**8. The medicalization of female sexuality and procreative activities**

Over the past decades, a persuasive line of argument has been developed which allows us to look critically at the medical usurpation of childbirth and its control of obstetric care while noting both its positive and negative effects [22, 36-44]. Doctors have assumed essentially total control over the pregnant woman, for it has come to be expected to give birth in hospital, and so on. The focal point of our analysis is modern biomedical discourse in gynaecology and obstetrics, as well as selected institutional practices for pregnant women, women giving birth and women after childbirth, with a particular focus on female sexuality. The analysis delineates the extremes, limitations and trappings of the usurpation of female sexuality by medicine and draws attention to its internal contradictions, tensions and struggles.

Let us look at a few keys points. An important aspect of modernization is the regulation, management and control over the human body and sexuality in particular, and medicine has historically played an important role in these processes. Sciences and their application in medical practice are always established and formed within a certain social context, as proven by the historian of sexuality and the body Thomas Laqueur, who studied various conceptu‐ alizations of the body through sex differences in great detail. Inter alia, he drew attention to a particularly key shift from the uniform model of the human sexual anatomy in Europe in the 18th and 19th centuries to the dualist conceptual model of two sexes. One-sex theory concep‐ tualized the human body as the same both in men and women – women have the same genitalia as men, only that female genitalia are on the inside rather than on the outside, meaning the only difference was superficial. Two-sex theory considered femaleness as permeating every cell of the body, meaning that the female body fundamentally differs from the male body [45]. This new conceptualization of the woman in medicine as the "other sex" resulted in positioning the female body as a separate entity. The emergence of gynaecology and sex endocrinology in the late 18th and early 19th century is linked to the dominance of a discourse practice in which sex and reproduction are more essential and determine women more greatly than men. Sexual anatomy and sexual differences were used to support the superiority of men over women. The subordination of women by men was based on hierarchical ordering of two different bodies and helped to establish a new understanding of gender with firmly defined roles. The oneand two-sex models and the victory of the latter over the former have been consolidated through their use in anatomy, gynaecology and practical diagnoses and treatment of women. According to Laqueur, no differences between male and female sexuality emerge in the onesex model, and attention is drawn to the importance of female pleasure and orgasm in order to conceive, which later lose any visible role in the two-sex model, where the woman is designated a passive recipient of male active sexuality. Specific gender theories and gender differences or similarities are shaped in interdependence with social conditions, and the culture was the force which denied women the ability to experience sexual pleasure and gratification despite the already existing anatomical evidence about the role of specific female body parts and the importance of the clitoris.

In the 20th century Freud's theory about the vaginal orgasm, which replaced the adolescent clitoral orgasm and was a sign of a woman's maturation, and whose absence signified frigidity, turned out to be based on the two-sex model, which requires women to adapt their pleasure to their expected social role in spite of their bodily structure and neurology, rather than because of it. This theory, labelled "the cultural myth of the vaginal orgasm" by Laqueur, was followed by a number of male and female authors and made many women wonder about their inap‐ propriate, infantile sexuality and undergo therapy.

After the Second World War, sexuality began to be studied empirically. American biologist Alfred Charles Kinsey published the Kinsey Report in two volumes, *Sexual Behavior in the Human Male* in the 1948 and *Sexual Behavior in the Human Female* in 1953. These findings were built upon in a confidential study at a St. Louis clinic carried out in the late 1950s by the American gynaecologist William Howell Masters to observe and empirically study the human sex act under laboratory conditions, along with his assistant Virginia Eshelman Johnson, who had no degree or official medical credentials. The pair carried out controversial studies about sexual experience in men and women. Their findings regarding female sexuality were relatively straightforward – almost all female orgasms are caused by direct or indirect stimulation of the clitoris. This empirically disproved Freud's theory about an "immature" clitoral and a "mature" vaginal orgasm.

What is important is to understand how particular knowledge is incorporated in mainstream discourses, medicine included, and used for normalization and control in the everyday lives of women. Medicine tends to commodify female sexuality. The emergence and acceptance of particular theories on female sexuality are linked to the social conditions of the time in which supposedly objective and independent scientific findings become a convenient tool to achieve goals not related to the wellbeing of individuals; at the same time, the conditions for the emergence and development of certain knowledge are themselves an intrinsic part of a certain reference frame of the dominant culture.

Medicine has contributed both to the improved sex lives of women and of their reproductive lives more generally; however, let us not forget its contributions to blaming mothers for a variety of social problems supposedly caused by inappropriate motherhood [20], ranging from various addictions to the increase in violence and the emergence of a narcissistic society [46].

anatomy and sexual differences were used to support the superiority of men over women. The subordination of women by men was based on hierarchical ordering of two different bodies and helped to establish a new understanding of gender with firmly defined roles. The oneand two-sex models and the victory of the latter over the former have been consolidated through their use in anatomy, gynaecology and practical diagnoses and treatment of women. According to Laqueur, no differences between male and female sexuality emerge in the onesex model, and attention is drawn to the importance of female pleasure and orgasm in order to conceive, which later lose any visible role in the two-sex model, where the woman is designated a passive recipient of male active sexuality. Specific gender theories and gender differences or similarities are shaped in interdependence with social conditions, and the culture was the force which denied women the ability to experience sexual pleasure and gratification despite the already existing anatomical evidence about the role of specific female

In the 20th century Freud's theory about the vaginal orgasm, which replaced the adolescent clitoral orgasm and was a sign of a woman's maturation, and whose absence signified frigidity, turned out to be based on the two-sex model, which requires women to adapt their pleasure to their expected social role in spite of their bodily structure and neurology, rather than because of it. This theory, labelled "the cultural myth of the vaginal orgasm" by Laqueur, was followed by a number of male and female authors and made many women wonder about their inap‐

After the Second World War, sexuality began to be studied empirically. American biologist Alfred Charles Kinsey published the Kinsey Report in two volumes, *Sexual Behavior in the Human Male* in the 1948 and *Sexual Behavior in the Human Female* in 1953. These findings were built upon in a confidential study at a St. Louis clinic carried out in the late 1950s by the American gynaecologist William Howell Masters to observe and empirically study the human sex act under laboratory conditions, along with his assistant Virginia Eshelman Johnson, who had no degree or official medical credentials. The pair carried out controversial studies about sexual experience in men and women. Their findings regarding female sexuality were relatively straightforward – almost all female orgasms are caused by direct or indirect stimulation of the clitoris. This empirically disproved Freud's theory about an "immature"

What is important is to understand how particular knowledge is incorporated in mainstream discourses, medicine included, and used for normalization and control in the everyday lives of women. Medicine tends to commodify female sexuality. The emergence and acceptance of particular theories on female sexuality are linked to the social conditions of the time in which supposedly objective and independent scientific findings become a convenient tool to achieve goals not related to the wellbeing of individuals; at the same time, the conditions for the emergence and development of certain knowledge are themselves an intrinsic part of a certain

Medicine has contributed both to the improved sex lives of women and of their reproductive lives more generally; however, let us not forget its contributions to blaming mothers for a

body parts and the importance of the clitoris.

152 Sexology in Midwifery

propriate, infantile sexuality and undergo therapy.

clitoral and a "mature" vaginal orgasm.

reference frame of the dominant culture.

Female sexuality has been pathologized with diagnoses like "hysterical" and "neurotic", and these so-called disorders treated in a variety of ways with differing levels of brutality; during the obsessive preoccupation with masturbation in the 19th century, even clitoridectomies were in use, among other methods, and contributions to reducing women to specific desirable and acceptable aspects were made by theories such as the concept of women's masochism [12].

Medicine facilitates the expansion of a market providing modern services modifying the female body to (socially) desirable norms, which women either voluntarily or involuntarily adhere to. For-profit medicine, with the express cooperation of physicians, markets absurd plastic-surgery procedures on the hymen, known as hymenoplasty or "re-virgination", which is problematic from an ethical standpoint. As long as a few drops of blood determine the value of women, women will be forced to undergo surgery to replace a potential "lost" patch of tissue with a couple of stitches. On the one hand, young women who live under specific religious or social norms regarding the "virginal", sexually "not-yet-tainted" female body, which is to belong to a particular man – often not of her own choosing – believe they need to undergo this procedure to protect themselves and their families. On the other hand, with every such procedure, medicine contributes to the perpetuation of "virginity", a construct affecting entire generations of women.

Other procedures promoted by the plastic-surgery industry include "vaginal rejuvenation", breast augmentation, facial cosmetic surgery, body-contouring surgery and facial procedures in the absence of any pathological condition, which are frequently, though not necessarily, based on the patriarchal idea of the sexual and sexualized female body as seen through the male gaze; this is at the very least controversial, if not outrightly upholding and consolidating the remnants of the patriarchal social order.

Currently, some branches of medicine also participate in the development of some ethically questionable new reproduction technologies, which have been proven to involve misuse and even abuse of women, like trafficking with eggs and embryos to offer commercial services of surrogate motherhood.

In history, discourses in medicine feature assumptions about the female orgasm, the lesser capacity of women to enjoy sex, or women's passive and men's active sexuality, as well as questioning of lesbian love and sex. Contrary to common (self-)perception, even today medicine is not neutral regarding sex expressions of gender and still participates in attempts to normalize certain sexual practices while pathologizing others, based on obsolete and disproven concepts – as seen in recent history in relation to the provision of access to infertility treatment for single women in Slovenia in 2001, for example. In public debate, those who opposed the proposed law problematized among other things the supposed motherhood of single or maybe homosexual women, where the sexual activity of a man is not desired or needed – with the support of some medical professionals.

### **8.1. Female sexuality and childbirth – The modern desexualization of childbirth**

Female sexuality and its controversial links to medicine should be the focus of everyone dedicated to women's well-being, particularly during important transitions in life, such as puberty, childbirth and menopause. The medicalization of female sexuality is a phenomenon that affects women around the world and requires a detailed structured critique. As can be inferred from data obtained by studies, analyses of delivery-room procedures and available literature, the practices in modern obstetrics are frequently at odds with women's autonomy, ignore their feelings and knowledge and harm their bodies, mind and soul time and time again. It is part of a structural issue connected to the status of medicine, its position in the modern understanding and management of life, its power over transitions in life such as childbirth, the transfer of childbirth into the hospital, the use of specific prosthetic means to control life, illness and death, the "objective" and "legitimate" definitions of the normal and the patho‐ logical, the technologization of pregnancy, and the specific attitude to female sexuality.

This paper studies some of the types of medical discourse and practices in relation to the female gender, particular attitudes to female desire, pleasure and gratification that evolve with time, the control over reproduction, and the definition and construction of "good" motherhood.

How should we interpret the relationship between medicine and female sexuality, which is perceived as a gender-specific experience and practice in the life-cycles of ordinary women? We study the contributions of medicine to the everyday lives of women, which remain closely linked in many ways to caring for other family members and bringing the family into existence in the first place, that is, to the "production" and "reproduction" of people in general. In order to facilitate understanding of the issue of the medicalization of female sexuality as an important issue for midwives, quotes will be used below from archived statements made by women on their experience with care in maternity wards over the last decade – the testimonies were gathered by the author. This approach aims to facilitate greater awareness of the issue by using a research method that gives women a special position and is particularly esteemed in women's studies and feminist theory. Women's voices are heard and listened to, which is an important way of empowering women and one that may promote their contributions to thinking about cultural childbirth practices and their influence on the practice of perinatal care, which is supposed to be about helping and supporting mothers and their newborns.

Medicine aggressively participates in the development of new reproductive technologies and various practices which make parenthood possible despite any number of physical or medical obstacles – these are practices ranging from a variety of medically assisted conception methods to the overseeing of individual surrogacy procedures. Medicine's attitude to women, the female body and female sexuality is often full of contradiction; on the one hand, it assists women in achieving their goals or becoming a mother, while at the same time contributing to the exploitation of women's reproductive capacity by the privileged. Conception itself no longer requires sexual intercourse, and as specific knowledge and technology develops, medicine has begun looking into ways of reaching the phantasmatic goal of creating human life in a way that would eliminate the need for a female body to carry the child to term and give birth [47].

A special element of the medicalization of female sexuality, which this paper shall focus on, is the participation of medicine in separating motherhood from sexuality, excising female sexuality from childbirth and erasing the sexual component of the experience of giving birth. Paradoxically, the desexualization of childbirth functions as a component of control over female sexuality – that which is obscured or pushed aside and denied is just as important as that what is manifest or even excessive. The exclusion of certain knowledge and the link between knowledge and power is something to which Foucault has already drawn attention [28]. As noted by anthropologist Robbie Davis-Floyd, routine care for the mother at the maternity ward is so effective in masking the sexuality of childbirth that the majority of modern women are not even aware of the sexual character of childbirth [38]. It can be said that the culturally dominant image of modern childbirth has been "cleansed" of anything implying sexuality, and that any discourse involving a link between childbirth and sexuality is margi‐ nalized – what you would see in a typical birthing room is a woman in a hospital gown lying on a bed and covered with a sheet, looking more like a patient than an empowered woman giving birth to her child.

**8.1. Female sexuality and childbirth – The modern desexualization of childbirth**

Female sexuality and its controversial links to medicine should be the focus of everyone dedicated to women's well-being, particularly during important transitions in life, such as puberty, childbirth and menopause. The medicalization of female sexuality is a phenomenon that affects women around the world and requires a detailed structured critique. As can be inferred from data obtained by studies, analyses of delivery-room procedures and available literature, the practices in modern obstetrics are frequently at odds with women's autonomy, ignore their feelings and knowledge and harm their bodies, mind and soul time and time again. It is part of a structural issue connected to the status of medicine, its position in the modern understanding and management of life, its power over transitions in life such as childbirth, the transfer of childbirth into the hospital, the use of specific prosthetic means to control life, illness and death, the "objective" and "legitimate" definitions of the normal and the patho‐ logical, the technologization of pregnancy, and the specific attitude to female sexuality.

This paper studies some of the types of medical discourse and practices in relation to the female gender, particular attitudes to female desire, pleasure and gratification that evolve with time, the control over reproduction, and the definition and construction of "good" motherhood.

How should we interpret the relationship between medicine and female sexuality, which is perceived as a gender-specific experience and practice in the life-cycles of ordinary women? We study the contributions of medicine to the everyday lives of women, which remain closely linked in many ways to caring for other family members and bringing the family into existence in the first place, that is, to the "production" and "reproduction" of people in general. In order to facilitate understanding of the issue of the medicalization of female sexuality as an important issue for midwives, quotes will be used below from archived statements made by women on their experience with care in maternity wards over the last decade – the testimonies were gathered by the author. This approach aims to facilitate greater awareness of the issue by using a research method that gives women a special position and is particularly esteemed in women's studies and feminist theory. Women's voices are heard and listened to, which is an important way of empowering women and one that may promote their contributions to thinking about cultural childbirth practices and their influence on the practice of perinatal care, which is

Medicine aggressively participates in the development of new reproductive technologies and various practices which make parenthood possible despite any number of physical or medical obstacles – these are practices ranging from a variety of medically assisted conception methods to the overseeing of individual surrogacy procedures. Medicine's attitude to women, the female body and female sexuality is often full of contradiction; on the one hand, it assists women in achieving their goals or becoming a mother, while at the same time contributing to the exploitation of women's reproductive capacity by the privileged. Conception itself no longer requires sexual intercourse, and as specific knowledge and technology develops, medicine has begun looking into ways of reaching the phantasmatic goal of creating human life in a way that would eliminate the need for a female body to carry the child to term and

supposed to be about helping and supporting mothers and their newborns.

give birth [47].

154 Sexology in Midwifery

Let us take a closer look step by step. The entry of men into the process of childbirth as healers, medicine men and male midwives [40], which only expanded with the medical takeover of childbirth [48], also reopened questions about female sexuality. On one hand, this is intercon‐ nected with the need to control women's reproductive ability, while on the other, the idea of female sexuality as a threat to patriarchal order creates discomfort and anxiety and demands regulatory tools be developed. In light of this, some characteristics of the modern "design of childbirth" need to be reconsidered – including the institutionalization of childbirth, routine care and the implementation of certain procedures, such as the shaving of pubic hair, enemas, vaginal examinations and episiotomy, while foregoing others, such as nudity of the birthing women, body support and close contact between the birthing woman and her support network, the restrictions on audibly expressing labour pain and other feelings, pleasure included, and so on.

We can use a historical case to make the point. The emerging use of chloroform rather than ether to alleviate labour pain triggered a fight in the scientific community, which was detailed in the prestigious *Lancet* magazine. Some interpreted the "hysterical behaviour" of mothers in labour who had been given ether as an expression of sexual arousal, which was a threat to the obstetrician. According to certain medical opinions, labour pain merely masked sexual pleasure not requiring the involvement of a male. To prevent labour pain might then stop the mechanism neutralizing sexual arousal. A woman who is medicated to a pain-free state and whose sexual arousal is therefore unhindered regresses to an animal state and can no longer be controlled by a physician. This is the contradictory idea of the woman in the 19th century – is the woman primarily a sexual or a moral being; is she a seductress of men (doctors included) or a moral guiding light? The line of thought of the time, based on the two-sex theory discussed above, is easy to follow: the woman is a primarily reproductive being, meaning that her character is sexual, that is to say, animalistic; considering that the biologists of the time observed that animals were keen to copulate after giving birth, the idea emerged that childbirth could be a sexually arousing event for women. Physicians were suddenly trapped in their own contradictory (mostly unreflected) conceptualization of the woman. They considered the idea of "sexually aroused" women going through labour under anaesthesia to be "a danger to the patients, doctors and medicine in general". To assume as great a degree of control as possible, they recommended chloroform, which was to be administered in quantities that exceeded the dosage needed for mere pain alleviation. Anaesthesia during labour was approved not only to ease women's labour pain, but also to protect the physicians from unwanted reactions of the women in their care [19].

The current prevailing attitude to labour pain leads women to dissociate from physical sensations and pain as well as joy, pleasure and ecstasy. Some women, such as individuals recovering from sexual abuse, consider it vital to keep at least minimal control over the process of childbirth and dissociation is one way to achieve that, for example with effective medication to treat labour pain, such as epidural anaesthesia. Due to forgotten or at the very least incredibly marginalized knowledge about the integrity and interconnectedness of childbirth on the physical, mental and spiritual level and the physiological laws of labour, which (may) include both pain and pleasure, it is entirely understandable that many women consider the medical alleviation of labour pain to be a requirement, while seeing discussions about the internal power and capacity of the body to respond with its own way of alleviating pain as pushing women back to (ruthless) nature.

Assuming the vantage point of tension between pain and pleasure, intertwined during childbirth, let us think about how women experience usual childbirth practice in hospital with predetermined routine procedures. These have the woman lying on her back in bed, "hooked" on IV with induced and/or augmented contractions, with no constant midwife presence, making her feel that she has lost control of the situation and the procedures of the medical staff: she feels objectified – *"like being a walking uterus"* – and reduced to her physical body – *"I felt like a slab of meat*" – and has no say in what happens to/in her body: *"The doctor entered and without looking at me, pushed his hand inside of me, which hurt horribly, mumbled something and left."* Routine vaginal examinations are particularly revelatory, as this is the body part considered to be the most intimate of all. An interviewee recounts acts by the medical staff once she felt the need to push that she thought were wholly inappropriate. The medical staff carried out a vaginal examination, which she experienced as an act of violence: *"When the midwife called them over, they said, 'Impossible, it's impossible that she would be this dilated.' They go inside, 'Fantastic, fantastic, so soft, feel it, come and feel it.' They're just wriggling their hands inside of me! /the speaker is extremely distressed, note by Z. D./ Look at that, oh.'"* [49].

Ignorance about the interconnectedness of sexuality and childbirth is the consequence of induced amnesia, which, however, is not total and is visible, for example, in jokes made by doctors and sometimes midwives who act more like obstetrical nurses, at the expense of women – jokes they can make because of their status within the health-care hierarchy. For example: "It'll come out the same way it went in!" or "A woman of normal sexual health should enjoy childbirth a lot, considering that the child is so much larger than the penis" (as I find written in the notes I made during an interview with a Slovenian obstetrician in 1993). The problem lies in power relations; power is used to define how (if at all) female sexuality may be expressed at the maternity ward and to define what is normal and what pathological, and

frequently what is moral as well. That a specific medical idea of childbirth is prevalent in maternity wards is precisely why the idea that childbirth could be aided or labour pain alleviated with practices involving, for example, a woman stimulating her nipples or clitoris is unacceptable, and such advice is met with derision or disgust by health professionals. The problem is not that medical professionals are unaware of the effect of nipple stimulation on contractions, since understanding of this mechanism was the basis for the construction of a special device patented in the US to achieve stronger uterine contractions [50]. The device does not cause the same discomfort usually expressed by medical professionals when confronted with an explicit expression of female sexuality during childbirth, because it allows them to establish a distance. According to women's testimonies, as little as requesting perineal massage during labour, which can prevent rupture and injuries if applied gently, can meet with the disapproval of midwives in maternity hospitals. The medical approach to childbirth in modern hospitals is very much the "high-tech, low-touch" approach, in opposition to the "low-tech, high-touch" approach where understanding of the needs of women during birth includes the sexual aspect of the birthing process. Established ignorance about certain aspects of female sexuality and the potential for abuse is illustrated by a delivery-room case documented by the author, which involved the obstetrician "helping" the woman in labour during her vaginal examination by stimulating her clitoris without informing her beforehand or obtaining her consent; according to my personal notes, none of the experts moved in to stop this, acting rather as voyeuristic witnesses.

contradictory (mostly unreflected) conceptualization of the woman. They considered the idea of "sexually aroused" women going through labour under anaesthesia to be "a danger to the patients, doctors and medicine in general". To assume as great a degree of control as possible, they recommended chloroform, which was to be administered in quantities that exceeded the dosage needed for mere pain alleviation. Anaesthesia during labour was approved not only to ease women's labour pain, but also to protect the physicians from unwanted reactions of

The current prevailing attitude to labour pain leads women to dissociate from physical sensations and pain as well as joy, pleasure and ecstasy. Some women, such as individuals recovering from sexual abuse, consider it vital to keep at least minimal control over the process of childbirth and dissociation is one way to achieve that, for example with effective medication to treat labour pain, such as epidural anaesthesia. Due to forgotten or at the very least incredibly marginalized knowledge about the integrity and interconnectedness of childbirth on the physical, mental and spiritual level and the physiological laws of labour, which (may) include both pain and pleasure, it is entirely understandable that many women consider the medical alleviation of labour pain to be a requirement, while seeing discussions about the internal power and capacity of the body to respond with its own way of alleviating pain as

Assuming the vantage point of tension between pain and pleasure, intertwined during childbirth, let us think about how women experience usual childbirth practice in hospital with predetermined routine procedures. These have the woman lying on her back in bed, "hooked" on IV with induced and/or augmented contractions, with no constant midwife presence, making her feel that she has lost control of the situation and the procedures of the medical staff: she feels objectified – *"like being a walking uterus"* – and reduced to her physical body – *"I felt like a slab of meat*" – and has no say in what happens to/in her body: *"The doctor entered and without looking at me, pushed his hand inside of me, which hurt horribly, mumbled something and left."* Routine vaginal examinations are particularly revelatory, as this is the body part considered to be the most intimate of all. An interviewee recounts acts by the medical staff once she felt the need to push that she thought were wholly inappropriate. The medical staff carried out a vaginal examination, which she experienced as an act of violence: *"When the midwife called them over, they said, 'Impossible, it's impossible that she would be this dilated.' They go inside, 'Fantastic, fantastic, so soft, feel it, come and feel it.' They're just wriggling their hands inside*

Ignorance about the interconnectedness of sexuality and childbirth is the consequence of induced amnesia, which, however, is not total and is visible, for example, in jokes made by doctors and sometimes midwives who act more like obstetrical nurses, at the expense of women – jokes they can make because of their status within the health-care hierarchy. For example: "It'll come out the same way it went in!" or "A woman of normal sexual health should enjoy childbirth a lot, considering that the child is so much larger than the penis" (as I find written in the notes I made during an interview with a Slovenian obstetrician in 1993). The problem lies in power relations; power is used to define how (if at all) female sexuality may be expressed at the maternity ward and to define what is normal and what pathological, and

*of me! /the speaker is extremely distressed, note by Z. D./ Look at that, oh.'"* [49].

the women in their care [19].

156 Sexology in Midwifery

pushing women back to (ruthless) nature.

The desexualization of childbirth was also significantly advanced due to the relocation of childbirth into institutions, which largely occurred in the second half of the 20th century; this involved the creation of a new norm stipulating that women should give birth in a hospital setting, and the forcible enforcement of this norm – despite current efforts to expand the choice of childbirth settings. This shift was initially presented as an important factor for maintaining the good health of women and children and the prevention of illnesses and death, while overlooking or disregarding the effect of institutionalization on the process of childbirth, the lack of privacy, the failure to provide certain aspects of care and the introduction of new routine procedures as well as the increased participation of men in a field where technology and routine procedures are given priority. What emerged was a desexualized female body in labour, shaven, genitals exposed, exposed to a controlling gaze and authoritarian touch, while ignoring sexual content, forbidden expression or care that would evoke the institutionally undesirable sexual aspect of childbirth; this, too, is an important vantage point from which the consequences of the framing of the maternity ward, with professional care provided by the public health-care system, as the mandatory childbirth setting, need to be examined.

The issue of desexualizing childbirth is multi-layered – childbirth is more difficult when women are forced to disassociate from what their bodies are telling them and bow down to a procedure imposed from the outside, when they have to ignore their own expression and sounds and control themselves in order for the professionals to find their behaviour acceptable. It is especially ironic considering that the institutionalization of childbirth was intended to provide higher-quality birth care. The routine use in hospitals of artificial oxytocin, which induces contractions and/or stimulates them, may be interpreted as an anticipated response to the conditions of childbirth in an institution where the logic of the natural progression of childbirth is devalued or even ignored. Physiological childbirth is on one level based on a sensitive, changing hormone cocktail in the birthing woman and baby, and is closely connected to the well-being of the woman and child. If we obstruct or hinder otherwise functioning patterns, external interference becomes a necessary replacement for the physiological dosing of oxytocin in birth care that places the woman at the centre and respectfully supports her – this becomes more likely to happen outside of an institution. In contrast to authentic midwifery [51], taking natural body responses into account is not a strength of modern obstetrics, and staff, both doctors and medicalized midwives, frequently interfere and express a sense of hurry – or even, completely inappropriately, impatience. One example from data collected in an Internet questionnaire about birth experiences in Slovenia in 2005: *"What bothered me the most was that the staff kept saying, 'Come on, ma'am, everyone else gave birth already!"* [49]. In order to understand the basic needs of women during childbirth, we need to find a gender-specific understanding and sensibility and then develop appropriate approaches. Authors who acknowledge the interconnectedness of childbirth and sexuality compare the usual conditions under which we have sex, which provide intimacy, a relaxed environment and the knowledge we are not under anyone's control, with the conditions for successful childbirth, which are exactly the same: privacy, a warm, darkened space, no control or comments on appearance or behaviour. It is clear that pressuring your partner to have an orgasm will almost certainly have the exact opposite effect; similarly, scolding and expressing disapproval of a woman and her partner for kissing while she is in labour is only going to hinder the process, as often remarked by Marsden Wagner, a medical dissident who dedicated his work to supporting the well-being of mothers and babies and supporting autonomous midwifery [52].

Women need their individual course of pregnancy and childbirth to be respected, with the lowest possible degree of interference and forced adherence to routine; they do not wish to be told to hurry up or slow down, as corroborated by modern studies of childbirth physiology – childbirth is optimal when interference and intrusive procedures are the fewest. What is more, it has been proven that women and children benefit hugely from the presence of support networks and staff who deliberately try to be as non-intrusive as possible in order to allow the individual to relax and let the natural progress of childbirth take over. It must also be taken into account that every individual mother has her own particular way of giving birth, and she must be offered support, which includes adapting the setting. If individuals are able to relax and focus on giving birth, they will find it easier to listen to their own body, which in turn makes the midwife's job easier and more fulfilling. The degree of restrictions and expectations imposed by medical staff on women in labour, especially regarding her physical expression, is illustrated by another example from my notes of a consultation with a mother of a newborn in 2011, who bared her breasts during childbirth and was subsequently scolded by the midwife, *"Put your clothes back on, will you, this is not a beach."*

Ensuring privacy is one of the important aspects of a birth setting. Individual women have differing definitions of privacy. However, the feeling of one's privacy being limited definitely has no positive effects on childbirth; too many people in the delivery room, unknown person‐ nel performing care, having to disclose personal information or even undergo a physical examination, even a vaginal examination, in the presence of others, e.g., during the rounds in post-natal wards, etc., are all intrusions on privacy. It should be kept in mind that, rather than being irrational, the institutional bans or restrictions on the presence of people the mother-tobe feels close to – her partner, other supportive women or doulas – are based on the under‐ standing of power and control over the woman in labour and her freedom, and on the expectation that she must conform to the social expectations imposed by the institution during birth.

The widespread practice of episiotomy during typical childbirths is a classic example of a specific conceptualization of the female gender and her body in obstetrics, which is based on doubts over the capacity of the female reproductive system to deliver a baby without harming it. A decade ago, episiotomies were performed in over 50% of vaginal births in Slovenian maternity wards [49]. Episiotomy has adverse short-term and long-term consequences – more bleeding, pain, vaginal deformity – and affects women's sex lives both mentally and physically. Scientific data on when an episiotomy is justified show that an acceptable rate of episiotomy that would not increase the number of injuries in women and babies would be about 10%. There are midwifery practices with significantly lower rates of episiotomies or even none, but the disassociation from the sexual dimension of childbirth in modern obstetrics is made abundantly clear by the generous use of the procedure. One cannot help but agree with authors who have labelled the practice "sexual mutilation of women" [53].
