During the interwar period and onwards, family planning centres expanded their birth control sessions into sexual advice, which became available primarily through the activities of women doctors in Britain. They set up advisory sessions on ‘sub-fertility’, which were framed as sexual disorders and infertility, and published on these issues. ² As was the case with the development of medical knowledge of birth control, working in women's welfare centres and birth control clinics provided women doctors with a privileged position from which to observe, learn, acquire and develop new skills. Among these new skills were the handling of sexual difficulties and infertility. Birth control clinics and women's welfare centres therefore constituted spaces for experimentation in these new domains. Paradoxically, it was the specific nature of the clinics and the fact that working there meant occupying a marginal position within the medical hierarchy that allowed scope for exploration and innovation. The constant need to assert the legitimacy of this new field was a driver for developing new medical knowledge and therapeutics. Joan Malleson, Helena Wright and Margaret Jackson played a pivotal role in the development of this field. Their most important contribution was to create and sustain a new holistic approach to family planning where birth control advice (as we saw in Chapter 1), sexual disorders and infertility were treated together. They contributed to the development of the prevention and treatment of sexual disorders and thus participated in the medicalisation of sexuality. Women doctors paved the way for the formal integration of sexual counselling and sub-fertility and the predominance of these issues in family planning clinics from the 1970s onwards. The production of scientific knowledge of sexual disorders by women doctors remains marginal and has mainly been written about as part of a broad analysis of sexual manuals in general. This chapter therefore analyses a range of hitherto understudied material on sexual counselling and infertility. It examines women doctors’ contributions to sex and medical manuals, scientific publications and sexual counselling sessions with their patients from the 1930s to the 1970s, and the extent to which these contributions reflected or challenged the broader conceptions about heterosexuality and gender norms that prevailed at that time. It shows that this new ‘positive’ dimension of the work of the clinic developed in response to the needs and demands of the patients. Historians, by and large, have presented the patient–doctor relationship before the Second World War as an unbalanced and problematic power relationship where doctors ‘knew best’ and where patients were pictured as passive agents with little autonomy. It has been shown that this paternalist attitude of the medical profession towards their patients lasted up until the 1960s. ³ I argue that a set of doctors had already planted the seed for a more active role for patients, as they were aware of the significance of the patient's autonomy before the Second World War. Indeed, in contrast to histories that present doctors as all-powerful agents in the patient/client–doctor relationship, the historical practice of sexual counselling in many ways provides a more positive vision of this relationship. By developing an appropriate medical response to the sexual difficulties faced by their patients, women doctors took their patients’ demands and needs seriously and used them to shape, to a certain extent, the development and content of sexual counselling. ⁴

Integrating sexual disorders into the work of the clinic: 1935–58

Research on the history of sexuality and marital intimacy has underlined the advent of the companionate marriage model that became ideologically dominant in the mid-twentieth century. ⁵ In this model – mainly put forward by sex reformers and sexologists as well as by members of the medical profession – the sexual pleasure of both spouses was portrayed as the key to a successful marriage. Historical studies have shown the influence of Freud's theory on psychosexual development, which profoundly impacted the medical understanding of sexual disorders, especially that of ‘frigidity’. Female sexual disorders became extensively debated around the end of the nineteenth century, at a time when sexology, psychiatry and criminology were developing and mutually influencing each other. Middle-class women were generally constructed and represented as passionless and naturally less sexual than men; they were nonetheless portrayed as having the capacity to be sexually ‘heated’, and therefore this lack of capacity was referred to as ‘coldness’. ⁶ Freud's theory shifted the emphasis towards women's emotional development. In his view, women who did not experience vaginal orgasm were sexually immature. ⁷ Indeed, Freud thought that young girls did enjoy sexual pleasure through clitoral stimulation, in the same way that small boys experienced pleasure with their penis. However, during puberty, young women entered a new phase in their sexual development where an erotic transfer took place from the clitoris to the vagina, which became the locus for the mature expression of sexual pleasure. This emphasis on mutual sexual pleasure functioned alongside the idea of the importance of expressing sexual instincts; any attempts to repress them could lead to a neurosis. These ideas influenced the marriage and sexual manuals written in the first half of the twentieth century in that they promoted prescriptive gender roles where wives remained passive sexual agents and husbands, as active agents, had to initiate sexual intercourse while awakening their wives to sexual pleasure. ⁸ However, many historians have underlined the limited impact of these sex manuals on ordinary individuals; couples struggled to enjoy a happy and mutually satisfying sexual life. Indeed, many studies have shown the prevalence of sexual ignorance among the British that lasted until mid-century. Respectable women were expected to be ignorant of sexual matters, which means that they remained passive. ⁹

The history of sexual manuals, marriage guidance and individual behaviours has also attracted growing attention; however, we know little about the practicalities, the nitty-gritty and the content of sexual counselling provided at birth control clinics before the 1970s. ¹⁰ The sexual counselling provided by the staff at these clinics has received almost no historical attention. ¹¹ There is some work done on Germany and Australia with regards to psychosexual counselling, but not on interwar and postwar Britain ¹² . As there exists no history of sexual counselling in Britain, the first section fills this gap by tracing this history from its early form in the mid-1930s to the first dedicated training seminars in 1958. It offers an overview of the many different actors involved in the subject and the decisive role played by Joan Malleson and Helena Wright in making this new topic a focus of research, expertise and practice.

When the National Birth Control Association changed its name to the Family Planning Association in 1939, its members broadened the scope of the work of the association and extended it to providing advice for women and treatments for ‘involuntary sterility, minor gynaecological ailments and difficulties connected with the marriage relationships’. ¹³ This happened in a context where the mental hygiene movement and social psychiatry were gaining traction in interwar Britain, placing an emphasis on family relations and familial environment as key influences on an individual's behaviour and mental health. ¹⁴ Social psychiatry and psychology had great impact on the Eugenics Society, in particular its secretary C. P. Blacker, who was a close friend of Malleson. The latter was a keen supporter of the use of psychological frameworks. ¹⁵ In 1935 she had already recognised the necessity to expand the work of the clinics towards the incorporation of advice on sexual disorders, ‘suggest[ing] that psychological help might be given at one of the sessions’ and offering ‘to take this session voluntarily for a little while’. ¹⁶ This quotation illustrates the extent of Joan Malleson's commitment to the well-being of her patients, since she agreed to advise them without being paid; it also illustrates the pivotal role she played in developing this new field of work. This work was triggered by her patients’ experiences and demands. In 1938, she became head of the clinic for marital difficulties at the North Kensington Women's Welfare Centre. Hence, marriage relationships were elevated to a place of utmost importance in the family planning agenda. In this new arrangement, resolving sexual disorders could lay the foundations for a better marital relationship.

The medical interest in sexual relationships in heterosexual marriage did not appear in a vacuum. The idea that sexuality was central to a successful marriage gained in visibility during the interwar years in a context in which anxieties were aroused around the dissolution of marriages, the relaxation of the divorce law in 1937, the breakdown of family life, the quality of the population, and decreasing birth rates. Many historians have stressed the rise of the ideal of companionate marriage in the interwar years. ¹⁷ Marriage reformers were particularly vocal. Historian Marcus Collins defined them as ‘a school of thought in favour of measured revision of matrimonial law, enlightened sexual attitudes and a radical restructuring of marital roles in the wake of women's emancipation’. ¹⁸ The main leaders of this school were Arthur Herbert Gray, Presbyterian minister and promoter of marriage guidance; Methodist minister David R. Mace; and Dr Edward Griffith, a popular sex-education author and member of the Eugenics Society, the NBCA, and, later, the Family Planning Association. Griffith ran his own birth control clinic in Guildford until the FPA asked him to resign when a recommendation was made to appoint only women doctors at the NBCA. ¹⁹ These three male reformers were the founding members of the Marriage Guidance Council (MGC) – a body created in 1938 aimed at promoting marriage and family life, which relied on the help of the clergy and the medical profession. ²⁰ They published sexual manuals hoping to alleviate the suffering caused by unhappy sexual lives, which ultimately led to unhappy marriages. Female sexual pleasure – generally through penetration – became a central component of their idea of the happy marriage. ²¹ Clitoral pleasure was also discussed and made legitimate, especially if it helped to ease penetration. They also set up advisory sessions on sexual difficulties in married life. Hence, marriage counselling was primarily meant to preserve the stability of the family. As outlined by Claire Langhamer, ‘sex and love became tightly bound together within the widely promoted notions of modern marriage’. ²²

Women doctors who provided marital and sexual counselling were in close contact and forged alliances with several members of this new movement aimed at developing harmonious marital relationships. These alliances gave them legitimacy. For instance, Arthur Herbert Gray wrote the introduction to Helena Wright's sex manual, Sex Factor in Marriage, published in 1930, as well as Dr Mary Macaulay's Art of Marriage in 1952. Mary Macaulay was medical officer to the Liverpool branch of the FPA between 1930 and 1956, and a marriage guidance counsellor. Malleson was a consulting gynaecologist on the advisory board of the Marriage Guidance Council, ²³ and she and Wright gave talks on ‘sexual difficulties in marriage’ and ‘how to make a good job of marriage’, respectively, for conference days organised by the Marriage Guidance Council in 1938. ²⁴ Wright seemed to have held Griffith in high esteem. According to Lady Houghton, secretary of the International Committee on Planned Parenthood (ICPP) from 1949, for Wright, ‘Edward Griffith could do no wrong’. ²⁵ She shared ideas with Griffith about the organisational aspect of the North Kensington clinic. In 1939 they discussed the opportunity of an ‘occasional advisory session on marital difficulties to husbands. […] It might be possible to run such a session at the same time as Dr Malleson runs hers so that the two could be co-related.’  ²⁶ Malleson discussed cases with Griffith and exchanged information on possible treatment and support that could be offered to patients. Many individuals wrote to the Family Planning Association to ask them for advice and guidance on sexual disorders. In 1940, a man wrote to be referred to someone for treatment for impotence. Since the FPA did not yet engage with male patients they wrote to Edward Griffith, asking him to deal with it. ²⁷ Sylvia Dawkins was also active in the MGC, and she was a marriage guidance counsellor. There was, therefore, close collaboration between the members of these different organisations.

In 1948, in London, three centres offered marital sexual difficulties sessions. At the North Kensington clinic, Malleson was the medical officer in charge of the Clinic for Marital Adjustment; in 1950, she was appointed to the contraceptive clinic at University College Hospital, where she later established a dyspaneuria clinic. Meanwhile, Dawkins counselled couples at the Family Planning Centre of Welwyn Garden City. ²⁸ She was trained in contraceptive advice by Wright and in sexual counselling by observing Malleson, with whom she worked: ‘In my particular case, Joan Malleson was doing the problems because she was a great pioneer in this and when she was appointed to University College Hospital she said to Will Nixon, half these patients need more time, I need an assistant to do the straight contraception, and that was me. I was very privileged. And so I used to do the contraceptive bit and refer cases to her.’  ²⁹

This interest in psychosexual counselling was not limited to the FPA and MGC. In 1948, the Family Welfare Association created the Family Discussion Bureau, an organisation specialising in marriage problems. Its caseworkers underwent psychotherapy training at the Tavistock Clinic, ‘one of Britain's leading flag-ships in psychoanalysis’. ³⁰ Their work focused mainly on marriage difficulties and spousal relationships; the underpinning sexual dimension was not predominant, as was the case in FPA clinics. Illustrating the growing interest in and demand for information on these subjects, the medical conference of the FPA held in 1949 was dedicated to marital difficulties. Here, again, the main organisers and leading figures were women doctors. Wright chaired a morning session on ways to help cases of marital difficulty at FPA clinics, while Macaulay acted as the mediator. Malleson, as an FPA specialist in this work, took the stage to share her experience. ³¹ She saw this new specialty as inherently connected to the work undertaken in family planning clinics; importantly, she regarded it as a new job opportunity for married women doctors: ‘such new lines of work are urgently needed and offer highly suitable opportunities, say to the married women doctors who cannot undertake the full burden of general practice, and to the medical psychologists who would undertake part-time work in the various clinics of the neighbourhood.’  ³²

In 1954, the North Kensington Marriage Welfare Centre, following the retirement of Malleson as consultant on sexual disorders, opened a special session on marriage problems under the supervision of Dr Margaret Neal-Edwards, gynaecological surgeon to the New Sussex Hospital and the Lady Chichester Hospital for nervous diseases. ³³ In 1955, the conference of clinical medical officers and nurses for the FPA dedicated its meeting to marital difficulties. One of the speakers was Dr A. G. Thompson, a consultant psychiatrist at the Tavistock Clinic, who delivered a speech on ‘The Provision of Advice on Marital Difficulties’. He warned the audience that when ‘one meets these psychological problems they cannot be dealt with by giving advice to the patients’  ³⁴ . He provided a gloomy depiction of what could be done to help the patient by emphasising the limitation of the knowledge and skills available to doctors: ‘it has been found at the Tavistock Clinic that every type of worker in this field is dissatisfied with the inadequacy both of their own knowledge and of the recognised technique’. ³⁵ FPA members were then asked to share their own experiences of this topic; many, such as Dr Spicer from North Kensington, underlined that they were not ‘educated enough to deal with this problem’  ³⁶ . Stemming from the discussion, a resolution was passed at the 1956 general subcommittee meeting stating that the ‘FPA nationally and each Branch, within its area and according to its power, should co-operate in programmes for providing education and preparation for marriage and advice on sexual problems, and where existing programmes are not adequate should initiate them when facilities are available’. ³⁷ In 1957, an ad hoc committee on help with sex problems in marriage and related matters was put together. Its aim was to address the growing demand from birth control patients for help with sex difficulties. ³⁸ As a result, the committee agreed on the necessity of offering training for all clinic medical officers prepared to advise on these difficulties. ³⁹ In 1958, the medical committee of the FPA issued a call for enrolling clinic medical officers from London and the Home Counties who dealt with marriage difficulties on a weekend course. ⁴⁰ The two-day programme included six sessions. The participants’ names again highlight the central contribution of women doctors to campaigning for establishing this field as an important part of the FPA's work. Helena Wright and Mary Macaulay discussed the doctor–patient relationship in FPA work. Dr Clifford Allen, consultant psychiatrist in charge of the psychiatric department at the Dreadnought Seamen's Hospital, Greenwich, consultant neuropsychiatrist to the Ministry of Pensions, and the future author of a Textbook for Psychosexual Disorders in 1961, approached the question of male problems. Issues linked to dissatisfied couples and failure cases were presented by Margaret Jackson; Dr Margaret Neal-Edwards, consultant gynaecologist and medical officer at the Eastbourne Family Planning Centre and assistant medical officer for maternity and child welfare in Brighton, who had also replaced Malleson at the North Kensington Marriage Welfare Centre, addressed the topic of vaginismus; and Sylvia Dawkins covered relaxation. Here again, women doctors were at the forefront of developing knowledge on the subject. Following these calls for better training on marital problems, training seminars were instituted in August 1958 under the leadership of Michael Balint, directed at family planning doctors.

Before entering into the analysis of Balint's seminar, I turn to the early form of therapy for sexual disorders developed by Wright and Malleson prior to the establishment of Balint's ‘unofficial training’. The years 1935–58 were a period of transition in which traditional notions around sexuality were challenged. This time, I argue, should be regarded as a period of experimentation, before the establishment of a more ‘conservative’ view on sexuality through Balint's seminars, which reaffirmed traditional gender roles in married life. Therefore, the early form of sexual counselling was a radical endeavour, one that laid the foundation for the second-wave feminist criticisms of sexuality as oppressive towards women that were voiced after the sexual revolution.

Centrality of female sexual pleasure: 1935–58

Many significant contributions to the understanding of sexual disorders were made by women doctors, owing to their encounters with patients in birth control, women's welfare and family planning clinics, as well as in their private practices, from 1935 onwards. This section draws on articles and books published by female doctors working in the field of sexual counselling, oral history interviews carried out in the 1980s, and fourteen recordings of sexual counselling sessions carried out by Malleson and held at the Wellcome Library. I use these sources to explore the underpinning motives for addressing female sexual disorders. These sources raise a number of important issues about the relationship between women's sexual pleasure and ‘pathology’, between natural instinct and education. Moreover, female sexual pleasure served as a forum for a competing vision of female sexuality and a new definition of the realm of doctors’ work. Women doctors, therefore, were building a citadel of expertise on birth control, family planning and sexual disorders; in so doing they expanded their professional identities and consolidated a new field of medical intervention. Furthermore, they reinforced their positions among their medical colleagues as forerunners in women's sexual health.

From 1935, Malleson held sexual counselling sessions with patients experiencing different ‘sexual disorders’, either at birth control and family planning clinics or in her own private practice. Her early form of sexual therapy seemed to have been triggered by her patients’ demands. The birth control clinic – a place where birth control was discussed and where women were encouraged to touch their genitals while placing contraceptive devices – at least provided, if not an ideal forum, a safe space for discussing sexual difficulties. Indeed, contraception was only one aspect of the sexual relationship, and patients therefore often hinted at sexual difficulties. Malleson was largely self-taught in her approach to sexual and married counselling. She never underwent any formal training in psychology or psychiatry, and seems to have built her own method out of experience, as she explained in the foreword to her book, Any Wife or Any Husband: A Book for Couples Who Have Met Sexual Difficulties and for Doctors (1950): ‘I write as a medical woman whose work deals mainly in women's health and childbearing problems. Although I lack psychiatric qualifications, I am fortunate in sharing cases with colleagues who have this training, and from them and from my patients I have acquired knowledge of sexual disorders. The gynaecologist who takes an interest in such conditions has infinite opportunities to observe and learn.’  ⁴¹ As a result, psychology and psychiatry informally entered birth control clinics as a new diagnostic tool for understanding sexual disorders. Malleson was well aware that she was a pioneer in the field of sexual counselling and complained that ‘psychotherapists apart, doctors have offered relatively little towards the solution of these intimate yet prevalent problems’. ⁴²

Many colleagues stressed the fact that Malleson's personality was extremely well-suited to this type of work. In a flattering tribute to Malleson after her death, Margaret Jackson, who had known Malleson since they attended University College Hospital together, praised her ‘great gifts of sympathy and gentleness’. She ‘brought untold comfort to the many couples who came to her with their marital difficulties and problems. Her own experiences of life and particular qualities of temperament gave her a special insight into such matters so that as a medical adviser she possessed a value quite unique and all her own.’  ⁴³ In much the same way, Dr Andrew Morland, a Harley Street chest physician, explained that Malleson's ‘profound interest in people of all types, her universal sympathy and her failure to pass judgement made her the ideal person to give advice on the problems of marriage, both mental and physical, and it is not surprising that this part of her work soon outstripped the rest’. ⁴⁴ These quotations reflect the centrality of the human dimension of this new work, which put the patient's well-being and happiness at the centre.

The recordings contain fourteen cases of sexual disorders; one was the case of a menopausal woman and is not considered here. There were eight cases of ‘vaginismus’, two cases of ‘frigidity’, and three cases of ‘inhibition of orgasm’. Three husbands came along and spoke separately with Malleson. The majority of the patients were referred by other doctors and psychiatrists, showing the increasing esteem in which Malleson's work was held. In one case, a couple who had not consummated their marriage came of their own accord, having read Malleson's book, Any Husband or Any Wife. These sessions provide useful and fascinating insights into the way Malleson deployed moral and medical frameworks to treat patients who experienced sexual disorders. These tapes were recorded in the 1950s, before her death in 1956, without her patients’ consent. It is worth mentioning that contemporary ethical guidelines did not prohibit the recording of patients’ sessions. These sessions seem to have been the only ones that she recorded. To avoid any ethical problems, these tapes have been anonymised and any personal information has been withdrawn. They were recorded plausibly at different locations: at Malleson's private practice, at the Islington clinic, and at the dyspareunia clinic attached to University College Hospital where Malleson worked until her death. ⁴⁵ Malleson plausibly aimed to use these recordings for teaching, since, as explained by William Nixon, who had convinced Malleson to join the hospital, ‘with the realisation of the importance of this subject for general practitioners it was agreed that one student should be present at each session. Many students have expressed their appreciation for the privilege of having learnt from Joan Malleson the way to deal with sexual problems which beset many married women and which if not alleviated lead to the bankruptcy of marriage.’  ⁴⁶ The intentional recording of the session as a teaching tool is also suggested by the fact that, after the sexual counselling sessions, she would make a brief summary of the case, highlighting its main features. In one case, she stressed the patient's difficulty in finding her words and emphasised the benefit of the session as ‘good for teaching purposes’. In her view, the session ‘shows the sort of expressions the patient would use and perhaps the sort of expressions that she would accept’. ⁴⁷

These recordings reveal how she approached the topic of sexual disorders, the type of questions she asked, the dynamic between her and the patient and the emphasis she placed on sexual pleasure. These cases constitute, therefore, a crucial source for illuminating how sexual problems might be understood, not only by practitioners but by the patients themselves. They reveal what was perceived as ‘normal sexuality’, what was considered pathological, and the type of treatments recommended for curing these conditions. Of course, treating these records as historical evidence is problematic in several ways. First, the doctor–patient relationship is, in itself, a power relationship. Every sexual counselling session was mediated through this relationship. Hence, every answer from the patients might have been an attempt to conform to the expectation of the doctor and to present themselves in a favourable light. However, rather than viewing this as a problem, I argue that this relationship reveals as much about what was perceived as ‘normal’ or ‘pathological’ sexual behaviour as the content of sexual counselling itself. These records, therefore, offer a glimpse into the ideas around heterosexuality that circulated at the time, both in lay and medical circles. ⁴⁸

Clinics constituted an invaluable place to gain intimate knowledge of difficulties faced by couples. The value of the experience acquired through encounters with patients was made clear in the sex advice manuals and articles that women doctors published. They paid tribute to their patients for providing them with adequate knowledge of sexual disorders: ‘the daily work of a gynaecologist brings her into continual touch with married life in all sections of the community. It was not long after I began practice that the dismal act of sexual success which was spoiling the lives of patients showed itself as an unnecessary tragedy compelling attention’, ⁴⁹ wrote Wright in 1947. Meanwhile, Malleson acknowledged in 1942 that her understanding of some specific types of sexual disorder, and therefore her own devising of therapy, owed much to her patients’ explanations:

This first-hand experience with patients’ difficulties convinced Malleson that much of their mental and physical ill health was caused by sexual difficulties due to ignorance. Overcoming sexual ignorance seemed to have been the driving force behind women doctors’ writing of sexual manuals. As expressed by Malleson as early as 1935 while writing about women's lack of pleasure:

To help women overcome this lack of knowledge, Malleson wrote two books and three leaflets for the Family Planning Association at the end of the 1940s, one on ‘Sex Facts in Marriage’ and the other two on ‘Sex Problems in Marriage’. The targeted audience included female and male patients of FPA clinics who were encountering sexual difficulties and were thought of as being ignorant about sexual intercourse. The first leaflet provided basic information on the functioning of sexual intercourse, since ‘the understanding of these facts is the foundation on which a good relationship must be built’. ⁵² The leaflet depicted the penis, clitoris, and vagina as loci for sexual pleasure, while emphasising that women's pleasure is different from that of men, since women had two places where sexual pleasure could be felt. In the two leaflets addressing sex problems in marriage, Malleson identified five main reasons behind the failure to achieve sexual satisfaction: inability or lack of knowledge ‘to give the other the kind of intercourse that she or he needed’; ⁵³ the nervousness of one partner, ‘(usually women)’, Malleson added; fear of pregnancy; dissatisfaction with birth control method; and low frequency or absence of intercourse. The second leaflet concentrated on female sexual disorders only. Here, again, Malleson put forward women's ignorance about their own bodies and men's lack of skills in sexual matters as the main reasons behind female sexual dissatisfaction. Building on this idea, she contended that patients could overcome their difficulties if they ‘understand a little of how these are caused’. ⁵⁴

Malleson was not alone in her belief that sexual ignorance was the main cause of sexual dissatisfaction. Helena Wright clearly laid out the same idea in the foreword of her 1930 book: ‘When no trouble is taken to learn how to make sexual intercourse harmonious and happy, a variety of complications arise. Very often wives remain sexually unawakened and therefore inclined to dislike sexual intercourse.’  ⁵⁵ About eighteen years later, she introduced the readers to her new book by referring to her first attempt to arm married people with sexual knowledge:

In 1982, reflecting on the work she carried out in family planning clinics, she remembered a specific example in which ignorance accounted for sexual dissatisfaction: ‘I used to give these patients any chance to talk. I would say now you are perfectly safe you won't have another child. Do you enjoy having intercourse at all? And the patient said these historic words: “But doctor, what is it to enjoy?” Now when you look deeply into that, it was total ignorance.’  ⁵⁷

Importantly, women doctors actively created a vision and depiction of English women as intrinsically ignorant about sexual behaviours, which had long-lasting and very often dramatic consequences for their married sexual lives.

The work undertaken by women doctors in birth control clinics, while adhering to the vision of preserving the family and the well-being of overburdened mothers, also expanded the notion of sexual pleasure in a more radical way. To these women doctors, sexual pleasure represented a central priority in sexual counselling sessions. Of course, the fact that women doctors were women facilitated conversations about sex and pleasure. Indeed, sex was still a taboo topic, and the fact that the idea of respectability was connected with sexual ignorance might have prevented female patients from broaching the subject freely in the presence of men. As Sylvia Dawkins recalled in an interview for the Television History Workshop in 1988 about work in the clinic: ‘it was the situation of women talking to women who accepted that women enjoyed sex, wanted sex. Not only for procreation, that it was a very bonding thing which helped the relationship. Very valuable.’  ⁵⁸ Women's sexual pleasure, or lack of, became a central element of sexual counselling. Women doctors would ask, as related by Dawkins: ‘Do you have pleasure, are you enjoying it?’ However, ignorance of basic terminology on the part of the patient meant that women doctors did not refer to medical language: ‘I didn't use the word orgasm because most of them wouldn't have understood.’  ⁵⁹

Historian Hera Cook has shown that female sexual pleasure, though through penetration, became a central component of a happy marriage, as described by sexual manuals in the interwar years. ⁶⁰ What has not been fully acknowledged, however, is the care with which Malleson and Wright emphasised it and the fact that they believed in the educative role of the doctor. This was very much a legacy of the social hygiene movement, where working-class mothers were taught the basics of hygiene in maternal health and antenatal care by medically trained public servants in antenatal clinics. ⁶¹

According to Malleson, the role of the doctor was clearly active, by broaching the subject: ‘The practitioner who has knowledge of these important aspects of family life will find what a vast amount of unhappiness is caused by ignorance and sexual maladjustment. It is surprising how frequently help can be given by a little sympathetic and practical advice.’  ⁶² Malleson also explained that ‘once the confidence of the patient is gained it is not difficult to ask her whether she is getting her own satisfaction and to explain that if she is capable of getting a climax it is necessary for her health that she should do so’. ⁶³ Similarly, Wright believed in the importance of education for a fulfilled sexual life. There was a constant tension in her writing between the idea that sexuality was a ‘natural’ thing – ’Sex desire is a natural characteristic of every normal adult woman and man, in itself as beautiful and blameless as moving or breathing’  ⁶⁴ – but that it nevertheless needed to be educated and monitored for individuals to make the most of it and to prevent ‘an overwhelming majority of people [from] fling[ing] themselves into marriage, ignorant, unprepared, vaguely hoping for the best’. Wright repeated this argument multiple times in her career:

However, women doctors’ views on sexual pleasure were ambivalent and embodied contradictions. Arguments supporting female sexual pleasure melded traditional and radical visions of sexuality by navigating between established ideas of female sexuality (passive agent that needed to be aroused by the man and the idea of the vagina as the locus of mature sexual pleasure) and the new radical vision of women as active agents in sexual relationships and of the centrality of the clitoris. The coexistence of these arguments not only reflected the transitional period between the 1930s and the 1950s in which social attitudes towards sexuality and female pleasure were shifting, but also the idea that sexuality might be, in itself, multiple, and that there existed different lived experiences. One of the first things Malleson put forward in her 1935 book was the fact that individuals needed different things in their sexual lives; therefore, no clear guideline for behaviours existed: ‘It should be remembered that it is always unwise to urge a line of sexual behaviour on another person, for in every case the sexual life of the individual is intricately bound up with his physiological and psychological needs and those of his partner.’  ⁶⁶

While members of the marriage reform movement underplayed the importance of clitoral orgasm and praised the vaginal one, following the Freudian vision of sexual maturity, Malleson and Wright, informed by the difficulties experienced by their patients in simply reaching climax, rehabilitated clitoral orgasms as a way for the wife to experience sexual pleasure in a marital sexual relationship. For instance, Malleson explained that only one woman out of three could achieve sexual satisfaction through the ‘straightforward act of sexual intercourse’. ⁶⁷ The majority of women seemed to get their ‘greatest sexual feelings’  ⁶⁸ from the clitoris, which was its ‘sole purpose’. The clitoris was easily aroused if given the right kind of ‘caressing movement by the husband's hand’, she argued. Following this line of thinking, she explained that vaginal sensations are not easy to feel at the beginning of sexual experience, but that ‘time and experience gradually awaken feelings in the vagina’. ⁶⁹ Two ‘conflicting’ views coexisted side by side in Malleson's work. She recognised the central significance of the clitoris as the main place for women's sexual pleasure, presenting it as more straightforward than the vagina, while nevertheless acknowledging the vaginal orgasm as a deeper and more rewarding orgasm: ‘Although some women cannot distinguish between clitoral and vaginal orgasm, usually the functions are quite distinct. A woman who can get both types of orgasms nearly always values the vaginal one most: normally it evokes deeper emotion and is more satisfying.’  ⁷⁰ At times she challenged the Freudian vision of sexuality by positively emphasising the key role of the clitoris in women's sexuality, though at other times she seemed to agree with the idea that clitoral orgasm was linked with inexperienced sexuality. While emphasising that there were no ‘norms’ or ‘normality’ when it came to sexuality, Malleson nevertheless described what she considered to be the ‘fairly average standard’. An ‘experienced woman’ should moisten and penetration should be painless. A vaginal orgasm should ‘ideally’ take place after a prolonged back and forth movement of the penis inside the vagina. Unless able to attain a vaginal orgasm, she should reach a clitoral climax produced by the husband's fingertips. The clitoral orgasm therefore appears to have been seen as compensation for a failed vaginal orgasm.

This ambivalence was perpetuated in sexual counselling sessions. The following excerpt is taken from the recording of a sexual counselling session with a young unmarried female patient who ‘complained she did not get [an] orgasm’, ⁷¹ as recorded by Malleson when introducing the case. The patient did not seem to mind experiencing no pleasure, but her partner did and wanted her to have an orgasm. This reveals an increasing male interest in female sexual pleasure, plausibly reflecting the stabilisation of the new norm of mutual pleasure; the unmarried female patient said: ‘I had intercourse with three men, I didn't really mind, I knew some women didn't. It was sort of pleasant and the chap was enjoying it and I think I didn't really mind. But I have recently met with a man who does mind if I don't. That makes me worry about it.’ The patient was anxious to understand what an orgasm was and the difference between a clitoral and vaginal orgasm. Malleson responded by emphasising the significance of sexual experience in the attainment of a vaginal climax. Her answer was testimony to her partial adherence to Freudian principles: ‘It's rather the same as an outside one but as you rightly say, it's got different sensations. [pause] I think it's quite early on to expect a vaginal one yet, you know. It takes much more learning. Its err, most little girls can get a clitoral one. Urm, the vaginal one is much more, that of an experienced woman.’  ⁷² However, Malleson nevertheless validated the clitoral orgasm and presented it as a legitimate solution for sexual pleasure:

Interestingly, the young woman stressed her desire to reach a mutual orgasm, showing how the new norm of mutual sexual pleasure and the centrality of the vagina might have been internalised. Malleson repeatedly emphasised the fact that women who could reach clitoral orgasm were ‘not too badly off’.

Another ambivalence found in Malleson's written production and counselling sessions is connected to the role of women in their search for sexual pleasure. She encouraged women to take an active role in guiding their husband towards the provision of adequate caressing of the clitoris in order to trigger their clitoral orgasm. The example of a married woman with inhibition of orgasm illustrates Malleson's commitment to female sexual pleasure. The patient could reach clitoral climax while masturbating, but her husband was unable to sexually satisfy her. Malleson advised the patient to discuss this issue with her husband and to show him how to provide her with pleasure:

While recommending that this patient carefully express her feelings, Malleson nevertheless explicitly warned other female patients against the spoken formulation of their sexual dissatisfaction, which could endanger the husband's confidence in his sexual capacity, thereby threatening his masculinity. Indeed, as the following example shows, Malleson praised one of her patients for her sensitivity in hiding from her partner her lack of sexual pleasure, but paradoxically urged her to take a leading role in the sexual act. The patient was a woman in her mid-thirties who had got married for the second time and was seeking advice about her lack of sexual pleasure and feeling of depression. At the time of the interview, she had been married for a year and was sexually unsatisfied. To a question about her husband's sexual ability, she reckoned that her husband was not ‘very competent but he is trying hard’. ⁷⁵ Afraid of hurting his feelings, she kept her lack of pleasure hidden from him. Contrasting her present experience with that with her ex-husband, she explained that her new husband was quick to come, while with the previous one she had had vaginal orgasms but after longer intercourse of about twenty minutes. Malleson applauded her good reaction and provided advice on the best way to handle the situation:

Interestingly, Malleson counselled the patient to initiate sexual intercourse as a means of reassuring the husband that he was desired and loved. Similarly, she encouraged a patient who suffered from vaginismus and ‘acute anxiety neurosis’ and cried anytime she tried to have intercourse to steady her husband's penis with her hands and guide it towards the vagina. Malleson emphasised the fact that the patient's behaviour, and notably her tears, might have upset the husband who might have lost his confidence:

These excerpts show the ambivalence towards male sexuality as well as ongoing constructions of masculinity. Husbands were presented as in need of education on their wife's pleasure, but they nevertheless required a special form of treatment that preserved their feelings of confidence, and therefore their masculinity. The performance of sexuality was intrinsically linked with that of masculinity, and any attempts to criticise the techniques of the husband might lead to feelings of inferiority on his part. Women therefore carried the burden of making sure not only that their husband gave them sexual pleasure, but also that the latter knew how to satisfy them through a careful education on the importance of the clitoris while, at the same time, safeguarding their husband's feelings and masculinity. This inclination of the medical body towards the preservation of the male's virility was not confined to sexual pleasure but extended to treatment for infertility through artificial insemination by donor. Gayle Davis has underlined the fact that the doctors who practised this procedure, such as Mary Barton and Eleanor Mears in London, did not inform the sterile husband of the extent of his sterility, but rather said that he was ‘impaired’, and consequently mixed his semen with the donor's to preserve the husband's sense of masculinity and virility. ⁷⁸

This contradictory injunction led Malleson to recommend that her patients keep trying to have sexual intercourse, despite their lack of pleasure or feelings of pain. She paralleled the learning and development of sexual capacity with the practice of cycling. To a 22 year-old married female patient, who suffered vaginismus and great distress anytime her husband tried to have intercourse, and who, as a result, wanted to ‘get a rest’ from intercourse, she said: ‘But one doesn't learn to do a thing by not trying. Well, if you are afraid to ride your bicycle you shouldn't put it in the shelter. It is not the way to do it.’  ⁷⁹

Malleson played with prevailing gendered sexual norms, at times challenging them radically and on other occasions counselling the patient to abide by them. However, a fine line was drawn on the necessity for men to have sexual satisfaction. Women should try to reach orgasm, but even if they could not, they were nevertheless urged to satisfy their husband. Malleson's vision of female pleasure during ‘problematic’ sexual intercourse tended to be more of a psychological and emotional nature rather than of physical one. Giving the husband sexual pleasure, she argued, was in itself a form of satisfaction for the wife. This stance was made clear in the advice she gave to one of her patients; aged thirty-eight, the patient had been married for ten years, but never experienced sexual pleasure. She was sent to Malleson by a psychiatrist who described her as ‘an extraordinary crude creature who resents any sign of affection at all from the part of the husband and never had any interest in intercourse’. ⁸⁰ The patient explained that she told her husband that she didn't get any pleasure at all from intercourse. She further argued that it was not in her nature to show any form of affection; that she had been brought up this way. The husband, hurt by this revelation, no longer wanted to have sexual intercourse. Malleson seems to have been shocked by the detachment of the patient and, as a result, with a gentle, soft voice, nevertheless condemned her behaviour:

To save their marriage, Malleson suggested to the patient that she should tell her husband that she did enjoy pleasing him:

Malleson later reflected on this session and reckoned that she ‘probably didn't handle it as well as I should. It was hard not to be repelled by her coldness. Perhaps had I approached her differently, a way would have opened.’  ⁸³ This disapproval of the wife's behaviour reflects Malleson's view of what a good wife should be – namely a loving and affectionate partner. Her belief that sexual intercourse could be enjoyable for reasons other than sexual pleasure seems to have been widespread at that time. Indeed, similar statements were found by Szreter and Fisher in their oral history study on birth control and sexual behaviour among middle- and working-class people before the sexual revolution. They contended that couples perceived sex as fulfilling when the following conditions were met:

Comparatively, Wright's view on female sexual pleasure evolved drastically over time, mainly because of a careful analysis of her patients’ difficulties. Wright was more inclined than Malleson, who had a more authoritarian approach to counselling, to reconsider her own views on female pleasure. In her first sexual manual, Wright contended that women needed to be aroused by their husband, a common stance in the sexual manuals at the time, yet their pleasure constituted an essential component of a successful married sexual life:

Paradoxically, Wright simultaneously retained an active role for the wife in the enhancement of her own sexual pleasure: ‘The wife must decide with all her strength that she wants her body to feel all the sensations of sex with the greatest possible vividness.’  ⁸⁶ Wright strategically valued the clitoral orgasm by comparing the role of the clitoris with that of the penis:

Moreover, the clitoris was the ‘gateway’ to vaginal sensation. However, after fifteen years of working with patients who found it difficult to reach orgasm, Wright came to a dramatic conclusion – one that prefigured the 1970's discourses about the critics of sexuality as being patriarchal, and the idea that gender identities were socially and culturally constructed. Three reasons, she argued, might explain why 50 per cent of married women did not experience sexual satisfaction during their marital life: failure to identify the difference between ‘sexual response in the erogenous zones and an orgasm’, ⁸⁸ underplaying the importance of the clitoris, and adherence to a male definition of sexuality. Indeed, she said that women did not experience pleasure because of their unconscious adherence to a preconceived mental picture of the way they should feel during intercourse, based on the male pattern. This pattern had been established and reaffirmed over time, since the majority of people who wrote about love and sexuality were men:

Tradition had defined men as active and women as passive, she argued, and individuals had internalised the fixation on penis–vagina sex. This internalisation of the male pattern, namely the fixation on penis–vagina sex and the active role of men, had prevented women from understanding their own bodies and, as a result, they ignored the function of the clitoris. ‘Is the vagina the natural place where a woman should feel an orgasm at the beginning of her sexual life?’, ⁹⁰ asked Wright provocatively. The answer was no, and the clitoris, asserted Wright, was the natural place for female sexual pleasure. To support her claim, she compared the physiology of the penis with that of the vagina: ‘Looking at the male and female organs from a sensation point of view, it is immediately obvious that similarity of function exists between the sensitive head of the penis and the clitoris, and not between the penis and the vagina.’  ⁹¹ The development of the organs during the gestational time was a second indicator of similarity, as was the fact that both organs are covered by ‘sensitive mucous membrane and both are protected by a surrounding hood of tissue’. ⁹²

Wright urged women to identify their clitoris and discover its sensitivity by gently stroking it with an external object such as ‘an uncut pencil’. In so doing, they should identify their preferred rhythmic friction and then teach their husband the way they enjoyed being caressed by guiding and moving his hands accordingly. Wright called for a radical reshaping of the way men and women thought about sex. She emphasised the historical gendered construction of sexual identities, in which men were depicted as active agents and women as passive: ‘He is the heir to an inheritance of sexual behaviours with a continuous history stretching back to the whole mammalian evolution. For him to take the initiative and to be active in sexual matters is its most natural behaviour’. ⁹³ Women too had inherited a long tradition of sexual behaviours, but theirs went ‘in the opposite direction’: ‘History, society and her own feeling suggest that she should be the one who is sought. To be active and to take initiative in sexual concerns is, for the most majority of women, an unnatural proceeding.’  ⁹⁴ Wright encouraged women to depart from this tradition and to take an active role in their sexual life.

This internalisation of distinctive sexual roles was reflected in Malleson's patients. Indeed, they echoed the ‘fixation on the penis–vagina’. Most of them sought help for curing a lack of vaginal sensation, believing that a sexual relationship should be penetrative and enjoyable and lead to a mutual orgasm, due to the prevailing strength of cultural and social constructions of female and male pleasure. Malleson, in particular, negatively denounced the new pressure to conform to the new sexual norm of reaching orgasm that women were encountering: ‘I think it is a difficulty of your generation because twenty to thirty years ago hardly any women got orgasms, and it was not talked about. Now it is talked about everybody feels that it should be a standard measurement and wonders if there is something wrong with them if they are not exactly like someone else they've heard about. It's miserable. Everybody is different. You cannot compare with somebody else.’  ⁹⁵

Sexual disorders in women: identification and therapeutics

Just as sexual pleasure was becoming central to the work of Wright and Malleson, the latter, triggered by an accumulation of cases that underlined the difficulties for many women in experiencing sexual pleasure, published several articles in medical journals that offered a scientific classification and description of female sexual disorders and suggested therapy for them. Replicating the strategy of asserting their legitimacy through the medicalisation of the issue, a strategy that had successfully been used for birth control (see Chapter 1), these pioneer women published articles in respected medical journals and spread scientific knowledge of sexual disorders. This medicalisation of sexual disorders, which paradoxically relied on informal psychology, was a strategic move to make this new field of inquiry respectable.

Distinguishing between frigidity, lack of sexual capacity, vaginismus, vaginal anaesthesia and inhibition of orgasm, Malleson first endeavoured to provide an accurate description of each term in an attempt to position sexual disorders as a new scientific field of research. Frigidity referred to the absence of emotional and physical response to ‘the sexual relationship under discussion’. ⁹⁶ This condition should be differentiated from that of women who could experience erotic feelings, but lacked the intensity to bring about orgasm. She suggested referring to these women as ‘lacking orgasmic capacity’. This condition did not necessarily imply difficulties in health or in their married life; ‘the fact remains that many women with no such capacity are perfectly healthy and stable’. ⁹⁷ She also pursued the description of ‘vaginismus’; the term denoted a condition of ‘vaginal spasm varying from a constriction at the beginning of coitus (so slight that it may merely discomfort the woman herself) up to the extreme case in which the spasm causes acute pain to the woman and entirely prohibits any penetration by the husband’. Another condition was that of vaginal anaesthesia, which varied in degree and persistence from women capable of a little sensation to women suffering complete and permanent anaesthesia. This condition appeared to be common in newly married women. While reaching vaginal orgasm might be difficult for these women, some of them would experience a clitoral orgasm and have a happy and enjoyable sexual life. Inhibition of orgasm – a condition in which sexual feeling and erotic sensation were present but no orgasm could be reached – represented another sexual disorder. Women affected by this condition experienced sleeplessness, depression, frustration, aching back and pelvis the day after intercourse, and eventually symptoms of anxiety neurosis. A potential result of this condition might be secondary frigidity, which went hand in hand with distaste for sexual intercourse.

Malleson developed a sophisticated therapy over the course of her career, from the early 1930s to her death. Her therapeutic framework was psychological. As early as 1935, in a manual published for fellow practitioners, she resorted to specialist psychological vocabulary, which clearly indicates her knowledge of the field: ‘The recent understanding of anxiety-neurosis has thrown a floodlight onto types of functional ill health which make up of the work of a general practitioner. Among the factors which cause this condition must be considered the sexual (and therefore contraceptive) adjustment of the patient.’  ⁹⁸ The relationship between anxiety and ‘interferences with the satisfactory completion of the sexual act’ therefore became a central aspect of her work. This relationship had profound implications for the way Malleson understood her patients’ sexual difficulties and the type of treatment and therapy that she would prescribe. She drew on Freud's ideas on the psychosexual development of men and women, though she did not adhere entirely to his vision of female sexuality. She was recognised as a Freudian by her colleagues, as shown by her response to a letter from Griffith in which he asked whether the Freudian school approved or disapproved of the practice of stretching the hymen: ‘I have certainly never heard of any condemnation of the practice by a Freudian.’  ⁹⁹ In a tribute to Malleson published in the New Statesman and Nation after her death, the journalist Kingsley Martin, who knew Malleson during the last years of her life, wrote that she ‘early discovered that it was impossible to divide gynaecology from psychology […] She could argue about Freud and Jung with psycho-analysts, and no doubt she found the key to many neuroses in their works. But a prolonged course of psycho-analysis is not a useful remedy to recommend to a woman with a family and a husband earning 10 pounds a week.’  ¹⁰⁰ Furthermore, publishing in different medical journals, she referred to the Freudian idea of psychosexual development of the child: ‘In fact, psychologists assert that the earlier in infancy the trauma is experienced the more indelible will be its impression.’  ¹⁰¹ In her sex manual for couples, she stated: ‘What writers have largely failed to recognise, perhaps because they cannot tolerate the acceptance – is that many people's sexual handicaps are, since childhood, deeply engrained […] I shall hope to show that most sexual disorders have a nervous origin.’  ¹⁰²

For Malleson, what was at stake in trying to help couples face and overcome – if possible – their sexual difficulties was informing them about the unconscious barrier that prevented them from fully achieving climax. This approach was applied for inhibition of orgasm and vaginismus. She believed that most sexual disorders derived from emotions and from an inhibition of erotic impulses, restricted since early childhood. As a result, she asked her patients to talk and sought to find causes for ‘inhibition’ and ‘vaginismus’ in childhood traumatic experiences or unconscious conflicts. For instance, Malleson treated four cases of vaginismus and two cases of inhibition of orgasm at her clinic at University College Hospital. In the first case of vaginismus, the patient, attending for the second time said she had made some progress: ‘I feel more relaxed and I feel much better and I feel less pain. I still feel in my mind that I need to relax. It is not physical, it is in my mind, and I cannot find a way to do that.’ Malleson encouraged her to dig into her childhood memories to find any cause of possible trauma, as shown by the following excerpt:

She followed the same type of procedure with each patient, pushing them to explain what was going on in their sexual life and why they were seeking advice. By encouraging the patient to speak and reflect on their own sexual life, she challenged the sexual culture that told women to be ignorant and passive. She mediated between the prescriptive and the subjective, leading the patient to reflect on their own history; but also very often she put words into the patient's mouth, imposing, to some extent, her own views about their sexual life. Sexual counselling was an intense negotiation between patients’ individual experience and needs and an expert's prescriptive advice. Indeed, while encouraging the patient to self-diagnose, Malleson nevertheless discouraged self-diagnosis when it came directly from the patient herself without having been first mediated by her, as shown by the following example with a 37 year-old divorced and remarried woman who lacked sexual pleasure in her current married life:

In one case she also used the concept of transference, without naming it, which showed her deep knowledge of psychological concepts. To the frigid patient who did not express her love to her husband, she suggested that her cold behaviour reflected the hate she felt for her father instead of her husband:

Besides developing a therapy based on discussion and in-depth reflection on the sexual experience of her patients, Malleson also elaborated practical means to improve female sexual life. For instance, she encouraged ‘tight’ women to dilate their hymen themselves: ‘it is my own habit to show a woman how to do it for herself, and I imagine this reduces any psychological trauma to a minimum. I find only a very few cases which need a whiff of gas, or any real procedure.’ She lent them different sizes of dilators to take home and ensured they came back for checking. Second, for women with secondary frigidity or vaginismus, she taught them the lying position they must adopt to relax the entrance of the vagina, which should ease the penetration of the penis. Through simple exercises that they practised within the office, Malleson educated and corrected her patient: ‘It's all a matter of learning various sorts of tricks with your muscles to relax because you see it is not that a person is too small, it is about being too tight; they hold themselves too tight because they're frightened. If I show you some way to relax, it's easy to cure this disorder. It doesn't go on for ever, but you do need rather a special help.’  ¹⁰⁶ Vaginal lubrication was routinely prescribed by Malleson as a means to improve sexual relationships. She was convinced that a great deal of sexual disorders could be resolved by adequate lubrication, vaginal lubrication being of ‘inestimable value’. ¹⁰⁷ For women who lacked moisture and found penetration difficult, she would explain:

Meanwhile, the therapy developed by Wright was based on her own experience with sexuality. Being married to a man five years younger, who was a virgin, meant that her sexual experiences had not been enjoyable from the beginning. In a private conversation with her biographer Barbara Evans, Wright explained:

Already before marriage, Wright, anxious to have pleasant intercourse, looked for information in textbooks about her hymen and the way to stretch it herself. As a result, she recalled that the ‘first intercourse wasn't painful, but everything felt dead. I didn't want to wound Peter, but I thought to myself, “there must be some way of doing this”.’  ¹¹⁰ She sought inspiration in books: she read the Kama Sutra and the six volumes of Havelock Ellis's Studies in the Psychology of Sex (1896). She then encouraged Peter to experiment with their sexual life, and ‘they did’. During their married life, Wright had several lovers. Drawing on her readings and personal experience, Wright devised a method for the patient who consulted her about sexual difficulties. She would first begin the appointment with a physiology lesson with the help of a drawing of a nude male to give the patient a basic understanding of the sex organs. She would then go on with a lesson in the female and male anatomy and the sensitive part of their bodies. Using a mirror, she showed the patient the precise location of the clitoris and let her discover the joy of caressing it. ¹¹¹ She then urged the patient to teach her partner her preferred rhythmic friction and emphasised that the man should also play his part and adapt to his partner rhythm for the patient to have an enjoyable sex life.

The seminars, set up after Malleson's death, derived from women doctors’ will to meet their clients’ needs. For instance, Dawkins remembered that when Malleson died in 1956, she ‘had to take on her clinic’ at University College Hospital. Having the feeling that she did not know enough, she attended Michael Balint's seminar on psychosexual counselling. Over a period of two years, the scheme provided weekly case seminars conducted by Balint, modelled on those provided by him at the Tavistock Clinic for General Practitioners. Balint was a Hungarian psychoanalyst who lived in London and worked as a consultant at the Tavistock Clinic in London. He developed a method to ‘train’ as opposed to ‘teach’ the general practitioner in psychotherapy based on the relationship between patient and doctor and group seminars. In Balint's view, more than one quarter of the work of the general practitioner consisted of providing psychotherapy. However, the general practitioner responded inadequately to these cases as, most of the time, his or her role was limited to prescribing a bottle of medicine or reassuring the patient that ‘nothing organically wrong has been found’. ¹¹² To remedy this problem, the general practitioner should acquire new skills: ‘the doctor has to discover in himself an ability to listen to things in his patient that are barely said, and, in consequence, he will start listening to the same kind of language in himself’.

Formalising psychosexual training: the setting up of Balint's seminar 1958–74

To sum up Balint's main idea, the consultation between a doctor and patient is a moment of human negotiation in which the patient ‘offers’ his or her illness, which might not be the main reason for the consultation, and the doctor offers a response to it through listening, reassuring and suggesting a treatment. In so doing, the doctor ‘helps the patient to organise an illness around certain symptoms’. ¹¹³ However, the way the doctor answers the demands of his or her patient in turn influences what a patient expects and says. Moreover, the doctor's answer is shaped by what Balint called the ‘apostolic function of the doctor’, which is the meaning and perception that the doctor gives to his or her work. The doctor's training, the mores within the medical profession, and the doctor's personality are all factors influencing this apostolic function, creating an ‘automatic pattern of response’. Therefore, in addition to the patient, the doctor should also be considered an object of study so as to free himself or herself from this automatic pattern. The training provided by Balint consisted of a group of eight to ten doctors led by a ‘supervisor’ or ‘leader’. Each doctor was instructed to share his or her own experience with ongoing cases and to describe, as frankly as possible, his or her difficulties. The cohesion of the group would enable the doctor to identify mistakes, blind spots and limitations, allowing a better understanding of his or her problems. Sharing their experiences encouraged the doctors to experiment, thereby breaking the automatic behaviour.

From 1958 onwards, a group of ten women doctors followed this training scheme and met under the guidance of Balint to discuss individual cases of ‘sexual and marital disharmony’. The group included Sylvia Dawkins, who had worked with the FPA for over twenty years when she started the training; Rosalie Taylor, who had twenty-five years of experience in medical gynaecology; Jean Pasmore, a general practitioner; Mary Pollock, a gynaecologist; Alison Giles, a general practitioner who had worked for the FPA for ten years; Eleanor Mears, who had seventeen years of experience in medical gynaecology; Margaret Blair, a general practitioner with an interest in medical gynaecology; Rosamond Bischoff, a specialist in medical gynaecology and obstetrics; Ruth Lloyd-Thomas, a general practitioner; and Eileen Mallinson, a maternity and child welfare medical officer.

As explained by Balint, the aim of these meetings was to ‘develop therapeutic techniques by combining the routine gynaecological and the psychotherapeutic examination into one integrated approach to the patient's problems’. Since most of the patients coming to family planning centres were women, members of the training scheme primarily discussed female sexual difficulties, the more common ones being non-consummation and dyspareunia. The group shed light on the main reason behind these sexual difficulties, which they attributed to the female patient's inability to accept her own body as a site of pleasure for both her and her partner. In addition, the group identified various ‘nightmarish phantasies’ about what a sexual relationship should be. The therapy developed by the group to resolve these difficulties consisted of trying to find the reason for the patient's rejection of her own body. ¹¹⁴ Three main publications resulted from these meetings: in 1961, Alison Giles published ‘Learning to deal with sexual difficulties’ in the Family Planning Journal, while Sylvia Dawkins and Rosalie Taylor wrote ‘Non-consummation of marriage’ for the Lancet and, in 1962, Leonard Friedman released Virgin Wives: A Study of Unconsummated Marriages. The book offered an analysis of non-consummation in marriage based on the classifications of patients into three categories. The first category was the ‘sleeping beauty’ – namely patients who ‘restrict conscious awareness of sexual feelings. They use the defence mechanism of “not knowing” about their sexual organs to ward off anxiety.’  ¹¹⁵ The second category was ‘aggressive women’, who made their husbands impotent. In these cases, the doctor had to be able to decode the behaviour of the patient while simultaneously being aware of his or her own feelings towards the latter. The last category was women who were still virgin, but nevertheless became virgin mothers through the injection of their husband's semen into their vagina with a syringe. In all cases, the therapeutic method developed is one of interpreting the patient's conflicts rather than reassuring her. One recurrent element, emphasised by numerous doctors who undertook this psychosexual training, was the fact that patients revealed their deepest anxieties, fears and fantasies during the vaginal examination. Consequently, several doctors referred to it as ‘the moment of truth’. Doctors encouraged their patients to describe what they thought their vagina and uterus looked like and, to dissipate any misconceptions, urged them to explore it and feel it for themselves. ¹¹⁶

Aside from Balint's training, two other leaders oversaw psychosexual training: Dr Tom Main, director of the Cassel Marital Clinic, and Dr Thompson, a senior member of the staff of the Tavistock Clinic. There was resistance from the FPA headquarters to the formal implementation of sexual counselling and its connected training, in part due to financial constraints and in part to do with the nature of the service provided. Prudence Tunnadine recalled the way people working in sexual counselling were deemed a ‘lunatic’ fringe:

Thus, seminar training arose from a grassroots base; it emerged from the pressure of many doctors requesting help to deal with their patients’ sexual problems. First established informally, they grew in numbers, and formal, official training was put together in 1974. ¹¹⁸ These seminars appeared to be more conventional than subversive in terms of the gender roles they conveyed, since they relied heavily on Freud's vision of sexuality and urged male and female patients to comply with and perform the traditional gender roles of the feminine and loving wife and the masculine, active and virile husband.

Under the training of Balint and Main, women doctors developed a more gendered, differentiated perception of sexual behaviours, linked with notions of femininity and masculinity. Indeed, in the 1966 Handbook on Family Planning, Jean Pasmore, who was trained by Balint, presented frigidity as the expression of a woman's ‘fear or dislike of physical relationship with the man, her difficulty in accepting the social role of being a woman and her resentment against the man’. ¹¹⁹ In her 1970 book, based on her individual practice as a sexual counsellor in a family planning clinic and her training under Thomas Main, Prudence Tunnedine presented a case of secondary frigidity: a mother who could no longer experience orgasm. Resorting to gendered expressions of femininity, Tunnedine argued that her patient's childhood explained this lack of sexual pleasure:

Tunnadine also narrowed the notion of frigidity as described by Malleson from an absence of feelings to the inability to achieve vaginal orgasm within the act of intercourse; therefore, she adopted the penis–vagina fixation denounced by Wright. When she acknowledged the role of the clitoris in sexual pleasure, she asserted that, departing from Masters and Johnson's analysis of vaginal orgasm as the result of the penis petting the clitoris, this type of orgasm conveyed a different emotional signification: ‘the togetherness, mutual abandonment of control systems, the emotional acceptance of the penis and all it implies in terms of the man, and of the vagina and all it implies in terms of the woman, make this a unique experience that is not mimicked emotionally by mutual masturbation, however loving’. ¹²¹ Her approach to frigidity was deeply rooted in Freud's theory of child development. Indeed, she further invoked the concept of ‘penis envy’ to explain why some women could not achieve vaginal orgasm: they unconsciously envied ‘man, the organ and all it represents and reacted against them with resentment, anger and the need to control and destroy’. ¹²² This depiction of female sexuality would be strongly criticised by second-wave feminists. As this example illustrates, although the 1960s are often perceived as a period of sexual radicalism, this does not hold true for sexual counselling. In terms of sexual counselling, the period featured a return to traditional values around gendered responsibilities within marriage.

Sterility session

The second orientation of the work done under the label ‘sub-fertility’ was the handling of sterility cases and difficulties conceiving. Again, this service was grounded in patients’ demand for advice on the issue. From the 1920s, scientific developments took place within the field of infertility; tubal insufflation and the salpingogram became used as tests for tubal patency. Despite these new techniques, surgeries were still rare and women's chances of conceiving remained low. Semen analysis was increasingly practised, but there was no consensus on the number of sperm needed for successful conception. ¹²³ Until the setting up of specialised sessions in family planning clinics, medical ‘treatments’ for infertility were still only available on a private basis. For instance, Margaret Moore White was the first assistant at the gynaecology department of the Royal Free Hospital, where she treated infertile patients from the mid-1930s onwards. Mary Barton counselled infertile patients in her private practice. The latter was famous for practicing artificial insemination by donors – the sperm came from anonymous donors, among them her second husband, Dr Berthold Wiesner, who was said to have fathered more than a hundred babies – and many patients who wrote to the FPA in the late 1940s asking for advice on this practice were referred to her. Other famous male professionals, such as Wiesner and Kenneth Walker, also specialised in infertility.

However, it was only after 1930, when Margaret Jackson started to advise and treat couples for infertility in the Exeter and District Women's Welfare Centre, that the possibility of seeking medical treatment opened up for working-class and middle-class patients. Out of the total number of patients attending the clinic in 1933, only 1 per cent sought advice on infertility. In 1943, this had increased to 33 per cent, totalling 161 patients. ¹²⁴ Initially, Jackson wished to refer the patients in need of full investigation and treatment ‘elsewhere’, but she rapidly realised that there were no facilities to deal with them and if this type of work ‘was to be done at all’, members of the clinic ‘had better do it themselves’. ¹²⁵ Consequently, she actively looked for financial and material help with developing this new area of work through three essential steps: acquiring new skills and instruments, access to an X-ray department, and access to a laboratory that could run semen analysis and examine biological materials. These requirements were met through the support of the Royal Devon and Exeter Hospital and their radiology department, and the University College of the South West of England, which allowed the free use of their facilities; this was where the medical secretary of the clinic, Mrs Clare Harvey – who had previously been trained as a biologist – could examine vaginal and seminal fluid and cervical mucus. Based on this specialised work, Exeter grew in reputation and patients were sent to the clinic from general practitioners and hospitals.

Exeter was not the only place that endeavoured to answer patients’ cries for help in sub-fertility matters. In 1942, Helena Wright suggested to the medical committee of the North Kensington Women's Welfare Centre that a new session be started, dedicated to the investigation of sterility cases. ¹²⁶ Similarly, Joan Malleson encouraged the FPA to address the needs of patients through the opening of ‘motherhood clinics’ where patients could be advised on sexual disorders and sub-fertility. In 1943, at the height of wartime mobilisation, the president of the FPA, Lord Horder, published an article in the Lancet that informed his colleagues of the relevance of the work done in FPA clinics at a time of declining birth rate: ‘In view of the fact that at least 10 per cent of married couples suffer from involuntary sterility, it is obvious that the problem of such sterility is one of great national importance, not only because of the personal unhappiness it may cause, but because [of] the urgent need to increase our present birth-rate if a falling population is to be averted.’  ¹²⁷ This anxiety about the state of the British population should be understood in view of the fact that, in 1943, Britain was looking ahead of the war, as the Beveridge Report testifies, and was increasingly thinking about rebuilding the country. In this context, the state of the population was put on the political agenda, as exemplified by the setting up of the Royal Commission on Population in 1944. Horder announced the creation of an ad hoc committee ‘which intended to organise clinics to deal with cases of sterility either by referring them where necessary to the appropriate hospital centres or where these do not exist by providing such expert attention as facilities permit’. The committee was made up of leading experts in infertility: Margaret Jackson, Joan Malleson, Margaret Moore White, Annis Gillie, Alex Bourne, William Nixon, Cedric Lane Robert, Kenneth Walker and Albert Sharman. To assess practitioners’ willingness to offer sterility sessions, the subcommittee sent out a questionnaire to all clinic medical officers. While some of them saw no necessity to develop this work, since local hospitals took care of this aspect, a great number of medical officers had seen enough interest and demand from patients to want to integrate this aspect, as shown by the answer from Dr Gwendoline Smith: ‘This question of sterility is a problem in our Carlisle Clinic. I get quite a lot of it, and so far have been able to do very little for the women and I am very glad this subject is considered and hope something really helpful will be the results.’  ¹²⁸ These answers led the subcommittee to prioritise the opening of a laboratory in London for semen analysis. In 1944, following several months of debate and tension between members of the subcommittee on the best strategy to adopt – i.e. whether to open a sub-fertility clinic or use the resources of St Mary's Hospital, London to carry out seminal tests – a seminological centre opened in London under the supervision of Dr Hans Davidson, expert in seminology. The clinic saw an average of 2,000 patients per annum. ¹²⁹ In September, an infertility conference was held in Exeter, where Margaret Jackson and Claire Harvey taught medical officers the basics of semen analysis. From then onwards, the FPA organised an annual sub-fertility conference where participants covered male infertility in depth, and basic procedures for testing husbands and wives were presented. ¹³⁰

Following this new emphasis on sub-fertility, the North Kensington Women's Welfare Centre appointed a consultant gynaecologist, Dr Kathleen Harding, to their sub-fertility clinic in 1945. The work was slow to develop, since many clinics maintained their close relationship with local hospitals and referred their patients to them. In 1950, Kathleen Harding pleaded for more sub-fertility clinics in the work of the FPA at the general meeting. Based on her own experience, both in North Kensington and in hospital, she urged FPA clinics to develop this aspect of the work, since it required ‘more patience, understanding and perseverance than most aspect[s] of obstetrics and gynaecology’. Such work was better suited to FPA clinics than to hospitals, where time was a central issue. Supporting her claim, she put the patient's emotions at the centre of her argument, emphasising that well-being was central in FPA clinics and that it ‘means a great deal to a patient who is so sensitive about her failure to reproduce (as it was still the woman who sought treatment first)’. ¹³¹ While the work was slow to grow, mainly due to lack of funding, it nevertheless expanded. In 1957, twelve clinics held special sub-fertility sessions, and out of the 220 family planning clinics 170 gave preliminary advice and referred their patients to local hospitals. ¹³² The work continued to develop in the 1960s.

The topic of infertility was, however, not confined to the world of the clinic; it broke out in the wider medical circle in the mid-1940s. A great number of articles were published in medical journals to inform doctors about the issue of infertility, trying to offer lines of inquiry and suggestions for treating sub-fertility and infertility from the interwar years onwards. Again, a great number of these articles were authored by women doctors who encountered this problem in their private practice and at family planning clinics. Chief among them were Margaret Jackson, Margaret Moore White, Mary Barton, Katherine Harding and Joan Malleson. Their main contribution was the articulation of a guideline of extremely detailed medical procedures that doctors should follow in order to identify, diagnose and handle sub-fertility cases. They covered the array of laboratory techniques to diagnose and identify the causes of infertility, published their latest results, and helped advance the state of research in the field. ¹³³

They published together, as shown by the joint paper from Margaret Moore White and Mary Barton published in 1951 in the British Medical Journal. ¹³⁴ Beyond the focus on medical procedure, women doctors actively challenged the gender dynamic underpinning fertility diagnosis. In fact, infertility was commonly perceived as a female pathology, since ‘diseases affecting reproductive health were principally addressed under the auspices of gynaecology during the nineteenth and early twentieth centuries, thereby establishing infertility as a female problem’. ¹³⁵ It was against this background that women doctors tried to dismiss the assumption that the causes of infertility must be related to the woman. For instance, in 1935, Frances Huxley, member of the Medical Women's Federation and birth control activist, published The Clinical Study of Sterility Cases with Notes and Treatment in the bulletin of the federation. Drawing on the knowledge gained after a visit to fertility clinics in the US, she familiarised her female colleagues with this topic. She introduced her readers to different methods of determining sterility: insufflation of CO₂ into the uterus and tubes, and the battery of tests made by a clinic that not only tested the wife but also the husband. She then presented a step-by-step description of the way she handled sterility cases. She first showed how to diagnose sterility and reviewed all the possible causes. She dealt with the wife and the husband, insisted on obtaining a ‘report of the doctor who made the examination’, ¹³⁶ and used the Huhner test, which detects active spermatozoa. Similarly, in an article presenting the work she carried out at the Exeter and District Women's Welfare Centre in 1944, Margaret Jackson insisted on investigating the husband: ‘too often women are subjected to examination and operation without their husbands having been asked to submit a seminal specimen for examination’. ¹³⁷ This emphasis yielded positive results; during the 1947 FPA conference on infertility, a speaker underlined that both spouses should be examined:

Similarly, Margaret Moore White, in a 1947 article published in The Practitioner, reminded the reader:

The acknowledgement of the possibility that men could be responsible for sterility seemed to have won acceptance in 1960, to the extent that Kathleen Harding affirmed: ‘the fact that the man is responsible in quite one-third of the couples is now accepted’. ¹⁴⁰ This shift plausibly reflected a change in attitude towards gender roles in heterosexual relationships, as the rise of companionate marriage meant that a more egalitarian relationship was encouraged.

Aside from these technical publications, more accessible work was published by the FPA, such as the leaflet Childless Wife, which offered detailed but simple explanations of possible causes for infertility and a step-by-step guide to seeking medical help. The leaflet started by asserting that infertility was not a given and couples should seek advice:

The leaflet offered basic information on the biology of reproduction and provided advice on the best bodily position to adopt for increasing the chance of conception and the optimal time for conception. It described the possible causes and means to diagnose infertility in the husband and the wife, such as post-coital tests, semen analysis, tubal insufflation, support of the womb in the vagina, electric heat and glandular injections. In cases where total infertility was diagnosed, adoption was to be recommended. Women were urged to seek treatment, and those who failed to get pregnant without trying all the other alternatives were said not to deserve sympathy: ‘The woman who is disappointed should not really ask for sympathy until she has consulted a doctor and undertaken every possible measure he suggests.’ This excerpt shows the pressure women were under and the gender expectations underpinning fertility treatment. This pathologisation of the sterile wife that accepted her situation without looking for medical advice indicated a faith in medicine and the new role taken by doctors in the handling of sexual lives.

Connected to infertility was the hotly contested topic of artificial insemination by donor (AID), or what were commonly called ‘test-tube babies’. Margaret Jackson, Mary Barton, Margaret Moore White, Joan Malleson and Helena Wright defended and/or practised this procedure in their private practices as early as the late 1930s. The FPA, which still had difficulties establishing its legitimacy, was reluctant to engage with this controversial topic. As a result, the association provided advice on treatment for infertility and then referred patients who wanted AID to Mary Barton and Margaret Jackson. Malleson also designed a syringe for artificial insemination that was manufactured by Allen & Hanburys. ¹⁴²

A debate on AID took place in the House of Lords in July 1943, followed by an answer from Mary Barton in the BMJ, which triggered dozens of letters in the column of the journal. This debate has been analysed in detail by historians Angus McLaren, Naomi Pfeffer and Andrew Hanley. ¹⁴³ What needs to be remembered is the crucial role played by women doctors in the advocacy for artificial insemination. Also, these debates focused mainly on the ethical and moral aspects of AID, to the great despair of Margaret Jackson, who complained in the BMJ:

Nevertheless, the debates eased public concern about the subject and gave rise to numerous letters to the FPA from childless individuals who wanted to try this method. These letters revealed the agency of patients, who were proactive in searching for advice and treatment on the issue of sub-fertility; patient agency was an important element in the development of sub-fertility services. ¹⁴⁵

The issue of AID remained a contentious one throughout the 1950s, as shown by the setting up of the Feversham Committee in 1958. Its aim was ‘to enquire into the existing practice of human artificial insemination and its legal consequences; and to consider whether, taking account of the interests of individuals involved and of society as a whole, any change in the law is necessary or desirable’. ¹⁴⁶ Several doctors who practised the method were appointed as experts, more than half of them being female doctors: Margaret Jackson, Eleanor Mears, Mary Barton and Helena Wright. Their role was therefore recognised as an important one in the issue of infertility. The debate took place between opponents of AID, who viewed this procedure as sinful and considered it beyond the scope of the medical profession, and partisans of it, who regarded it as a valuable means to help childless people. The outcome of this fierce debate was that AID between consenting adults should not be prohibited. In her report for the Journal of the Family Planning Association, Margaret Jackson commented on the selection of experts for the Feversham Committee:

Her remark has two key interests. First, it shows Jackson's awareness of the need to listen to and integrate the individual experiences of sterile couples, which had been absent from the public debate on infertility until then. It reflects her own medical ethic, which placed individual experiences and needs at the core of her practice. Second, it shows that infertility, while known by everyone, was not publicly recognised. Despite the repeated attacks on the practice, women doctors persisted in helping the patients who asked for AID. The procedure therefore continued to be practised alongside new assisted reproductive technologies, such as in vitro fertilisation.

Conclusion

During the interwar years, in a context of fears about marriage – thought of as the cornerstone of British society – and population at the fore of political concerns, women doctors developed sexual counselling and infertility advice as a way of preserving the stability of marriage as an institution. They framed this side of their work as the positive side of family planning and medicalised sexual disorders. However, while their aim could be called ‘traditional’ from our post-feminist perspective, the methods and ideas they developed were radical and challenged common assumptions around gender roles. Indeed, with the issues of sexual disorders and infertility, they called into question the lack of acknowledgement of women's sexual pleasure for the former and the strong bias towards women's responsibility for infertility for the latter. They also spread information, through medical articles and sexual manuals, on the sexual relationship and its associated difficulties. Hence, women doctors were pivotal in developing sexual counselling in interwar Britain. They did so as a result of the sexual disorders their patients faced. By listening to their patients’ needs, difficulties and emotions, they forged therapeutics that emphasised the role of the clitoris as the place for sexual pleasure. In so doing, they challenged the central role of the vagina. While their views might have been at some points contradictory, they nevertheless opened the way for more female agency in the realm of sexuality. Wright was ahead of her time in her gendered analysis of sexual roles, while Malleson anticipated the second-wave feminist criticism of the increasing pressure to achieve orgasm, or what she called the ‘fallacy of orgasm’. The period in which they actively pressed the extension of the work of the clinic (1930–56) should be considered as a peak of radicalism that would die down when formal training in sexual counselling was established in the 1960s.

Regarding the issue of sub-fertility, here, again, women doctors met their patients’ needs by creating sub-fertility sessions and practising AID in their private practice. They also advocated for testing the husband, therefore breaking with the tradition of performing long and, too often, useless invasive treatments and surgical procedures on the female body only. But invasive investigations on women continued once the husband had been tested and found to have adequate sperm. Family planning clinics therefore offered a privileged space for developing new skills and fields of expertise, as well as cutting-edge therapy in sexual health. Women doctors working in these spaces created a new professional identity that revolved around a holistic approach to family planning where their patients’ needs were taken seriously. All in all, looking at the historical development of sexual and infertility counselling helps to correct the myth of all-powerful doctors counselling passive patients.