In the beginning there was sex. And sex begat skill, and skill (or its absence) begat judgment, and judgment begat insecurity, and insecurity begat doctors’ visits, which begat treatments, which have flourished into a multibillion-dollar industry, so that sex between men and women is today almost inconceivable without the shadow of disorder, dysfunction, the “little blue pill” or myriad other medical interventions designed to bring sex back to some longed-for beginning: a state of certified healthfulness, the illusion of normal.

Sex has been missing from the healthcare debate. A shame, because sexual health, and disputes over its meaning, reveals most nakedly the problem at the core of a medical system that requires profit, huge profit, hence sickness, or people who can come to believe they are sick or deformed or lacking and therefore in need of a pill, a procedure or device. Case in point: female sexual dysfunction (FSD), said to afflict great numbers of women–43 percent according to some, 70 percent according to others, an “epidemic” in the heterosexual bedroom according to Oprah. Ka-ching!

More on that in a moment, but first a bit about FSD’s precursor, hysteria, and the rustic science of bringing women off.

In my room is a curious artifact of late-nineteenth-century medicine: a heavy wooden chair with a cast-iron lever extending up to each arm, within easy grasp of the sitter. Pull the levers, and powerful springs activate a mechanism below to rock or jolt the sitter (depending on the vigor of the thrust) in a manner intended to produce the healthful effects of horseback riding for ladies suffering from “pelvic congestion.”

This particular jolting chair was discovered by an antiques-dealer friend, Gilbert Ruff, in Chester, Vermont, but its provenance as an invention reaches back to a fabled arena of psychosexual medicine, the Salpêtrière hospital in Paris, and to Jean-Martin Charcot, teacher of Freud and father of modern neurology. Charcot was an enthusiast for the idea that women with a grab bag of complaints, from irritability to sleeplessness to sexual fantasies and ungratified desire, were diseased. Hysteroneurasthenic disorder was the name for their sickness then. For some, he prescribed long train trips over rough track beds. If they took another doctor’s advice and sat in the rail carriage “so as to be leaning forward,” they might have got surprising relief. But such journeys were impractical, so Charcot and his colleagues devised a more homely vibration therapy.

Various iterations of the jolting chair entered commercial self-help markets. Mine was manufactured in New York, and contemporary advertisements promoted it to strengthen “the parts that are usually most neglected by the fair beings.” Now, a woman might enjoy the humpy bounce of this chair, varying the intensity, parting her legs, leaning forward and breathing deep, even calibrating her motions to the rhythms of a French dance tune, or gavotte, written for the purpose, but the jolting chair never proved as efficient at achieving that “hysterical paroxysm” of relief that doctors had been inducing in their female patients since at least the first century AD simply with their fingers. Nor could it compete with pulsing water cures or that ultimate women’s aid, the vibrator, also invented by a doctor and first used on hysterics at Salpêtrière.

As Rachel Maines demonstrates in her delightfully illuminating history The Technology of Orgasm, making patients out of sexually unsatisfied women was good business. The afflicted would neither die nor be cured but required regular massage treatments, weekly, sometimes daily, for an hour or even three. By one 1863 estimate, such therapies accounted for three-quarters of physicians’ business, but doctors seem to have got no pleasure out of diddling women. It was, Maines says, “the job nobody wanted.” And bringing women off was work, abstracted from sex (i.e., the robust progression from male hard-on to vaginal penetration to male orgasm) and requiring time and skill. With the vibrator, doctors’ productivity exploded, as sixty-minute visits shrank to ten, raising more revenue from more patients per day, until the device became so popular and multipurpose (Sears marketed a home vibrator with attachments for beating eggs, churning butter, operating a fan) that the medical profession had worked itself out of a job. Miraculously, the sick were healed as soon as the first vibrator popped up in porno in the 1920s.

Leap across the decades, and this quaint history appears positively progressive in that, willy-nilly, medicalization marched toward putting sexuality into women’s hands, into their heads in terms of body knowledge, and into the mix of culture, personal relations and a polymorphous physicality more true to life than biological function alone. The white coats came out again with Masters and Johnson but bumped into a counterculture and an emancipation movement that pushed against their categorizations of normal or not. Every 1970s woman might not have gone to one of Betty Dodson’s masturbation workshops; every man certainly was not reborn as an attentive, exploring lover. But nor was everyone straight, in all senses of the word, and the fluidity of sexuality as part of the great mishmash of human experience was in the air-conditioning system of the culture. It was sexual but political, too. Today the cultural air is thick with sex, but the rhetoric of freedom and rights largely serves a commodified notion of sexual satisfaction. The politics has dropped out, and without politics we’re all just patients, or potential patients.

How else to explain that a reality as old as god–that the vast majority of women do not climax simply through intercourse–has re-emerged as dysfunction? Or that another grab bag of indicators of dissatisfaction and low desire are renamed as symptoms of hypoactive sexual desire disorder, for which a female Viagra or a testosterone patch or cream or nasal spray must be developed? How to explain that middle-aged women go under the knife for vaginal rejuvenation, basically pussy tightening, and that young women go under the knife for laser labiaplasty, basically genital mutilation, saying they only want to feel pretty, normal, and raise their chances of orgasm through intercourse? How to explain that a doctor like Stuart Meloy of North Carolina, a throwback to charlatans who tried to shock hysterics into health with electric charges, has even one patient to test his Orgasmatron, an electrode threaded up a woman’s spinal cord and controlled by a hand-held button that the patient can push (assuming the procedure doesn’t paralyze her) to make her clit throb with excitement during intercourse and reach the grail of mutually assured orgasm?

A terrific new documentary, Orgasm Inc., by Liz Canner, addresses those questions in terms of corporate medicine and the creation of need via pseudofeminist incitements to full sexual mastery by Dr. Laura Berman and other shills for the drug industry. Female sexual dysfunction, it turns out, was wholly created by drug companies hoping to make even bigger money off women than they have off men with the comparatively smaller market for erectile dysfunction drugs. That’s capitalism; that’s its nature. The more obstinate question is why so many people are willing to be its slaves, and whether a resistant politics can grow up to say not just “We want in” to healthcare but “We want out” of the profit system and, on the sex front, out of a medical model that elevates a doctor over “playing doctor” or a more sensual ease with oneself and others.

“So many times I don’t think sex is a matter of health,” Dr. Leonore Tiefer, a sex therapist and founder of the New View Campaign to challenge the medicalization of sex, told me the other day. “I think it’s more like dancing or cooking. Yes, you do it with your body. You dance with your body, too. That doesn’t mean there’s a department of dance in the medical school. You don’t go to the doctor to learn to dance. And in dancing school the waltz class is no more normal than the samba class.” You might not be a good dancer by some scale of values. You might not get the steps right, or do steps at all, but even in wheelchairs people learn to move to the music.