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Full citation: 

Cadden, Joan. 1993. Meanings of Sex Difference in the Middle Ages: Medicine, Science, and Culture. Cambridge: Cambridge University Press. ISBN 0-521-48378-6

Contents summary: 

While covering much of the same timeframe, Cadden takes a broader and more diverse view than Laqueur, while acknowledging the reality of his two models (the one-sex and two-sex models). In all eras, the “facts” about sex and sexuality are filtered through cultural prejudices. Medieval ideas about sex difference were part of the culture’s assumptions about gender. Medieval society was not a single culture, and the era covered several overall shifts in thinking, so there isn’t a single unified “medieval idea” of sex difference that can be pointed to.

Cadden differs from Laqueur, who considered pre-18th century ideas as deriving from a unified “one-sex” concept in which male and female existed on a single scale. Though much of the medieval evidence fits this one-sex model, other views were present throughout. [Note: Laqueur acknowledges this even though he considers one model to have predominated at any given time.] Even when systems of thought (e.g., theology and medicine) agreed on a principle relating to sexuality, they might come to it from different rationales.

It isn’t possible to make an overall judgement of whether medieval thought on sex difference was “good” or “bad” for women. Some concepts, such as the importance of female orgasm to conception, had both positive and negative consequences. In the later middle ages (12-14th century), European culture became more inflexible and intolerant in general, which affected attitudes toward women and sex. Cadden’s book looks at the diversity and eclecticism of medieval thought regarding sexual difference during this period.

Most sources were in Latin and therefore reflect the learned class dominated by men, but these sources also sometimes include “popular” thought, collected into encyclopedic works. This can include material collected from female professionals. The diversity of sources, authors, and genres makes interpretation more complex as it isn't easy to determine whether contrasting opinions reflected different traditions of thought or were simply accepted in their inherent contradiction. Topics include the physical and functional differences between female and male, details of reproduction, and behavioral differences between the sexes. The texts rarely addressed the idea of sex difference directly, but the underlying concepts inform other topics. Masculine and feminine (i.e., gender) were viewed as attributes separate from male and female (i.e., sex).

Cadden points out that Foucault’s History of Sexuality boils down to a history of male sexuality and doesn’t touch on sex difference much at all.

The structure of the work is laid out: Part I (chapters 1-3) traces the evolution of medieval medical and natural philosophy about sex difference. Part II (chapters 4-6) looks at the collection of learned ideas with regard to specific topics. From this, no overall unified picture emerges, rather a cluster of related ideas that didn’t always align or agree.

Contents summary: 

Part I

Medieval philosophy rested on classical and theological traditions, but these traditions could be contradictory and their contents were sometimes adapted to new uses and beliefs.

Chapter 1: Prelude to medieval theories and debates

This chapter covers Greek and Latin source materials that would form part of the basis of medieval understanding of sex differences. These philosophers presented both “scientific” and metaphorical explanations for sex difference. Different writers presented different concepts that overlapped and contradicted each other.

Hippocrates covered wide-ranging medical information which was transmitted via Galen’s later framing and commentary. His primary concept was that of balance and imbalance, moderation, and the origins of humoral theory, resting on the concept of polarities that did not have hierarchical relationships. The sexes have different compositions of these attributes and they affect health and reproduction. Sexual activity both affected and was influenced by humoral balance.

[Note: A brief understanding of humoral theory is helpful, especially since I will tend to use this label to cover concepts that aren’t precisely “humoral”. Basically, all things are composed of attributes that exist on binary scales; hot to cold, dry to wet. Health, well-being, and “good life” come from having these properties in the correct balance. Medicine is designed to alter an imbalance, as disease and improper functioning are caused by one’s attributes being out of balance. But some “imbalance” in these qualities is inherent based on one’s nature, and group characteristics may be attributed to a general tendency to try to seek to balance those qualities. Thus, for example, male human beings are, by nature, considered to be “hotter” than female human beings. Certain sexual differences are considered to be a consequence of this “fact.” So, for example, under this theory women experience menstruation and men don’t because menstruation is the female body’s attempt to rid itself of an imbalance of these properties specific to the condition of being female, while in turn that specific imbalance is part of what defines femaleness. “Humoral theory” proper visualizes the two binaries in terms of bodily fluids: blood (hot and wet), phlegm (cold and wet), black bile (cold and dry), and yellow bile (hot and dry). Humoral balance could be affected by diet, by environment, by behavior and activity. Although the rise of experimental science and medical treatments based on it eventually discredited humoral theory in Western medicine, the philosophical underpinnings can be compared to those of various systems of traditional medicine elsewhere in the world.]

Aristotle also subscribed to this balance/humoral theory but took a more systematic approach. His theory of form and matter sought to understand the causes of things and events. He took a more teleological approach (i.e., that things act to achieve a predestined goal). He applied value judgments to polar attributes that reflected an assumption of female inferiority.

The writings of Soranus (2nd century Greek) on gynecology brought in Greco-Egyptian thought. By his thinking, health related to concepts of laxness/tension, but still with the goal of balance. His philosophy treated female and male bodies as largely similar in function.

Galen (2nd century Greek) was also familiar with the Egyptian (Alexandrian) school of medical thinking, as well as other conflicting medical doctinres. He often rejected earlier writings while adopting specific elements of them. Like Aristotle, he preferred a philosophical framework for the practical medical knowledge he discussed. He ascribed purpose to nature (again: teleological thinking). His work didn’t focus on gender and reproduction. He embraced humoral theory and the principle of balance, focusing on binary oppositions but with less emphasis on sex differences, simply on contrasts. With respect to reproduction, he treated the uterus as having special importance, not simply as an analog of male anatomy and function.

Medieval philosophers might draw on these authors but often used their work to address questions that the classical authors hadn’t considered important, e.g., the role of sexual pleasure. The process by which classical texts were transmitted, translated, and assimilated was complicated as later authors added their own interpretation to the classical material.

Contents summary: 

The rise of universities, growing importance of towns, and shifts in the focus of ecclesiastical and secular courts created a new context for discussing sex differences. The rise of universities also inspired translation of vast quantities of Greek and Arabic material on natural philosophy and mediecine, providing access to classical sources that had been altered in the course of Latin transmission. This wealth of detail highlighted problems with the consistency and structure of the body of knowledge. This chapter highlights several texts grappling with this diversity. The very diversity of material meant that no single model of sex difference prevailed.

Constantine the African, an 11th century monk, connected with North Arica, a Moslem converted to Christianity, brought in Arabic medical texts and the influence of the medical school at Salerno. He wrote topic-based treatises intended for practical use, not only philosophical discussion. He took a consistent approach to explanation and treatment that followed humoral theory and consiered sexual desire in the context of procreation as well as discussing female and male roles in conception. He accepted that sex determination was caused by the uterine environment and the balance of the male and female seeds. In addition to the classical hot/cold, wet/dry distinctions, he discussed the bodily importance of a left/right polarity. He was more concerned with male influence on conception than female but accepted the physiological equivalence of the male and female organs and semen. He acknowledged female libido but did not put much focus on it, though he considered sexual pleasure to be an essential part of procreation. He also discussed how to decrease libido, when experiencing it was inappropriate. He considered women to take greater pleasure in intercourse (based on a theory of how sexual activity affected humoral gradients).

Hildegard of Bingen (12th century German abbess and prolific author) is an example of how monastic thought adapted to new learning without a radical transformation of conclusions. Her approach is eclectic and non-systematic. Her writing generally had a conservative context but she was also a visionary and largely self-taught. A collector, not an innovator. Her work mixes traditional remedies with theological explanations. She does not specifically address sex differences and reproduction, but these topics arise in other contexts, shedding light on her thoughts on the nature of male and female. She saw procreation as inherently related to the Fall from Eden and as resulting from physical imperfection. She viewed the female part in conception as more passive, but in the context that “active” conception resulted from bodily imbalances. The key binary properties in her theory were strength/weakness, with a lesser input of hot/cold. Her gender distinctions were not aligned clearly with positive and negative judgments. She viewed the gender binary as strong/soft (not strong/weak). There is an emphasis on difference, but not necessarily on hierarchy. Her discussion on the physical aspects of sexual arousal is incoherent and based on the idea of forces moving through the organs. She distinguishes delectatio (delight, arousal) from libido (lust, with a negative connotation).

Anonymous 12th century dialogue on sex and generation. This text addresses sexual topics openly and argues for them as a respectable subject. The author works from an assumption that the male is the primary influence in conception. The uterus is treated simply as a vessel, but he also follows the idea of right/left influence on conception. [Note: in this theory, the uterus was thought to have multiple chambers aligned on a right-left axis, and the both sex and gender were influenced by which one the fetus developed in.] But the dialogues also place an importance on female orgasm and female seed in the process. Given the belief in the importance of female orgasm to conception, the text debates why prostitutes rarely conceive. Various theories are offered deriving from different philosophical frameworks. He also touches on the question of pregnancy from rape as a contradiction of this principle, but concludes that if a pregnancy resulted, then the woman must have enjoyed the rape at some point. He recognizes that children often resemble their mothers (suggesting more female influence than some theories allowed for) and that even loving marriages might be barren. But these questions are then answered by finding explanations that support the original philosophical premises. Moral concerns in the work tend to be sublimated within the focus on examples of prostitution and rape, and misogynistic assumptions go unquestioned. In general, he turns the subject matter into an intellectual game rather than taking a medical approach.

Contents summary: 

This chapter looks at academic questions regarding the nature of male and female. With no agreed-on set of source texts or fixed principles of interpretation, the diversity and imaginativeness of late medieval interpretations was a natural consequence. But the contributions of Greek and Arabic writers and the development of structures for argumentation and presentation also affected the resulting conclusions. The formality of the field and its presentation can make it difficult to separate intellectualizing versus popular understanding.

Topics that the classical writers had overlooked were treated in more imaginative ways by medieval writers. Questions were more focused, precise, and contentious in the context of university debates. The answers were no clearer, but the questions were more sharply articulated. Some texts were newly accessible, such as Avicenna, who incorporated classical material via the Arabic tradition. New questions that had been of less concern to the ancients included how to determine the sex of a fetus and the nature and purpose of female and male sexual desire and pleasure.

The dissemination of these texts and debates were not only via academic institutions, but also in secular urban schools, such as the one at Salerno, that were not constrained by theological concerns. For example, while Albertus Magnus debated the logical arguments for why sex should or should not be pleasurable, later humanists considered such debates to be vain and pointless exercises.

Works that focused specifically on female medical concerns began to be created (typically by male authors). Debate over male and female contributions to conception were framed later as an “Aristotelian” position (which held that there was no female contribution) versus a “Galenic” position (which held that there were equal male and female contributions). Such positions oversimplified and exaggerated the classical authors’ views, while emphasizing the diversity of thought that remained current. But medieval authors often took a more compex position, drawing on a wider variety of authors, rather than following a single classical author.

The chapter has an extended discussion of how various authors considered and resolved these conflicts.

Sex determination had a practical as well as theoretical importance. If you know how the sex of a fetus was determined, then you could take actions to increase the chance of the desired sex (typically male). Whether this was due to the heat, strength, or other qualities of the man’s seed, he was considered to be the deciding factor in the child’s sex, though the position in the uterus was also considered relevant. These conflicting factors were also considered to account for non-binary sex and gender (i.e., intersex conditions and people who didn’t conform to gender norms). Such explanations always started with the assumption that the male was more perfect and more desirable. But even this presumption was sometimes contradicted on theological grounds (that God doesn’t create errors).

The role and purpose of sexual pleasure was not of special interest to classical authors, so medieval treatments of the topic were less constrained by precedent. Arabic sources focused more on desire than pleasure (to the extent that the two can be distinguished in the texts) and primarily on male experiences. The basic understanding of sexual pleasure was functional: to encourage procreation. But the rationales expanded to include health (via the balancing of humors). Psychology was also invoked, especially for disorders of desire such as lovesickness, as being due to a failure of reason.

Men’s sexual pleasure could be attributed to orgasm/ejaculation, but opinions were varied on how women received pleasure, especially in connection with theories about female seed. Even if female seed was not assumed to be a factor in procreation, orgasm was thought to enable conception by various means, such as by “opening the womb.” Later medieval writers on sexual pleasure could de-couple it from the mechanics of procreation when considering marginal cases such as desire during puberty, during pregnancy, etc. Specifically non-procreative pleasure (e.g., masturbation) was disapproved but discussed. (Albertus Magnus describes penetrative masturbation by women in this context.)

Debates over whether women or men had greater pleasure in sex were tinged by anxieties about gender traits. Is male orgasm a symbol of strength or of loss of control? Discussions often compared and contrasted consideratoins of pleasure (delectatio), love (amor), and desire (appetitus). Overall discussions of sexual pleasure were typically teleological--designed to explain pre-determined conclusions.

Contents summary: 


Discussions about sex difference became more detailed and complex from the 11th through 14th century. This included defining male and female natures and functions. There was expanded interest in the role of and differences in sexual pleasure and other experiential factors. These discussions give us evidence of medieval people’s notions of men and women, masculine and feminine. The context of production affected how such discussions were presented, e.g., the monastic view of women as dangerous temptresses. But these systems of thought were never simple and straightforward. The gendered nature of the institutions discussing the topics affected the content and conclusions. And even though intermediate case studies might be discussed, the conclusions always returned to the binary.

Chapter 4

Medieval thought assigned many traits to women and men, but these did not neatly align with the philosophic theories. The assignment of gendered traits was founded on both observation and mythic lore, while some gendered characteristics can be easily contradicted by human observation. These assigned gendered characteristics created a bridge between theories of reproduction and societal roles, e.g., symbolic domination during sex based on relative position. Contradictions presented by intersex, cross-gender, or homophile instances needed to be forced into the binary.

The theory of qualities/humoral theory were used to justify gendered conclusions, but these qualities were interpreted as being metaphoric (e.g., “heat”) when direct observation contradicted a literal understanding. “Heat” was considered a definatively masculine quality that both caused and was a consequence of masculinity. But the manifestations of this metaphorical “heat” were defined according to pre-determined conclusions about sex differences.

Menstruation was a particular focus of theories about humoral differences between the sexes. Why did menstruation exist? What purpose did it serve? Anatomy was an obvious focus of discussion on sex differences. Women’s physiology was often considered “child-like” in these discussions. Hair was strongly gendered, both when discussing body/facial hair as inherently masculine, and the hair of the head as feminine. These associations were once more justified via humoral theory.

In addition to hot/cold, moist/dry binaries, gendered characteristics included details of physiognomy (the interpretation of facial features, hair, eyes, etc.), though the field of physiognomy was much broader than simply interpreting gender traits.

Sex difference is inherent in ideas about the process of sexual differentiation during conception. Many ideas were examined about the conditions that would influence an embryo to one sex or another, and thus how to cause a particular sex. Theories needed to explain indeterminate types, either of physiology or by a presumed conflict between body and personality categories. Environmental factors might cause someone to deviate from the gender characteristics associated with their (physical) sex.

When considering “masculine” character traits, the “virago” (i.e., a female-bodied person with male-assigned traits) was originally a term of praise for a female with “manly” qualities. This was a consequence of the theory that women were “imperfect men”. To achieve manliness was therefore an elevation of state, a matter of “rising above” one’s nature. Only later did “virago” become a derogatory term, indicating an appropriation of male social status.

In parallel, physically male people might sometimes be praised for positive “feminine” traits, especially in specific Christian contexts (e.g., Christ as nurturing mother, believers as “brides” of Christ), though this was less common. This imagery did not imply a positive value for women as people, as contrasted with specific idealized feminine traits.

This abstraction of gender could be applied to entire species/kinds in the natural world. Panthers were considered feminine, lions masculine. Planets were masculine or feminine and influenced these qualities in humans. Alchemy involved manipulating these symbolic gender qualities in physical substances to cause transformation.

This gender systematicity relied heavily on binary oppositions, even when it allowd for indeterminate/ambiguous states between the binary. Abstract gender metaphors were embraced even when their consequences for the material world were rejected, as with the acceptance of allegorical understandings of Zeus and Ganymede, or the figure of Hermaphroditus, while at the same time condemning sodomites and requiring intersex persons to adhere to a binary. Males with feminine traits or females with masculine traits disrupted the social and even the political order. It was either a usurpation of authority (for masculine females) or a degradation (for feminine males).

If “sodomy”--loosely defined as any type of sexual activity other than penis-in-vagina--could be given a physiological explanation, this implied that it was in some sense “natural.” This approach tended to appear in medical texts, and conflicted with the moral explanation of sodomy as a spiritual failure to perform the appropriate gender role. Even when a medical explanation was offered (i.e., that a tendency toward sodomy might be innate) the position was that it should still be resisted. For a man to commit sodomy made him “womanly” not simply as a receptive sexual partner, but because it showed moral weakness in the face of temptation, and weakness was categorized as feminine.

Medical texts tended not to condemn variant sexual behavior or anatomical ambiguity. The condemnation was left to theological writings. This can sometimes be seen in a single author’s works in both genres. Starting in the mid-13th century, there was a shift in theological writings to a focus on the control of sexual behavior in general: who, how, why. This coincided with ecclesiastical reform movements, the establishment of marriage as a sacrament, and concern with defining distinctions between celibacy, abstinence, and marital fidelity. Another set of co-occuring factors was the rise of heretical movements, such as the Cathars, that challenged orthodox thought on sex.

Prohibitions on homosexual acts usually framed the problem as gender reversal (i.e., one partner taking on the sexual role of the other gender), which also manifested in concern about transvestism, especially if done in the context of women usurping male social privileges, such as the right to celebrate Mass. At the same time, there was more space given in the texts to concern about males taking on feminine roles, possibly because the audience was presumed to be men, possibly because the “degradation” of taking on feminine roles was considered less understandable. Viewing homosexual acts as gender transgression simultaneously reinforced and undermined binary gender categories. Legal condemnation of homosexual acts focused more on men than women. The earliest known court case involving a sex act between women is from 1405.

The ambiguous space between the binary poles of masculine men and feminine women held a number of concepts (homosexuals, intersex people, eunuchs, etc.) which might all be lumped under the term “hermaphrodites”. Because there was not a clear distinction between how this term applied to sex characteristics (physiology) versus gender characteristics (sociology), the use of the term hermaphrodite for a specific person cannot always be clearly interpreted.

Contents summary: 

The concepts and theories around in/fertility have shifted over the centuries much as those around sex/gender. Medieval authors were highly preoccupied with childbearing and anything that helped or impeded it. The expression of this concern was closely connected to theories of reproduction. Medieval treatments for infertility followed from the varied theoretical understandings of the process of conception and gestation.

Procreation was not only an individual concern but a familial one, as social ties, economic strength, and other consequences depended on the production of children. Surplus children presented a different set of difficulties so despite official disapproval of contraception, knowledge about how to avoid pregnancy was also desired.

Sterility might, in an individual instance, be considered an innate property or a fixable condition. The question of the female role in conception affected understandings and treatment of infertility.

But the topic of this chapter is largely outside the scope of the LHMP so I’m skipping a detailed summary of the rest.

Contents summary: 

Medieval opinions about abstinence--as expressed in medical, philosophical, theological, and social literature--are more complicated and ambivalent than those about procreation. Given that much of the discourse around procreative sex frames it as driven by medical and moral imperatives (e.g., theories about how sexual desire has the goal of achieving balance and promoting health), how can abstinence fit into the same framework without being considered unhealthy?

There were varieties of abstinence. Virginity was the one held in highest regard, especially in the early Christian period, and represented a complete avoidance of the experience of intercourse at any point in one’s life. Virginity was often contrasted with marriage (in contexts where marriage assumed sexual activity), with marriage being a “second-best” way of avoiding fornication (unauthorized sex). But one could also be a virgin within marriage, a condition that often features in saints lives.

Men could be virgins, just as women could, though the condition was more salient for women. In the later middle ages, the Church deemphasized virginity, either as an ongoing state, or as a requirement for various events such as marriage or taking monastic vows. This seems to have been largely a matter of practicality.

In a social context, only women’s virginity was emphasized and subject to family protection and control. This was driven by the desire for controlling the parentage of offspring. A number of medical tests purported to be able to determine whether or not a woman was a virgin, and of course the ultimate proof of non-virgin status was pregnancy and childbirth. There were no equivalent tests and proofs for male virginity or fidelity. Countering these tests, there were also manuals with instructions for how to counterfeit proofs of virginity, especially the bleeding after penetration that was associated with myths about the hymen.

Although religious principles regarding sexual continence were, in theory, gender-neutral, they were generally compatible with the secular interest specifically in female virginity. One exception was that the Church allowed for the possibility of “spiritual virginity” even after the experience of intercourse. Thus some held that those who only experienced approved sex within marriage (the usual understanding of the term “chastity”) could be considered virgin. Theology was also less interested in the sex-specific “proof” offered by an unbroken hymen.

The next “rank” of sexual abstinence after virginity was permanent celibacy, as for those who took religious vows. Monastic institutions regularly had problems with enforcing this and the sexual misconduct of monks and nuns was a regular trope in medieval popular culture. A sincere religious vocation was only one of the paths to monastic life. Monastic institutions were commonly used as a place to store “surplus” sons and daughters for whom no land or dowries were available--a purpose that would be undermined by procreation. But conversely, for people (especially women) who wished to abstain from sex, a religious life was a useful option.

Far more common than these lifelong commitments to celibacy were temporary periods of abstinence such as due to postponed marriage or abstinence during certain religious festivals. Certain regional marriage patterns involved postponement of marriage well into the 20s, and demographics indicate that this wasn’t accompanied by significant illegitimacy rates. Medical texts indicate that this could be considered a problematic condition, and might recommend nonreproductive sexual activity such as masturbation (in conflict with the theological position on the topic). Both theology and medical theory supported a woman being abstinent while menstruating. The two also agreed on the desirability of women being abstinent during pregnancy, though some medical theories recognized that women might experience sexual desire during pregnancy even though it served no biological purpose. The prohibition was largely on moral grounds regarding the justifications for enjoying sex, though there were also anecdotal theories that a pregnant woman who committed adultery could achieve a second pregnancy with her lover’s child.

The central theme in all of these is that even for those who have a context for licit sex, the desired state is “continence”, that is, sex only in approved circumstances for the purpose of procreation. This was the principle behind condemnations of contraception, abortion, sodomy, and masturbation, as well as sex during pregnancy. This theme of the desirability of control over sexual impulses belongs to theological literature, while medical texts address only specific types of nonprocreative sex that are considered harmful. In other contexts, medical manuals (such as the one attributed to a female author, Trotula) acknowledge the harmful effects of abstinence on women who have no licit outlet (such as widows), or the ill effects on some women of sexual activity (and its consequences) who are not in a position to abstain, and offer treatments for those situations. One approach was the use of anaphrodisiacs to decrease sexual desire. This was not an approved theological solution as it removed the moral benefit of actively resisting temptation.

In general, medical authorities considered sexual activity to be essential for good health. Abstaining would put the body out of balance, unless one’s personal constitutional balance was already out of balance in a way that sex would aggravate. For those whose constitutions required sex for good health, but whose personal circumstances did not offer the opportunity, remedies might include medicines, diets, or activities that addressed the imbalance in other ways. But some medical authorities recommended masturbation as a way of restoring health. This might be dressed in the guise of a professional treatment, as in some prescriptions for women to have a midwife massage their genitals until orgasm.


While the interests of medical, philosophical, and religious traditions often aligned in principle around issues of sex and gender, when dealing with specific medical problems and conditions, the secular authors often showed flexibility and practicality in applying the varied and contradictory theoretical traditions to the topic at hand. There was no unified over-arching system to their approach, but the general principles of polarities, balance, and a “whole life” approach carry through. Beliefs about inherent differences between male and female bodies result in different assumptions and approaches. Although medical theories were sometimes used in support of social or theological concerns, as a general rule, medical writers did not feel constrained by purely theological principles (though theology might be an unnoticed part of the underlying assumptions).

The enforcement of a philosophical system of binaries, and the acceptance that qualities could manifest in contradiction to their expected assignment as a form of “imbalance,” meant that medieval medical and philosophical theories had no framework for understanding homosexuality as a distinct phenomenon. Rather, individuals were viewed as manifesting properties at odds with their nature. So, for example, a female person who desired sex with another female person was not viewed as having “same-sex desire” but rather as being of a masculine nature, where part of the inherent properties of a masculine nature was to desire women. [Note: One should not lose sight of other behaviors that could indicate a “masculine nature” in a female person, such as being strong, brave, intellectual, and in control of one’s emotions.]