as mental dysfunctions. ‘In dysfunction, the mind like any other organ is in arrhythmia, and either overworks or underworks’ (1941: 181). Since Mackenzie was writing during wartime, mental functioning is not simply an individual problem but one with wider national consequences:

Many things are required of Medicine, but this is one of its greatest responsibilities both to-day and in the aftermath of to-morrow. The war of minds will be won by the most vigorous national mind in full function, and medicine must do all in its power to relieve the individual – and thus, indirectly, the nation – from the disabling effects of Anxiety, Apathy and Depression or any other of the secondary manifestations of dysfunction of the mind. (1941: 204)

The theme of ‘the war of minds’ and the ascension of the body-functional were also implicated in ideologies of human productivity and labour maximization during the early 20th century. For example, the implementation of intelligence testing during the First World War, based solely on the functioning of intelligence apart from its individual development, led to the transcription of vague human qualities such as ‘aptitude’, ‘motivation’ and ‘skill’ into calculable human resources (Von Mayrhauser, 1989). In the context of Progressive Era industrial economies and eugenic pseudo-science, ‘conceptualizing “intelligence” in terms of “aptitude” allowed each of these terms to pick up and carry the semantic baggage of both evolutionary science and social utility’ (1989: 68; see also Rose, 1989). Thus the popularity of psychological testing of mental functionality exalted technologies of measurement as a way of coding human capacities for the widest possible industrial, military and social uses. Technologies to enhance functionality, measurability and productivity and portray human capacities as both knowable and governable reverberate throughout 20th-century industrial psychology and efficiency studies.

Our point is that within these two genealogical sites, the first in medical science where organic function triumphed over form, and the second in industrial science where physical (including mental) function triumphed over other subjective states, function emerged as a core element of the life sciences. Above all, it became an ideal truth-making articulation of the macroscopic universalism of biological nature with the microscopic technologies of measuring and testing nature’s species and bodies. As we discuss in the following section, such an articulation still lies at the heart of contemporary discourses of functionality. However, recent reorientations in biology, pharmacology and the nature of nature itself, have pushed functionality beyond its past triumphs to the center of a new politics of health and enablement. The article now turns to a discussion of these orientations and then proceeds to explore selected illustrations from the fields of aging and sexuality.

Elements Of The Functional / Dysfunctional Binary

The functional/dysfunctional binary encapsulates earlier medical and industrial discourses about functionality, which we propose are combined into an heightened and commanding assemblage of instruments, knowledges and practices that can be broken down into the following seven constituent elements.

(1) Measurability

The immediate and multidisciplinary appeal of functionality as a bodily state has to do with its measurability, a feature of medical research that dates back to historical physiological models of structure and function mentioned above. However, today functionality makes the body available to the widest variety of techniques and interventions, relatively unimpeded by the conventional moralities of class-ridden and patriarchal codes imbricated within ‘the normal’. Functional states are quantifiable states, and the greater the technical proficiency of the tools of measurement, the greater the number, types and problems of function that can be known. The question to be asked of measurable functionality/dysfunctionality is what precisely does it measure, and what kind of healthy states do functional assessments standardize?

(2) Standardization

Behind the measurability of functional states lie the bio-cultural standards of enablement. It is not difficult to see their connection to prevailing neo-liberal social mandates around individualism, active and mobile life-styles, responsible self-care and economic independence. The goal of being ‘functional’ is often couched in a discourse of freedom, choice and adaptability. To be enabled and aligned to such mandates is not framed within a traditional problematic of normalcy, however, because the objective of enabled functional states is doing rather than being; that is, to do school, work, family, etc., without becoming dependent on social programs to do so. Pathologies do not necessarily inhibit functional performances and can coexist with them because of enabling pharmacological and therapeutic interventions and a social acceptance that modifiable dysfunctions are not abnormal. Functional states are also standardized by their adaptability to interventions.

(3) Interventions

The interventions that deal with functional/dysfunctional states are crucial and very different from past medical approaches for four reasons: (a) the expansion of pharmaceutical treatment of dysfunctional states; (b) the centrality of disorders (such as depression, ADD, addictions, sexual dysfunction, Alzheimer’s Disease) whose care is geared to enablement rather than ‘cure’; (c) the increased significance of genetic explanations and evidence where intervention has become a matter of genetic mapping, counselling and riskmanagement regimes; and (d) the predominance of a paradigm of expertise in which organic nature is modifiable. In all these areas the pharma-industries have expanded to unprecedented heights commercially, culturally and globally (see Healy, 2002a; Metzl, 2003). This also makes the problem of who is dysfunctional and ‘deserving’ of intervention more acute. While in the past it was the pathological figure who was stigmatized and marginalized by the requiring of professional treatment, today the dsyfunctional person is ostracized if he or she resists such treatment or any technically assisted program leading to enabled and adjusted normalcy. Thus, one of the demands of successful biosocial citizenry is an acceptance and literate understanding of functional states as naturally adaptable. This understanding, however, is largely based on the way the body is represented in informational technologies.

(4) Posthuman informatics

Biosocial rationalities rely on informational technologies to stream individuals and groups across a data-sphere connecting expert literature, research studies, conferences, population statistics, advertising and marketing. Scanning, screening, mapping, imaging, coding and modeling are the familiar means by which such connectivity is achieved. Not only are we connected to reproductive technologies, intelligent machines and prosthetic extensions, but also to informational modes of representation and transferability. As N. Katherine Hayles remarks, the posthuman subject is ‘a material-informational entity whose boundaries undergo continuous construction and reconstruction’ (1999: 3). Posthuman bodies and functional/dysfunctional classifications come together where they relay human capacities across data-streams and virtual environments. In other words, the truth of what is functional and what dysfunctional is a product of the informational technologies that shape it and make it transparent in the cultural flows between bodies, individuals, populations and peoples. Posthuman informatics is essential to the establishment of a bond between the experts and the public in which the individual can participate as a responsible citizen of the information society. This leads to the next element regarding bio-identities.

(5) Bio-identities

The vital politics surrounding functional/dysfunctional states and posthuman bodies produces new personal realms of identity-formation tied to ethical and reflexive practices. Specifically, as we come to understand ourselves in terms of the life-strategies, risk-managing skills and universal rights associated with ‘biological ethics’ (Rose, 2001: 21; Novas and Rose, 2000), we also assume new bio-identities, ranked by orders of privilege, status, responsibility and self-care. The increasingly finer distinctions made between degrees of functional capability, or functional disorders and their interventions, make for an inventive expanse of identities rooted in somatic experience. Doing, acting and performing functionality and dysfunctionality create the conditions by which one becomes functional or dysfunctional. This is not simply an example of sociological ‘labelling’ theory or social constructivism, but a process whereby successful living is achieved through reflexive, embodying technologies of the self. Neither is this process necessarily a ‘negative’ one since bio-identities and bio-ethics are also forged through change, curiosity and resistance.³ In this way, bio-identities share something of what Ian Hacking considers to be the ‘dynamical interaction’ of the classificatory style of reasoning in the human and social sciences, where new or modified classifications both open up and close off ways ‘for us to be, or to act’ (2002: 10–12). The problem is that classification, like other styles of reasoning, not only ‘introduces new ways of finding out the truth’ but also ‘its own criteria of proof and demonstration’ and is thus ‘self-authenticating’ (2002: 4). This problem is certainly evident in how expertise is filtered into our everyday lives to create shared explanatory discourses about common problems. Since the functional/dysfunctional provides such a powerful bond between the classificatory structures of the life sciences and the bio-identities of its subjects and their self-assessing ‘quality-of-life’ decisions, it also creates a kind of natural discursive community that self-authenticates the functional/ dysfunctional as a grid for understanding, testing and adapting to everyday life in such a way that one is ‘in the know’ about it. In a sense the relationship between the practices of everyday life and the making of bio-identities is one way in which the functional/dysfunctional is materialized.

(6) Materialization

Superceding older notions of corporeality that embodied a conception of the body as a unified, organic entity that could be treated, the functional/dysfunctional, as a biomedical framing, disassembles the body and materializes it around discrete functional subsystems such as genetic, hormonal, neurochemical and vascular systems. The informatics and interventions that are the hallmark of contemporary technoscience construct the bodily processes on which they seek to act through their effects, materializing function and dysfunction at the somatic level. These materialized subsystems are neither ‘natural’ nor ‘cultural’ – they are a congealment of complex networks of interactions among (to use the language of recent science studies) both human (scientists, doctors, patients, etc.) and non-human (chemicals, technical apparatuses, etc.) actants.⁴ To claim that function and dysfunction are materialized in this way is not, however, to suggest that they are fictional. Technoscientific materializations of bodily systems have both explanatory power and visceral effects. For example, as David Healy has argued with respect to the understanding and treatment of mood disorders, the replacement of ‘psychobabble’ with ‘biobabble’ ‘has pervasive consequences for the ways we view and experience ourselves, and not just for the labels we give to our discontents’ (2002b: 8–9). The materialization of the brain itself around functional levels of seratonins is inextricably linked to the fact that drugs such as Prozac (a selective seratonin reuptake inhibitor) produce an effect. Bodies thus become materialized around functional subsystems linked to particular technologies.

(7) Biologistic imperative

Accumulatively, the elements of the functional/dysfunctional binary enumerated above – measurability, standardization, interventions, posthuman informatics, bio-identities and materialization – situate the body within a new order of nature and culture. Paradoxically, just as critical scholarship has largely de-biologized and de-essentialized the body, the body has become renaturalized under different conditions. Unlike social Darwinist, Malthusian and eugenics ideologies that remade the cultural as a template for the steadfast laws of nature, the contemporary biologistic imperative is remaking the natural as a template for the malleable laws of culture.

To illustrate how the biologistic imperative of the functional/dysfunctional and its assemblage of elements operate in practical contexts, we turn to two areas of research where notions of functionality are ubiquitous: gerontology and sexology. In the former case ‘functional health’ and ‘functional age’ are linked to successful aging, and in the latter case, sexual function and dysfunction have become all-encompassing bio-markers of heterosexual competence and health management. As we will demonstrate, both cases exemplify how the shift from the normal/pathological to the functional/dysfunctional as a framing binary is refracted in the relationship between professional expertise and the mobilization of everyday anxieties.

Healthy Aging And The Gerontology Of Function

The functional aging body

Since their emergence in the 19th century, geriatrics and gerontology have sought to map the aging process along well-defined chronological transitions. In the later 20th century, however, the life-sciences reconsidered chronological age as an obstacle to research because the concept lacked predictive value and conceptual rigour. According to James Birren, ‘chronological age is only an index, and unrelated sets of data show correlations with chronological age that have no intrinsic or causal relationship with each other. Thus a goal of theory and research has been to replace chronological age with variables that reflect the causes of change we initially identify as being closely related to chronological age’ (1999: 460). Gerontologists, beginning with I. M. Murray (1951) and later Heron and Chown (1967), had already started working towards Birren’s ‘goal’. To understand the causes of aging, they claimed, several ‘ages’ were required along with a new bodily point of articulation – functional age. Murray’s research with an all-male group of 21–84-year-olds demonstrated that physiologic and chronologic ages vary relative to each other, producing in the end a measurable ‘age’ based on ‘functions’ (also advantageous to life insurance companies, according to Murray). However, Murray’s functional ages are not absolute norms set against deviating pathologies. Rather, they are calculable instances of variation that culminate in the physiological materialization of the aging body.

Murray’s methodological work and that of other bio-gerontologists was praised for revealing how individuals of similar chronological ages could have different physiological or functional ages. Beginning in 1963, these ideas about functional age were extended in a major gerontological undertaking called the Normative Aging Study (NAS), conducted at the American Veterans Administration Outpatient Clinic in Boston. Results of the study were gathered into a special issue of the journal Aging & Human Development in 1972. The journal’s editorial, ‘Is Functional Age Functional?’, posed functional age as the alternative to chronological age but also asked (p. 143): ‘Are we ready, as a society, to base age-related decisions upon scientific findings rather than tradition and expediency?’ David Bell, director of the Boston clinic, responded in the affirmative, stating that ‘we are looking for a unifying concept which would enable the measurement of aging in its various aspects, and the relative rates of age change, both across these areas and over the lifespan’ (1972: 145). Bell’s unifying concept includes psychological and behavioural as well as biological functions, thus extending the logic of functional health to a person’s whole life. Such social parameters of functional age are more pronounced in the paper by Charles Rose, a sociologist contributing to the journal who invents ‘social age’ as ‘a changing composite of social life styles, attributes, and attitudes at various points of the life cycle’ (1972: 153).

On the one hand the NAS failed to create the sophisticated measurement tools necessary to make functional age into a major conceptual breakthrough in gerontology (Bookstein and Achenbaum, 1993: 37). As follow-up research ensued with more accurate and culturally nuanced test batteries (Chappell et al., 2003: 180–1), so did the internal criticisms of functional age (Costa and McCrae, 1985; Spiriduso, 1995: 49–52). On the other hand, the concept of functional age expanded because of the professional enthusiasm for its potential to measure, standardize, informate and materialize the aging body in ways theoretically elaborated above, while justifying a new inventory of risks and interventions appropriate to aging individuals. Functional age also drives the imperative to biologize the aging process apart from chronological aging by co-ordinating the body’s biomarkers. Biomarkers are defined in the recent Encyclopedia of Aging (2002) in the following way:

The assumptions that underlie the concept of biomarkers of aging are that organisms age at different rates and thus chronological age is not a good predictor of remaining life expectancy, that different tissues, organs, and organ systems within an organism may age at different rates, that these differences can be measured and predicted, and finally that it may be possible to alter the rate of aging of any or all of the components of organisms. (Sprott, 2002: 133; emphasis added)

Today ‘function-oriented’ (as distinct from ‘disease-oriented’) approaches in gerontology are directed to healthy-aging, health-promotion programs in areas of mobility, cognition and social activities. In turn these activities are measured and tested by a broad set of instruments, such as the popular ADL (activities of daily living) checklists first proposed in 1959, the IADL (instrumental activities of daily living) in the late 1960s and the more recent ALSAR (assessment of living skills and resources) and the Standardized Test of Fitness developed in Canada. These instruments typically examine the functions of daily life (toileting, dressing, eating, mobility, etc.), highlight their dysfunctional impediments (disease, disability, environmental limitations) and identify possible interventions (physiotherapy, service plans, fitness programs, residential care). Ultimately, the language of functional testing is geared towards ‘independent living’, used interchangeably with ‘successful’, ‘healthy’ and ‘productive’ aging. ‘Dependency-free life expectancy’ is also referred to as ‘health life expectancy’, ‘active life expectancy’, ‘disability-free life expectancy’ and ‘functional life expectancy’ (Chappell et al., 2003: 12). The biosocial rationalities of functional age and independent living correspond, therefore, linking functional bodies to functional populations. Supporting this correspondence are the bio-identities by which people can know themselves.

The functional aging self

In the 1972 special issue of Aging & Human Development on functional age, gerontologist Robert Kastenbaum and co-researchers posit a subjective dimension to functional age (1972: 197–211). By administering an interview schedule called the ‘ages of me’ to a sample of 75 adults aged 20–69, the researchers find that personal age tends to be viewed as younger than chronological age, with the gap increasing further up the chronological scale (1972: 206). Their work also introduces the self-skills and professional vocabularies by which people judge themselves in functional terms. In their conclusions the authors ask: ‘Is it “healthy” or “pathological” to embrace an ever-moreyouthful self-conception as one grows older?’ (1972: 210). However, measures of healthy, normal or pathological have little to do with the adjudication of functional/dysfunctional aging and health because the latter are flexible and relative standards, modifiable through personal actions, attitudes and lifestyle practices. To understand the determination of these standards, the qualitative research tradition in which Kastenbaum and others participate looks to self-reporting, a technique directing subjects to self-rate selected aspects of their everyday activities (Herzog and Markus, 1999; Leinonen et al., 2001; He et al., 2003; The Gerontologist, 2003: 369–411). However, the self-skills required to differentiate between general health status and functional health status have been found to be haphazard and there are incongruities between what people say they do and what they actually do (Glass, 1998). Research subjects, drawn to the abstract authority of expertise discourse, conspire to make their lives fit the research design by reinterpreting their functional abilities according to its standards. Not surprisingly, many ADL and related self-rated surveys contain measurement errors and inconsistent subjective responses (Rodgers and Miller, 1997). After all, how does one know oneself as functional? How can the activities of everyday life be transcribed into measurable units leading to interventionist strategies? And even if selfreports express what a person can do, they bypass what a person likes to do or resists doing. Rather, the professionals avoid these and other questions by prioritizing only those self-skills assigned to comprehending subjective functional health status according to authoritative codes of health literacy.

Health literacy refers to the skills required to read and understand healthrelated literature, pharmaceutical products, physicians’ instructions, homecare schedules and therapeutic procedures, hence there is a close connection between being functionally healthy and functionally literate. For example, Don Nutbeam argues that for health literacy to be a successful public health goal and ‘promote greater independence and empowerment among the individuals and communities we work with’ (2000: 267), functional literacy levels of competence need to include ‘interactional’ and ‘critical’ skills. Despite the evidence showing that health literacy is embedded in class, gender, racial and regional inequalities and hierarchical forms of cultural capital (Lumme- Standt and Virtanen, 2002; Blaxter, 2000; Abel et al., 2000), it, along with functional status self-reporting, is held aloft as a democratic self-skill which permits the aging individual entry into the privileged and professionally approved realm of quality-of-life autonomy and life-style choice-making. It is a skill which allows gerontological bio-identities to be both created and experienced.

This section has considered how a gerontology of chronology gave way to a gerontology of function, and how the latter has emerged to bio-mark the human lifecourse across a horizon of divergent problems and interventions spanning the genetic to the populational. The next section extends the analysis to one of the sites where ‘functionality’ has become particularly compulsory for the responsible subject – sexuality.

The Science Of (Hetero)Sexual Function

Sexually functional bodies

Successful heterosexual functionality, narrowly defined as the ability to perform heterosexual intercourse adequately and consistently, has been promoted as a stable ‘social good’ over the past century in the midst of rapidly changing moral, scientific and political rationales. Earlier concerns with population and regeneration were somewhat eclipsed, though not entirely, by a growing 20th-century admission of erotic pleasure as key to marital (and hence social) stability. Since the latter part of the 20th century, sexual functionality has also become largely detached from its conventional affiliations with procreation and refashioned as a concern for healthy relationships and personal fulfillment. However, the recent emphasis on physiological function as defining sexuality has opened up new discourses of bodily performance and anxieties about decline, which are particularly significant as Western societies worry about aging populations. Dominating the sexological sciences of most of the 20th century were psychological paradigms of sexual dysfunction that sought emotional and psychological explanations for bodily dysfunctions. In the late 20th and early 21st centuries, sexual dysfunction has become linked to predominantly organic explanations even as bodily dysfunction is considered to produce potentially serious emotional consequences. This shift from the psychological to the organic refashioned sexual dysfunction as a threat to both the physical and psychological well-being of individuals and the aging population itself (Marshall and Katz, 2002). Hence it has become a matter for public concern. In other words, sexual dysfunction, reconceptualized as a modifiable and largely mechanical disorder with profound repercussions for human health, was seen to require a social response.

The transition from psychological to physiological etiologies of sexual dysfunction was signaled by the change in language from ‘impotence’ to ‘erectile dysfunction’ in men, and from ‘frigidity’ to ‘female sexual arousal disorder’ in women.⁵ Despite shifting etiologies, Masters and Johnson’s physiology of the ‘human sexual response cycle’ (HSRC) continues to be the standard of ‘function’ against which sexual ‘dysfunction’ is measured (Masters and Johnson, 1966). The HSRC standardizes a series of stages or phases of physiological change that defines sexual function. The original HSRC identified ‘arousal’, ‘plateau’, ‘orgasm’ and ‘resolution’ as involving identifiable and quantifiable physical events, involving blood flow, tissue expansion and contraction, changes in heart rate and blood pressure, secretion of fluids and so on. Later revised, largely due to the influence of Helen Kaplan’s work (1977, 1995), to include ‘desire’ as a preliminary stage (although no physical changes are associated with this stage), the HSRC continues to be received as ‘truth’, forming the framework for the diagnosis of sexual dysfunction in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM IV).

The nomenclature of sexual dysfunction identifies particular disorders in terms of deviation from the expected physiological response for each stage. For example, at the arousal stage there is a ‘failure to attain or maintain the lubrication-swelling response’ or ‘the inability to achieve or sustain an adequate erection’ (Halvorsen, 1997: 45). Penile-vaginal intercourse is the assumed goal of arousal, as both lubrication in women and the erection in men are deemed adequate if each is sufficient to allow their proceeding to successful intercourse. A satisfactory orgasm, which is neither ‘premature’ nor ‘delayed’, is the assumed goal of intercourse for both partners. Thus, the HSRC requires physiological success at each stage to move on to the next in enacting this cycle, while ‘dysfunctions’ are defined and treated as events that disrupt the cycle’s ‘natural flow’. Despite its obviously socially constructed format, the HSRC has a remarkable tenacity to represent itself as a scientific and self-authenticating standard for sexual function. What is deemed to be an ‘adequate’ response or ‘sufficient’ excitement is defined by criteria of the model itself. As Leonore Tiefer puts it: ‘Effective sexual stimulation is that stimulation which facilitates a response that conforms to the HSRC’ (1995: 85). For both men and women, arousal becomes coterminous with measurable vasculogenic activity. The physiological corollary of erectile dysfunction in men is ‘vaginal engorgement and clitoral erectile insufficiency syndromes’ in women (Goldstein and Berman, 1998). Here the organic substratum is a functionalized organic, where physiological disorders are materialized as diagnosable, treatable and perhaps preventable.

One need look no further than the advent of Viagra and related pharmaceutical erectile enhancements to see how the contemporary construction of sexually functional bodies is a matter of biomedical intervention. Viagra has the highest efficacy rates for erectile dysfunction of ‘undiagnosed origin’, a fact whose widespread reiteration confirms that sexual dysfunction, whatever its cause or stage of manifestation, is a physical, vascular problem. The functional effect of the drug, and not the disorder, defines the bodily condition. Similarly, in a far cry from Hippocrates’ assertion that ‘the nature of the body is the beginning of medical science’,⁶ Dr Irwin Goldstein, probably the most internationally renowned authority on medicalized sexual dysfunction, has recently declared that ‘the ideal female candidate for Viagra has not yet been defined’ (cited in Health Facts, 2003: 1). There is no pretense of a natural body here, other than that which is waiting to be technically materialized by the interests of the medical and pharmaceutical industries. Part of this materialization hinges on the enforced inculcation of responsibilizing self-skills for all those who might suffer from sexual dysfunctionality.

Sexual function and the responsible self

Sexual ‘function’ is thus measurable, standardizable and keyed to biotechnical intervention in a manner that departs significantly from older notions of ‘normality’. ‘Function’ can be defined in the absence of any normative data, as is the case with much of the work linking female sexual arousal to genital vasocongestion. Nor does sexual function require any correlate of normality. In fact, research on sexual function has largely proceeded on the basis of redefining what might be statistically normative as dysfunctional, whether this be erectile function or testosterone levels in aging men, or libido or orgasmic capacities in women at various stages of life. And while the shift from psychological to physiological etiologies of sexual dysfunction has been praised for relieving individuals of one sort of moral responsibility for their predicament – that is, ‘it’s not all in your head’ – another kind of moral responsibility replaces it as individuals are responsibilized for their own preventative and rehabilitative bodily care.

The process of this responsibilization requires individuals to become skilled at self-assessing their sexual functionality aided by the resources of medical informatics, marketing and health promotion literature and their technical indices that purport to measure the system complexes that indicate dysfunction in both men and women. These indices include, for instance, the International Index of Erectile Function (Rosen et al., 1999), the Androgen Deficiency in the Aging Male Questionnaire (Morley et al., 2000) and the Index of Female Sexual Dysfunction (Meston and Derogatis, 2002; Rosen et al., 2000). Despite their air of clinical precision, however, the indices do not reflect an empirical ‘normality’ from which deviation is measured. Rather, they collate into a professional show-of-hands standardized models of function and dysfunction which attract those with an interest in capitalizing on interventions for dysfunctions and willing to invest heavily in their instruments of measurability and diagnoses. A good example is the sponsorship of the development of the Index of Female Sexual Function by the pharmaceutical giants Zonagen and Bayer (see also Moynihan, 2003).

Both for men and for women sexual dysfunctions are rendered as potentially epidemic progressive diseases for which all are ‘at risk’. As Linda Singer (1993) has argued, the language of epidemics provides a particular way to mobilize bodily and social resources. To these resources we add the mobilization of the self, whereby in the late 20th and early 21st centuries the convergence of scientific expertise and commercial interests has fashioned ‘sexual function’ as a pivotal site of intervention that enrolls the individual into selective life-style regimes of risk-management and self-care, particularly as these relate to idealized programs for healthy aging. In this way sexual dysfunction and the overall colonization of sexuality by the functional/dysfunctional binary joins a long list of other afflictions, such as obesity, that are characterized as moral disorders reflecting an individual’s lack of skillfulness in learning about, choosing and consuming appropriate medical expertise and life-style products (Slater, 1997: 92). The commercial successes of pharmaceutical and mechanical remedies for sexual dysfunction rest, therefore, on a relatively recent cultural-scientific conviction that lifelong sexual function is a primary component of achieving successful personhood in general. Given these economic, cultural, scientific and political exhortations to conflate sexual health with successful living, how can anyone legitimately refuse to be ‘functional’?

Conclusions

In this article we have proposed that a powerfully new binary figure, the functional/dysfunctional, has absorbed earlier notions of ‘normal’ and ‘pathological’ to foist upon human health, aging and sexuality a sweeping assemblage of instruments, knowledges and practices. This process of absorption accords with Paul Rabinow’s claim that ‘a multiplication and complex imbrication of rationalities continue to exist’ whereby ‘older cultural classifications’ are ‘joined by a vast array of new ones which will cross-cut, partially supercede, and eventually redefine the older categories’ (1996: 103). Thus, bio-identities ranked by life-style and health statuses both intersect and alter those based on race, class, gender and age. The specific result with which we are concerned is that the physical disorders of late modern bodies, selves and populations and their links to neo-liberal mandates of activity, enablement, responsibility, self-care and independence, have become grouped around quantifiable states of functionality. Such states set the biomarkers of human life with exhaustive batteries of tests, aggregations of data, scales, indices and self-reports, all of which implicate the individual as an active participant in striving towards functionality rather than normality. The standards of functionality also lead to the collective ideal of enabled fitness. However, both fitness and its professional correlates of function are bound up with the dictates of consumer society, characterized by Zygmunt Bauman as creating ‘a sliding, ascending and infinite scale of rapture which, when applied to the actually experienced, casts on every experience a deep shadow of “malfunction”’ (1998: 227). While this kind of subjective problem might seem irrelevant to past standards of normal/pathological health and illness, it fits well within functional/dysfunctional codes which include subjective experiences because of the enforced individualism demanded of projects of enablement. In fact subjective experience and the lengthening expectations of self-skilling are integral to the adaptability of functional problems to interventions and the reversal of values between culture and nature which we outlined earlier. Other writers such as Andrew Webster (2002), in addition to those reviewed in the first section of this article, have made important claims about this reversal, contending that innovative health technologies are actively reconfiguring the boundaries between the natural and the social, medicine and society, normality and abnormality, health and illness, and opening classificatory spaces for ‘patients without symptoms’, or the ‘worried well’ to participate as partners in the life-sciences. We agree with these writers that, in biosocial regimes, the biological is used to blur rather than demarcate the lines separating the cultural and the natural. Our contribution to these studies is to insist on a more detailed and critical focus on the functional/dysfunctional, question its role in biologizing, medicalizing and geneticizing social problems, and trace its governing of human life under that artifice of signs that pass for the natural, the fit and the healthy.

Acknowledgement:

This paper was first published in "History of the Human Sciences" Vol. 17 No. 1, pp. 53-75, 2004

Notes

1. The scope of this discussion prevents a fuller elaboration of the development of mechanistic and vitalist medical discourses and their place within the influential Paris school of medicine in the late 18th and early 19th centuries. While traditional Cartesian mechanistic models promoted the idea of the universal unity of all matter, vitalism, best exemplified by the work of Xavier Bichat (1771–1802), introduced a new medicine separating life from non-life and creating an ‘imagery of active tissues whose activity is not reducible to that of the non-living world’ (Haigh, 1984: 44; see also Gelfand, 1980). Bichat’s ideas on vitalism and his tissue theory of anatomy were gradually dismissed by those who followed him and by modern researchers in cellular pathology. However, his idea that life itself, and death, could be located in the microscopic depths of the body remained an significant medical axiom. In Britain the physiologist George Cheyne (1671–1743) has been credited with developing early vitalist medical ideas in the context of Newtonian mechanistic theories (Guerrini, 1985). A fascinating collection of papers spanning the history of metaphysical debates in medicine can be found in Psyche and Soma: Physicians and Metaphysicians on the Mind-Body Problem from Antiquity to Enlightenment (Wright and Potter, 2003).
2. One of the interesting offshoots of this grounding was phrenology, that quirky undertaking to determine the physical co-ordinates of the body and behaviour in specific areas of the brain and to create craniometric maps indicating the localization of functions. Two examples out of many are: The Mental Functions of the Brain: An Investigation into their Localisation and their Manifestation in Health and Disease, by Bernard Hollander (1901) and Histological Studies of the Localisation of Cerebral Function by Alfred W. Campbell (1905). On the history of brain research, mental testing and the localization of function, see Stephen Jay Gould’s splendid critique, The Mismeasure of Man (1981).
3. Here Paul Rabinow’s writing on ‘the third culture’ is instructive (1994). By looking at persons with AIDS in France as figures of ‘social reform’ who demand to participate in drug experimentation and research, Rabinow concludes that this is a case where a rights-based, bio-identified political rationality is used to contest one based on populational risk and medical authority. Rabinow also discusses the role of critical curiosity; that is, how the governed are motivated to become curious about their conditions of being governed, suggesting that the limits of neo-liberal governance are being tested by the reflexive forces such as curiosity that come from people being governed in a liberal way. In a related and important context Lisa Adkins examines how categories of risk, sexuality and health around HIV–AIDS in workplace governance create the contradictory conditions for new bio-identities (Adkins, 2002).
4. The notion that science does not simply ‘discover’ and ‘act’ on an already constituted natural world is central to constructivist science studies. This perspective has been fruitfully developed within feminist science studies in seeking to understand the materialization of sexually differentiated bodies in such a way as to avoid both biological and discursive forms of reductionism (e.g. Barad, 1998; Haraway, 1997; Hird, 2002; Oudshoorn, 2001). For a brief but excellent overview see Roberts’s review essay on Haraway (1999). A state-of-the-art series of articles on feminism and science can be found in SIGNS 28 (Spring 2003).
5. A more detailed history of the shifts in medical paradigms of sexual function and dysfunction is recounted in Marshall (2002), Marshall and Katz (2002) and Katz and Marshall (2003). A pivotal moment occurred in urology in the 1980s, when it was demonstrated that the injection of drugs directly into the penis could produce an erection in the absence of any tactile or erotic stimulation. This served to reconceptualize sexual arousal as a molecular, physical event, a perspective that has now become orthodoxy via the discovery of the role of nitrous oxide in the erectile mechanism and the development of drugs such as Viagra that act on this mechanism. A key problem for contemporary sexual medicine is trying to transfer this knowledge of the male erectile mechanism to processes of female sexual arousal, with the goal of equivalent success in the pharmaceutical enablement of sexual function in women.
6. This quote from Hippocrates is engraved over the entrance to the medical sciences building at the University of Indiana at Bloomington, home of the Kinsey Institute.

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