Summary with Human sexuality and its problems by Bancroft - 3th edition

What is the book "Human sexuality and its problems" about? - Chapter 1

Sexuality has always played a fundamental part in the lives of many of us, and continues to do so. However, there are always changes in the sexual world. Most marked in the twenty to thirty years before 1989, when the second edition of this book came out, were the changes in the sexuality of women. These changes enabled women to express their sexualities more openly. An important theme in this book is the pattern and challenge of comparing and contrasting the sexuality of men and women. Since 1989 we have not seen any reversal of the changes in women’s sexuality, but it has not been so evident as in the decades before 1989, the era of sexual liberation or revolution. For example, the age at which sexual initiation happens has not dropped much further since, and has even gone up slightly. However, the trend towards more sexual experience before marriage has continued in the Western world.

Since before 1989, HIV and AIDS have had a major impact. While seen as a ‘gay disease’ in the beginning, the subsequent worldwide pandemic shows it to be a predominantly heterosexual problem. More recent attention focused on the vulnerabilities of heterosexual women as an important demonstration of the consequences of gender inequality. HIV/AIDS has added further complexity to the issues of responsible sexual behaviour.

Since the previous edition of this book, a new phase of sex survey research has started. This has been largely driven by the HIV/AIDS pandemic. The need for surveys in order to research behaviours and attitudes relevant to HIV-transmission has been acknowledged, though it remains difficult to obtain funding for sex research in general. Also, the fear that attempting to understand sex will somehow encourage it, has persisted in the USA in particular.

Despite this, the past 20 years have seen a huge increase in literature relating to human sexuality and its problems. The objective of this book is to provide a broad cross-disciplinary perspective. The structuring of the book reflects its core theme: that human sexuality results from an interaction between the psychobiological mechanisms inherent in the individual and the culture in which he or she lives. Socio-cultural factors are especially important when trying to understand the development of gender identity, sexual identity and emerging patterns of sexual behaviour.

HIV, AIDS and other STIs now have their own chapter, as do transgender and gender non-conformity. The assessment of sexual problems is now incorporated into the chapter on their treatment. This reflects changes in the clinical field, where there has been a shift away from surgical interventions (since the start of the ‘Viagra-era’), for example for erectile dysfunction.

The internet is also a major new factor in the modern sexual world, crossing age, cultural, and geographic boundaries. It has both positive and negative effects on human sexuality, which we have hardly begun to understand.

Practice questions CH.1

1. Which changes were the most marked in the two to three decades before 1989?

2. What is a trend in sexual behaviour changes that has continued in the western world since 1989?

3. The HIV/AIDS pandemic has led to a new phase in which we see an increase in a certain kind of research. What kind is that?

4. In the clinical field, there has been a shift. Was this shift more towards surgical interventions, or away from these? And what caused this shift?

What are models and theories on human sexuality? - Chapter 2

In 1998, Weis concluded that the majority of the sex research literature had no explicit theoretical base. He presented a range of theoretical models which were of potential relevance, but sex researchers had made very little use of them. This chapter explores the role that theory can play in sex research. In 1993, a conference was organised about theorising sexuality. The organisers were hoping to facilitate a paradigm shift towards a broader interdisciplinary study of human sexuality, while pointing out the previous neglect of scholarly attention to sexual pleasure (as opposed to a focus purely on reproductive sex). Anthropologist Tuzin saw human sexuality as an interaction between biological mechanisms and cultural processes.

How do we construct knowledge?

In recent years we have seen a growing divide between conventional sex researchers (who attribute reality to the biological basis of sexuality) and social constructionists (who point to the social construction of sexuality and its changes throughout history). There has been an increase in attention to the ‘what is’ type of question among conventional sex researchers, which is an approach that points to sexuality in humans being a social construct (‘what is sexual desire?’).

The concepts we have of sexuality have been constructed dependent on the level of relevant knowledge available. These concepts have differed across societies and through history. Ideas persist until convincing evidence comes up that challenges these ideas. In recent times, we can see constructs of gender difference become shaped by the accumulation of scientific evidence. Sex is merely a name for our total impression of all aspects of gender differences.

Harris makes a distinction between ‘emic’ knowledge – that which the native accepts as real, meaningful and appropriate – and ‘etic’ knowledge: concepts and categories used by experts and scientists. Common sense is influenced by science, we can look back over history and see how this happened, only to be shown to be wrong by later scientific progress. We should keep in mind that whether we are a ‘native’ or an expert, we should remain uncertain about what ‘reality’ is. Each phase of scientific progress uncovers a new layer of complexity, so we wonder if we will ever really understand how our brains work. Making ‘conceptual systems’, which are at best simple versions of reality, may help us deal more effectively with the growing complexity and provide a structure for organising our thinking on related topics.

What is political correctness?

Many postmodernists believe that conventional science is used to gain social control (particularly of sexual aspects of life), and is therefore politically suspect. Treating the problem of risky sex as a property of an individual would blame the individual for something they can do nothing about. From this perspective, scholarly inaction seemed to be the solution. In clinical psychology, there is a strong movement to avoid clinical intervention which has not been empirically validated, such an intervention would be unethical. Therefore clinical help is often withheld in situations of need.

However, social control of sexual behaviour is a cause for concern, many of the sexual problems people have can be attributed to the negative effects of social control. Much of the social control of sexuality is imposed on women and is used to suppress homosexuality. Here we have a challenge of sorting out the scientific from the political.

Conventional sex research often focused on the individual, but this met with much criticism. For example, focusing on the individual when theorising why some teenage girls are more at risk of unplanned pregnancy means ignoring the influence of society (often poverty was to blame). Holding the individual responsible could lead to further social control. It’s good to keep in mind that situational factors can increase the likelihood of risky sexual behaviour and that we should be looking for ways to promote less problematic socio-cultural contexts. But we should not forget that there is also still individual responsibility. Community as well as individual responsibility should be encouraged, but we also have to pay attention to differences between various cultures.

What is the Sexual Strategy Theory (SST)?

This theory was first presented by Buss & Schmitt in 1993. SST is an application of evolutionary psychology principles. It focuses on desire and all of its interpersonal ramifications: attraction tactics, conflict between the sexes, mate expulsion tactics, causes of conjugal dissolution, mate retention tactics, and harmony between the sexes. Psychological mechanisms dealing with these ramifications can each be regarded as an adaptation and are activated depending on context.

These mechanisms can be divided into short-term and long-term strategies. Men are more involved in short-term strategies than women. Distinct short-term strategies for men are (1) desire for a variety of partners, (2) assessment of sexual accessibility, (3) assessment of physical cues linked with fertility and (4) strategies for keeping time and investments to a minimum. Women can reap some benefits from this, including immediate resources, ‘mate insurance’ if she loses her regular mate and genetic benefits from mating with superior men. Long-term strategies have more to do with good parenting: women have to be reproductively valuable while men need to be able to acquire resources and show they are willing to invest those and are willing to commit long term.

SST has been far more successful at explaining gender differences than gender similarities, and even less in explaining individual differences. One would expect non-adaptive mechanisms would already have been selected out of existence, but this seems not to be the case. It is possible that optimal strategies vary depending on the individual’s psychological mechanisms, or they may fluctuate over time, or over different situations.

The problem with this theory is that the gender differences cited as supporting SST were all well known before the model was proposed. So in terms of its heuristic value, it can’t really predict anything that is not already predictable from other theoretical approaches.

What is Sexual Scripting Theory?

This model was first proposed by Gagnon & Simon in 1973. It uses the metaphor of ‘script’ to describe the sequence followed by an ‘actor’ engaged in sexual behaviour. The script must precede the behaviour: there is very little human behaviour that can in full measure be called spontaneous. A script can be described as an organised and time-bound sequence of conduct. It can be used to envisage future behaviour and to check on the quality of ongoing behaviour. It is critical that the script is flexible, so the individual can adapt responses to new circumstances in our changing internal and external environment.

According to this theory, all sexual meanings and desire are embedded in the social context. Sexual scripts have three distinct levels: cultural scenarios (social norms), interpersonal scripts (where social convention and personal desire meet) and intrapsychic scripts (the self-process).

Even though sexual script theory provides an all-embracing model to account for sexual behaviour, this is still very complex. Even in the most traditional social settings, cultural scenarios will very rarely predict actual behaviour. Sexual scripts are often relatively incomplete and do not specify each act precisely. Also, physiological arousal (though not necessarily sexual) is only given meaning by the socio-cultural context. The social aspects that organise the action provide the script. According to this theory, no biological factor finds its way into the behaviour of an individual except through socio-cultural mediation.

Studying scripts directly is very difficult, it requires detailed data on what activities occur during a sexual encounter, and also on the order in which the activities occur, which is impossible to implement in a survey. An interesting application of the theory is sex therapy. A therapist can use these scripts explicitly by explaining what words to use, what sequences to follow. The couple or individual will receive individual scripted assignments to follow. Comparing the scripts of the two partners in the relationship can also be effective in identifying reasons for low sexual desire.

It seems that the authors of this theory use it mostly as a metaphor, rather than a theory. It has never truly been put to the test by them, but their statements about the theory are utterly certain in tone. It seems that this is more of an intuitive grasp of the essence of a concept, rather than a real scientific theory. However, implementation of the scientific method requires control of the circumstances, and therefore removing the factor under study from the ordinary world. This can make interpretation in terms of this ordinary world very difficult. We have to keep in mind that a research finding resulting in clinical benefits can be useful, even if it doesn’t help us understand how the beneficial changes were achieved.

What is the big picture?

It’s clear that the determinants of human sexuality and its behavioural manifestations are many and varied. The prevailing culture shapes the sexual mores and taboos, but we need to take the individual biological variability into account when trying to explain the fact that in a given cultural setting, individuals vary considerably. And so we need a basic model that acknowledges the full range and complexity of human sexual expression and its determinants.

A good start for such a model is Marvin Harris’s account of cultural materialism. He was interested in the material resources around which culture and social structure are created. The model has three parts: (1) infrastructure (mode of production: food and energy; mode of reproduction: methods for expanding, limiting or maintaining population size), (2) structure (domestic economy: family structure, age and sex roles, domestic division of labour, education; political economy: division of labour, class system, police, war) and (3) superstructure (shared beliefs, symbolism, taboos, religion, epistemologies and expressions of culture). In this model, infrastructure determines structure, and structure in turn determines superstructure.

This model may serve as a foundation for our theoretical model of human sexuality, but is not complete. This model explains differences and similarities between different cultures, but not yet between individuals within those cultures, something that is needed in a model describing human sexuality. We therefore need to incorporate the individuals in terms of their innate characteristics and capacities, as an element of the infrastructure of that culture.

These characteristics for the infrastructure can be divided into: demographics of population, neurobiological basis of sexual responsiveness, age-related developmental processes, development of patterns of sexual attraction and methods of fertility regulation.

For the structure we see: mating patterns, levels of sexual stratification, levels of sexual segregation, age at marriage, family structure (matri- or patrilinearity, fatherless families), social management of adolescence and transition to sexual adult, reactions to cultural norms and communication systems.

For the superstructure we have: shared concepts of masculinity, femininity and male-female relationships, shared constructs of sexual identity, shared beliefs about appropriate patterns of sexual behaviour, shared beliefs or attitudes about values surrounding marriage, sexual conformity and identification with sexual counter cultures.

What is the Dual Control model?

The Dual Control Model states that whether sexual response and arousal occurs in an individual, is ultimately determined by the balance between two systems in the brain: the sexual activation or excitation system, and the sexual inhibition system. Individuals vary in their propensity for both these systems. Individuals with an unusually higher propensity for excitation would be more likely to engage in problematic sexual behaviour, while someone with a higher propensity for inhibition would be more likely to experience sexual dysfunctions (problems with response).

Women, on average, show higher propensities for inhibition than men while men show higher propensity for excitation, and there are gender differences in the situations which evoke inhibition of sexual response. In women, the excitation system is more often activated by positive partner characteristics and hormonal changes, in men more often by a variety of sexual stimuli and negative mood states. The inhibition factors most prevalent for women were situations not characterised by trust and intimacy, concerns about sexual functioning and the setting. The impact of tendencies caused by the inhibition/excitation-systems is determined by the culture, or subculture, to which the individual belongs.

Practice questions CH.2

1. How did Tuzin describe human sexuality?

2. What is the difference in ideas between conventional sex researchers and social constructionists?

3. Explain what Harris means when he talks about ‘emic’ and ‘etic’ knowledge?

4. Did conventional sex research focus more on the individual or on situational factors? Why should this be done differently?

5. What is the most important difference between Sexual Strategy Theory and Sexual Scripting Theory?

6. Which shortcoming can we, as human sexuality-researchers, find in Marvin Harris’s account of cultural materialism?

7. Which two systems in the brain determine whether sexual response and arousal occur, according to the Dual Control Model?

What are sexual differentiation and gender identity? - Chapter 3

In this chapter, the process of sexual differentiation is considered, together with typical male and female genital anatomy. We also look at the process of gender identity development and abnormalities of sexual differentiation or intersex conditions.

What are our reproductive hormones?

A hormone is a form of chemical messenger, which typically travels from its cell of origin to its target cell via the bloodstream. There are two main chemical types of hormone: steroids and peptides. Steroids are to some extent stored in the blood since they are bound to plasma proteins (for example testosterone). Peptides on the other hand are stored in the cell or gland that makes them and are released when required. This means their level in the blood can fluctuate considerably. Many peptides function as neurotransmitters in some contexts and as classical hormones in others. Some only function in releasing other peptides from their cells of origins.

Most cells will only be affected by a hormone if they contain its specific receptor, for steroids these lie within the cytoplasm and when activated lead to the unique steroid pattern of protein synthesis. For peptides, the receptors are mainly found in the cell membrane.

The principal hormone system concerned with reproduction and sexual behaviour is the anterior pituitary gonadal axis.

What are some of the different peptides and brain systems involved with sexuality?

The posterior pituitary releases vasopressin and oxytocin (OT). Many functions can be carried out by a variety of peptides, so if one peptide is missing, others can take over. The specific effect of a peptide may depend on its site of action, or even the context in which it is acting.

Endogenous opioids are a recent addition to the list of peptides and play an important part in the hypothalamic-pituitary-gonadal system, modulating the feedback effects of steroids on the hypothalamus and pituitary. Prolactin remains a mystery peptide. It has a function in stimulating growth and activity of the milk-secreting system of the breast. Other effects are less well understood. As we shall see, high levels of prolactin are usually associated with impaired sexual function in men. Inhibin is produced in very small quantities by the ovary and the testis. It exerts negative feedback on the hypothalamic pituitary system, reducing the release of follicle stimulating hormone (FSH). The local hormones of most reproductive significance are the various prostaglandins, which have a special and as yet incompletely understood role in the reproductive system.

The anterior pituitary-gonadal system consists of several components. The hypothalamus mediates control of the system by other parts of the brain, such as the cortex and pineal gland. It directly influences the system by controlling hormones, which it secretes and transports to the anterior pituitary gland. A key control system is the regulation of gonadotrophin production by the anterior pituitary, which is carried out by gonadotrophin releasing hormone (GnRH). Receptors for GnRH are found in particular in the ovary and testis.

Gonadotrophins are the glycoproteins LH and FSH, released from the anterior pituitary. They affect the gonads. Both play key roles in reproductive function in both men and women, by stimulating follicular growth among other things.

Sex steroids (oestrogens, progestagens and androgens) are produced mainly by the gonads and the adrenal cortex. They have a particular role in reproduction: androgens in sexual differentiation, both androgens and oestrogens in the development of secondary sexual characteristics at puberty. Oestrogens and progestagens establish and maintain pregnancy and lactation, androgens establish spermatogenesis. An additional and somewhat mysterious feedback mechanism is responsible for ovulation in the female, this will be discussed in more detail later.

The main oestrogens are oestradiol and oestrone. The ovary is the principal source of oestradiol. Progesterone, the main progestagen, is produced mainly by the corpus luteum in the ovary. The principal androgens can be converted in the tissues into oestradiol in women, half comes from the ovary, the other half from the adrenal cortex. In men they are produced mainly by the testes. Androgen DHEA is regarded by some as a major precursor of the principal sex steroids testosterone (T) and oestradiol. But apart from the agreement that DHEA is a more important source of T in women than in men, there is little consensus on how much of these principal steroids is derived from DHEA. There is growing evidence of a role for DHEA and DHEAS in maintaining the immune system, and for a dissociation between DHEA and corticosteroids in the response to depression and stress. However, DHEA and DHEAS remain an intriguing mystery, with their unusually high concentrations in the circulation.

What anatomical sexual differentiation is there in humans?

Humans develop as either female or male, with rare exceptions when the differentiation is ambiguous (intersex). We still believe femaleness is the default position, whereas maleness requires an active hormonal intervention, however, further research has revealed a much greater complexity. Sexual differentiation and the development of gender identity can be summarised in seven stages: (1) chromosomes, (2) gonads, (3) hormones, (4) internal sexual organs, (5) external genitalia and secondary sexual characteristics, (6) the gender assigned at birth (‘it’s a boy!) and (7) gender identity (‘I am a girl’).

The most basic manifestation of gender lies in our sex chromosomes, present in every cell of the body. The normal female has two X chromosomes, the normal male has one X and one Y. There are 23 pairs of chromosomes (so 46 in total). The Y chromosome in males is much smaller than the X. The key gene in the Y chromosome is known as SRY, the testes determining factor.

The next stage is the differentiation of the primitive gonad into either testis or ovary. The presence of a normal testis will lead to sexual differentiation as a male, the absence of a testis will be associated with differentiation along female lines. In the presence of the SRY gene, the process of forming testes will start in about the eighth week of foetal life. If SRY is absent, ovaries will develop, but only starting in the 12^th week.

In the male foetus, the testis start to produce steroids from about the 8^th week, reaching a maximum between the 10^th and 18^th week. This phase of maximal foetal steroid production is a crucial time for differentiation of the male internal and external genitalia. In the female foetus, differentiation of the reproductive tract does not depend on steroids.

The Wolffian duct can develop into the internal sexual organs of the male. The Müllerian duct can develop into female internal organs. The early foetus has the potential for both. The hormone T stimulates male development, together with Müllerian-inhibiting factor (MIF). Unless MIF is present, the foetus will develop along female lines.

Prior to external differentiation, the external genitalia are the same regardless of genetic sex. In the presence of androgens, these will develop into male genitalia.

What are the effects of hormone levels during childhood and adolescence?

Over the first few days after birth, hormone levels in both male and female infants fluctuate. Some drop immediately to pre-pubertal levels, others keep rising for a few days before dropping to their pre-pubertal level. The secondary, post-natal surge of androgens may play a role in the masculinisation of the central nervous system. A pattern of low endocrine activity persists for several years during early childhood, in both males and females.

The next endocrine change involves the adrenal cortex. From about the age of 6 in girls and 8 in boys, there is an increased production of DHEAS followed by DHEA, and later androstenedione. The purpose of this so called adrenarche is not clear. The increase in adrenal androgens is probably responsible for early axillary and pubic hair growth in both sexes.

The onset of puberty involves a change in the production and release of GnRH, but what the cause of that change is, is not yet clear. The hypothalamus causes a more substantial rise in gonadotrophins and steroids. The response of the testis to HCG administration increases closer to puberty, indicating some maturation of the testis. The earliest signs of pubertal endocrine changes are nocturnal surges of gonadotrophins, before there is a noticeable change in daytime levels.

In girls, breast development and growth of pubic hair starts between the ages of 9 and 13 years, whilst menarche occurs between 11.5 and 15.5 years. There are some ethnic differences in the onset, in the USA for example each stage occurs earlier in African American than in white girls. The growth spurt starts about 2 years earlier in girls than in boys. It may take a few months before the cycles become regular, after first menstruation.

In boys, it is not until about 12 years that there is any increase in T production, which lasts (though it decreases) until the early to mid-20s. The earliest development of secondary sexual characteristics is accelerated growth of the testes and scrotum (9.5-13.5 years), followed by growth of pubic hairs. The penis starts to grow around 10.5-14.5 years, accompanied by development of the internal structures. About a year after the start of penile growth the first ejaculation occurs. The growth spurt starts between 10.5 and 16 years, with deceleration about 18 months later. The voice starts to change towards the end of the growth spurt.

In the male, the increases in androgens are responsible for the enlargement of the penis, scrotum and possibly testes as well as for the greater responsiveness of these to tactile stimulation. They also determine masculine body hair growth, they result in deepening the voice and activate the sweat glands and sometimes lead to acne. The promote increased muscle and influence bone growth. In females, androgens also influence body hair growth and gland activity and may be necessary in small amounts for the development of the external genitalia.

In girls, oestrogens cause enlargement of the breasts, pubertal growth of the uterus and fallopian tubes, vagina and vulva, and are responsible for the growth spurt. They may influence pubic and axillary hair growth, but this is not certain. They indirectly provoke ovulation. Progesterone has a special function in maintaining pregnancy. It acts on breast tissue to promote the milk production.

How does gender identity develop?

There are two components to gender identity development: the recognition that ‘I am a girl/boy’ (core gender identity) and a sense of masculinity or femininity, expressed in behaviour. It is this issue of masculinity versus femininity that generates the fiercest arguments. To which extent are these gender roles socially or innately determined (nature/nurture)? Research mostly found overlap in gender behaviour, with just two consistent areas of gender differences: motor performance (e.g. throwing) and certain aspects of sex (e.g. masturbation). This issue is at the heart of the political campaign to liberate women, and as a result what appears to be a scientific argument is often a political one with a consequent loss of scientific objectivity. Twin research found that genetic factors as well as intra-uterine experiences all determine how we interact later with our environment. We have much to learn, however, about the relative importance of different determinants at specific stages of development.

Most children have gained some understanding of gender labels and accompanying stereotypical behaviours by their second birthday. ‘Core gender identity’ is established early. The first signs of gender non-conformity may be evident at this age. They are able to categorise other people’s gender by age 5, and can do so for adults earlier than for other children. By age 7, children become more flexible in how they apply gender stereotypes and allow for more variation in masculinity and femininity. Girls show the least stereotypical behaviours around age 13, but withdraw from male-typical activities after that. By middle to late childhood girls give more importance to intimacy and closeness in friendships and talk more to their friends than boys do. By middle adolescence, the pattern of same-sex friendships starts to break and various types of cross-sex interactions and networks emerge, paving the way for dating. Emotionally, boys usually start to conceal negative emotions, while girls become more concerned about hurting other people’s feelings. They report more negative feelings in adolescence, while boys are more likely to deny them. Regarding to body image, girls focus more on weight, while boys focus more on how muscular they are. Children who watch the most television also have the more gender stereotyped attitudes, although direction of causality is not yet clear.

How is the genital anatomy in adults?

How is it in women?

The clitoris is a much more extensive structure than its visible part, the glans, would suggest. It consists of the glans and the erectile bodies. The glans is packed with sensory nerve endings, the other parts form a pyramidal-shaped structure. The body of the clitoris contains erectile tissue similar to that of the penis.

The vulva is what can be seen on the outside. Flanking the vaginal opening are the labia minora, folds of skin much thinner than the labia majora. The labia minora may be visible between the labia majora, accounting for considerable variability in external appearance of the vulva in different women. Between the clitoris and the vaginal opening lies the urethral opening.

The vagina is a tube, which, in the non-aroused state, is collapsed. It is usually 10-11cm in length. The lower third of the vagina is closely invested by the surrounding pelvic floor muscles. They support the vagina and rectum in resting state, and contraction of the muscles may elevate the vagina. The vagina has a rich arterial blood supply.

The uterus is a pear-shaped organ with a thick muscular wall, with a narrow lower part: the cervix or neck, which protrudes into the vagina. The body of the uterus is more mobile, necessary for pregnancy when it enlarges.

The fallopian tubes enter the upper part of the uterus, the ovaries lie below the fallopian tubes. Each ovary contains ova (egg cells), surrounded by a follicle. Every month a single follicle ripens and is transported to the uterine cavity.

How is it in men?

The shaft or body of the penis is formed principally by a fused pair of corpora cavernosa, filled with erectile tissue, which inflates with blood during erection. Beneath the two fused corpora cavernosa lies another erectile column, the corpus spongiosum, which envelops the urethra. Near the root of the penis are layers of muscle, which contract rhythmically during orgasm and semi-voluntarily during the development of erections. Near the tip of the penis, the corpus spongiosum expands to form the glans, which is usually covered by the foreskin. This is connected to the glans by a fold of skin, the frenum.

The gonads or testes lie in a superficial pouch of skin and muscle, the scrotum. This provides them with a cooler environmental temperature, essential for normal spermatogenesis. The testes contain cells which produce steroid hormones, and tubular cells from which spermatozoa are derived. The structure is linked on each side to the urethra by a long tube.

The genitalia of both men and women have many sensory nerve endings, some may be important in monitoring vasocongestion, others may be peculiar to erotic perception. There is considerable variation between individuals in the number and distribution of these nerve endings, explaining the variation in degree and localisation of erotic sensitivity.

What are biological rhythms and normal patterns of change in reproductive hormones?

By convention the first day of menstruation is the first day of a new cycle. There is a gradual rise in levels of FSH and LH, which leads to the development of a new follicle. As oestradiol rises, so the FSH level starts to fall and when oestradiol reaches a certain level, this produces a pre-ovulatory surge of LH. This provokes the ovulation of the ovum from the by now ripe follicle. In the second phase of the cycle, the endometrium is prepared for implantation of the ovum if it is fertilised. If this does not happen, the endometrial lining (corpus luteum) is shed, this is menstruation.

Pregnancy has special endocrine characteristics, due to the presence of an additional endocrine gland: the placenta. The placenta can produce huge quantities of progesterone and seems to be autonomous, so not controlled by any kind of feedback. Fertilisation of the egg prevents the shedding of the corpus luteum, allowing continued production of progesterone. Bye the 20^th week, the placenta takes over progesterone and oestrogens production. Oestrogen and progesterone together stimulate growth of the pregnant uterus and breast.

The process of parturition begins before the onset of labour. The principal and most immediate change obviously follows the expulsion of the placenta. The progesterone level drops within 24h of delivery and continues to decline until it reaches a low level from 7 to 14 days onwards. The initial fall in oestrogens is the same, but after that further change depends on whether or not the woman breastfeeds. If lactation does happen, the levels continue to decline and are then maintained at a low level. If not, oestrogens rise to more normal levels from the third post-partum week until normal menstruation resumes. During pregnancy, oestrogens inhibit actual milk production but stimulate prolactin production, which helps develop the milk-secreting mechanism. When oestrogen drops after delivery, milk production and release ensue. Ovulatory cycles usually return only after there has been a substantial drop in suckling frequency.

Whereas men continue to be fertile into late life, women have a relatively abrupt cessation of fertility around the menopause. The ovary has a limited number of primitive ova present at birth and these undergo some form of ageing so that follicles become increasingly resistant to gonadotrophic stimulation, so that eventually ovarian activity and menstruation cease. This is a gradual process. The average age in the Western world for the last menstrual bleed is 51. This age is however quite variable, mostly caused by genetic factors. During the transition, oestradiol levels decline, the major reduction of which happens only in the last 6 months of the transition. FSH and LH levels start to rise. The post-menopausal ovary virtually ceases to secrete oestradiol, although androstenedione and T continue to be produced. Symptoms of menopause are hot flushes and night sweats. A more persistent negative effect is vaginal dryness.

What are anomalies of sexual differentiation?

Anomalies in sexual differentiation present the clinician and parent with difficult decisions about how the intersex child should be raised, and whether surgical interventions are appropriate. It seems that, if pre-natal development is normal, early gender reassignment after birth is unlikely to be fully successful.

What are examples of sex chromosome aneuploidies?

45-XO (Turner’s syndrome). Here the second X chromosome is missing completely or is abnormal. This results in normally female externa genitalia, but the ovaries don’t develop, nor do the secondary female sexual characteristics such as breasts. Other problems, such as webbing of the neck, coarctation of the aorta and diabetes, may also occur. Gender identity is female, menstruation can be initiated and maintained with oestrogen substitution therapy.

47-XXX (Triple X). Here puberty may be delayed and some do not menstruate normally. Some of these women are fertile.

47-XXY (Klinefelter’s syndrome). Development here follows male lines. It includes small testes, hypogonadism, infertility, and tall stature. There may be intellectual impairment, personality problems and abnormal sexual preferences. Heterosexual interest and socio-sexual behaviour are often delayed.

47-XYY. Here there are no obvious sexual consequences except occasional testicular abnormalities with impaired spermatogenesis and tubular atrophy. They are often fertile and have chromosomally normal children. These men show tall stature, but the majority live their lives without obvious problems or stigmata.

What are examples of inborn errors of metabolism?

Androgen insensitivity syndrome (AIS) is a reduced affinity of cellular receptors for androgens. This means there are next to no androgenic effects at cellular level in the entire body. The body develops along female lines (despite being 46-XY), but no fallopian tubes, uterus or upper vagina develop. External genitalia look normal. Testes are found in the abdominal cavity or in the groin or labia, these are usually removed during adulthood. Brest development and feminine contours do arise, but there is a deficiency of body and pubic hair. The first sign is usually failure to menstruate. Other than that, gender identity and sexual orientation develop normally. When someone has partial androgen insensitivity syndrome, they also have intra-abdominal or inguinal testes and have breast development at puberty, but there may be a micropenis and bifid scrotum. Gender identity can be either male or female and there is a relatively high likelihood of gender problems.

5α-ductase 2 deficiency (5-ARD) means there is not enough DHT in individuals with 46-XY, which is necessary for the male development of normal external genitalia. These individuals have ambiguous genitalia. Most of them are reared as girls, but at puberty the penile stump and scrotum occur, associated with deepening of the voice and masculine muscle development. There is also a change to a masculine gender identity with sexual feelings directed at females in many of these individuals.

17β-Hydroxysteroid dehydrogenase deficiency means that males (46-XY) are susceptible to impaired masculinisation in early development. There is very little information about their sexuality, but most of those assigned as female have later been re-assigned as male.

Congenital adrenal hyperplasia (in 46-XX females) is the result of an autosomal recessive gene defect in cortisol synthesis. It varies in onset and severity, probably due to variation in the degree of enzyme deficiency. In the male this causes precocious puberty. In girls it leads to pre-natal virilisation with varying degrees of masculinisation of the external genitalia. Some such children have successfully been reared as males, though needing surgery to remove the uterus. Usually however, the child is reared as female.

Some mothers were given synthetic progestagen steroids during pregnancy in order to prevent spontaneous abortion. In girls, this led to some male-typical characteristics: more tomboyism, preferences for male toys and playmates, more physical aggression. Children exposed to oestrogenic steroids did not show more male-type behaviours, but they did have an increased likelihood of developing homosexual preferences.

What are other congenital abnormalities of the genitalia?

Hypospadias results form an incomplete development of the anterior urethra, which in extreme cases may open in the perineum (between the scrotum and the anus). The anomaly may form part of a more extensive endocrine abnormality, such as testicular dysgenesis, or partial androgen insensitivity. Men with this condition are more likely to experience depression and anxiety as well as poorer adjustment during childhood. They tend to have an insecure gender identity and are delayed in their sexual development.

It seems that in the absence of pre-natal androgen effects, particularly if there are unambiguous female external genitalia, a stable female gender identity develops. Pre-natal exposure to androgens results in some masculinisation of behaviour. Problems with gender identity are slightly more likely in such cases.

As for clinical management, the Intersex Society of North America strongly advocates avoidance of surgery, promoting the use of ‘intersex’ gender, until the child can choose.

Practice questions CH.3

1. Explain the difference between steroids and peptides.

2. What does the hypothalamus mediate in the anterior pituitary-gonadal system? And in what way does it use direct influence?

3. Where are the sex steroids mainly produced?

4. What are the normal sex chromosomes for males? What are they for females?

5. What are androgens responsible for in males? What’s responsible for these same effects in females?

6. Describe the female internal and external genitalia by naming the different parts. Do the same for the male genitalia.

7. What are sex chromosome aneuploidies? What is the difference between these and inborn errors of metabolism? And what are the similarities?

What is the psychosomatic circle of sexual arousal and response? - Chapter 4

The biological characteristics of a sexual experience include changes in our genitalia (erection of the penis in a male and tumescence of the clitoris and lubrication of the vagina in a female), heightened awareness of pleasurable erotic sensations and changes in our subjective state (sexual excitement or arousal). Cognitive processes attend more to the sexual meaning of what is happening, this can be conscious or unconscious. This sexual experience can be shown in a psychosomatic circle. In this circle, we recognise links between (1) cognitive processes, (2) the emotional brain, (3) the spinal cord and reflex centres within it, which control (4) genital responses as well as (5) other peripheral manifestations of sexual excitement. Fitting somewhat uncertainly in the schema is (6) the orgasm. It probably involves mechanisms within both the brain and the spinal cord and is followed by a refractory period of inhibited sexual response.

The most important advance in studying human sexuality is functional brain imaging, which allows identification of sites in the brain where activation or deactivation occurs in response to sexual stimulation.

Phrenologists assumed that complex traits were controlled by specific brain areas, which expanded as the trait developed. Therefore, an individual’s character could, according to them, be determined by the bumps in that person’s skull. Later, brain mechanisms were reduced to one over-riding function, sort of like a soul. Only by the end of the 19^th century did the first theories regarding cellular connections and neurons arise. This leads to what we find in sexual behaviour research: a range of processing operations that are not specific to sex, but combine to create what we call a ‘sexual experience’.

How does the brain work?

The central nervous system has seven main structural divisions: (1) the cerebral hemispheres, consisting of the cerebral cortex, divided into four lobes (frontal, parietal, temporal and occipital), the underlying white matter, the basal ganglia, the amygdala and the hippocampus; (2) diencephalon, has two components, the thalamus and hypothalamus; (3) cerebellum, involved in posture, motor coordination, language and other cognitive functions; (4) midbrain, smallest part of the brain stem, has components of the auditory and visual systems; (5) pons, involved as an intermediary between cerebellum and cortex in processing movement and sensation; (6) medulla, involved in regulation of blood pressure and respiration, and (7) spinal cord, divided into dorsal and ventral horns, dorsal includes sensory neurons entering the cord, ventral includes motor neurons that leave the cord. The midbrain, pons and medulla together form the brain stem.

Also to be considered is the autonomic nervous system, a visceral sensory and motor system controlling the heart, smooth muscle and glandular structures, regulated by the brain stem, hypothalamus and other parts of the forebrain. It is divided into sympathetic (innervates throughout the body), parasympathetic (more restricted to the lungs, heart and upper parts of the gastrointestinal tract) and enteric (regulating gastrointestinal tract).

How does sexual differentiation develop in the brain?

While in rats and other animals, we can see clear differences between the brains of males and females, in humans we have much less evidence and greater uncertainty about sexual differentiation of the brain. There has been considerable attention paid to gender differences in the size and shape of the corpus callosum, which connects the olfactory systems in the two hemispheres. It may be relevant to gender differences in certain aspects of cognitive function, but these are not of obvious relevance to sexual behaviour. Of more direct relevance is the anterior hypothalamic/preoptic area (AH/POA), which contains many androgen and oestrogen (E) receptors. The bed nucleus of the stria terminalis (BNST) has been found to be larger in men and it is possible that it is related in some way to core gender identity.

How does the brain change from childhood and adolescence?

Research has found that there are major changes in the brain during the second decade of life. The brain doubles in size from birth to young adult-hood and the surface folds become more complex, reflecting a substantial change in the number of new synapses. During early adulthood, the predominance in synapses shifts from excitatory to inhibitory. There are also more and faster (myelinated) connections between different brain regions. The prefrontal cortex however keeps getting more myelinated well into the third decade of life. Development of this brain area makes for more mature judgments and impulse control. The way the prefrontal cortex, hippocampus and amygdala interact changes, leading to greater control of previously automatic response patterns. So adolescence is not just a matter of learning new skills, but also of developing brain mechanisms to facilitate such learning.

We should not expect to find specifically sexual brain mechanisms, but rather complex interactions of more general mechanisms, such as impulse control and risk assessment, influencing our sexual behaviour.

What is the emotional brain?

As sexual experience is partly an emotional experience, we need to consider the brain mechanisms underlying emotions. Current thinking allows for conscious feelings to both precede bodily changes and follow them. According to Arnold, emotions are generated by an unconscious evaluation of a stimulus, which is followed by a tendency to act in a certain way, followed by peripheral responses, and finally conscious experience (‘feeling’). The feeling is mediated by the cerebral cortex, whereas the autonomic responses, preparing the body for action, are mediated by the hypothalamus, with the amygdala playing a crucial organising role, integrating the central (cortical) and peripheral (autonomic) components. The hippocampus is involved in memorising of emotional experience.

The emotional brain, as described above, is characterised by peptidergic neurotransmission, contrasting with the synaptic neuronal structure of the cortex. The specific effect of a peptide may depend on its site of action or the context in which it is acting. Most of the monoaminergic innervation of the emotional brain comes from five fibre systems ascending from the brain stem: (1) the NA system, activated by novel sensory input and orients and attends to sudden contrasting or aversive sensory input; (2) the dopaminergic system; (3) the serotonergic system, mainly inhibitory in its effect; (4) the cholinergic system, involved in regulating sleep-wake cycles and enhancing responses to sensory input, and (5) the histaminergic system, involved in maintaining arousal.

The principal neurotransmitters in the autonomic nervous system are acetylcholine (ACh) and noradrenaline (NA).

The concept of a balance between excitation and inhibition is fundamental to neurophysiology. This can take place on a neuronal level, but we will be looking at systems within the central nervous system (CNS). Gray has proposed three fundamental emotion systems: a behavioural approach system (BAS), a fight/flight system (F/FLS) and a behavioural inhibition system (BIS). Gamma-aminobutyric acid (GABA) and 5HT are major inhibitory neurotransmitters in the brain and spinal cord, but GABA can also play a role in excitatory processes. To look at how the BAS works, we need to look at the neurophysiology of pleasure and the anticipation of pleasure, of central relevance to the experience of sexual arousal. For this, we must likely look at the dopamine (DA) systems in the brain, as ‘pleasure’ can be seen as the conscious manifestation of the reward process.

In a positive sexual context, this is a sexual example of Gray’s BAS. It involves an unconscious evaluation of a stimulus, associated with a tendency to act in a particular way, which is a form of incentive motivation, accompanied by a state of general arousal. This will sooner or later be experienced as a sexual event. In a negative sexual content, we may see an example of the BIS, with inhibition of the more specifically sexual components. These two response patterns have been embodied in the Dual Control model. There is a distinction between appetitive (desire for sexual contact) and consummatory (actual sexual contact) behaviour. Then we should also consider the range of possible rewards or motives for human sexual behaviour, apart from sexual pleasure. Then there is conscious and unconscious processing, where unconscious processing is also fundamental to the appraisal of emotional events.

The distinction we make in this book between sexual arousal and sexual desire is that with sexual arousal, everything is full on: cognitive processing (conscious and unconscious) as well as genital response. In sexual desire, we may be aware of the incentive motivational state, but experience little or no general arousal or genital response.

What is the central control of sexual excitation and inhibition?

For things like body temperature or blood pressure, often an excitatory and inhibitory system work together to create a steady state, a balance. For sexual behaviour, there is no direct individual-based homeostatic parallel like this. There may however be a homeostat for the group, rather than the individual, in that sexual activity may lead to reproduction and inhibition of sexual activity avoids reproduction. This may keep the population density in a balance. Fertility is also dependent on inhibition in some ways. A simple example is the refractory period in the male, to prevent multiple ejaculations and therefore depletion of the sperm store. In females, an example is the organising of sexual activity around the time of ovulation, maximising the chance of fertile mating. It has been proposed that the main effect of reproductive hormones on sexual behaviour is to reduce inhibition of sexual responses in a permissive fashion. Inhibition can be useful because sexual activity may prevent the individual from paying attention to threats in the environment, or may distract from other important adaptive functions. Inhibition may also serve to avoid risks like sexually transmitted diseases, and to prevent incest (which is biologically unfeasible).

What evidence do we have?

In animals, there is some evidence that oxytocin (OT) plays a role in the sexual excitation system. It causes stimulation of a direct hypothalamic-spinal pathway that induces erection. Β-endorphin, with certain levels, also produces enhancing effects of sexual response.

Dopaminergic mechanisms are involved in aspects of the sexual excitation system, three of the five DA systems impact on sexual behaviour. The nigro-stratial tract initiates motor responses and ‘readiness to respond’, the meso-limbic tract promotes appetite for a variety of behaviours and the MPOA receives sensory input from many parts of the brain and is involved in a number of response patterns, among which genital response.

The noradrenaline (NA) system is involved in inhibition of male genital response in the periphery, but central effects of NA on sexual response are excitatory. This seems dependent of the dose, and these dose-response relationships are not well understood. One of the principal mysteries of the central NA system is how it is mobilised to serve sexual function in some situations and avoidance behaviour in others. Testosterone may be relevant to this selective process.

There is evidence for a role of serotonin in the inhibitory system. Here, we again see a dose-response curve that shows dose determines which receptors are activated, with low doses facilitating and high doses inhibiting behaviour. GABA seems to have an inhibitory effect on male sexual behaviour in the rat.

Much of what we know about the human comes from effects of pharmacological agents used to enhance sexual response, as well as the sexual side effects of other drugs. There is some information from brain-imaging studies and clinical evidence of the effects of spinal cord damage.

As with animals, dopamine has an effect in enhancing erectile response in humans, so it is involved in the human sexual excitation system. Considering the NA system, we can look at spontaneous erections occurring during sleep (NPT). These happen mostly during REM-sleep, and for REM to occur, certain inhibitory signals need to be switched off. It seems there is a reorganisation of peripheral autonomic activity during REM, which includes decreased sympathetic activity, which results in reduction of the inhibitory tone of the erectile tissue. This explains why erections can happen during REM, but does not explain why they do happen during that time.

Evidence in women has largely relied on vaginal pulse amplitude (VPA) as a measure of genital response. It seems that NA enhances VPA. The observed effects probably resulted from central action, increasing general arousal and hence facilitating genital response. This study did however not find a significant increase in subjective ratings of arousal to go with this genital response.

Serotonin effects can best be observed in the sexual side effects of SSRIs (used for depressive and anxiety symptoms). Delayed ejaculation or orgasm is the most commonly reported sexual side effect of these drugs in both men and women. It is not clear why inhibition of orgasm is so much more predictable than inhibition of erection or other genital response, considering that the most clearly established sexually relevant action of 5HT (which is inhibited by serotonin) is inhibiting erectile response.

What does brain imaging show during sexual stimulation?

The caudal anterior cingulate cortex processes contradictory signals or intentions, which could include the conflict between ‘go’ and ‘no-go’ signals in response to sexual stimuli. The putamen is a basal ganglion that is correlated with penile erection. The amygdala is also activated in response to visual sexual stimuli (VSS). Given the crucial role of the amygdala in emotional responses in general, it is not clear that these observed patterns were specifically related to sexual stimulation. Activation of the claustrum in response to VSS has been more consistent. It seems that in humans the role of the amygdala in more positive emotional states could have been taken over by the claustrum.

Evidence of inhibition may be apparent when specific brain areas are deactivated during a response to VSS. A number of studies have found deactivation of the temporal lobes and medial orbito-frontal cortex (MOVC). Between men and women, most activation seems to be the same. However, activation of the thalamus and hypothalamus was only evident in the men.

Brain imaging is probably going to be the most important source of information about the neural basis of human sexuality in the next few decades, but as yet it is at an early stage of development.

On the basis of the evidence so far, there is a four-component model of brain processing involved in sexual excitation and a three-component model of sexual inhibition. For excitation, these components are: (1) A cognitive component involving appraisal of stimuli as sexually relevant, attentional processes that focus on the stimuli and activation of areas involved in motor imagery networks; (2) a motivational component that directs behaviour to a sexual goal; (3) an autonomic and neuroendocrine component, including cardiovascular, respiratory and genital responses; (4) an emotional component involving the pleasure associated with rising arousal and penile tumescence. For inhibition, these components are: (1) Inhibitory processes operating in the resting state; (2) processes that limit the active expression of sexual excitation once initiated; (3) cognitive processes.

What can be seen when looking at romantic love?

When comparing ‘romantic’ and ‘maternal’ love, both similarities and differences can be found in the areas of activation and deactivation. Similar activation included areas associated with pleasant touch, emotive processing, a variety of incentive/reward stimuli and affiliation and attachment. Areas activated by romantic but not maternal love included those related to sexual arousal. Areas activated by maternal but not romantic stimuli involved in maternal attachment. Deactivation was similar for processes involved in critical social assessment and negative emotions.

When someone is in love, we see parts of the incentive/reward system activated. There is a positive correlation between length of relationship and degree of activation in a number of areas. Aron said that rather than being a specific emotion, romantic love is better characterised as a motivation or goal-oriented state that leads to various specific emotions such as euphoria or anxiety.

What are genital responses (anatomy and physiology) in men and women?

The most fundamental function of genital response in the male and the female is to enable entry of the penis into the vagina. Humans are unique in their use of sexual activity for the purpose of pleasure, as opposed to purely reproductive reasons.

What are the genital responses in men?

In the male, the principal response is erection of the penis. In addition to this, the testes become somewhat enlarged, and elevated due to retraction of the spermatic cords. The wall of the scrotum becomes thicker and tighter and if stimulation is prolonged or intensified, the testes are pulled up to the perineal floor and enlarge even more.

The stiffness of an erect penis depends on the filling with blood of the erectile tissues, but apart from that, reduced emptying is obviously also required. Drugs that produce erection in men all share the capacity for relaxing smooth muscle, some by adrenergic blockade, some by calcium channel blocking. This, it was assumed, then led to filling and enlargement of the erectile spaces with blood. The pressure of the corpus cavernosum enlarging inside the tunica leads to pressure on the tunica, which effectively blocks the veins responsible for the outflow of blood. The combination of these processes, it was assumed, leads to an effective sealing off of the corpora cavernosa and a build-up of pressure, sufficient to produce rigidity.

What are the genital responses in women?

The conventional view of the process of genital response in women is as follows: the venous plexus, surrounding the lower part of the vagina, the bulbs of the clitoris and the body and crura of the clitoris, become engorged. This narrows and elongates the outer third of the coital canal. If the phase preceding orgasm (the plateau phase) is reached, congestive swelling of the vulva causes reddening and ‘pouting’ of the labia minora. The uterus also becomes engorged and increases in size, rising in the pelvis. Slow irregular contractions of the vaginal vault may occur as stimulation continues. This process also facilitates entry of the penis into the vagina, with the opening of the labia and lubrication of the vaginal barrel. The narrowing of the vagina adds to the stimulation of the penis and possibly to the erotic stimulation of the woman. Elevation of the uterus pulls the cervix out of the way of the thrusting penis.

The lining of the vagina is normally moist, close to ovulation there is a marked increase in volume of this secreted fluid, to facilitate entry of sperm from the vagina into the uterus. However, without sexual stimulation, the vagina is not sufficiently lubricated for the entry of an erect penis. The lubrication that follows stimulation results from a substantial increase in vaginal blood flow (VBF). Measuring vaginal pulse amplitude (VPA) brings some problems along. For one, it is not clear what is measured by VPA. We also don’t really understand its relationship with sexual arousal: even when sexual stimuli are negatively evaluated or induce no feeling of sexual arousal, genital responses are still measured by VPA. This means there is an inconsistency between vaginal response and subjective arousal, which is completely incomparable to the strong correlation between penile erection and subjective arousal in men.

Conventional wisdom stated that, as a girl reached womanhood, sensitivity from the clitoris should go over to the vaginal orifice. However, Kinsey found that 92-98% of women indicated tactile sensitivity in the clitoris and surrounding areas, whereas only 11-14% indicated sensitivity in the walls of the vagina, and if they did usually only on the upper wall just inside the vaginal entrance. This area is often referred to as the ‘G spot’ and it is likely that the increased sensitivity is due to the fact that the urethra, which passes close to the vaginal wall, is surrounded by erectile tissue.

An intriguing phenomenon in the sensory system of women’s genitalia is a mechanism by which pressure on the anterior vaginal wall or the cervix produces an increase in pain threshold; an analgesic effect. The effect in rats has been estimated to be at least five times greater than a standard analgesic dose of morphine.

With regard to clitoral response, it is interesting to know how clitoral tumescence relates to other aspects of sexual arousal. One study found a relatively high correlation between clitoral volume and subjective sexual arousal. They also found a high correlation in volume on two occasions in the same woman, which is promising for the future of this method, relevant to measurement of penile response.

What are orgasm, seminal emission and ejaculation?

Of all the various sexual responses, orgasm remains the most mysterious and the least well-understood, partly because it is such a subjective experience in which one’s powers of observation are impaired. Kinsey defined the orgasm as ‘an explosive discharge of neuromuscular tension’. We conceptualise it as follows: an increase in both the central and the peripheral aspects of sexual arousal to a peak, where a neurophysiological process is triggered with several manifestations (intense feeling of pleasure, altered consciousness, reduced awareness, genital sensations, muscle contractions and other non-genital changes), followed by a post-orgasmic state resulting in a ‘refractory period’ when further sexual arousal is inhibited. For men, orgasm is usually accompanied by seminal emission (ejaculation).

In the male, awareness that ejaculation is imminent usually precedes the actual orgasm by about 1-3 seconds. Ejaculation is divided into two stages. First, smooth muscle contraction occurs in the testis, prostate and ampulla. Accumulation of fluid builds up in the prostatic urethra and the urethral bulb dilates in anticipation. Second, relaxation of the external bladder sphincter allows the fluid into the urethral bulb. It is then propelled along the urethra by rhythmic contractions.

In the female we see much more variety in their capacity for experiencing orgasm. Some women achieve orgasm from fantasy alone, or from stimulation of non-genital areas, others require very specific forms of genital stimulation. The duration is 20 seconds on average. A few seconds after the subjective experience of orgasm, the muscles around the outer third of the vagina spasm, followed by a series of rhythmic contractions.

With orgasm, there is a predictable though short-lived rise in both heart rate and blood pressure, starting shortly before the orgasm occurs. Respiration shows hyperventilation shortly before orgasm. Also, a ‘sex flush’, a rash affecting the skin of the body, occurs shortly before orgasm in some people.

There seem to be different kinds of female orgasm. Masters & Johnson claimed that either direct or indirect stimulation of the clitoris is always necessary for orgasm and that the physiological changes accompanying it are the same whatever the method of stimulation. This led to the conclusion that instead of two types of female orgasm (clitoral and vaginal), there was only one. Singer however, claims that there is a vulval orgasm (which relies on clitoral stimulation) and a uterine orgasm, which occurs with deep vaginal penetration and would be more emotionally fulfilling and cause a female refractory period. The controversy about typologies of female orgasms continues to this day.

What are mechanisms underlying orgasm, seminal emission and ejaculation?

In the male, we face the challenge of distinguishing between orgasm, seminal emission and ejaculation. We see that antiadrenergic compound drugs may lead to failure of ejaculation, while the man does experience orgasm. The relationship between these three components remains uncertain, except that they usually occur together. However, it is reasonable to conclude that the muscular contractions that produce ejaculation are part of the motor component of orgasm, whereas emission, a smooth muscle response, is distinct and separable.

When we look at the brain, it seems that the amygdala and hippocampus show similar changes during orgasm as during an epileptic seizure, though more localised. Activation has also been found in dopamine-related structures in the brain. In women, the areas most directly related to orgasm were the hypothalamus, amygdala, anterior cingulate region and nucleus accumbens. Activation during purely ‘thought-induced’ orgasms was mainly similar, but there was a lack of activation of the amygdala. This suggests that the amygdala has a genital sensory role in orgasm, whereas the other areas have a more cognitive role.

The explanation for the intense pleasure, only one component of orgasm but perhaps the most important, remains unknown. Activation of the dopamine system may serve as an explanation, and research found a comparison to the ‘rush’ of addictive drugs when looking at this DA system activation. Mesolimbic activation is associated with anticipation of intense pleasure and the ‘incentive motivation’ to obtain such reward.

What happens after the orgasm? The refractory period

A characteristic of orgasm is the state of calm that follows it, together with a fairly rapid return of the various physiological manifestations of arousal to normal. The male usually experiences a refractory period after orgasm, which may last for minutes in young males but many hours in older males. Women may be able to experience repeated orgasms in a short period. There are however also females who describe a definite refractory period. In the same way, there have also been a few case reports of men who appear to lack the normal post-ejaculatory refraction period and are able to experience multiple orgasms. Many men report that they were able to have multiple orgasms before they experienced their first ejaculation. This suggests that something in puberty, possibly the onset of ejaculation, triggers the inhibitory mechanism causing the refractory period. This period has a reproductive benefit: if males ejaculate to frequently, their sperm count declines and they become less fertile. It was found that levels of prolactin (PRL) in the blood increased strongly following orgasm, in both men and women. Researchers think that the post-orgasmic rise in PRL acts as a feedback control of sexual drive, contributing to the post-orgasmic refractory period. However, as this happens in both men and women, it seems not to be a fundamental component of the male-type refractory period.

What is female ejaculation?

Some women pass fluid from the urethra during orgasm. It is possible that these women still have vestigial remnants of prostatic tissue, which may account for the fluid, which seems similar in composition to the fluid produced in the male prostate. The glands that cause this in female may have the same embryological origin as the glands in males. If these glands originate from the Wolffian system (which produces the male organs in embryos), this may mean that women with relatively high androgen levels are more likely to experience ejaculation during orgasm.

What are the functions of orgasm?

The reproductive function of orgasm in the male is obvious because of the associated ejaculation of semen. The pleasure experience will also act as a motivator for further reproductive acts. In the female, the function of orgasm is not so clear. Many possible explanations have been suggested, such as reward for coitus, stimulating the male to ejaculate, allowing the semen to be taken into the uterus, etc. None of these seem likely upon further inspection though, as there is no clear evidence that the female orgasm in any way enhances fertility. An alternative explanation is the by-product explanation, which sees orgasm as a pattern that has evolved to allow orgasm and ejaculation in the male, but occurs as a ‘potential’ response pattern in the female because there has not been any evolutionary reason selectively to suppress its development. An example of a similar by-product would be the male nipple. The ‘meaning’ and acceptability of orgasm is likely to be influenced by socio-cultural factors. This could explain why some women feel more comfortable with orgasms that occur during vaginal intercourse, possibly because of the link between clitoral stimulation and masturbation, which is often seen as a ‘taboo activity’.

How do we process sexual information?

Many men and women can produce genital responses at will, by concentrating on sexual thoughts or fantasies, and often respond to non-tactile external erotic stimuli. Many men can also voluntarily inhibit erections in response to such stimuli. Visual stimuli are among the most important in eliciting sexual interest, desire and arousal. Erotic films elicit stronger sexual responses in men than sexual fantasies or pictures do.

Smell is also important to sexual behaviour, as in primates, urinary and vaginal odours indicate that the female is close to ovulation and therefore ‘attractive’. Sleeping with a male partner increases the incidence of ovulation, possibly because of axillary odours from the male. Women vary through the menstrual cycle in their ability to perceive odours, with maximal sensitivity around ovulation. Anecdotal evidence suggests that olfactory cues may be extremely important, not only in initial attraction but also in the maintenance of a stable relationship.

Touch is obviously an important source of erotic stimulation, especially during vasocongestive responses such as penile erection or labial engorgement. Sensory mechanisms are altered so that ordinary sensations on the skin become erotic in quality. Loss of sensation in the genitalia (for example due to multiple sclerosis) may contribute to erectile failure.

Feedback may play an important role too, research found that when men can see their penis response to a strong erotic stimulus, this had an enhancing effect on the production of erection. On the other hand, men perceiving a weak response to erotic stimuli experienced the opposite effect: perceiving a poor response is sexually inhibiting.

What are models of information processing?

Explicit, conscious or declarative memory is mediated by the hippocampus and related cortical areas. Implicit or unconscious forms of memory are mediated by a number of different systems. The ‘fear’ memory system involves the amygdala and related systems. It is not yet clear which system is involved in ‘implicit’ or unconscious sexual memory.

Automatic processes are rapid, dynamic, but unconscious, they are fundamental to the appraisal of events resulting in emotional reactions, even though attentional processes may also contribute to this. Conscious processing involves awareness and attention. So automatic processing may lead to an emotional response to a sexual stimulus, the attentional component then leads to the attribution of sexual meaning. The automatic response to a sexual stimulus depends on implicit sexual memory: reflexes, scripts and conditioned sensations.

Sexual content-induced delay (SCID) means that men and women experience delay in completing a task when an erotic element is present, showing that attention can be attracted to these stimuli. Distraction was also researched, and it was found that the harder the main task is, the lower erectile response was to a sexual stimulus presented at the same time. Subjective arousal seemed not to be affected by the distraction. Attribution and misattribution also have an effect. Men who receive a placebo pill and are told this pill will increase their sexual response to stimuli attribute their response to the pill and report less subjective arousal, men who receive a placebo pill and are told this will decrease their sexual response report the exact opposite.

What do EEG and brain-imaging studies show?

EEG studies find that, because of their motivational significance, emotional stimuli are selected by the brain for sustained attentive processing. Less attention is paid to other potentially distracting stimuli when attentional resources are devoted to emotional stimuli. The reaction of men towards sexual stimuli, more specifically nude images of women, is stronger than women’s reaction toward nude images of men. Why this is remains obscure.

Until now the majority of brain imaging studies has focused on response to visual sexual stimuli (VSS). Not surprisingly, activity was found mostly in areas in the brain involved in information processing, rather than the brain stem.

What are conditioning, learning and habituation?

Conditioning has been used to modify sexual preferences, to reduce the sexual impact of unwanted fetish objects, or to change sexual orientation from homosexual to heterosexual. This involved electric shocks and of course these treatments raised ethical issues and are no longer used. Studies did find that it is possible to increase erectile response towards a mildly erotic conditioned stimulus, by associating it with a highly arousing unconditioned stimulus. Habituation could also be relevant to learning of sexual response patterns. Some individuals continue to show preference for very specific sexual stimuli, whereas others require novelty to maintain sexual arousability. At the present time however, there is little support for classical conditioning as being of fundamental importance for normal sexual learning.

What effect does mood have on sexuality?

It is conventional clinical wisdom that negative mood (anxiety, depression or anger) has a negative impact on sexual arousability. Since sexual arousal can be regarded as an emotion, it is interesting to consider how the processing of negative emotions differs from that of sexual arousal, and to what extent these two types interact.

Depressed women were found to report more inhibited sexual arousal and orgasm and less satisfaction and pleasure. However, they also reported more interest than the control group in masturbating. This may be because masturbating may provide a form of self-soothing mood regulation. In depressed men, increased sexual interest was found in a group that was not responding to treatment for their mood disorder.

When it comes to anxiety, an amplifying effect of arousal was found. Arousal will enhance the focus of the information processing, if it is focused on sexual cues, then the sexual response will be enhanced, whereas if it is focused on non-erotic or anti-erotic cues, such as worrying thoughts about failure, then the anti-erotic effect will be enhanced. An anxiety-inducing film followed by an erotic film may therefore enhance erotic response to the second film. When an erotic film follows a depression-inducing film however, sexual response to the erotic film was reduced. Induced positive mood, like anxiety, also led to increased sexual response to erotic stimuli. Regarding anger, there is some evidence to suggest that anger and sexual response may facilitate each other.

When looking at the menstrual cycle, many women who experience perimenstrual mood change had their peak in sexual interest in the post-menstrual week, which was also the commonest time for their most positive mood.

It has become increasingly clear that the interaction between negative mood and sexuality is variable in both men and women. This probably reflects, in part, the context and cause of the negative mood, but also considerable individual variability. When using the Dual Control Model to look at this, it seems depression shows a reduction in excitation proneness or arousability, and an increase in inhibition. The latter may also reflect the individual’s propensity for inhibition, which may not be a direct function of cognitive processing. In men, a low propensity for inhibition increases the likelihood of a paradoxical mood sexuality pattern, while a high propensity for inhibition increases the likelihood of negative effects of depression on sexuality.

With anxiety there is the possibility of excitation transfer, whereby the physical activations associated with the anxiety strengthen the arousal response to the sexual stimulus. The presence of low inhibition proneness may allow excitation transfer without the counteracting effect of inhibition.

What is the role of hormones in sexual arousal and response?

What do androgens in the male do?

Men experiencing testosterone (T) withdrawal predictably show a reduction in the level of sexual interest. If T withdrawal lasts long enough, seminal emission will eventually be impaired. T replacement restores sexual interest, showing a dose-response relationship. Increasing T levels may have subtle increasing effects on sexuality, without the basic parameters of sexual activity (sexual interaction with the partner) being obviously affected. When men are administered T, this did not have an effect on frequency, degree or duration of NPT (erection during REM-sleep), but did increase penile rigidity during NPT. It seems from research among pubertal boys that the impact of T on sexual arousability (and hence behaviour) has to go through stages of development, which may involve changes in receptor numbers or sensitivity, a process that will also be influenced by individual differences in receptor sensitivity. It is fairly clear that in men who have gone through normal puberty, and who have not yet been affected by aging, T plays an important role in their sexual interest and associated sexual arousability.

What do androgens in the female do?

In the female we find inconsistent and often contradictory evidence for the key role of T for sexual arousability, despite having many more studies of women, usually involving large samples. This may in part result from the greater complexity of the reproductive endocrine system in women, experiencing menstrual cycles, pregnancy and lactation and a clearly identifiable menopause. Women may also be more variable than men in their responsiveness to T, however, they do respond to levels of T or increases in T that would be totally ineffective in males.

Though much less substantial than in the male, increasing levels of T occur in the development of girls as they approach and go through puberty. One study found a relation between T levels and measures of sexual interest and masturbation, but not with the likelihood of having experienced sexual intercourse. Also, while boys usually start masturbating within a window of 2 years either side of the onset of puberty, girls showed a much wider window around the first menstruation. This could be partially explained by a more variable behavioural sensitivity to androgens in females. Those with high sensitivity may start early, while those with low sensitivity may not start masturbating till much later.

It is interesting to see that women who consider themselves to have a ‘sexual problem’, do not show correlations between T levels and sexuality, whereas women who do not regard themselves as having a problem do show correlations. A possible explanation for this is that the establishment of a ‘sexual problem’ may serve to obscure subtle hormone-behaviour relationships.

Regarding the menstrual cycle, once a woman settles into a pattern of regular ovulatory cycles, T levels typically rise during the follicular phase and are at a maximum approximately for the middle third of the cycle, declining during the final third. Given this pattern, if T is important for sexual arousability in women, we should expect to find related temporal patterns of arousability through the cycle. A tendency was found across studies for sexual interest to be highest during the follicular phase or around ovulation, though with considerable individual variability. This is compatible with an effect of the rising T during the follicular phase, although one would have expected a continuation of this effect into the next phase of the cycle.

Women who received anti-androgens, which also produce reduction in T levels, reported negative effects on their sex life. Also interesting is that with surgical removal of the ovaries there is an immediate and substantial drop in circulating androgens. About half of the women who have had this procedure reported a decrease in sexual interest.

The effects of androgen administration on the sexuality of women

Administration of T in pre-menopausal women with sexual problems showed significant improvement in satisfaction with vaginal lubrication, sexual interest and coital pleasure. This was however not sustained at follow-up, unless the women received sex therapy as well. Women with endocrine disease showed significant improvement in mood and in sexuality after administration of T. Healthy women who received a single dose of T also reported enhanced response to stimuli, sexual lust and genital sensations. Post-menopausal women showed improvement in several aspects of sexuality (over several studies), including libido and sexual enjoyment after being administered E and T. More or less the same effect was found on women who had surgical induced menopause (removal of uterus and ovaries), and T administration was also found to have positive effect on mood and positive well-being in these women. The response to administration of T was moderate, but it is likely that this is a result of reporting the mean of the whole group, while in reality, some women showed no response while others showed rather more significant improvement than the mean results suggest.

Research among women with complete androgen insensitivity syndrome (CAIS) suggests that the main part of the sexual response in these women was E-dependent and as found in normal women, but the clitoral component may be T-dependent and was therefore found lacking. The women all experienced orgasm, but the involuntary spasm component was missing. It seems some aspects of sexuality in women are not androgen-dependent, suggesting a distinction between an E-dependent component of female sexuality and an androgen-dependent component.

One possible explanation for the many inconsistent results that are found in studies regarding androgen effects on women’s sexuality is that there may be a threshold effect, like in men, but with a much lower threshold in women.

What roles do oestrogens play?

There is consistent evidence of the importance of E for normal vaginal lubrication, with post-menopausal decline in E commonly resulting in vaginal dryness. However, whether E has a direct effect on sexual interest and arousability has been less certain. It seems that the dramatic decline in sexual functioning that occurs with the natural menopausal transition shows correlations between most aspects of sexual function and levels of oestradiol, but not androgens. Research among post-menopausal women found correlations between administration of E and factors like sexual desire, mood, sexual fantasies, better lubrication, less coital pain and more sexual enjoyment. In men, administration of E has a negative effect on sexuality.

What do androgens and oestrogens in the brain do?

E and progesterone can have rapid effects directly on the cell membrane, with E activation having an excitatory and progesterone activation an inhibitory effect. In mice, two different E receptors were found: ERα and ERβ. When the mice did not have ERα, they show slightly impaired sexual behaviour and are unable to ejaculate and are infertile. Mice missing ERβ show little impairment. Mice missing both varieties of receptor show major disruption of sexual behaviour. It seems both receptors can substitute for each other, but at least one has to be present for normal male sexual behaviour.

Androgen receptors (ARs) appear to be widespread in the primate and human brain, including various cortical areas. What specific role androgens have in these areas is not yet clear, but in addition to more specifically reproductive actions, other relatively non-specific androgen-mediated brain functions need to be considered, including activation or general arousal as well as stimulation of neuronal growth and gender differentiation of brain function.

When looking at brain imaging, hypogonadal men who have had T replacement show greater activation of the inferior frontal lobe, cingulate gyrus, insula and corpus callosum. We can by now reasonably conclude that both T and E are involved in brain activity, probably including that mediating sexual response and behaviour.

How do gonadal steroid effects in men compare to those of women?

E in the male may play a fundamental role in the mechanisms underlying sexuality in the brain. Circulating E activates negative mechanisms. In the female, E probably plays a fundamental role in various aspects of a woman’s sexuality, especially vaginal lubrication.

In the male, evidence points to a threshold, above which increased T levels have only subtle behavioural effects, and below which signs of androgen deficiency action on sexual desire are likely to occur. Women have circulating levels of T on average around a tenth of those found in males, whether there is a threshold is uncertain. Women seem to be much more variable in their responsiveness and can sometimes experience substantial reductions in T without adverse sexual or mood effects. As men need more T to achieve and maintain peripheral masculinisation, desensitisation of the brain to the behavioural effects of T occurs during early development. This reduces the manifestations of genetically determined variations in T responsiveness, which remain more manifest in women at lower levels of T. A key factor to keep in mind is that androgens and E can influence mood and that, particularly in women, normal sexuality depends on normal mood and energy, so effects of gonadal steroids on sexuality could be mediated via direct effects on mood and well-being.

What do peptides do?

Oxytocin (OT) plays a key role during lactation, facilitating the milk ejection reflex. It has also been proposed as a key factor in affiliative behaviour or pair bonding. OT plays a role in smooth muscle relaxation and therefore in producing erection, and in muscle contraction and therefore ejaculation.

β-Endorphin is the endogenous opiate that has received the most research attention, and is supposed to have negative effects on sexuality, reducing sexual interest, impairing genital response and blocking ejaculation and orgasm. These effects are believed to occur mainly through their action on the MPOA and the amygdala.

Prolactin (PRL) is a peptide hormone that, like OT, promotes lactation. With PRL receptors being found in most parts of the body, PRL has been reported as having more than 300 functions across vertebrates, a substantial majority of which relate to reproduction. In the human, low sexual desire is a common symptom of hyperprolactinaemia often associated, in men, with erectile problems. This can occur even without obvious gonadal steroid deficiency. A clear increase in PRL was observed following orgasm in both men and women.

Melanocortins in animals have sex-related effects including grooming, stretching, yawning and penile erection. Diamond showed an increase in spontaneous erections in sexually functional men.

It can be argued that women’s sexuality has been determined and shaped at three levels. First is a basic component of female sexuality, essential for reproduction. Second, there are superadded effects of sexual responsiveness and associated sexual pleasure, which have the same developmental origins as in the male and which are either ‘adaptations’ or ‘by-products’ (the female orgasm). Third is the impact of socio-cultural influences, shaping how women in different societies experience, interpret and come to terms with their sexuality.

Practice questions CH.4

1. Which seven main structural divisions does the central nervous system have?

2. Which three fundamental emotion systems did Gray propose?

3. Which systems are involved in the excitation and inhibition systems of sexual behaviour?

4. Which brain structures have been found to have an effect on sexuality? Which sexual functions are the specific structures associated with?

5. How is orgasm conceptualised in the book?

6. Which explanation does the book use for the function of female orgasm?

7. What effect can negative mood have on sexuality?

8. Why do sexually healthy men only experience subtle behavioural effects when they are administered Testosterone?

How do humans develop sexually? - Chapter 5

In this chapter we consider how various strands of development during childhood and early adolescence eventually combine to produce the sexual adult. We also need to keep in mind that the adult continues to develop sexually well into the latter part of his or her life.

How does the developmental process occur?

The differentiation of the genitalia and the development of gender identity have already been discussed, here we focus on development as it affects our capacity for sexual response and behaviour, and the development of our sexual identities. We want to formulate the continuing interaction between inborn, including genetic determinants (nature), and environmental influences (nurture). Two models to consider are social learning (reward and punishment, modelling or example by others) and cognitive learning (stimuli and responses are cognitively organised according to categories). These two types of learning interact with each other. How we conceptualise and categorise our environment and our experiences must also develop, and as Piaget has shown this ability goes through crucial stages in a stepwise rather than continuous fashion, analogous to the development of the motor nervous system.

There have been many different theories about the sexual development, from psychoanalytic theory (Freud) to theories stemming from sociology to biological theories.

What is the eclectic interactional model of sexual development?

The following model attempts to integrate both biological and socio-cultural factors. First there are three main strands: (1) sexual differentiation into male or female and development of gender identity; (2) sexual responsiveness, and; (3) the capacity for close, dyadic relationships.

Then there are six basic stages: (1) pre-natal stage; (2) childhood; (3) adolescence and early adulthood; (4) marriage (or a stable sexual relationship); (5) early and late parenthood, and; (6) mid-life.

During most of childhood, the three strands are developing in relative independence of one another, but in early adolescence they start to be woven together to form the young sexual adult.

Many functions, apart from reproduction, of sexual behaviour can be recognised: assertion of masculinity or femininity; bolstering of self-esteem; exertion of power or dominance; bonding dyadic relationships and intimacy; source of pleasure; reduction of tension; expression of hostility; risk-taking as a source of excitement and material gain. Also, the sexual preference we recognise in ourselves plays an important part in the cognitive learning process.. The most important dimension of this is the sex of the preferred partner, but fetishism could come into play here as well.

How does the development of sexual behaviour and sexual relationships occur?

There are some problems with researching sexual development, as most of the research is based on self-report, involving adult recall of things that occurred at a time in our development when the sexual significance of them may not have been apparent to us. On the other hand, asking adults about their masturbation habits during adolescence may give us more valid answers than asking adolescents about their current habits in that regard, as adolescents may be less willing to share that information and will give false answers.

Most research focused on getting information directly from the child has focused on the child’s sexual knowledge and how this varies with stage of cognitive development.

How is the sexual development in the pre-pubertal child?

It is clear from observations of both boys and girls that genital stimulation is a source of pleasure. Boys usually begin genital play at about 6-7 months of age, whereas girls start at 10-11 months. Boys continued this form of stimulation until more obvious masturbation became established at 15-16 months. Masturbation to the point of obvious orgasm has been observed in children of both sexes as young as 6 months. Even though sexually relevant behaviours are seen in most children, they are more common in sexually abused children. The shift towards ‘concealed’ sexuality occurs somewhere between the ages of 6 and 10, when children start to understand sexual taboos.

The acquisition of ‘sexual meaning’ and the experience of a response, such as orgasm or erotic sensation, can be disconnected during childhood. It was found that children perceived a special relationship between men and women early in development, but took much longer to recognise or comprehend the sexuality of such relationships. One study found a shift from understanding sex as a means to procreate, at age 11, to seeing it, by mid-adolescence, as central to affectionate relationships. Not only the stage of cognitive development but also the environment and culture (taboos etc.) determines the learning of sexual meaning.

A child learning that sexual issues are taboo is mainly an issue of a child learning when and how to maintain privacy. The child is either explicitly encouraged to keep sexual acts private, or concludes that this is necessary to avoid censure. In one study, about 87% of males and 84% of females reported childhood sexual experiences with peers (CSEP), most commonly during elementary school years and CSEP involving genital touching or more advanced sexual behaviour increased substantially with age, especially among males. The most frequently stated reason for CSEP at each stage was curiosity about sexual matters.

Eighty percent of males starts masturbating within 2 years either side of the age at puberty. For women, the age of onset was much more widely spread, but looking at pre-pubertal onset, females on average started 2 years earlier than males. How parents or other adults react to a child’s emerging sexuality can have major effects on that child’s subsequent development, either positively or negatively.

Penile erections occur in infants and children. The relevance of erections during childhood to erectile function post-puberty is not clear. NPT (sleep erection) does occur before puberty, but the erections are less frequent, and of shorter duration. As genital response in female children is much less likely to be observed by adults, we have little evidence of this. Some children may be more sexually responsive, and others relatively unresponsive prior to puberty. We don’t know whether variability across children depends on variable learning experiences or is genetically determined. It is possible that girls who are highly sensitive to the behavioural effects of androgens experience onset of sexual interest and masturbation early, while those who are relatively insensitive to such effects develop sexual arousability more gradually, in late adolescence or early adulthood.

How is the transition from childhood to adolescence?

There is a point where we see the onset of dating behaviour in a proportion of children, where we see the impact of socially sanctioned scripts for interactions between boys and girls. Probably these scripts remain disconnected from their earlier or current childhood sexual experiences.

Sexual arousal first occurs before puberty, with an average age of 9.7 for boys and 10.8 for girls. First sexual attraction occurs around the age of 11.4 in boys and 12.4 in girls. The onset of sexual fantasies is about 11.6 in boys and 13.3 in girls. This shows again the wider variability in girls, just like in onset of masturbation.

Dating may start from age 10, but it is not until 11 or 12 that interactions between boys and girls acquire a sexual connotation. 10-11-year-olds express some heterosexual interest, kissing games etc. 12-13-year-olds showed little inclination to form close attachments with the opposite sex, but were likely to identify objects of romantic attraction. 14-15 years is an age of transition, with increasing cross-gender social interaction and dating becoming increasingly popular. The average age for first ‘crush’ is 8-9 years, first girl/boyfriend is 12-13 years, first date between 14 and 15 years, roughly 2.5 years after the onset of menstruation.

Oral sex is becoming more and more popular before the first vaginal intercourse. Where 40 years ago, oral sex was still regarded as a more advanced sexual act, now a majority of males and females has experience of oral sex before intercourse. In the 1970s and 80s, the age at first intercourse for girls decreased, but this levelled out in the 1990s, although the number of girls with experience of sexual intercourse before age 15 has continued to increase. Overall, male adolescents tend to initiate sexual experience earlier and to have more sexual partners than female adolescents.

When distinguishing between appropriate and inappropriate sexual development we have at least three patterns to consider. First, the emerging sexual responsiveness. Second, adolescence involves a process of developing a separate identity, which in part is achieved by rejecting some of the values or norms that one’s parents uphold: sex is a vehicle for asserting one’s emerging autonomy. Third, we see sexual behaviour as one of the adolescent externalising behaviours which are often part of a pattern of maladaptive behaviour beginning in childhood and associated with a range of negative developmental influences. The peri-pubertal pattern is thus intrinsically about normal sexual development, although individuals clearly vary in how they experience this process, reflecting the interaction between hormonal changes and evolving brain function.

The bodily changes that occur in association with puberty represent probably the most discontinuous phase in human development. All of these changes impact on the individual’s gender identity. Social scripts change too, with sexual scripts taking on a new importance. In males, sexual attraction starts around age 10, and this seems to be linked to the hormonal changes associated with adrenarche, which occurs around 8 years. Kinsey found that boys going through puberty earlier showed earlier onset and higher frequency of sexual activity subsequently, suggesting a higher level of sexual desire or arousability. This was not found in women.

If an individual goes through normal puberty and then experiences hormone deficiency, hormone administration restores sexual arousability to its previous level. The other necessary developmental changes had already occurred. On the other hand, in hypogonadal adolescents or young adults who have not gone through normal puberty, administration of hormones has an incomplete effect on sexual arousability. Twin studies found that both genetic and non-shared environmental factors were related to age at first sexual intercourse and number of sexual partners.

The strongest predictor of sexual initiation was the belief that most friends had already experienced sexual intercourse, indicating a significant peer group effect. But parental communication about sex and birth control is also seen as important for reducing adolescent sexual risk behaviour, delay of first intercourse may be caused by maternal disapproval of sexual intercourse, but a high degree of warmth in the mother-child relationship.

Religion also has an influence, personal devotion and frequent attendance at church activities was associated with greater sexual responsibility. Personal conservatism, rigid adherence to one’s religious creed, was associated with more exposure to unprotected sex and greater tendency to leave birth control to male partners.

There is a curvilinear relationship between intelligence and experience of sexual intercourse: those at the extreme ends of the intelligence scales were least likely to have experienced sexual intercourse.`

Maladaptive behaviour in childhood is found to be predictive of later, sexual patterns in adolescence, for example low constraint. Childhood sexual abuse (CSA) is also predictive of maladaptive patterns of sexual behaviour and function in adolescence and adulthood.

How do sexual preferences and sexual identity develop?

Sexual identity, a key element among the sexual meanings, emerges at the start of adolescence, defining what kind of person someone is sexually attracted to and what kind of sexual person they are themselves. In western culture, an important aspect is ‘am I heterosexual or homosexual?’ The nature-nurture debate on this subject has been especially strong. The proportion of individuals identifying as exclusively homosexual is around 2-3% in males and 1-2% in females. But women often show less certainty and bisexual identity is more prevalent among them.

For both heterosexual and homosexual women, emotional attraction often precedes erotic attraction, whereas the reverse applies for men. In men, sexual identity is most predictably related to the gender of those found sexually attractive. In women, the emphasis is on emotional involvement and closeness. If she finds this consistently in relationships with women, she will be likely to identify as lesbian, but it is possible that in a later stage she will find herself in a comparable relationship with a man, or vice versa. We might therefore expect different trajectories and timing of sexual identity development between men and women.

There is a strong association between gender non-conformity during childhood and subsequent homosexual identity in both men and women, though much more in men. First awareness of homosexual orientation occurs typically at age 10, with first disclosure to others around age 16, though similar studies have found varying results in this regard. In any case, it appears that something of importance to the development of sexual identity is happening in the period from about age 8 or 9 until the onset of puberty.

There are long standing ideas that homosexuality is a consequence of an abnormality of masculinisation of the brain, deficient in male homosexuals, excessive in lesbians. However, a crucial point here is the need to distinguish between effects on gender identity (which may secondarily influence sexual identity) and direct hormonal effects on sexual identity. Overall, there is no consistent support for early masculinisation of the brain by androgens as being relevant to female homosexuality.

There is somewhat inconsistent evidence that men show more lateralisation of functions in the two brain hemispheres than women, and that gay men may come midway between heterosexual men and women in this regard. Brain processing of olfactory cues has also shown differences related to gender and sexual orientation, demonstrating a link between pheromonal stimuli and sexual orientation. As yet we cannot say to what extent this is learnt pattern that reflects the development of sexual identity or is an intrinsic mechanism that influences that development.

Twin study results point to both genetic and non-shared environmental influences on sexual identity development, with a suggestion that genetic influences are stronger in males than females. Other genetic studies found some evidence that the X chromosome is regulating sexual orientation, at least in some men, possibly as a result of an as yet unidentified imprinted gene on the X-chromosome. This study found that mothers of homosexual sons more often had extreme skewing of X inactivation (more than 90% of cells of a particular type having the same X chromosome, instead of 50-50% divide between both X chromosomes). However, it remains to be seen whether a genotype exists directly related to same-sex or opposite-sex sexual attraction.

A possibly relevant aspect of learning is conditioning. To what extent do our sexual responses become conditioned to certain types of sexual stimuli? Overall the evidence is inconclusive, however, the more unusual forms of sexual preference, such as fetishes, are almost exclusively found in men. Something is happening in the sexual development of some men that results in their developing predictable sexual arousal to very specific types of stimulus. This is consistent with the idea that sexual attraction in men is stimulus specific, whereas in women it is more determined by relationship factors.

Cultural factors might predispose to adoption of an exclusively homosexual or heterosexual identity in some cultural contexts, and a more flexible or bisexual identity in other contexts which do not require such a distinction and accept various types of sexual interaction at different times in a person’s life.

How is the sexual preference in animals?

Some female animals show a preference for male animals of their species even when they have no previous mating experience. The extent of same-sex behaviour varies considerably across species. For mammals it seems the main variable is the extent of bisexuality. Often in species where the male shows a lot of bisexual behaviour, the female tends to show little and vice versa, though in most species the female shows the most bisexual behaviour.

In primates, we often see males mount the same amount of males and females until puberty. During that time, the mounting of other males is most likely an expression of dominance. After puberty, when erotic responses become enhanced by hormonal effects, the dominance function is superseded by the sexual. In female primates, bisexual behaviour may be a form of soliciting, affectional ties may be important.

In all species of mammals so far, being deprived of tactile contact with either the mother or the peer group during infancy and early childhood results in abnormal or disrupted adult sexual behaviour in male animals. The same effect has not been demonstrated in females.

It seems that long-lasting exclusive homosexual preference is extremely rare in other primates. There is evidence of such preference in only five species, one of which was a primate: the Japanese macaque. Exclusive male homosexual preference is perhaps a uniquely human phenomenon, but one which is likely to result from an interaction between socio-cultural influence and some more biological, possibly genetically determined set of characteristics.

What are the interactive processes leading to sexual identity?

For those children who find themselves attracted to the same sex, what follows will probably depend to a considerable extent on two related factors: the child’s self-confidence and self-esteem, and involvement in and acceptance by the peer group. In the Western world, it becomes increasingly difficult for children to ignore the bombardment of sexual messages that pervades modern society and boys who show gender non-conformity were more likely to show anxiety about sexuality because of this and were less accepted by their peer group, which may increase the likelihood of attraction to the same sex.

It seems that if an individual enters puberty early, he or she is more likely to be associated with a peer group of the same sex. Given that the pubertal process, particularly in boys, is associated with an increased sexual arousability, this could result in sexual arousal in response to same-sex members of the peer group. However, the differences in age at puberty between homosexual and heterosexual males is small and reflects substantial individual variability, so this may not be fact. It is most often a ‘discontinuous’ developmental phase, determined more by sexual pleasure and the availability of other boys as a stimulus for that pleasure than by the sexual attractiveness of those other boys. The majority of these boys do not develop homosexual identities.

In contrast to those who develop a heterosexual identity, one who is experiencing same-gender attraction will be either struggling in a socio-cultural vacuum or, more likely, experiencing the impact of social stigmatisation. It is to be expected that the integration of our three developmental strands will take substantially longer in those who emerge with a homosexual identity, rendering them more psychologically vulnerable in the process.

We can speculate that if there was no cultural control of the gender of sexual partners, but rather an acceptance of diverse types of sexual relationship, we would, by nature, have a widespread capacity for sexual interaction with either same or opposite sex partners, until the time that we chose to settle into a reproductive phase and rear a family. This while a minority would end up with exclusively same-sex partners, or have opposite-sex partners from the start.

Practice questions CH.5

1. What are the three strands that make up the interactional model of sexual development used in this chapter?

2. What is a possible explanation for the more widely spread onset of masturbation in girls, compared to boys?

3. What is the average age for first sexual arousal in boys? And in girls?

4. What kind of interaction is reflected by the variability seen in how individuals experience sexual development?

5. What does sexual identity define about a person?

6. In what order do men experience emotional attraction and erotic attraction? And women? Why this difference?

7. What would be a likely course of sexual identity development if there was no cultural control of the gender of sexual partners?

What are cultural views and differences on sexuality? - Chapter 6

The preceding chapters have considered the psychobiological basis of human sexuality and how it interacts with culture during sexual development. We will now look at how human sexuality is experienced and expressed. In this chapter, we look at heterosexuality.

What is the history of sex surveys?

Our main sources of information are the various surveys of modern Western societies. Over the 20^th century, we see that although the way we think does change with the passage of time, many of the basic ideas seem to recur and then become reburied. Relevant concerns that have driven sex research have been: concern about male masturbation; the declining birth rate; the need for good sex education; the need to improve marital sex and hence improve marriage; concern that the lower social classes were having more children than the middle classes; the sexual revolution and subsequent increase in premarital sex; the harmful effects of premarital sex on marriage; teenage pregnancies; sexually transmitted diseases and AIDS. No research has been primarily driven by a need to know more about or to better understand human sexuality.

Kinsey is the biologist who has probably had the biggest influence on sex survey research. His primary objective was to demonstrate the extraordinary individual variability in human sexuality, no two people were the same and there was no cut-off that would justify the concept of ‘normal’ versus ‘abnormal’. He considered marriage to be important in both personal and social terms, and sex to be an important factor in determining marital well-being and stability. He focused on the differences between male and female sexuality, and the resulting lack of mutual understanding that accounted for many marital problems. Reactions to Kinsey’s openly publicised work ranged from outrage to admiration, outrage mostly for his nerve to provide the general population with information about sex: the details of the sexual experiences of ordinary men and women were out in the open for all to read. One of the lessons from Kinsey’s research is that, typically, there is a discrepancy between what people do sexually and what society assumes, and expects them to do.

Though Kinsey’s research and the impact it had on society eventually led to him losing his funding, by the 1960s we see increasing involvement of the National Institutes of Health, government agencies for funding research, in surveys of various consequences of sexual behaviour. Research found that as women felt more secure in their ability to avoid conception, their interest in sex increased, which led to increased attention to the fertility of the lower socio-economic groups and Afro-American women, who were found to have more unplanned children. In the 1960s and 70s, the ‘sexual revolution’, research attention shifted away from sex as purely an aspect of marriage and towards the behaviour of the unmarried, particularly the adolescent. Attention was paid to whether premarital sex had a negative impact on marital sexual adjustment.

An increasing acceptance that sex occurred before marriage was countered by a growing concern that young adolescent girls were not only having sex, but also getting pregnant. Focus was also on other sex-related problems, such as sexually transmitted diseases and sexual assault and rape. We also see a phase of interest in homosexuality, around the early 1970s. By the mid-1980s, concern about AIDS dominated the scene. Over the past decades, it has been very difficult to get government approval and funding for sex research: American politicians do not find sex an easy topic to discuss, other than negatively. The situation in Europe, though not well chronicled, shows a somewhat less troubling story, but given the societal and political constraints on funding as well as allowing such surveys, objectives for doing the research are often stated which may have more to do with making the study acceptable than describing what the researcher is actually interested in.

What is the methodology of sex surveys?

Most community-based surveys have been and will continue to be cross-sectional, rather than longitudinal, due to implementation issues. However, longitudinal studies involving repeated assessment over a relatively short periods (2 or 3 years) are becoming increasingly feasible with the development of established survey panels.

Obtaining a random and therefore representative sample for the general population presents a challenge. Participation biases have to be taken into consideration, in one study the people explicitly consenting to the sex survey had higher levels of education, attended church less often and had less conservative sexual attitudes and voting preferences. Research focusing on relationships between factors of possible causal relevance do not need representative samples as much as research focusing on prevalence rates does.

Surveys conventionally have used self-report questionnaires, interview methods, or a combination of the two. There are advantages and disadvantages with each of these methods. In interviews, the meaning of questions can be clarified, but can also differ between interviewers, and we see under-reporting of sexual problems due to concerns about stigmatisation. Telephone surveys have also been used, questions here were more easily answered but were more likely to be influenced by social desirability. Computer-assisted interviews have become more and more popular and have a number of advantages, such as easier personalisation of the questionnaire based on previous answers and increased confidentiality and anonymity. A newer method is the use of internet panels, consisting of a large amount of individuals who agree to complete a short survey every few weeks and are a fairly representative sample demographically. This method has been found to have some advantages in terms of data quality over telephone interviewing, but it remains to be seen whether this approach is effective in collecting sexuality-related data.

Survey items should be as clear and specific as possible, should be pre-tested and checked in pilot surveys. Assessing the frequency of sexual activity or sexual problems raises important methodological issues, mainly because of recall error over time. Asking for approximate frequencies (e.g. number of times sexual intercourse per month) invites ‘normative’ answers, people choose which answer they think it should be. Also, the non-judgemental approach (as first seen in Kinsey’s research) remains a requirement for any effective research in the sexual area, which is a problem for many critics. Persuading someone to describe the full range of his or her sexual experiences, devoid of moral judgement, is seen by them as giving that person implicit permission to engage in such behaviours, therefore undermining the prevailing moral values. Therefore research subjects should be told that the survey is not intended to convey any message about what they should or should not do. Because of this criticism however, very little research has been done on ‘normal’ adolescent sexuality, and on how adolescents learn to be sexual and acquire sexual responsibility. The bulk of sex research has, until recently, been atheoretical and descriptive rather than hypothesis testing. Large-scale surveys would benefit by the inclusion of clearly-defined theoretically-based hypotheses central to the main objectives of the survey. Qualitative data is very important in cross-cultural studies, to find out how certain aspects of sexuality are conceptualised in different cultures, before formulation the precise questions for a survey.

What are the attitudes towards masturbation?

There are still negative attitudes to masturbation and other forms of non-procreative sex, which have universally prevailed, despite the fact that almost all men and a substantial majority of women masturbate at least occasionally. People seem afraid that discussing masturbation more openly will ‘teach’ children to masturbate, even though the large majority actually learn to do so without being taught. At a time when sexual behaviour of young people is causing so much concern, the low risk of masturbation as a way of dealing with one’s sexual appetite is something to be taken seriously. It is clearly an example of a behaviour which is almost universal, which plays an important part in normal sexual development for many of us, is a source of pleasure without risks, is used constructively by sex therapists to help men and women deal with sexual problems, and in no way warrants its negative reputation. Over the course of history however, two themes regarding attitudes to masturbation have recurred: a threat to health and a form of immorality. As religion gave way to medical science as the main influence on sexual standards in the late 18^th century, these two themes became combined, with the threat to health used to reinforce the traditional moral message. Most apparent has been the moral threat stemming from lack of sexual control, which should protect the dignity and civilised status of man.

The prevalence of masturbation

Cross-cultural evidence of masturbation is limited, partly reflecting varying degrees of reluctance to report or ask about it. In some primitive societies, masturbation is expected and accepted as normal among children, but should not be needed by adults, but in other societies there is a more accepting view of masturbation even among adults. In the England it was found that, when asked, 73% of men and 36.8% of women had masturbated in the previous 4 weeks, showing a significant gender difference. This was most likely in the 25-34-year-age group for men and the 35-44-year-age group for women, less likely in the married and in those with children. It was more likely in social class I/II than lower classes, but only significantly so in men, more likely in the higher educated groups, but less likely in those for whom religion was important (only significant for women). For men, the more partner activity, the less likelihood they had masturbated; for women the other way round. In another study, 27% of men and 8% of women indicated they masturbated at least once a week. 73% of men and 63% of women said they masturbated ‘to relieve sex tension’, 32% of men and women because ‘partner was unavailable’, and 40% of men and 42% of women ‘for physical pleasure’.

In a study focusing on a similar sample that Kinsey used, but 50 years later, a striking increase was found in the proportion of women reporting having masturbated in the more recent sample, whereas differences in age of onset of masturbation between men and women were very similar across the two samples. When looking at masturbation by generation rather than simply by age, it was found that each new generation has masturbated more than previous generations.

For the male by far the commonest method is manual stimulation. For women, the principal method is direct stimulation of the clitoris, sometimes associated with insertion of something into the vagina (vibrators are now commonly used for this purpose).

Although masturbation is compatible with sexual health and can play a positive role in our sexual development, we should also look at the negative outcomes. Using sex as a mood regulator for example, may not lead directly to developing ‘out of control’ sexual behaviour, but may serve to reinforce this.

How do we look at sex in the unmarried?

Societies vary hugely in their view of sexuality outside marriage, as well as their view of adolescence. In some cultures, adolescence is a long period involving expectations and responsibilities from both childhood and full adulthood, while in others there may just be a puberty ritual, so that the child passes suddenly into adulthood. These rituals often revolve around responsibility for boys and fertility-sexuality for girls. In some societies, we see dormitories as an influence on adolescent sexuality, in which the older adolescents are the sex educators for the younger.

Important dimensions when looking at cultural variations are importance of wealth and inheritance, the degree of differentiation of sexual roles, sexual segregation and sexual stratification (when one gender group has greater access to rewards, prestige and power), and the complexity of social structure. When looking at earlier societies, the hunger-gatherer society was most likely to be permissive towards premarital sexuality and the class-ridden agricultural society restrictive, as the need to protect lineage and the inheritance of wealth became more relevant.

When considering the social history of sexual behaviour and marriage in Europe we have two dimensions to consider: geographical and temporal. North and south Europe have different early sources of influence on this behaviour. Temporally, there is a turning point in the latter part of the 18^th century, in the early stages of the Industrial Revolution, showing a dramatic rise in both prenuptial pregnancy and illegitimacy and an associated fall in the age at marriage, leading to an increase in birth rate. Before this point, courtship was highly ritualised, with the graduated process of mate selection the important element. This preceded coitus and pregnancy, and the commitment associated with coitus. There was a clear set of rules linked to betrothal and marriage.

In the 16^th century and earlier, the purpose of life was to assure continuity of the family, the class, the village or the state. In the 16^th and 17^th centuries, there was an increasing tendency to recognise the uniqueness of the individual, leading to competition. In the late 17^th and 18^th centuries, the sense of individual uniqueness and pursuit of personal happiness was tempered by respect for the rights of others. The middle class that emerged at that time espoused the new religious attitude, that led to greater emphasis on holy matrimony and therefore the importance of personal choice in selecting one’s spouse. The lower class benefited most from the work input of younger teenage children, pregnancy became a means of securing a marriage or parish maintenance. Here we see clearly the separation of sexual values between the classes.

As societies evolved, body function, including sex, became something to be concealed. Expressions of feelings became inhibited, and keeping oneself under control was regarded as a moral virtue. Premarital sex became forbidden. However, the more people struggled against sexuality, the more the environment became sexualised. This led to dissociation between love and sexuality, that previously had been combined so effectively and we see increases in prostitution and negative consequences for the role of women. We see this in the virginity- and dowry traditions, which basically treat the woman as a form of property, handed over from one man (the father) to another.

What was the age at first intercourse in Europe and North America during the 20th century?

There are two themes that, over the course of history, have contributed to the present picture: the virginity ethic and the role of fertility. The importance of virginity of the woman at marriage has been linked to the property rights of men over women, a pattern with a long tradition in Mediterranean countries in particular. The idea is that men prefer chaste women in order to ensure their paternity. In the so-called ‘bundling’ system, pregnancy was expected to lead to marriage and in many respects was required in order to demonstrate the young woman’s fertility.

In humans and some higher primates, a period of sterility occurs after puberty, possibly important for allowing proper sexual learning and mate selection to occur, free from the complications of early pregnancy. The human female is the only primate in which full breast development occurs at puberty, rather than at the time of first pregnancy, possibly to allow sexual attractiveness to develop in advance of fertility. This may lead to the need to prove fertility after a period of infertile sexual activity, which is the background for the necessary fertility demonstration in some societies. However, age at puberty has declined, and therefore age at full fertility has also declined over the past century, most likely because of improvement in nutrition. Especially in societies where there aren’t many alternative ways for a young girl to gain status and bolster her self-esteem, parenthood may be one of the very few forms of achievement open to her and it should not be surprising that such girls get themselves pregnant early, despite long term disadvantages.

Evidence from early studies indicated a significant increase in premarital sexuality in the 1920s followed by a period of relative stability until the 1960s. A universal trend among women towards earlier age at first sexual intercourse has been noticeable since the mid-1960s, accelerating most rapidly during the 1970s and levelling off during the 1980s. Males, who have shown on average younger age at first intercourse than females throughout the 20^th century, showed less obvious dramatic increase during the 1960s and 1970s, with a reduction in the gender difference by the late 1980s.

Around 1970, it was found that although fewer girls were sexually experienced, those that were had intercourse more frequently but with fewer partners than boys. The pattern of female teenage sexuality was more linked to stable relationships than it was for boys. By 1983, a fall in the number of women with only one previous or current partner was observed, and an increase in the number who had had two or three partners.

In more recent years, the rates for women regarding age at first intercourse remained relatively stable, while for males there was more consistent evidence of decline in age at first intercourse. The percentage of females who have experienced sexual intercourse by age shows a substantial jump between 17 and 18 years, followed by a more gradual rise. For both males and females it seems that the younger the age at puberty, the greater the odds of a pre-18 first sexual intercourse. After the sexual revolution, gender, social class and religion had less influence on age at first intercourse than in those who reached adolescence before the sexual revolution.

Women were twice as likely as men to regret the first occasion, and three times more likely to say that they were the less willing partner. Level of education was a strikingly relevant variable as well, with the likelihood of early onset much higher for those leaving school without qualifications. Whereas there had been an increase in early onset of sexual intercourse, it had been accompanied by an encouraging increase in use of risk reduction (condoms).

What has changed in teenagers?

Prior to 1989, most teenagers engaged in ‘necking’ (kissing and caressing of breasts and above) and ‘petting’ (including genital caressing with or without orgasm) before they first experienced intercourse. The changing trends amongst the unmarried in oral sex are of some interest. In the Kinsey surveys oral sex was more or less confined to people who were already coitally active. By 1982, it was found that a higher percentage than before of adolescents without experience with intercourse had given or received oral-genital stimulation. It was beginning to occur as a precursor of coital sex.

Following 1938, the birth rate amongst teenagers rose, reaching a peak in the early 1970s and then showing an unsteady decline since. Abortion rates increased and by 1975 nearly one in three pregnant adolescents elected to have their pregnancy terminated. Teenage childbearing was positively associated with a measure of low socio-economic status and with the level of maternity benefit. Two predictors for early motherhood were found: first intercourse before the age of 16, and educational level. After a constant period through the 1980s, the US teen abortion rate started to decline, together with unintended pregnancy and unintended birth in young women. 25% of this decline in pregnancy rates was attributable to increased abstinence, and the remainder to changes in teenager’s sexual behaviour. There had been only slight increase in overall contraceptive use, but a more relevant increase in more effective methods, such as long acting hormonal contraceptives. In 2000, a striking increase in use of condoms on the first occasion of sexual intercourse was found in the younger age groups. 26% of women had started on oral contraception before first sexual intercourse. Education level had a strong effect on contraceptive use. Higher pregnancy and birth rates in the USA compared with other countries reflects a generally more negative attitude to the provision of contraception for teenagers in the USA, which lasts to this day.

What role does the influence of the family play?

Research found that the lowest incidence of premarital sexuality occurred in girls living in families headed by their natural fathers. This effect was less marked in Afro-American girls, however. Also, the presence of both biological parents and a more consistent pattern of parenting were associated with later onset of sexual activity in both European and African American women. Sexual experience was more likely in teenagers subjected to less parental discipline: single parents offered more information about sex whilst tending to be more permissive. Teenagers whose parents were more open about sex were more likely to use contraception. Having parents who did not complete high school increased the odds of early onset of sexual intercourse.

What is the relationship between marriage and co-habitation?

Human beings are unusual amongst mammals in maintaining an alliance between a sexual pair that persists through gestation and lactation. Also, across cultures, if there was a preference for one sex in terms of power, privilege or opportunity it would be in favour of men. In most societies, husbands are usually more than 4 years older than their wives, which may contribute to the relative weakness of the position of women.

The emphasis on monogamy in the Western world has been strongly reinforced by the Christian church, also making divorce and remarriage difficult, if not impossible, up until recently. When these social constraints are lessened, we see that lifelong monogamy gives way to serial monogamy in an increasing number of people. Regarding arranged marriages, the general tendency has been for parental control to remain strongest where parental affluence and hence the importance of inheritance is greater.

What is the relationship between sexual attraction and mate selection?

Sexual attraction involves visual signals of how a person looks and how he or she behaves. Smell may also be important for some people, but could operate without their knowledge. Once two people begin to interact, personality factors will also operate. Selection favoured men who perceived cues of ‘nubility’ (beginning to ovulate) and of good health and ‘design’ (bilateral symmetry) as sexually attractive. Galton found that the ‘average’ face, made up out of a number of individual faces, was more attractive than any of the contributing faces individually. When asked about the characteristics of importance in choosing a husband or wife, men attached more importance to a wife being physically attractive and younger, women wanted a man who was older and with good financial prospects. In women BMI was also predictive of sexual attractiveness. In men, a mesomorph body type (muscular with broader shoulders than hips) is seen as most attractive, enhanced by evidence of body hair. It seems in preliterate societies and many cultures in Africa, plump women are seen as more attractive than slim ones, the opposite of predominantly "white cultures" such as in America and Britain. Women also preferred men who appeared to belong to the same social class as themselves. Eysenck & Wilson stated that the essence of sexual attractiveness is the difference between male and female features: an attractive woman is one who is clearly non-male and vice versa.

Sexual attraction is not a passive process: in addition to the impact of culture, the response of the individual to the subject may influence how attractive that individual appears. Eye contact is an important part of the courting process. During a so-called ‘courtship sequence’ there are ‘escalation points’, such as facing each other and touching – what happens next depends on how the other person responds; if this is positive, the sequence ‘escalates’. It seems that women control such a sequence, by showing proceptive behaviour in a variety of subtle ways. She decides when to let the sequence develop or put a stop to it. When it comes to more long-term relationships, there is a tendency for like to marry like, on several possible characteristics (neighbourhood, degree of attractiveness, etc.). Marital breakdown is more likely when these boundaries are crossed. Of those who had started a new relationship within the past year (this was 2000), 56.5% of men and 42.8% of women had first sex with the new partner within the first month of meeting.

Men and women who said they last had sex to express love also reported more emotional satisfaction with their sexual relationship. Two-thirds of women said they were very much in love with their first sexual partner but only one-third of men said so. Evidence suggests that men more readily fall in love; women show more caution before becoming involved and are more likely to decide when an affair ends, while men take longer to get over a love affair. Romantic love has been expressed in different ways at different times in history and in different cultures, whilst involving some basic neuropsychological mechanisms in common. Whereas it was seen in previous times as a distraction from the orderly mating ritual involved in arranged marriages, there is no evidence that marriages based on romantic love are more likely to fall apart. The association between companionate love and satisfaction with life is stronger in women than men. The association between passionate love and positive and negative mood is stronger in men than in women.

What is the incidence of marriage and co-habitation?

The incidence of marriage rose from the early years of the century, reaching a peak in the late 1960s and early 1970s. Since then it has declined steadily. There has been a steady increase in co-habitation. Combining the two, however, shows a decline in the percentage either married or co-habiting.

The so-called European marriage pattern, with a relatively late age of marriage and a relatively high proportion of unmarried women reaching the menopause, has been a characteristic of Western Europe. However, there was a universal decline in age at first marriage after World War II. Between 1971 and 2002, the average at first marriage in the EU increased again. More or less the same pattern could be seen in the USA.

One of the most relevant changes in marriage in the second half of the 20^th century has been in its relevance to sexual activity. The change in acceptance of premarital sex has now gone much further. Marriage, increasingly, is a formal arrangement, which may be pursued by two people once they have stablished a sexual relationship. The frequency of sexual activity in any established sexual relationship does not show a continuous downward trend, but goes through stages in the development or evolution of the relationship. After the initial phase, often brought to an end by first childbirth, there is a more stable pattern of gradual decline. Several studies showed higher frequencies of sexual intercourse in co-habiting couples than married couples. Age is the strongest predictor of sexual activity in couples. Other significant negative predictors are unhappy marriage, educational level, poor health, having a young child, being Catholic and wife pregnant.

Men have traditionally been the initiators in love-making. Many men feel uncomfortable when their partner initiated, maybe feeling guilty for failing in their duty to initiate sex. Women found it more difficult than men to cope with refusal. Couples who are equal in their initiation and refusal of sex report happier sex lives.

Kissing is seen as highly intimate, people kiss less during sex when they feel somewhat removed emotionally but still want physical release. Oral sex is seen more often in co-habiting than in married couples, consistent with the idea that co-habiters have less traditional sexual attitudes. As with oral sex, a significant increase in anal sex was reported in heterosexual relationships.

72% of men reports always coming to a climax during sex with their partner. This happens most easily through vaginal penetration, then for manual stimulation and then fellatio. Women are much more variable than men in their likelihood of experiencing orgasm during sexual activity, and in the type of stimulation required to achieve orgasm. 49% of men and 43% of women agreed with the statement that sex without orgasm cannot be satisfying for a man. The same question about the woman was answered in agreement by 29% of women and 37% of men. Only 29% of women indicated that having an orgasm was very or extremely important to their sexual happiness.

In the majority of societies, the menstruating woman is considered unsuitable as a sexual partner, and in some cases there may be general rejection of the woman as ‘unclean’ during this phase of her cycle. A consistent finding is that all aspects of women’s sexuality, including their sexual interaction with their partner, is lowest during menstruation. About a third of men said they enjoyed sex during menstruation as usual, for the remainder it presented varying degrees of ‘turn off’.

What is the relationship between sexual well-being sex in marriage and relationships?

People with only one sexual partner tended to be happier than those with more than one or none. The physical pleasure and emotional satisfaction from a sexual relationship was greater in those with only one partner than in those with more than one. Those with a higher frequency of sexual activity with the partner tended to be happier, whereas frequency of masturbation showed the opposite association. Frequency of orgasm, while unrelated in men, was associated with happiness in women. It is difficult knowing what is cause or effect in such associations. Predictors for an excellent/very good sexual relationship in women are mental health, frequency of sexual activity, frequency of masturbation, partner’s sexual attractiveness and subjective response. For an excellent/very good own sexuality, predictors were mental health, orgasm frequency, self-ratings of sexual attractiveness and income. Important for sexual happiness for women are feeling emotionally close to one’s partner, knowing that your partner is sexually satisfied and feeling comfortable talking about sexual activity to one’s partner. These findings suggest that sexual happiness is more dependent on the relationship than the woman’s own sexuality.

What is the fate of marriage as an institution?

The increase in marital breakdown and divorce is an international phenomenon, occurring in just about every country in which it has been studied. About 20% of the general increase has been attributed to legal reforms making divorce easier. Divorce is most likely in the early years of marriage. Changes in the role of women, resulting in their having more independence, are likely to be relevant, as are changes in the emphasis on marriage as the only acceptable status for sexual activity.

Extramarital sex may be tried by someone in an unhappy marriage to see if an alternative relationship is preferable and in this sense commonly occurs in the period preceding divorce. There is a fundamental sex difference in the reproductive consequences of extramarital sexuality. The male may see the introduction of another man’s child into his ‘nest’ as a serious attack on his honour. Whereas there has been a substantial reduction in the stigma associated with premarital sex, this is not the case with extramarital sex. There seems to be a strengthening of the importance of fidelity and commitment whether married, co-habiting or not.

What is the impact of social class?

Kinsey’s data indicated a striking social class difference for teenage sexuality, also apparent in the sexual play of children. Working-class adolescents were more likely to experience sexual intercourse and at an earlier age than those from the middle classes. Middle-class adolescents were more likely to participate in sexual activity other than coitus. Between 1962 and 1970, there was a change and the striking social class difference in age of onset of sexual activity had largely disappeared. Conversely, the lower educational group was now experiencing more non-coital forms of sexual activity. Middle class men and women had more permissive sexual attitudes y 1981, were more likely to masturbate, starting earlier, more likely to experience orgasm during petting, had first premarital sexual intercourse at a later age.

What is the impact of culture?

The USA is a multi-cultured society, as are most European societies, and involves three types of culture. First, the indigenous Native Americans. Secondly, immigrant cultures; the predominant group here have been the Americans of European origin, but we also see many Hispanics and Asians. Third, there are African Americans, of whom most of there ancestors were slaves.

How is sexual activity in the Afro-American culture?

Kinsey found that African (Afro-) American males were much more likely to report early onset of sexual activity than American with an European origin. A similar difference is apparent for the females, but at a lower level. The African American females had almost twice the incidence of premarital pregnancy. More European American than Afro-American males had masturbated before the age of 13, but for the females the racial difference was in the opposite direction. In more recent years, both the gender and the racial gaps have persisted, but have been narrowing. We see an earlier average age at puberty in African Americans than "European" Americans, applying to both males and females.

Substantially more Afro-American marriages ended in divorce during the first 14 years. European American women were more likely than Afro-American women to link sexual enjoyment with affirmation of their marriage. Greater interest in one’s own sexual satisfaction than that of one’s partner was more often indicated by Afro-American than European American women, Afro-American women are also significantly more positive than European American women about their own sexuality, they are more likely to rate themselves as sexually attractive than European American women. This seems to stem from a higher self-esteem and more positive body image in Afro-American women. Regarding sexual happiness, European Amerian women attached more importance to feeling emotionally close to their partner, whereas African American women attached more importance to being able to talk to their partner about sex. Ethnic differences in permissiveness about premarital sex linked to religion are primarily found in ‘high church attenders’, with the Afro-American church attenders being more permissive. There is little evidence that virginity has held any importance in the African American culture, whereas there are indicators of a fertility factor.

What effect does acculturation have on sexuality?

In comparing, for example, European Americans and Asian Americans, we have to weigh up both the continuing impact of the culture of origin and the extent to which there has been acculturation to the new culture. This depends in part on the extent to which the family lives in a relatively discrete ethnic community, as well as the length of time lived in the USA. An interesting example of acculturation is that Zulu men living in their country of origin found heavier women more attractive, whereas Zulu men who had emigrated to the UK were similar to British men in their preferences for slimmer women.

Hispanic Americans seem to hold more traditional sexual values than European Americans and were more likely to believe that their religion shaped their sexuality, but showed little difference in their likelihood of experiencing premarital sex. Acculturation and education play a significant role in determining the extent to which the traditional Hispanic pattern persists. Asian Americans are significantly more conservative than non-Asian on all measures of interpersonal sexual behaviour. The number of years of residence was predictive of the change to more permissive sexual attitudes in the Asian immigrants.

What difference can be found in sexual desire and sexual fantasy between men and women?

‘Appetite’ for sex varies across time, dependent on a range of factors, varies across individuals and across genders. Very little research has been done on ‘normal’ sexual desire, compared to research on sexual problems in this area. Kinsey found that the average total sexual outlet (orgasm) was much lower in women, the variability much greater, than in males. Men were also found to think about sex much more frequently, 54% thought about sex daily or several times each day. But asking someone how often they think about sex does not necessarily reveal how interested they are or how much desire they experience. When asking more specific questions, an association was found in women between higher frequency of sexual thoughts and distress about the sexual relationship. Cause and effect was not clear here. Women were more likely than men to see the goal of desire as love or emotional intimacy, whereas men were more likely to see sexual activity as the goal.

Cues that stimulate sexual desire were found in research by McCall & Meston. They found there were emotional bonding cues (love with partner, security in a relationship, the partner being supportive), erotic/explicit cues (watching an erotic movie, reading about sexual activity, watching or listening to others engaging in sex), visual/proximity cues (seeing or talking to someone powerful, someone famous or someone wealthy) and romantic/implicit cues (partner whispering in your ear, dancing closely, having a romantic dinner).

Fantasizing about sex may be one manifestation of what we have been struggling to conceptualise as ‘sexual desire’. Dwelling on a sexual fantasy may lead to incentive motivation for sexual activity, and may result in sexual arousal, but may also be a reaction to awareness of incentive motivation cues or sexual arousal. Sexual fantasy therefore has the potential for being both stimulus and response, and is likely an interaction of both. These fantasies provide a whole new level of information about what an individual ‘desires’ or finds arousing. The possibility that one may act out a fantasy can cause considerable anxiety and fantasies of socially unacceptable or immoral sexual behaviour can cause guilt. Fantasies tend to be more frequent in those who are more sexually active, but decline with age. Men fantasize more during non-sexual activity and masturbation, but not during intercourse. Men are more likely to report sexually explicit and visual imagery, women more emotional and romantic imagery. Women are more likely to imagine themselves in a submissive role, men in a dominant role. A possible connection between force fantasies and childhood sexual abuse has been reported.

What is the difference in response to erotica?

Somewhere between overt sexual activity and sexual fantasy come the various forms of visual or literary erotica as sources of erotic stimulation. The main concern with these things is the possibility that pornography may have an undesirable effect on morals or on the behaviour of members of society, particularly the young. The short-term effects are much as one might expect. It has been conventional wisdom for some time that men are interested in explicit depictions of sexual activity, and women in more romantic accounts, as reflected in the predominant use of erotica by men and the predominant use of romantic fiction by women. Interestingly, no significant gender difference in sexual response was found between visual and non-visual stimuli, which challenges the evolutionary assumption that females are less influenced by visual stimuli to avoid impairing their judgement of likely parental investment by a potential male partner.

To a considerable extent the earlier imposition of social control of sexuality depended on control of information about sex. A major part of Kinsey’s impact was uncovering what was happening – releasing information that people were up to much more than was assumed to be the case. This process escalated dramatically with the advent of the internet. It is an interactive medium and many people use it for sexual purposes. Men use the internet more for access to sexually explicit material, whereas women use it more for interactions or cybersex. The amount of use of website with sexually explicit content is higher in gay/lesbian/bisexual men and women than in heterosexuals. The implications of this dramatic change for the social determinants of sexuality and sexual relationships are not yet known. It could be educational, informative, therapeutic or otherwise positive, but the potential to cause harm is alarming. We see an explosion of availability of sexually explicit material over which it is extremely difficult to exercise any kind of social control. Individuals, even young adolescents, get involved in web sex to an extent which is out of their control. It is reasonable to assume however that for those who use the internet for sexual purposes, this will not escalate into a problem.

What role does personality play in sexuality?

Surprisingly little attention has been paid to the influence of personality variables on sexual behaviour. Eysenck found that extroverts were high on libido and tended to the positive end of the satisfaction factor, whereas introverts were at the low end of the libido factor, but showed greater satisfaction at older age levels. People high on neuroticism complained more of sexual dysfunction and reported high anxiety about sex, whilst being high on the libido dimension. Other researchers have questioned Eysenck’s measures and findings and found weak or no predictive power in personality characteristics regarding to sexual behaviour.

A crucial aspect of individual variability concerns attitudes and values relating to sex (positive or negative). Androgynous men and women tend to be more erotophilic than those who conform to traditional sex roles. Erotophobic men generally tend to adhere more to the work ethic, in women this is associated with achievement aspirations. Erotophilia is related to frequency of masturbation, number of sexual partners and the amount of past sexual experience, in both men and women. It seems couples show more similarity on a measure of sexual attitudes than randomly paired individuals, suggesting relationships in which partners share similar patterns of erotophobia-erotophilia or SE/SI proneness are more successful.

Overall, there have been substantially more changes in the sexuality of women than of men during the 20^th century. This is consistent with a reduction in the socio-cultural suppression of women’s sexuality. Given the greater potential for inhibition of sexual response and arousal in women, it is not surprising that this reduction has affected women across the socio-economic spectrum.

Practice questions CH.6

1. What was Kinsey’s primary objective?

2. What is an advantage of the interview method? And what is a disadvantage?

3. What is a positive effect of masturbation? And what a negative outcome?

4. What are some important dimensions when looking at cultural variations in sexual behaviour and marriage?

5. What happened to birth rates after 1938? And what happened to abortion rates?

6. Which factors determine whether someone is sexually attractive?

7. What is an important difference we observe between European and African American men and women?

8. What may information about people’s sexual fantasies provide us with?

9. What difference between men and women can we see when looking at overall changes in sexuality?

What are the ageing effects on sexuality? - Chapter 7

Kinsey concluded that in males, from the early and middle years the decline in sexual activity is remarkably steady and there is no point at which old age suddenly enters the picture. In females however, there is little evidence of any ageing in the sexual capacities, until late in life.

A study among individuals with a mean age of 60 found that having a satisfying sexual relationship was considered important or very important for quality of life by 74% of men in the 45-59 age group, 61% in the 60-74 age group and 50% of the men in the 75+ age group. For women, these percentages were 66%, 48% and 44%. Across the age groups, we find a clear decrease in the frequency of sexual thoughts, as well as a striking gender difference, with women reporting much less frequent sexual thoughts. We also see decreasing frequencies of masturbation and a marked gender difference. Another study found a substantially greater link in women than in men between experiencing sexual desire and having a sexual partner. In both men and women, age was found to be the strongest predictor of sexual desire, followed by measures of attitudes towards sex. Increasing age in men was also clearly associated with erectile problems, difficulty in reaching orgasm and lack of sexual interest. In women, age was only associated with lubrication difficulties.

What does ageing change in sexual function in men?

A steady decline in the frequency of sexual activity in men was reported, it was also found that the extent of the decline was a function of the level of sexual activity during early adult life. Higher levels of sexual activity when younger means less decline. Whereas there is an age-related decline in male sexuality, it is very variable, with some men remaining sexually active well into old age. It seems sexual interest and morning erections decline in parallel fashion. Frequency of masturbation declines but less markedly than coitus, so that in the over 80s it is the more common sexual outlet. It was found that erectile dysfunction was much more likely to occur in men with submissive personalities, possibly because they have greater difficulty coping with stress.

With age, brain function declines, associated with loss of neurons in various parts of the brain. There has been no clear evidence of such loss relating directly to declining sexual function, but it does affect areas in the brain that are also associated with sexual function. However, attention to the role of androgens in older men has increased substantially, with the concept of PADAM (Partial Androgen Deficiency in Ageing Men) coming into fashion. There is growing evidence of health benefits from androgen administration to older men. There is a decline in T with increasing age. The normal circadian rhythm of young men, with peak T levels in the morning, flattens in older men. Older men with a high level of sexual activity are found to have significantly higher levels of T than those with a low level of sexual activity. No difference in T was found in relation to erectile dysfunction. The relationship between the age-related decline in free T and other age-related changes was not straightforward, but could be explained by an age-related alteration in receptor responsiveness to T or a reduction in androgen receptors within the CNS.

NPT (Nocturnal Penile Tumescence) is often reduced in older men who have no erectile problems, to an extent which in younger men would be suggestive of organic ED. This may be a marker of age-related decline in T-dependent central arousability. The interesting difference between younger and older men with ED suggests that there may be an age-related decline in responsiveness of the NA system which is not dependent on T reduction. T-replacement may lead to an increase in sexual desire, but no improvement in erections.

Age-related decrease in tactile sensitivity of the penis has been reported. Although in other species this is androgen dependent, the relevance of androgens to this mechanism in humans has not yet been clearly established. It was found that smooth muscle in the erectile tissues becomes more responsive to peripheral inhibitory (NA) stimulation with increasing age. Because this is also correlated to neuroticism and strongly with ED, this finding raises the possibility of an interaction between personality-related trait factors and ageing to increase the likelihood of ED.

What does ageing change in sexual function in women?

We saw a more complex, and to some extent less predictable, ageing pattern in women than in men, partly reflecting the fact that women’s sexuality is much more dependent on a current relationship, combined with the much greater likelihood that older women will be without sexual partners. Frequency of sexual intercourse, orgasm and enjoyment of sexual activity were positively related to marital adjustment and negatively related to age. However, women’s satisfaction with their sexual relationship was closely related to marital adjustment, but not to age. It seems sexual function and activities decline with age, possibly starting somewhere between the late 20s and late 30s. Interestingly, most studies reported that problems with pain during intercourse decrease with age or show little change. Sexual responsivity is adversely affected by both ageing and the menopausal transition, with further negative effects of post-menopausal status.

Age or menopause?

So far, there is inconclusive evidence as to whether decline in sexual functions is caused mainly by age or mainly by menopause. Hallstrom found that there is a dramatic decline in female sexual functioning with the natural menopausal transition, while age is not by far as relevant for sexual function. The relevance of androgens to the sexuality of women leaves us with an inconsistent picture. The explanation offered is that women vary in the impact that androgens have on their sexuality. It is likely, therefore, that the age-related decline in androgens is going to have a negative impact in some women, contributing to the varying pattern of change in women, and contrasting with the more predictable relevance of T decline in men. The dramatic decline in sexual functioning with the natural menopausal transition correlates mostly with levels of oestradiol but not androgens. However, we remain uncertain of how changes in oestradiol contribute to this decline.

What is the precise nature of the decline in sexuality?

Older age was found to be weakly predictive of distress about the relationship. Menopausal status was not predictive once age was added to the used model. The main conclusions of this study were that general health, especially mental health, and the subjective quality of sexual interactions were the most important determinants of sexual distress and they were not age or menopause-status related. Although there was a tendency for more older women to describe impairments of sexual function, it was the younger women with such impairments who were more likely to be worried or distressed about their sexual life. Menopausal status did not appear to explain sexual distress.

Lubrication difficulties were found to be the only sexual problem clearly related to age in women across most countries. The problem is not confined to women in the menopausal transition and later, and many post-menopausal women do not complain of vaginal dryness during sexual activity. A number of studies have reported correlations between these vaginal problems and levels of circulating oestradiol. Administration of oestradiol caused women to have significantly more sexual fantasies, better lubrication, less coital pain and more sexual enjoyment.

With regard to physiological response, nipple erection occurred in older much the same as in younger women. The vasocongestive increase in breast size however, showed an age-related decline. Clitoral response is very variable in extent in younger women. Visibly obvious swelling of the clitoral glans during sexual arousal is apparent in about 40% of pre-menopausal women. The clitoral retraction response, occurring shortly before orgasm, was evident in all of the older women. Changes in the labia majora were not apparent in these older women. They lose fatty tissue deposits and elastic tissue post-menopausally. The post-menopausal vagina has been described as losing the well-corrugated, thickened, reddish-purple appearance of the pre-menopausal vagina, becoming tissue-paper thin, and changing to a light pinkish colour. It also becomes shorter and narrower.

Vaginal lubrication, which may take 10-30 seconds of effective stimulation in younger women, may take up to 1-3 minutes in older women to occur. The orgasm continued in older women, but to a reduced extent and with fewer contractions. The uterus shrinks in size, and uterine contractions during orgasm weren’t observed in older women. Older women show a lower baseline VPA in post-menopausal women, but the increase following stimulation was similar to that of younger women. Baseline VPA is correlated with oestrogen level, but the VPA increase in response to sexual stimulation is not.

It seems the menopausal transition appears to be a phase of increased vulnerability to depression. Depression is also an important cause of loss of sexual desire and other forms of sexual impairment, and is therefore likely to be contributing to the increase in sexual problems during the menopausal transition. Relationship factors have also featured as important determinants, as is sexual dysfunction in the partner. Attitudes are also important: woman anticipating a negative change sexually during menopause were more likely to experience one. The decline in sexuality in post-menopausal women is greater in the lower socio-economic groups.

Practice questions CH.7

1. What difference do we see in sexual decline between men and women?

2. What could we say about the sexuality at old age of men that have high sexual activity during early adult life?

3. Why could the decline of brain function possibly have an effect on declining sexual function?

4. What is the only sexual problem clearly related to age in women?

5. What happens to VPA as women age? To what level of hormones is baseline VPA correlated? Is VPA increase in response to sexual stimulation correlated to that too?

6. How can depression influence (loss of) sexual desire during and after menopause?

What are homosexuality and bisexuality? - Chapter 8

The idea that the homosexual individual comes, in some sense, between the typical male and the typical female, has prevailed for some time. Hirschfield put forward the view that homosexuality was a form of hormonal intersex; male homosexuals did not have enough testosterone and lesbians had too much. This idea was disproven in the 1940s. More recently, attention has been paid to structural differences in the brains of men and women and, inevitably, to the possibility that homosexual individuals came somewhere in between. It is too early to reach firm conclusions from these new sources of data, however.

What is the historical background of homosexuality and bisexuality?

In ancient Greece, homosexuality was seen as a positive thing, it was good for young males to have lover-mentors. This was in addition to the more mundane heterosexuality of marriage. Ancient Rome was different, there was less idealisation, but homosexuality was not condemned. However, for a man to take the passive role was unacceptable, and this helped pave the way for the horrendous persecution and execution of (mainly male) homosexuals in the Christian era. ‘Faith-inspired’ intolerance of homosexuality in both men and women was evident in early Judaism and more strongly in Christianity. Between 1700 and 1900, the ‘social construction’ of a heterosexual majority and homosexual minority became increasingly evident.

There is much less to say about homosexuality between women in early history. Much less has been written about women in general, underlining their lowly position in society. It is therefore tempting to see the apparent increase of female homosexuality and bisexuality in the 20^th century reflecting the impact of the women’s movement.

In the 20^th century, we see four particular themes: (1) the continuing persecution and suppression of homosexuality, (2) the medicalisation of homosexuality (particularly in the male), (3) the gradual emergence of a campaign by homosexual men and women to protect their human rights and by some professionals to de-pathologise homosexuality, and (4) the legal status of homosexuality and homosexual relationships.

Persecution of homosexuals is still seen to this day, and in some fundamentalist societies we even still see execution. After WWII, homosexuals were excluded from many occupations, particularly in government, on the grounds of being a security risk. People believed they would corrupt their co-workers. During the late 19^th and early 20^th century, some medical professionals tried to compensate for the social stigmatisation of homosexuality by identifying it as pathology, the conversion of sin into sickness. Though this might have been construed as more tolerant, it carried its own price: having to live with an identity which is pathological. Hirschfield saw homosexuality as a congenital behavioural ‘intersex’ condition, which did not require treatment but rather help and support for those involved to enable them to accept this part of themselves. He can be seen as an early campaigner for homosexual rights and an unprejudiced researcher of human sexuality. However, his movement in Germany was obliterated by the Nazis.

Freud suggested psychoanalytic treatment as a possible solution, and some psychoanalysts have persisted with this view ever since. Attempts to normalise the male homosexual’s sexuality by the administration of testosterone had produced some suggestion of increased sexual desire but no evidence of its re-direction. In the 1960s we entered the era of modern learning theory and the development of behaviour therapy or behaviour modification, which was also used in an attempt to modify sexual preferences.

A challenge to the pathology model of homosexuality started to emerge in the 1950s with the work of Evelyn Hooker, who used various psychometric tests to compare homosexual and heterosexual men. She, unlike psychoanalysts, recruited homosexual men who were functioning well in their lives. Such ‘normal’ homosexual men showed a variability that was indistinguishable from heterosexual men in terms of personality characteristics.

The story of the emergence of the voice of the homosexual community reveals a long-running attempt by the medical profession to keep control; the view was that information for the general public on such matters should first be sanctioned by the medical or legal profession. Research had to be approved by these professionals first, before it could be published, which was not always easy.

The emergence of homosexual activist groups brings with it an interesting conflict: those who wanted gently to bring the medical profession and general public to see the positive features of the homosexual community, and those who lost patience and pursued a more confrontational approach. The pressure of demonstrations, legal challenges and other forms of political activism steadily increased. Pressure put on the APA (American Psychiatric Association) in 1972 eventually resulted in the removal of homosexuality from the DSM, and its replacement with ‘sexual orientation disturbance’, a condition in which an individual was disturbed or sought help because of his sexual orientation. In 1986, this was also removed. Yet we still see religious groups and certain clinicians who try to make homosexuality back into a sickness, offering something known as ‘reparative therapy’, to convert people back to heterosexuality. Despite the fact that there is evidence that homosexuality is not always fixed early and that people sometimes go through changes in orientation even without therapy, reparative therapy raises some important ethical issues. The most fundamental is the distinction between medical treatment for a pathological condition and the imposition of moral values under the guise of medical treatment. At the start of the 21^st century, there were around 70 countries in which homosexuality is still illegal, but in most there have been changes in a positive direction.

What is the concept of sexual identity?

It is difficult to think in terms of sexual identity, because identity is very subjective and we cannot expect to know much about other people’s identities. Especially when looking at sexual identity in history, what we know is often based on what people thought of others and not of themselves. People often did not know in what ways they were similar to others. Modern technology has probably been fundamental in changing this, starting with the emergence of the radio, which enabled people to find out about those outside their local communities and even other cultures.

Kinsey stated that nature rarely works with discrete categories, this is exclusive to the human mind. He therefore developed his ‘scales’, that were designed to indicate the proportion of behaviour that was homosexual or heterosexual during a specific period in an individual’s life. This led to a stronger gay movement, but the gay males discounted the lesbian women in their campaign. Their empowerment showed itself in more general feminist politics, in which heterosexual, homosexual and bisexual women joined forces. These homosexual identities were instrumental in bringing the community together, but according to Kinsey obscured variability in terms of sexual experience (that which his ‘scales’ showed). However, having a homosexual identity has much influence on many aspects of life: where you live, how you socialise, etc.

After the 1970s we see an important change in the general view of homosexuality. Cass described six stages of sexual identity development: (1) identity confusion, (2) identity comparison, (3) identity tolerance, (4) identity acceptance, (5) identity pride, and (5) identity synthesis (a blending of the sexual identity with other aspects of self-identity). There is little doubt that sexual identity is shaped by socio-cultural factors which themselves change over time, increasingly in this unstable modern world. However, there is also a strong influence by biological factors.

In a man, sexual identity is determined principally by the gender of people he finds sexually attractive. In a woman it is determined less by gender and sexual attractiveness, at least in terms of physical appearance, and more by relational factors. It is determined by the type of person with whom she establishes or wants to establish a close sexual relationship, preceded by the establishment of an intense affectionate relationship. It is therefore more common for women to move from a heterosexual to a homosexual identity and vice versa, or identify as bisexual.

What is bisexual identity?

Kinsey disapproved of the term ‘bisexual’, partly because it described an individual rather than a behaviour and was in conflict with his determination to avoid categorisation of individuals in terms of their sexual behaviour. The gay rights movement dismissed bisexuality as a cover for homosexuality, because in the process of struggling for their human rights, it served them more if they could distinguish between homosexuals and heterosexuals. Yet history and anthropological evidence indicate a bisexual potential that has always been realised by many, at least at certain stages in their life.

The majority of the bisexuals established heterosexuality first in their lives and added homosexuality later (often in their 20s or after). The availability of a bisexual identity, as a socially available alternative supported by a bisexual subculture, is relatively recent. In their heterosexual- and homosexual-identified groups, identity usually was only based on their earliest sexual experiences.

Weinberg found three types of bisexual, the most common being the ‘heterosexual-leaning type’: predominantly heterosexual but with some homosexual experience. Least frequent was the ‘pure’ bisexual, exactly in the middle between homo- and heterosexual. The ‘mid-bisexual’ type also scored in the middle, not exactly, the range here was a bit wider. Finally there was the ‘homosexual-leaning’ type. For romantic feelings, almost 60% rated themselves almost exclusively heterosexual. However, while for men it was easier to have sex with other men than fall in love with them, for women this was the other way around.

Compared to heterosexual women and lesbian women, bisexual women score higher on sexual excitation, Erotophilia and lifetime number of sexual partners, and also reported higher sexual desire. This supports the idea that women who are more easily sexually aroused are more likely to eroticise close affectional relationships, with either women or men. Heterosexual men, on the other hand, reported higher sexual drive than gay and bisexual men. In women we are less likely to see the lust separated from close emotional relationships than in men.

When it comes to stability of sexual identity, we see more changes in lesbian women over time than in gay men. Heterosexual men and women showed substantially lower mean change scores than the other two identity groups.

How do cultures compare to each other?

The form of social labelling varies across cultures, and in some cultures the ‘exclusive homosexual’ label does not seem to exist or is very rare. In pre-industrial societies, homosexuality was approved or tolerated in some form in 49 of the 78 societies studied. However, a person who was exclusively homosexual throughout his life was unusual. Some societies accommodated the behaviour, accepting that once in a while, an individual will be ‘born that way’. In others, there were commonly negative reactions and gender roles would be sharply dichotomised, often with laws against cross-dressing, and cross-gender behaviour. In societies where virginity until marriage is expected, we see more homosexual behaviour amongst the unmarried. Polygamy may result in lesbian relationships between the wives. In some societies, there were forms of ritualised homosexuality. Boys and girls were strongly segregated, staying in gender-determined ‘dormitories’, where the young boys had sexual relations with the older boys, until they finally grew old enough to enter a heterosexual arranged marriage. With more and more influence from Western society, these societies have changed to incorporate concepts of heterosexual and homosexual identities from the West.

In a comparison of three modern industrial societies, namely the USA, Denmark and The Netherlands, it was found that attitudes to homosexuality were more negative amongst the population in the USA than in the other two countries. The European countries had greater tolerance of, and less discrimination against, homosexuals, especially in The Netherlands. Usually, when changes in the law regarding homosexuals have occurred, they have been associated with some recorded changes in public opinion. Therefore, we can perhaps take the legal status of homosexuals, and how it varies cross-culturally, as one indicator of cross-cultural attitudes to homosexuality. However, countries that have legalised same-sex sexual behaviour for the longest time should not be assumed to show the more accepting public attitudes. In the case of Italy, it is more a ‘don’t ask, don’t tell’ attitude, a modern version of the collective denial prevailing in much of Europe before 1900.

What is the prevalence of homosexual and bisexual behaviours and identities?

In Kinsey’s research, he found that 37% of males had at least some overt homosexual experience to the point of orgasm between adolescence and old age. 50% of males who remained single until the age of 35 had such an experience. 10% of males are more or less exclusively homosexual for at least 3 years between ages 16 and 55. 4% are exclusively homosexual throughout their lives. Later, Gebhard concluded that 4% of college educated males and 1-2% of the total adult female population were predominantly homosexual. However, most of these surveys did not ask about self-identified sexual identity, but only whether same-sex sexual behaviour had occurred. When asked about this, we often see much higher percentages of men and women reporting same-gender sex experiences than men and women who think of themselves as having a homosexual or bisexual identity.

For men, the likelihood of having a first homosexual experience increases steeply during the early teens and then, after 20, shows a gradual increase. For women, this likelihood increases steadily over the age range until the fifth decade. This gender difference is consistent with Kinsey’s data. Men with homosexual experience report many more lifetime same-sex partners than women with homosexual experience. For both men and women, however, the ‘homosexually identified’ report more same-sex partners than the number of opposite sex partners reported by the ‘heterosexually identified’.

Of men who identified as homosexual, the large majority had engaged in oral sex and a somewhat smaller majority in anal sex with their male partners. Overall, there are less data on sexual practices for lesbian women. About 61.8% of the women reported active and 72.2% receptive oral sex. The prevalence of oral sex in women who have sex with women seems to have increased across age groups. Nearly all women reported manual stimulation by their female partner, or of their female partner. About half reported genital-genital contact.

What are the characteristics of homosexual men and women?

The evidence of a link between gender non-conformity in childhood and subsequent homosexual identity has been well documented. What gender-related personality characteristics do we therefore find among adult gay men and lesbian women? Research has been done to find a link between preference for ‘receiving’ or ‘active’ sexual activity, but so far no association with gender identity has been found. The emerging picture is of adaptive flexibility that does not convey rigidly structured gender-related sex roles, so there is little reason to believe that such specific aspects of sexual interaction are determined by gender identity in gay men.

Studies found significant differences between homosexual and heterosexual males in psychological measures of femininity, although no distinguishing characteristics in terms of body shape were demonstrated. It is suggested that young men, soon after acknowledging homosexuality, often go through a crisis of masculine identity and that in the majority, as the identity crisis was resolved, the need to be effeminate receded. This despite gender atypicality in youth.

From the 1970s, masculinity was defined in terms of instrumentality (dominance, independence and assertiveness) and femininity in terms of expressiveness (nurturance, compassion and interpersonal sensitivity). Homosexual men were similar to heterosexual men in terms of instrumentality, but scored higher in terms of expressiveness. Lesbian women were similar to heterosexual women in terms of expressiveness, but higher in instrumentality. The evidence point to a blending of masculine and feminine traits in both gay men and lesbian women, which shows considerable variability across individuals. As with moth aspects of homosexual development, it seems a combination of nature and nurture is the cause.

How are their personalities and mental health?

The basic dimensions of personality have so far shown little predictable relationship to patterns of heterosexuality. The more sex-related measures derived from the Dual Control model are of potential interest in understanding homosexual expression, though so far relevant data are limited. A further form of individual variability of potential relevance to the well-being of gay men and lesbian women is the relationship between negative mood and sexuality.

Although it can be confidently concluded that homosexuality is not a manifestation of psychopathology, there is increasing evidence that homosexual men and women are more likely to experience depression and other negative mood states. Not surprising, given the level of stigma associated with homosexuality. One study found more psychosomatic symptoms, more loneliness, lower self-acceptance and more depression and suicidal ideas in homosexual men. The same study found lesbian women to have less current happiness, lower self-esteem and more suicidal ideas. For both the male homosexual and the lesbian subjects, a higher incidence of seeking professional help in the past was found. They were also found to be more at risk of substance abuse/dependence, anxiety and suicidal ideas. Effeminacy may be a contributing factor in male homosexuals, as those who are more effeminate also show a higher degree of neuroticism.

There is now a substantial body of evidence that homosexual men and women are at increased risk for mental health problems, though there remains a lack of conclusive explanations of why this is. Perhaps to answer this, we should consider the impact of uncertainty or perceived stigma related to sexual identity as the individual struggles with this phase of development during adolescence. In gay men, childhood rejection by parents (probably a result of childhood gender non-conformity rather than the cause of it), was associated with attachment problems in adult relationships.

What is the status of relationships in the gay male and lesbian world?

If men, as is often assumed to be the case, tend to be more promiscuous than women, then the heterosexual version of the male has to contend with the restraining influence of his female partner. The homosexual male has no such constraint, a possible explanation of why gay men have more sexual partners than lesbian women. On top of that, we find a long-standing lack of encouragement or reinforcement for gay men to establish stable sexual relationships, as is very evident in the opposition to gay marriage.

One study found that the woman’s tendency to feel uncomfortable with the sexual initiator role contributed to a relatively low frequency of sex in lesbian relationships. In male couples, we see that the end of the first year of the relationship is a common time to split up. Expectations of fidelity were high and sexual exclusivity was expected by the majority at the start of the relationship, but this soon changed. In most of the couples there was an assumption of equality. Emotional intimacy was the best predictor of satisfaction with the relationship, and young gay men valued the emotional aspects more than older gay men. In lesbian couples, emotional involvement was more important than sexuality per se, and lesbians are more likely to feel emotional closeness before they engage in sex.

Practice questions CH.8

1. What was the prevailing idea about homosexual individuals before the 1940s?

2. Which four particular themes surrounding homosexuality do we see in the 20^th century?

3. What kind of conflict was brought on by the emergence of homosexual activist groups?

4. What was Kinsey’s solution to his statement that nature rarely works with discrete categories, like the human mind does tend to do?

5. Name the six stages of sexual identity development, as described by Cass?

6. Why did Kinsey disapprove of the term ‘bisexual’?

7. Why can we take the legal status of homosexuals as an indicator of cross-cultural attitudes to homosexuality?

8. What effect can homosexuality have, regarding mental health?

What are sexual variations in humans? - Chapter 9

Over the course of history, the positive role of sex in establishing intimacy and binding relationships is gradually being acknowledged. We are seeing a shift in the involvement of the medical profession, particularly in their dealings with women, towards helping the maintenance of this positive component. This chapter considers some of the better known examples of sex that are not regarded as normal, including the lack of sex, or asexuality.

What terminology to use?

Sexual minorities refers to the many minority groups in society defined by their sexuality, such as homosexuals. Sexual deviance can be seen in three main forms; normal deviance (frowned upon behaviours that are nonetheless carried out by large numbers of people), subcultural deviance (the more obvious sexual minorities) and individual deviance (including sexual behaviours that are not clearly organised into subcultures or minority groups). The word perversion has often been used, but always means ‘wrong’, is therefore stigmatising and should be avoided. The currently conventional medical term is now paraphilia. It implies sexual behaviours that are rare and little understood, such as necrophilia and zoophilia. Sexual variations are patterns of sexuality that, while abnormal, are not necessarily problematic for the individuals involved. Here we focus on three such variations: asexuality, fetishism and sadomasochism.

What is asexuality?

At both extremes of the sexual activity and sexual desire scales, there may be individuals who are comfortable with either the high or low levels of their sexuality. This may determine their sexual identity in some respects. Earlier, when sexual expression was suppressed in society, the asexual individual sat comfortably within many aspects of that society, even marriage, as expressing the socio-culturally preferred ‘default’ position. We can ask ourselves whether asexuality is an identity that some people choose (they might choose a celibate life), or does it evolve? It seems that, unlike choosing to be celibate, asexuality is part of who someone is. An asexual just does not experience sexual attraction, but may experience non-sexual attraction and may therefore identify as gay, straight or bisexual. Those that indicate being asexual are more often female, report religiosity, have short stature, low education, low socio-economic status, and poor health. They also were more likely to report a late onset of menarche. This suggests that both biological and psychosocial determinants of asexuality exist.

What is fetishism?

An important component of sexual development is the emergence of sexual arousability in response to sexual stimuli. There appears to be a critical period in the young male’s sexual development when a connection between specific stimuli and sexual response is established. The most fundamental variability in this process is whether the selected sexual signal involves individuals of the same or opposite sex, but there is also the specificity of the signal. To what extent do we establish sexual preference during this stage that remains specific and unchanged through most of our lives? Males usually show preference for particular parts of the female (or male) body. The concept ‘fetishism’ becomes more relevant as the subject becomes more preoccupied with the signal itself and less concerned with the associated partner. The fetish serves to weaken rather than strengthen the sexual bond with the sexual partner and, in extreme forms, makes the partner as a person sexually redundant.

There are three principal categories of sexual signal or stimulus to consider: a part of the body (partialism), an inanimate extension of the body (e.g. clothing) or a source of specific tactile stimulation. In partialism, interest in specific body parts (the foot being the most common) over-rides any interest in the rest of the person or the body as a whole. When we look at a fetish concerning a source of specific tactile stimulation, we most often talk about certain textures, the most common being (clothing made out of) rubber, leather, or shiny black plastic.

It is often assumed that fetishism results from the specific conditioning of sexual response to particular stimuli. In the male, the capacity for classical conditioning of erections to unusual stimuli has been demonstrated experimentally. The fact that women are much less aware of any genital response may then help to explain the apparent lack of such fetishistic learning. Masturbation and orgasm in response to the fetish object will serve to reinforce and maintain the association. It remains a puzzle why this only happens in some individuals, while in most there is a generalisation of learning which allows preferences to evolve and mature with experience, involving the whole person. We see two possibilities: some interference with the incorporation of specific sexual learning onto dyadic sexual relationships and an abnormality in the learning process.

It seems that if the sexual learning phase occurs too early (in the form of coincidence of early awareness of sexual arousal in connection with the fetish item), this might reduce the likelihood of appropriate incorporation into dyadic sexual relationships, resulting in a relatively impersonal establishment of sexual preferences. It may also be that sexual learning at an early age, before any mature concept of sexuality has developed, permits more unusual associations to develop. Many fetishists report a strong interest in the fetish object earlier in childhood before it became sexually arousing.

What is sadomasochism?

Sadism needs to be considered at two very different levels: as a factor in some forms of sexual violence and abuse, and as a component of ritualised sadomasochism, which is a consensual pattern of sexual interaction. Sadistic sexual violence ranges from sexual assault or rape, in which the rapist is motivated by the desire to dominate his victim, to sadistic sexual murder. There is a clear difference between this and the ritualised versions of sadomasochism enjoyed by both participants, but there remains considerable stigma associated with sadomasochism. Straight BDSM males tend to be more interested in humiliation, BDSM women, whether heterosexual or lesbian, tend to prefer bondage, spanking, or ‘master-slave’ scenarios. An important aspect is the strict setting of rules and limits, allowing participants to enjoy the experience without fear that it might go too far. Interestingly, coitus or genital stimulation to induce orgasm is unusual.

Fantasies of being raped or being forced into sexual activity by women are far from unusual, but they would likely not enjoy such experiences in reality. Some of them might learn to enjoy a ritualised version in which they know they are not going to be seriously hurt or be unable to stop when they want to. For both females and males, particularly those who have grown up associating sexual pleasure with guilt, the arousing effect of being dominated may derive from a sense that one cannot be blamed for the experience. This is largely speculation. While pain is not the main reason people get involved in BDSM, it is commonly involved to some degree and they can experience sexual arousal in the presence of pain.

What is ‘multivariant sexuality?’

Although the various kinds of sexual variations discussed in this chapter are scattered fairly widely through the population, they have a striking tendency to occur together. Fetishism and sadomasochism are commonly found in the same person, and may also be associated with one or more of the more obscure variations.

Practice questions CH.9

1. What does the term sexual minorities refer to?

2. Which three main forms of sexual deviance can be seen?

3. What are sexual variations?

4. Why could an asexual still identify as gay, straight or bisexual?

5. What effect could fetishism have on the sexual relationship someone has with their partner?

6. What three principal categories of sexual signal or stimulus do we consider in fetishism?

7. What is a possible explanation for the occurrence of fetishism?

8. What is an important aspect of BDSM that sets it apart from sadism as a factor in sexual violence and abuse?

9. What does the term ‘multivariant sexuality’ mean?

What is transgender, gender non-conformity and transvestism? - Chapter 10

Of primary importance in this chapter is gender reassignment, when a person changes his or her gender identity and lives in the opposite gender role. Fetishistic patterns of sexuality can interact with gender identity in complex ways, the prime example being fetishistic transvestism. Sexual identity, whether one considers oneself heterosexual or homosexual, is a further important component of this interactive pattern.

What role do socio-cultural factors play?

Variations in gender identity, with individuals not fitting clearly into socially prescribed male or female roles, are evident in most cultures, though with considerable differences in how these individuals are received. Some (Hindu) cultures recognise and accept a ‘third gender’. However, many (Christian) societies have not only enforced a clear male-female dichotomy, but in the process have assumed a superiority of the male gender. This idea became challenged in the 20^th century, during a new phase of scientific interest in the biology of sexual differentiation. In the early days, those struggling with gender dysphoria could not really do much about it and presumably kept it to themselves. The turning point came in 1952, when an American soldier went to Denmark and received hormonal treatment followed by sex change surgery to become a woman. After this, the dream of changing gender became a real possibility for many gender dysphoric individuals, and several subcultures started to form. In the second half of the 20^th century we see gender stereotypes becoming less rigid, and the boundaries between male and female behaviour and manners of dress less enforced. Given the more recent shift towards a more androgynous or ‘continuous’ concept of gender within the sexual minority world, many transgendered individuals are not seeking surgical change, but some do.

The use of medical interventions, both hormonal and surgical, has been strongly opposed by some. However, the persuasive evidence that gender reassignment has a positive outcome in the large majority of cases has, to some extent, countered this opposition. One recurring theme in clinical literature is that there are basically two male types, homosexual transsexualism and heterosexual fetishist transvestism. The second one has been defined as a male’s propensity to be erotically aroused by the thought or image of himself as a woman. In some cases this leads to a wish for gender reassignment.

We see that in cultures that reinforce clearly distinct gender stereotypes more than other countries, people more often seek help in the form of a gender reassignment, as these expectations about being male or female may generate greater anxiety and insecurity. The sex ratio in those with a transgender identity was found to be around 4:1 male to female.

What is the interactive explanatory approach?

What is clear is that both gender identity and sexuality are involved in being transgender, with the latter needing to be considered at two levels: sexual identity and patterns of sexual arousability, but how they interact is complex and varied. It is possible that a homosexual identity occurs, through a sequence much like this: ‘I am a homosexual, a homosexual male does not have to be masculine’. Another possible sequence, that may lead to a transgender identity, is: ‘I am sexually attracted to males, I am a woman (trapped in a man’s body), hence I am a heterosexual woman.’ All possible combinations of gender identity and sexuality can occur in male-to-female transsexuals. In female-to-male transsexuals, a heterosexual relationship with a woman is usually pursued, seldom if ever a homosexual relationship with a man.

Regarding fetishistic transvestites, they do not only continue their fetishistic practices over long periods of time, but may also establish otherwise normal heterosexual relationships and marriage. It is not unusual for the fetishistic transvestism to recede in importance once a rewarding sexual relationship becomes established, only to re-emerge when the sexual relationship runs into difficulties. It is possible that these individuals live a dual-role pattern, where they spend most of their time as a male, and only some time dressed as a female. It is also possible that they develop a stronger wish to change into a woman permanently, with associated bodily change.

It seems likely that Gender Identity Discordance (GID) is more common in children and that most children grow out of it. The possibility remains that there is a link to later GID in those who, for one reason or another, do not grow out of it. Factors that are sometimes found in the upbringing of GID boys are: (1) parental indifference to feminine behaviour in a boy during his first year; (2) parental encouragement of feminine behaviour during the first years; (3) repeated cross-dressing of a young boy by a female; (4) maternal over-protection of a son and inhibition of boyish or rough and tumble play; (5) excessive maternal attention and physical contact, resulting in lack of ‘individuation’ of a boy from his mother; (6) absence of or rejection by the father; (7) physical beauty of a boy, influencing adults to treat him in a feminine manner; and (8) lack of male playmates during early years of socialisation.

Young girls with typically boyish interests are considerably more common than their male counterparts, and such behaviour is regarded as more acceptable. In contrast to the effeminate boy who usually carries into adulthood considerable problems relating to gender identity, the tomboy girl seldom has any difficulty in adapting to an adult female role. Many female-to-male transsexuals report a marked degree of tomboyism during childhood and a disturbed parental relationship. Also, encouragement by both parents of masculinity in the daughter appeared to be common. While childhood GID may therefore be relevant to transgender identity in adulthood, the commonest outcome is homosexual orientation, more often so in boys than in girls (51% of childhood GID boys, against 6% of girls).

What is the role of biological factors?

As yet, we have no understanding of whether or how genetic factors influence gender identity development. Regarding brain function, we find a smaller bed nucleus of the solitary tract (BNST) in male-to-female transsexuals, related to the number of neurons. However, this difference may not become established until adolescence, so cause and effect are not clear. So far, in male-to-female transsexuals, no relevant differences in their adult reproductive hormone levels or responsiveness of the brain to positive or negative feedback mechanisms have been clearly identified. With female transsexuals, the story is somewhat different: some reported raised testosterone levels, menstrual irregularities or evidence of polycystic ovarian disease.

It is possible that, when a boy shows fetishistic forms of cross-dressing, he is already sensitised to female identification. The fetish object may be chosen also because it appeals to an already established cross-gender tendency. 50% of fetishistic transvestites had been cross-dressing before the behaviour had obvious sexual connotations.

What is the medical management of gender reassignment?

Usually, a clinician is faced with a request for help with the gender transition, and the challenge for the clinician is to assess whether such help is appropriate. 86% of those who had reassignment surgery scored their happiness post-surgery an 8 or higher, none reported consistent regret about having the surgery. The greatest improvements were in self-satisfaction, interpersonal interaction and psychological well-being. Sexual functioning is often impaired, but given the extent of overall satisfaction, this underlines the primary importance of gender identity over sexuality. Those whose transgender emerged from a previous phase of fetishistic transvestism were more likely to regret reassignment or have more negative outcomes than those whose gender identity discordance was primary.

Gender reassignment surgery has provided a goal or a would-be solution for a wide variety of gender identity problems. However, the well-being of the transgendered after reassignment depends only partly on the surgery. This aspect looms large and many transgendered patients want nothing else, they often know the information and literature as well as, if not better than, the clinician, and will present their case in such a way that they are most likely to receive the surgery. This is why the real-life test came into existence: the ability of the transgendered individual to live fully in the chosen gender role for a reasonable period of time before anything irreversible like surgery is undertaken. After all, many day-to-day problems that must be overcome first require patience and relearning, not surgery.

From an early stage the patient who feels certain about the change should be encouraged to spend more time ‘passing’ in the desired role, becoming increasingly ambitious and adventurous as time goes on. The therapist can provide advice and feedback about what to do. It is particularly important to meet and get to know any sexual partners, who are important because often their attitude may play a major part in the patient’s motivation for surgery. Alternatives to sex reassignment should periodically be reconsidered. For many transsexuals, life would be easier for them if they could accept and feel comfortable with a homosexual identity. In general, one is looking for evidence that the patient has a realistic view of the problems to be faced and of his or her abilities to overcome them.

The use of hormones also requires careful thought. Although many of their effects are reversible, this step should be seen as a definite move towards permanent reassignment that should not be started too early. In male-to-female transsexuals, oestrogens and progestagens are used, which cause some breast enlargement, redistribution of fat in a more feminine pattern, softening of the skin and usually a reduction in sexual interest. In female-to-male transsexuals, the appropriate hormone is testosterone, which will increase body and facial hair, some enlargement of the clitoris and increase of clitoral sensitivity, increase muscle bulk and body weight and deepen the voice. Doses should always be built up gradually to keep an eye on side-effects.

Practice questions CH.10

1. What is an importance difference between cultures when considering variations in gender identity?

2. What argument has served to counter the opposition of hormonal and surgical medical interventions in gender dysphoria?

3. Where do transgendered people search more help; in cultures that reinforce more or less clearly distinct gender stereotypes? Why?

4. What two possible patterns of gender identity development do we see in fetishistic transvestites?

5. What are the most important psychological improvements found after gender reassignment surgery?

6. What does the ‘real-life test’ do? Why is such a measure taken before surgery?

7. Which hormones are used for hormone treatment in male-to-female transsexuals? Which are used in female-to-male transsexuals? What changes do these hormones cause?

What problems can occur in human sexuality? - Chapter 11

Arousal is a physiological response, that involves interaction with another person. We can get sexually aroused when alone, but problems with our arousal responses are most often experienced in the context of a relationship. This relevance of the sexual relationship is usually ignored, mainly because few in the medical profession know how to assess or deal with it. Especially for a woman, her physiological responses contribute less than the relationship aspects to her sexual well-being. In contrast to a woman, a man judges both his level of sexual arousal and his effectiveness as a lover on the basis of what is happening in his penis.

Are sexual problems medicalised?

Male sexual dysfunction, mainly erectile, attracted the interest of surgeons in the 1930s, as a passing phase. For some years after that, the prevailing wisdom was that ED was 90% psychological in its origins, though psychological treatments were not available. Things changed in the 1970s, when such therapy did become available. Surgical intervention also made a re-entry. It was important to find out whether the problems were organic or psychogenic, because surgery reduced if not eliminated the possibility of a return of normal erectile function. The main method was measurement of NPT. However, psychological problems can worsen organic ED, or may make ED seem organic in its symptoms. The next phase followed the introduction of Viagra in the late 1990s, effective in around two-thirds of men with ED, but not without its significant possible side-effects.

When women’s sexuality was finally taken seriously, it was found that 43% of women suffered from sexual dysfunction, leading to the conclusion that sexual dysfunction is a largely uninvestigated yet significant public health problem.

What role does inhibition play in conceptualising sexual problems?

A fundamental issue in the nature of sexual problems is the basic inhibitory mechanism, that is appropriate and necessary to avoid sexual activity occurring in unsuitable or potentially disadvantageous circumstances. This is an adaptive mechanism. Men and women who score high with inhibition scores are more likely to report problems of impaired sexual response, while those at the low end are more likely to engage in high-risk or otherwise problematic sexual behaviour. Women tend to have higher propensity for inhibition than men. With excitation, the low and high ends of the distributions are also associated with problematic sexuality. Here it is much more likely that mechanisms resulting from ageing, pathological or pharmacological processes will reduce the propensity for excitation. There is no evidence of ethnic or racial differences in propensities for either excitation or inhibition proneness, but these factors are crucial to understanding how sexual problems are experienced in different cultures. To decide whether a problem can be seen as a dysfunction, it becomes necessary to distinguish between sexual problems that are adaptive, or at least understandable reactions to present circumstances, and those that are the result of malfunction.

The three windows approach is a way of conceptualising the approach to careful clinical assessment of sexual problems. Through the first window, we look at the extent in which the current situation or relationship is likely to result in ‘adaptive’ inhibition of sexual interest and response. Through the second window, we look for evidence that the individual with a problem has experienced that type of problem periodically through his or her sexual life, or whether it is of long duration. Through the third window, we look for any evidence of physical or pathological factors of relevance. We can now see if the problem is adaptive, of the psychosomatic trait variety, or caused by factors of relatively recent onset. The remainder of this chapter will look at three categories of sexual problem: (1) problems of reduced sexual interest or response; (2) problematic sexual behaviour; and (3) problems with gender or sexual identity.

What are problems of reduced sexual interest or responsiveness?

What are sexual problems in men?

There is a clear distinction between sexual arousal and orgasm/ejaculation in male sexual response. The lack of erection has a significant negative effect on the psychosomatic circle in a situation where sexual arousal is wanted, which underlines the psychosomatic nature of ED. The man’s reaction will play a large part in how problematic the erectile impairment becomes, which can lead to ‘performance anxiety’. Lack of sexual desire may occur even when the man still has the capacity for erection, though these men often report fewer ‘spontaneous erections’. Premature ejaculation is a problem when the man is unable to delay orgasm and ejaculation as he would wish, and the orgasm may be minimal, with muscle spasms being absent. The refractory period is in no way reduced in such cases. More rare in men are delayed or absent ejaculation and pain during sexual response.

What are sexual problems in women?

Vaginal dryness may be a problem because of discomfort or pain with penile entry, but is not necessarily accompanied by lack of sexual arousal in other respects. This can also be the other way around: lack of arousal, but some degree of vaginal lubrication. There may be different kinds of sexual desire in women, and, if so, this has a bearing on what women experience when the complain of loss of desire and how it should be treated. Pain during sexual activity is much more common in women than in men. It may be experienced following any tactile stimulation of the vulva, or associated with vaginal penetration by an erect penis or finger, or with deep thrusting during intercourse. Persistent genital arousal disorder (PGAD) is a problem where a woman is continuously sensitive in genitals and breasts, but this is unassociated with any sense of sexual desire and is intrusive and disturbing. It is only temporarily resolved following orgasm. Orgasms may occur spontaneously and maybe frequently.

What is the prevalence of problems in the community?

The percentage reporting a problem for at least 1 month during the past year is substantially higher than those reporting persistent problems (at least 6 months), emphasising the extent to which alteration of sexual interest or function can be short term, reactive to current circumstances. Lack of interest in sex is the most commonly reported problem, much higher in women than in men. Women express much more sexual problems than men in general. Age had a clear effect in men, with older men reporting more lack of sexual interest, erectile problems and difficulty ejaculating. For women, problems were more likely in the younger age groups, particularly pain during sex and anxiety about sex. Being married, and having more education, was associated with fewer sexual problems in both men and women. Overall, emotional and stress-related problems were associated with increased likelihood of sexual difficulties in all phases of the sexual response cycle, this association was stronger in women. No clear association between age and reporting of ‘brief’ problems was found, but the more persistent problems increased with age for both men and women. The strongest predictor of sexual distress was a measure of mental health. Physical health was also predictive, but more strongly for ‘own sexuality’ than ‘sexual relationship’. Frequency of orgasm, difficulties with vaginal lubrication and pain during sex were not predictive of sexual distress. A limited overlap is consistently found between definitions of female sexual dysfunction and how women conceptualise and experience sexual symptoms. We find the reporting of sexual problems is more clearly associated with the level of general wellbeing and quality of the relationship than with aspects of the woman’s sexual interest or physiological sexual response.

Do people attend clinics for their problems?

Given the variable associations between sexual function and the individual’s perception of a sexual problem, it is of some interest and relevance to look at the problems for which men and women seek help when they attend a sexual problem clinic. It seems that for men, ED was clearly the most commonly presented problem, whilst low sexual desire was relatively infrequent, and it was rare for men to complain principally of lack of sexual enjoyment. In women low sexual interest was the most common. Amongst the women we see a strong association between low interest and low enjoyment, though in part this reflects a common difficulty in women in making a clear distinction between the two. An important finding was that around a third of the couples visiting a clinic were having significant marital or relationship problems, though it was not easy to establish the causal relations between these and the sexual problem. There may have been a change to more younger men seeking help for ED, and possibly fewer men seeking help for premature ejaculation.

How to understand problems of reduced interest or responsiveness?

How to do it through the first window?

We first have to focus on the current situation, which can impact on an individual’s sexual responsiveness and hence the couple’s sexual interaction. It is important that a couple feels secure enough with each other to lose control to some extent, and ‘let go’. Expectations of sex are also important, for example expectations about orgasm. Another requirement for a good sexual relationship is communication about what both partners like and do not like. Misunderstandings or lack of correct information may cause a couple to doubt their sexual normality. Similarly, unsuitable circumstances such as lack of privacy, or lack of time, can contribute to sexual problems. Concerns about pregnancy, whether trying to conceive, or trying not to, may cause stress and less enjoyment of sexual activity, as do concerns about sexually transmitted infections. Low self-esteem regarding body image and negative moods can also cause problems. Regarding relationship problems, there are two emotions which cause havoc with sexual relationships: resentment and insecurity, these two are often closely related. Effective communication of anger is crucial to resolve these issues.

The first five years of a relationship or marriage are often difficult because both partners have to find their place in the relationship and find out if they’re ready to make a long term commitment. Sexual problems often accompany this phase of the relationship, and this phase is where marital breakdown occurs most often. Over the next 20 years, there may be substantial social changes to cope with, regarding career, health or children. Worries and anxiety about these things may have repercussions on the sexuality of the marital relationship.

How to do it through the second window?

Although a wide range of factors that can impact on our sexuality were identified above, it is also clear that individuals and couples vary substantially in the extent they are affected by such factors. It is important to look at earlier episodes of such vulnerability, or whether the problem has been long-standing and cannot be sufficiently explained by current circumstances. Negative attitudes, beliefs and values are important here. People may view sex as bad or even evil, or as disgusting, based on what they experienced or were taught in childhood. People are afraid they will lose self-control may have problems with sexual arousal, and the same goes for women who are afraid to lose contact with the loved one if they let go for orgasm. Earlier sexual abuse also leads to problems, usually more risk-taking and less intimacy, due to using sex as a mood regulator.

Findings suggest that propensity for inhibition is more of a trait aspect of vulnerability for ED, although it is a trait which can be amplified by the effects of ageing. Regarding PE, it has been considered that anxiety aggravates PE, or causes it, with performance anxiety resulting from PE making the problem worse. There is also a strong association between PE and erectile failure, men with lifelong problems of ejaculatory control typically develop erectile problems in middle age. Individuals self-identifying as asexual score lower on the excitation scale.

In women, situational problems or vulnerability caused by earlier experiences or negative attitudes, may lead to vaginal penetration begin uncomfortable or painful. There is also a variety of local disorders (infections etc.) that might lead to these complaints, but another cause could be problems in the specific sexual response system, readying the vagina for penile entry. It is important to find out what the cause of the pain problems is. It can be hard to distinguish cause from effect: does pain or discomfort result from vaginal dryness, or does vaginal dryness result from anticipation of pain or discomfort or do both causal mechanisms interact? Varying developmental patterns result in overlap of specific manifestations of sexual and genital pain, an initial problem can lead to more similar problems. However, the problem of vaginismus (pain or impossibility of inserting anything in the vagina) is relatively easy to treat.

Women may be sensitive to certain types of distraction that may interfere with their sexual arousal. This suggests a predominantly inhibitory pattern of response. A correlation was also found between trait anxiety and lack of arousal. We need to be aware that not all women have the same capacity for orgasm, so absence of this capacity need not be regarded as a dysfunction. Loss of the ability to experience orgasm in a woman who has typically been orgasmic previously is another matter.

How to do it through the third window?

Here we look for factors that alter or impair an individual’s capacity for sexual response and sexual interest. Of importance here are the effects of ageing. It is important not to interpret the consequences of normal ageing as dysfunctional, but to encourage older couples to accept and adapt to these changes. Health problems also adversely affect sexuality, whether directly interfering with sexual function or through metabolic disturbance or general lack of well-being and energy. Affective disorders, neurological disorders, peripheral vascular disease, endocrine disorders, diabetes, gynaecological conditions and genital infections may all have their effect on sexual function. Sexual side effects of medications may also occur, for example impairment of orgasm as a result of SSRIs.

In most respects, the sexual problems encountered by gay men and lesbian women are similar to those of heterosexuals, but with some interesting differences. Gay men seem to find sexual failure more embarrassing and suffer more performance anxiety as a consequence. Aversion towards anal sex is one characteristically gay male problem, whereas PE seems to be less common than amongst heterosexual men, possibly because gay men don’t feel the pressure not to reach orgasm before their female partner.

What is problematic sexual behaviour?

Here it is the behaviour, either because of its high frequency, or because of the potential negative consequences, that is the issue. Problems with sexual responsiveness may be relevant to some extent, but more because of a persistent sexual response than an impaired one. Problems may arise in a sexual relationship because of the resulting discrepancy of need between the two partners, which may lead to dissatisfaction and increase the likelihood of ‘extra-marital’ relationships.

High-risk sexual behaviour (HRSB) can lead to unwanted pregnancy, sexually transmitted infection, negative consequences for the primary relationship, or legal consequences. ‘Out-of-control’ sexual behaviour is seen in the form of ‘compulsive sexual behaviour’ or ‘sexual addiction’. Two types of behaviour may be involved here: masturbation, probably the most common, and behavioural interactions with others, of various kinds. A new and exceedingly important development is the use of the internet, which in some people gets out of control. Particularly men use the internet as an almost limitless extension of their out-of-control masturbatory behaviour. Sex addicts score higher on anxiety, depression, obsessive-compulsiveness and interpersonal sensitivity, and also with lifetime histories of substance use disorders. Out-of-control sexual behaviour seems to respond well to mood elevating drugs such as SSRIs, which supports the idea that it relates to affective disorder.

While negative mood is typically associated with a reduction of sexual interest, in a minority of individuals we find a paradoxical tendency for sexuality to be increased during negative mood states. It was indeed found that sex addicts are more likely to sexually act out when depressed, anxious or stressed. Three patterns can be considered: (1) sexual contact may be pursued to meet depression-related emotional needs; (2) sexual stimulation may be used to distract one’s attention form the issues, which when thought about induce negative mood; (3) the tendency for sexual interest and arousability to be increased in negative mood states characterised by increased arousal is a result of ‘excitation transfer’. Such paradoxical patterns are more likely in younger men, and presumably lessen for most as they get older.

Serotonin appears to play a crucial role in sexual inhibition. It was proposed that a dysregulation of central monoamine function underlies out-of-control sexual behaviour. One fundamental issue here is whether the problem lies in conscious mechanisms or self-regulation, or in the neurophysiological mechanisms of inhibition of sexual response and their variability across individuals.

There are three ingredients of self-regulation: standards (religion etc.), monitoring, and the operative phase of regulation. Highly restrictive attitudes to sexuality can result in inability to conform, starting off a cycle of guilt, pain and compulsivity. Alcohol, as well as fatigue and stress, can impair normal monitoring, as can sexual arousal. Important here is the ability to focus one’s awareness beyond the immediate situation.

Relevant when considering the role of ‘automatic’ or subconscious inhibition is the problem of persistent genital arousal disorder (PGAD). We see this only in women and their arousal is described as continuous, overwhelming, and distressing. A relevant gender difference here may be that women have much less refractory inhibition after orgasm than men, thus orgasms are less likely to have a limiting effect.

Sexual behaviour can also be found in the form of an obsessive-compulsive disorder. The symptoms may include intrusive sexual thoughts accompanied by penile erection, awareness of which intensified the anxiety and hence reinforced the process. Masturbation then temporarily relieves the tension.

Another type of problematic sexual behaviour is autoerotic asphyxia, which involves self-strangulation or suffocation. In some way, this has a sexually enhancing effect, but is usually done in secret and is only discovered when the person fails to stop in time and dies accidentally. The occurrence of penile erections in men who had been publicly executed by hanging has been observed on many occasions, sometimes associated with ejaculation. It is possible that many cases of accidental death associated with AEA are assumed to be suicide. AEA is most common in adolescence. There is often evidence of bondage, transvestism and anal stimulation as well. AEA is more common in men, but it is possible that these numbers are caused in part because women are less likely to display other evidence of sexual activity, making it easier to mistake these deaths for suicides.

Adolescent victims of AEA are usually well-adjusted, non-depressed high achievers. So what is it that leads to AEA? It may be that respiratory excitement has always been a conspicuous part of the whole process of tumescence and detumescence, of climax, this tends to heighten the state of sexual excitement associated with such activity. Asphyxiation might result in a euphoric ‘high’. It is possible that adolescents first learn this behaviour after playing the ‘choking game’, where young kids choke each other because it induces a pleasant ‘high’, though this is not done with sexual intent.

What are problems with sexual or gender identity?

Earlier, before the era of ‘gay liberation’ it was not unusual for a homosexual man to seek treatment to become heterosexual. These days, requests for such help are rare. Sometimes an individuals is uncertain about their sexual identity and seeks help to resolve the uncertainty. Religious condemnation has led to a resurgence of ‘reparative’ therapy for homosexuals lately. It is important to remember that someone who believes that homosexuality is wrong is entitled to that opinion, but is not entitled to impose it on others. Regarding gender identity, most individuals seeking help are doing so to obtain medical authorisation of their gender reassignment and the use of hormonal and surgical procedures for that purpose.

How to classify sexual problems?

The purpose of a classification system for sexual problems would be to provide a diagnostic system. Diagnostic categories in psychiatry are less straightforward than in general medicine. In psychiatry, less attention is paid to the therapeutic or prognostic significance of a diagnostic system. DSM-IV is a method of increasing reliability of diagnosis, providing more consistent diagnoses across clinicians. A classificatory system, or at least an explanatory model which covers the range of sexual problems, and with implications for the treatment as well as research, would be of value. The first two editions of the DSM did not use the concept sexual dysfunction. In DSM-I, the then commonly used terms for various sexual problems were grouped under ‘psychophysiological autonomic and visceral disorders’. In DSM-II, some were listed as examples of psychophysiologic genito-urinary disorders. In 1980, the concept of psychosexual dysfunction appeared in DSM-III.

The current (DSM-IV) classification defines sexual dysfunction as characterised by disturbance in sexual desire and in the psycho-physiological changes that characterise the sexual response cycle, causing marked distress and interpersonal difficulty. The use of the sexual response cycle for both men and women can be seen as an attempt to redress the societal view, which has prevailed in the past, that women’s sexuality was something fundamentally different to that of men. However, this attempt at ‘political correctness’ is no longer relevant, since there is now growing recognition of, and emphasis on, gender differences in sexuality.

The starting point for a better classification of sexual problems is to acknowledge that sexual activity is not essential for health, and that some individuals live long and rewarding lives without sex. However, it is also a central feature in the primary relationships of most of us and is necessary for reproduction. Even within sexual relationships, there is considerable variability of sexual responsivity and interest. This raises the question of when a ‘diagnosis’ is needed or appropriate. An example is asexuality: if a person has been asexual since adolescence, we may simply speak of a ‘difference’ rather than a dysfunction. If, however, a person became asexual after a period of relatively normal sexual function, a dysfunction may have arisen. But even then, the individual may not feel the need for change and may not seek help.

What are the benefits of being sexual?

Sexual activity can lead to three types of benefit: (1) reproduction; (2) a rewarding sexual relationship, and (3) sexual pleasure. Sexual dysfunction may cause problems in attaining each of these benefits. Inability to have sexual intercourse due to, for example, ED, naturally leads to inability to reproduce. In establishing a rewarding sexual relationship, not necessarily every woman who does not become obviously sexually aroused or does not experience an orgasm has a barrier in obtaining this relationship. They may just enjoy the experience of being desired, or giving her partner sexual pleasure. If, however, reaching orgasm for themselves is equally or more important than those things, they may experience a problem. Problems in experiencing sexual pleasure may arise when one or both of the partners notice a difference in current experienced pleasure and the pleasure they have come to expect from earlier experience. In treating sexual dysfunction, it is important to find out which barrier, or barriers, cause the problem and where this initiated.

Practice questions CH.11

1. In what context do we most often see problems with arousal responses?

2. Which kind of sexual problems do we most often see in those with high inhibition scores? And which kind in those with low inhibition scores?

3. What do we see through the three windows in the ‘three windows approach’?

4. What is Persistent genital arousal disorder (PGAD)?

5. Which aspects of the current situation may impact on an individual’s sexual responsiveness?

6. Which physical or pathological factors may impact on an individual’s sexual responsiveness?

7. What can high-risk sexual behaviour (HRSB) lead to?

8. Which two forms of ‘out-of-control’ sexual behaviour are there?

9. What is autoerotic asphyxia and what are the risks of this behaviour?

10. What are the three types of benefit that sexual activity can lead to?

What are the assessment and treatment options for sexual problems? - Chapter 12

In recent years, there has been an understandable shift towards integrating pharmacological and psychological methods of treatment, especially in relation to ED. Simply focusing on the erectile response by means of a drug, with no attention to other factors in the man’s current life or relationship that might be contributing, would be insufficient for many. Given the complexity of sexual relationships and the variety of patterns that can lead to sexual problems, and given the importance of a sexually satisfying relationship for the well-being and health of men and women in long-term relationships, it is clearly desirable for there to be specialist clinical services available that allow the full range of assessment and treatment. The reality is that such services are the exception and are becoming less in evidence than previously.

What is the historical background of the treatment of sexual problems?

The dominant influence in the first half of the 20^th century was psychoanalysis. Sexual problems were regarded as symptoms of disorders of personality development and their effective treatment was seen to require prolonged psychoanalytic therapy. Given the cost and time involved, such treatment was available to only a few of those with sexual problems and the benefits they obtained have not been clearly documented.

The psychoanalytic approach has always been countered to some extent by a more pragmatic and directive view of psychological treatment, in which learning or relearning or the acquisition of healthy habits has been the basic theme. Towards the end of the 19^th and the early 20^th century, hypnosis was popular, and is still evident to some extent today. Whilst such methods seem crude today, they contain much of the essence of more modern behavioural methods.

Modern behaviour therapy became established in the 1950s and 1960s. Practical behavioural approaches were based on the theoretical principles of learning derived from laboratory experiments. This was a reaction against the unscientific nature of psychoanalysis. Methods of aversive conditioning slowly gave way to more positive approaches – learning new behaviours rather than actively discouraging old ones.

Alongside these forms of therapy were those advocating surgical, pharmacological or mechanical methods of treatment. The 1940s saw the first attempts at inserting penile implants or prostheses, methods that increased dramatically in the 1970s and 80s. The tendency to see sexual dysfunction as either organic or psychogenic prevailed, in spite of unremitting evidence that both types of factor were involved.

1970 was a crucial year in the development of modern sex therapy, with Masters & Johnson claiming impressive results in a large number of couples with sexual dysfunction, using an intensive but very brief treatment method lasting only 2 weeks. Whereas the traditional behavioural approach as value when modifying specific aspects of behaviour, sex therapy more often than not has to deal with the complexities of the relationship.

What are problems of reduced sexual interest or response?

How is sex therapy for the couple?

From a theoretical perspective, the main objective of psychological treatment is to identify and reduce inhibition of sexual response. Therapy may reduce inhibition by identifying factors relevant to the individual or the couple, which invoke inhibition, and finding ways to make them less inhibiting. Goals of treatment include helping each person to accept and feel comfortable with his or her sexuality, helping the couple to establish trust and security and helping the couple to enhance the enjoyment and intimacy of love making. The assumption is that there is no abnormality of the basic physiological mechanisms involved.

The couple is given clearly defined tasks to try before the next session, these attempts are then examined in detail, identifying attitudes, feelings and conflicts that make the tasks difficult. These are then modified or resolved and the next task is set, etc. The first two stages of treatment are the non-genital phase, in which each partner practises self-asserting: making clear what they like, or find threatening. Stage 1 involves the touching of the partner in a way that the person touching finds pleasurable, the touched partner only indicates when anything unpleasant is felt. The goal is to relax and enjoy. In stage 2, touching without genital contact for your own and your partner’s pleasure is the goal.

An issue often identified during the first two stages is that a couple complains that they dislike the lack of spontaneity. However, it should be made clear that the therapist’s initially very directive role will change as treatment proceeds and control is progressively handed back to the couple. Breaking the ban on genital contact or reluctance to maintain it, provides valuable information on trust and interpersonal security. This may reflect a fear of rejection or sexual betrayal. Also, a requirement for clear alternation of who invites and initiates sessions is an effective way to elicit problematic attitudes such as the widely held belief that ‘nice’ women don’t initiate sex, they wait for their partners to do so.

In stage 3, the genital component is added. Beforehand, the therapist provides basic information about the anatomy and physiology of sexual response in both sexes, emphasising those aspects that are often misunderstood and underlie dysfunction. Stage 3 involves touching, but now with genitals and breasts included, still applying the alternation of who initiates and who touches. A useful method to prevent performance anxiety is to concentrate on the local sensations experienced while touching or being touched. If PE is a problem, techniques such as ‘stop-start’ or ‘squeeze’ are introduced at this stage. In the case of vaginismus, gradual vaginal dilatation with finger or graded dilators is used. In stage 4 touching is done by both partners simultaneously. Issues that arise once genital contact becomes involved can be negative attitudes about sex, issues of self-control and fear of losing control, and the impact of earlier traumatic experiences. This is also the time to see whether individual sessions to work on PE or vaginismus are necessary, and whether genital response is occurring.

Once the first four stages are successfully cleared, some vaginal containment is added to the session. During a touching session, the woman may adopt the female superior position and, at some stage, introduces the penis into her vagina. In this stage 5, it is encouraged to try this for short periods at first, without additional movements, gradually extending duration. Stage 5 merges into stage 6 when movement and pelvic thrusting are allowed, although initially for brief periods only. The confidence that either partner can say ‘stop’ at any stage, without incurring anger or hurt in the other, is a basic feature of a secure sexual relationship and should be practised. Issues often identified during this stage are performance anxiety, or incorrect notions about sex.

To help resolve obstacles, it is important that the therapist facilitates understanding of why one has difficulty in carrying out a particular task. This can be done by setting further task to focus on a specific problem, to encourage examination and correct labelling of experienced feelings, or to encourage the couple to work out an explanation for their difficulty in carrying out a task. The therapist should also find out whether both partners want to attack the encountered obstacles, does the patient find them unwelcome, or do they fit their value system? Problems caused by anxiety can be challenged on a rational basis. If an unwillingness to overcome a certain fear is incompatible with the goals of the treatment, the therapist should point this out to the patient. Next, the therapist should facilitate the expression of emotion and educate the couple about ways that unexpressed emotions adversely affect them. The duration of the therapy is typically 12 sessions over 4-5 months.

How does sex therapy for the individual work?

A proportion of patients presenting with problems of impaired sexual response or desire have no current sexual partner, not infrequently because of their sexual problem. For individual therapy, it is crucial that there are treatment goals that are not dependent on interaction with a partner. If problems only occur in interaction with a partner, but not during masturbation, that person will not benefit from individual therapy.

The patient-therapist relationship is very important, it should be clear that it is primarily an educational one between two adults, one providing expertise the other making use of that expertise in an active way. Some people profit more from a therapist of the opposite sex, others from a therapist of the same sex. This depends on the situation and the problem. The basic principles of behavioural psychotherapy, as described for couple therapy, are also applicable to the individual. More time is usually needed in the initial assessment and behavioural analysis before appropriate assignments are identified.

A person suffering from marked sexual inhibition or absence of sexual desire may experience this as a barrier to establishing a rewarding sexual relationship. The touching exercise from the couple’s therapy may be used here, to make a person more aware and open to their sexual feelings and bodily responses. This may reveal negative attitudes about sexuality or discomfort with body image, that can be cause for suggesting specific goals to resolve these issues. Step by step, the genitalia are explored in privacy, which should lead to gentle genital caressing. Relaxation exercises may be useful if the patient fears arousal resulting from these exercises. The therapist is employing a combination of education, giving permission, desensitization and the psychotherapeutic resolution of emotional blocks and conflicts when appropriate.

In women, vaginismus makes it difficult or impossible to allow entry of an erect penis or even a finger into the vagina. Treatment consist of inserting the finger, first only the tip, and leaving it in for a short time, extending the duration over time. When this goes well, the next step is graded vaginal dilators, which vary in size from the size of a finger to bigger than most penises. Woman with anorgasmia may be helped with an individual ‘sensate focus’ (touching exercises) approach, progressing gradually to genital stimulation. The key is to avoid ‘performance demand’ but to emphasise the pleasure that occurs without orgasm. By prolonging this, orgasm may eventually occur.

In men, delayed or absent ejaculation may be overcome by following an individual sensate focus programme, similar to the one described for women with anorgasmia. Premature ejaculation, if occurring during masturbation, can be helped with the sensate focus approach before reaching the phase of penile stimulation. Then he is taught the ‘stop-start’ technique, learning to recognise when he is getting close and to stop in time. Erectile problems are more difficult to treat individually, particularly in the case of performance anxiety. If erection during masturbation is also a problem, sensate focus may help regain the erections and increase self-confidence.

What is the outcome of sex therapy for couples?

There are many difficulties in defining success when evaluating sex therapy. More often than not the specific dysfunction is only one aspect of the sexual relationship and therapy can achieve substantial improvement in the quality of the relationship whilst leaving the dysfunction largely unaltered. Studies have demonstrated the importance to outcome of lack of motivation in at least one of the partners. The best outcomes of couple therapy are found for vaginismus and ED. It was found that improvement obtained during treatment was fairly stable during a follow-up period in couples that stayed together. Relapse was found especially in problems of low sexual desire. Half of those experiencing relapse during follow-up were able to deal with them effectively, often by adopting strategies learnt during therapy. Variation in results for ED and PE may indicate varying degrees of selection of cases without organic impairment.

It is difficult to see what the effects purely of a certain treatment are, because often differences that exist between couples beforehand have a significant effect on response to treatment. Indeed, controlled studies find a much lower treatment effect than uncontrolled studies. When looking at factors that influence prognosis, it was found that failure to complete treatment was significantly associated with lower social class and lower motivation on the part of the male partner, poorer general relationship and poorer progress by the third treatment session. Outcome of the whole group was related to the quality of the general relationship as rated by the therapist and female partner, and to motivation of the male partner. The extent to which couples were carrying out their homework assignments by the third session was also highly predictive of outcome. We need to identify more prognostic factors that relate to the specific sexual problem and the specific method of treatment in use.

What pharmacological and hormonal treatments are possible?

In the male, we look first at ED. The most important development in this field was the discovery that sildenafil, a phosphodiesterase-5 (PDE-5) inhibitor, enhances erectile response. This laid the basis for Viagra. In most studies, there is evidence of a dose-response effect. The most common side effects are headache, flushing and dyspepsia, they are also dose related. Most of the studies have looked at men with ED having an ‘organic’ component. In men with diabetes, 60-65% show improvement of erectile function with PDE-5 inhibitors. In men with ischaemic heart disease, around 70% have shown improvement in erectile function, but these patients suffer more from side effects. In men with spinal cord injuries causing loss of neural activation of erection, 80-88% reported improvement. In the long term however, most men do not keep taking the drug, for fear of side effects, partner concerns and lack of information from the physician.

Anti-adrenergic drugs, influencing the activity of noradrenaline (NA), are also researched as treatment for ED. Given the central role of dopamine (DA) in both incentive motivation and central control of genital response, the effects of DA agonists are also of obvious interest. However, early studies on the use on humans encountered substantial side effects, mainly nausea and dizziness. In later studies, solutions were found to counter these side effects. Melanocortin agonists, when tested on humans, resulted in erections and an increase in sexual desire. The use was limited by nausea and a long time before onset of action, around two hours.

The discovery that certain drugs injected into the corpus cavernosum induced erection contributed to our understanding of erectile physiology. It was initially used as a method of investigation, but soon became a form of treatment by self-injection. Prostaglandin E1, a potent smooth relaxant and vasodilator, is used for this purpose. Another, very new, approach is gene therapy. A DNA plasmid is injected that influences K⁺ outflow and CA²⁺ influx, influencing the smooth muscle contractile tone. The effects remain for several months and the injections have so far not resulted in any adverse effects.

For the treatment of premature ejaculation, attention goes mainly to the effects of antidepressants such as SSRIs, which have an effect of delayed or absent orgasm or ejaculation as sexual side effects. A new SSRI with rapid onset and short duration of action specifically designed for use to delay ejaculation has been developed. PDE-5 inhibitors have also been explored as treatment for PE. This may seem paradoxical since they are also used in enhancing erectile response, but the effects of erection result from relaxation of smooth muscle in the erectile tissues, and seminal emission involves smooth muscle contraction. The usefulness is probably limited to secondary PE, where there is some degree of associated ED, however. At the present time there is no accepted pharmacological treatment for delayed or absent ejaculation or orgasm. The most treatable cause of loss of sexual desire in men is hypogonadism, or androgen deficiency. T-replacement can be used in such cases.

In the female, there is still considerable uncertainty about the nature of sexual problems, so it is not surprising that the effectiveness of pharmacological methods in the treatment of women’s sexual dysfunction is unclear and probably limited. Lack of consistency in the outcome measures are based on the traditional linear sexual response model: sexual desire => arousal => orgasm. A woman’s motivation for sexual activity is frequently for reasons other than sexual desire and/or sexual thoughts and fantasies, and its absence does not equate to dysfunction. Also, emotional well-being and positive emotional responses during sexual activity are reported to contribute more to sexual satisfaction than physical or genital aspects of sexual response. Most relevant evidence involves administration of hormones, mainly androgens, to women, with most studies restricted to surgically or naturally menopausal women. Absolutely no attention has been paid in the existing literature to the general idea that there may be different types of women who would respond differently to pharmacological or hormonal treatments.

The impact of PDE-5 inhibitors on women’s sexual response is of interest. Some women report improvement after taking this drug, while others don’t. Is it possible that the women who reported improvement in this study differed from those who did not in their type of sexual problem, or in their normal pattern of sexual response? It seems women who show less VPA in response to erotic films, showed more increase in subjective arousal and reduction in latency to orgasm when taking PDE-5 inhibitors. It is possible that a subgroup of women who experience normal sexual interest and subjective arousal but lack vulval and vaginal response, might benefit from such treatment. Some women also benefit from T administration to help with low sexual desire, but differ in their sensitivity for T.

What are the other non-pharmacological methods of treatment?

For the male, vacuum constriction devices can be used to create an erection. A vacuum around the penis is created and the erection is maintained by applying a constriction ring around the base of the penis. This should not be maintained for more than 30 minutes to prevent damage. Penile implants are another option, early versions consisted of an inner twisted metal wire covered in silicone. This is difficult to ‘put away’ after use, so these days inflatable devices are used, which incorporate a small pump implanted in the scrotum, and two inflatable cylinders in the penis. The surgery is quite demanding and should be regarded as a last resort.

A combination of psycho-educational treatment combined with pharmacological treatment resulted in higher treatment satisfaction scores. These more recent evaluations point to the benefit of an integrated approach. Whatever approach is indicated however, the therapist should aim to work with the couple whenever possible.

When to treat and which treatments to use?

For the initial assessment interview, one hour is normally allowed, to set the patient or couple at ease and discuss the contents of the referral letter. The couple is then interviewed separately, and the following points are addressed: (1) the precise nature of the sexual problem; (2) the history of the sexual problem; (3) The nature of the general relationship and other details of the immediate family and children; (4) psychiatric history; (5) medical history; (6) contraceptive history; (7) use of alcohol or recreational drugs: the typical number of units taken by each partner in a week; and (8) attitudes to the sexual problem and possible treatment. In the final part of the interview, the clinician describes his or her initial impression of the nature of the problem to the couple together and a recommended programme of assessment and treatment.

Questions usually asked in assessment of the woman deal with her physical and psychological reaction during sexual activity and her experience of this, whether she experiences pain, and if so, where and when. She is also asked whether she experiences orgasm, and if this has always been the case, or has not been the case. She is asked about masturbation habits and attitudes towards this, about sexual desire and the different forms in which this presents itself (spontaneous vs. responsive). Also sexual attractiveness of the partner and to others, potential sexual problems in the partner and communication problems are important, just like body-image, the menstrual cycle and previous sexual relationships.

Physical examination of the genitalia is done in case of complaints about pain, history of ill-health, recent onset of loss of desire, approaching menopause, menstrual irregularity, abnormal puberty or if the patient believes a physical cause is most likely. The physiological reaction of the patient to the genital examination may give important information in addition to the direct results of the examination itself. Opportunities should be taken to explain details of the patient’s anatomy and physiology during the examination process. If during the examination the patient’s abdomen and thighs are kept covered by a draping sheet, she will be more ready to abduct her thighs widely, which is essential if the examination is to be comfortable and informative. With complaints of pain, the clinician should look for visible signs of lesions, and if these are not found, for a more generalised vulvar sensitivity. The next step is the vaginal examination, where a finger is introduced. The prospect of this may cause tension in the patient. In women with marked aversive response to examination, it can be carried out in steps on a number of occasions. The presence of deep pain warrants a full gynaecological assessment that may include laparoscopy (exploratory operation) or ultrasound. Possible pathologies include inflammations, retroversion of the uterus or vaginal vault scarring. Pain that occurs only during coital movement may be a sign of a vaginal infection.

In assessing erectile problems in the man, establish whether full erection can occur in any situation or at any stage during love-making. If so, at what stage does it start to fail? The man is also asked whether erections are painful or deformed in any way, and when the problems started, if this was suddenly or gradually, and if they also occur during masturbation or on other occasions when vaginal entry is not imminent (including morning erections). Premature ejaculation is a more difficult problem to specify, because it is a matter of how much control the man believes he has, and should have. He is asked if ejaculation occurs before or after vaginal entry, and how long after vaginal entry, when the problem started, how the partner reacts. He is also asked if he feels under pressure to delay ejaculation, how soon after PE he can become aroused again. Absent or delayed ejaculation also requires careful description. The man is asked if the problem only occurs in the presence of the partner, and whether the problem is only intra-vaginally (can he ejaculate normally during love play with the partner?). Some men with this problem also experience ‘wet dreams’. For the assessment of low sexual desire it is important to decide whether a loss of desire preceded or followed some other sexual dysfunction, such as ED. The man’s general health is also of importance, concern about sexual function is sometimes part of a general hypochondriacal pattern. In the case of pain, the pain should be precisely localised to find out what the cause may be.

Indication for physical examination in males is more or less the same as in women, but replace menopause with age over 50 and exclude menstrual irregularity. The examination can be carried out with the man either lying or standing. The size and consistency of the testes should be assessed. The shaft of the penis should be examined, feeling for plaques or scarring. The foreskin must be examined, checking if this can be fully retracted and if there is scarring. The area under the foreskin must be checked for infections. Pain accompanying ejaculation is cause for a rectal examination, which should be carried out with sensitivity and care. When erectile or ejaculatory function is impaired, neurological assessment of the pelvis and lower limbs may be indicated.

Checking urine for sugar should always be carried out for men with secondary erectile problems, to exclude the possibility of diabetes. Hormone tests can also be done in the laboratory. The assessment of erectile function starts with the measurement of NPT, to see whether erections do occur during REM sleep. If they don’t, this means there may be an ‘organic’ cause for ED. The possibility of psychometric assessment for the diagnosis of sexual dysfunction is being researched.

After the initial assessment, the clinician should start to present recommendations for a treatment plan. Sometimes, these are clear from the start; in other cases, the need for further assessments is required before recommendations can be confidently made. The clinician has to give adequate information about the content of the plan before asking the couple to decide whether to accept it. The three windows approach may be used to organise the findings during assessment. Along the way, grounds for use of pharmacological methods may arise.

The sexual problems encountered by same-sex couples are to a large extent similar to those in opposite sex relationships, and the treatment approaches, as outlined above, are equally appropriate. Obviously, there are likely to be some differences in the relevant factors, resulting from a different dynamic in the relationship.

What is problematic sexual behaviour?

One factor of particular relevance here is the tendency to be more sexual during negative mood states, as seen in previous chapters. These problems often lead to the pursuit of casual sex, with a range of potential negative consequences. The patient should be encouraged to examine and become familiar with the typical sequence of events: in what circumstances negative mood leads to out-of-control behaviour and what the stages are that intervene between awareness of the negative mood and enactment of the sexual behaviour. The therapist can help identify stages in the sequence which lend themselves to alternative and less problematic sequences. An alternative approach is pharmacological, especially the use of SSRIs. Both the effects on mood and on sexuality are relevant here.

What are sexual or gender identity problems?

When a patient expresses uncertainty about his sexual identity, it should be made clear that the therapist will accept and value any identity the patient may have, and that it may be necessary to explore more than one kind of relationship to resolve the problem. Also, it should be said that it will take time to work out what is right.

Practice questions CH.12

1. What are the most important different methods used over the course of history for the treatment of sexual problems?

2. What is the main objective of psychological treatment of sexual problems? What does therapy do to reach this goal?

3. What are the activities that belong to each stage in couple’s therapy?

4. What is an important requirement for someone wanting to go through individual therapy, rather than couple’s therapy?

5. What is one important problem in trying to define success when evaluation sex therapy?

6. How is a first assessment interview usually structured?

7. What requirements are there to decide whether a physical examination is necessary?

8. In what way is the treatment and assessment of same-sex couples similar to those in opposite sex relationships, and in what way do they differ?

What medical practice is common in sexual behaviour? - Chapter 13

Whilst it is probably true that the majority of sexual problems are not caused by medical conditions, there are few medical or surgical conditions that do not have sexual implications. A sexual problem may be the presenting symptom of an illness, or the medical problem may be linked to sexual activity (STD’s for example). In the recovery phase of most acute illnesses, there may be concern or anxiety about when to resume sexual activity and whether normal sexual function will be regained. The possible effects of a clinical condition on a patient’s sexuality can be summarised under the following headings: (1) the direct physical effects of the condition; (2) the psychological effects of the condition on the individual or the relationship; (3) the effects of treatment on sexuality. Of particular importance are those conditions that result in chronic physical handicap. Sexual repercussions, both from psychological and physical factors, occur in a large proportion of the handicapped population. Physical problems ranged from impairment of genital response to mechanical difficulties in adopting suitable positions for love-making, psychological reactions included fears about the consequences of sexual activity, loss of self-esteem and changes in the marriage. These patients need advice, reassurance and encouragement and good communication between themselves and their partner.

What is andrology?

When looking at penile problems, one example is Peyronie’s disease, which interferes with normal erection by causing a deformity of the erect penis, which can be embarrassing or painful, and sometimes interfering with ejaculation. The majority of cases resolve spontaneously, as the lesion that caused the problem heals. Priapism is a persistent erection that may be painful. It can be caused by too low, or too high blood flow through the penis.

Prostate disease is found mostly in men beyond their mid-40s, who often have an enlargement of the suburethral glands surrounding the prostatic part of the urethra. This may lead to a risk of infection due to incomplete emptying of the bladder. Surgical treatment of these problems may interfere with sexual function. Disturbance of ejaculation is usual in this case, resulting in retrograde ejaculation. ED is also very common.

Chronic pelvic pain syndrome (CPPS) is an extremely common problem among older men. It is manifested as chronic or recurring pain in the inguinal, testicular, retropubic or perineal regions, often worse during sexual activity. Painful and delayed ejaculation, pain during intercourse and ED may all occur. Other causes of pain may be painful retraction of a too tight foreskin, which may cause small tears in the frenulum during vigorous intercourse or masturbation. Another cause of pain is a deformity of the penis that causes bending or bowing during erection. Hypersensitivity of the glans following orgasm is also common.

Abnormalities of pelvic and penile blood flow may be a vascular cause for ED. Hypogonadism is associated with failure of T production (and sperm production). The commonest cause is Kleinfelter’s syndrome (XXY), which results in failure of testicular development in a proportion of cases. Other causes include trauma and infection. T deficiency as a result of this problem is associated with loss of sexual interest, impaired erectile response and ejaculation. T administration may resolve these problems.

What is gynaecology?

Vulvular vestibulitis syndrome is characterised by severe pain when the vestibule is touched or vaginal entry is attempted. Vulvodynia is a more persistent or intermittent burning pain not only resulting from tactile stimulation or pressure. It is thought to be caused by infections. These women are also often depressed and it is difficult to understand the causal relationship between the depression and the pain. Anti-depressants may work as treatment. Chronic pelvic pain can be associated with a variety of gynaecological or intra-abdominal pathologies and may be accentuated during intercourse.

Hysterectomy (removal of the uterus) is the most common major gynaecological operation, often done post-menopause. It could affect a woman’s sexuality because of damage to the autonomic nerve supply responsible for genital response, or the experience of orgasm may be altered due to damage to the pelvic floor muscles and suspensory ligaments. It can also lead to premature ovarian failure. However, the procedure is carried out on women suffering in some way and they may well be experiencing adverse sexual consequences pre-surgery. Vaginal repair is indicated when there is a degree of prolapse, by bladder or rectum, resulting from weakening of the pelvic supporting tissues. This happens mainly in older women who have borne children. Sexual functioning may be impaired resulting from undue narrowing of the vaginal introitus, shortening of the vagina or the presence of tender scar tissue.

The four most common malignancies of the genital tract are carcinoma of the endometrium, ovary, cervix and vulva. Treatment of these carcinoma often involve removing important organs for hormone regulation, such as the ovaries. This has predictable effects on sexuality.

Breast cancer is the most common form of malignancy in women, with one in eight women developing it at some stage in their life. Radical mastectomy has been the most common procedure in the past, but increasingly, breast-sparing procedures combined with radiotherapy or chemotherapy is being used as an alternative. Mastectomy has negative effects on body image, well-being and sexual function.

What is done in psychiatry?

Depression remains an important issue in sexual difficulties, loss of sexual interest was reported by 61% of severe depressives, compared with 27% non-depressed controls, in one study. Even past depressive illness may be an indicator for low sexual desire, but the initial depressive episode often coincided with the onset of loss of desire, a sign of an irreversible impact of depressive illness on sexuality. Whether this effect is one directly of depression on sexuality, or more of depression on the relationships is not yet clear. Higher rates of sexual dysfunction were also found in men and women with anxiety disorders. In women, we see mainly loss of sexual desire, while in men premature ejaculation is most common. In men, as described before, the association between negative mood (esp. anxiety) and sexuality is not always in the same direction. Sexual interest and activity are often increased in states of mania or hypomania.

There has been very little research on the impact of schizophrenia on sexuality. One study found that some patients already experienced problems associated with relationships before the real onset of the disease, though the majority had normal relationships. Over the course of their illness, many remained unmarried, some married, but many of those got divorced. Sexual dysfunction is more common in women with schizophrenia than men, but less common in general than in other types of psychiatric illness. The psychotic phenomena of schizophrenia in many cases have a sexual context or involve the genitalia. Sexual side effects of medication is also common in this group.

People with learning disability are believed to show uncontrolled or inappropriate sexual behaviour, leading to sexual offences in males and promiscuity in females. The limited available evidence suggests that those with LD are somewhat less sexually active than those with more normal intelligence and that the greater the degree of handicap, the less sexual they are likely to be. Their proneness to get involved in sexual offences may be due to their tendency to relate to people of similar mental age, leading to them sexually approaching children. Because institutions are often over-protective, these individuals often have few opportunities to explore and learn about close personal relationships with members of the opposite sex. Sex education should be given in a clear and adapted way. Children of LD couples often have IQ’s closer to the mean than that of their parents.

What is done in general medicine?

Diabetes mellitus (DM), or type I diabetes, is a state of chronic hyperglycaemia due to inadequate insulin activity. Type II diabetes has a later onset and is often associated with overweight. Diabetic men often suffer from ED, with an increasing prevalence of erectile failure with increasing duration of the diabetes. In some cases erectile failure is an early sign of other vascular or neurological damage.

The first sign of diabetic ED is usually a decline in either the strength or the duration of erection, this then becomes more consistent and severe as time goes on. Changes in the pattern of ejaculation are also common with diabetes. Usually, these men show impaired sleep erections (NPT), not necessarily accompanied by erectile failure. There is evidence of both autonomic and peripheral nerve damage in diabetic men with erectile failure, and also of narrowing or obstruction of the arterial supply to the erectile tissues. Diabetic men also have lower levels of T, but it is not certain to what extent this is due to diabetes, or due to older age. The presence of small vessel disease in the retina, caused by DM, is associated with reduction of pulse amplitude in the penis, but the relevance of this pulse amplitude to erection is not certain.

Sildenafil (PDE-5 inhibitor) has been shown to improve erections in men with ED and DM. Alternative options can be intracavernosal injections or vacuum devices.

In women, almost no attention was paid to sexual problems associated with diabetes, until one study found a higher incidence of orgasmic dysfunction in these women. However, this diagnosis may only be given when a woman becomes sufficiently aroused, but is unable to reach orgasm, and these criteria were not met in the study. Other studies found some evidence for inhibited sexual excitement and vaginal dryness. It seems these problems, along with negative body image, dissatisfaction with sex life, pain, and orgasmic problems, are more common in women with diabetes type II than women with diabetes type I. Because type II usually develops later in life, it is possible that stage of the life cycle and the relationship may be more important in relation to sexual function than the diabetic process itself, at least in women.

Diabetic women are also more vulnerable to vaginal infections, if their diabetes is not well controlled. Regarding pregnancy, fertility is impaired and there is a higher chance of miscarriage, premature birth and intrauterine death. Steroidal contraceptives may disturb the diabetic control, so this may cause problems too.

Cardiovascular disease usually results from a combination of narrowing of the arteries and raised blood pressure. Sometimes the arterial disease is confined to the heart, in other cases the main effects are in more peripheral vessels. Erectile failure may be an early manifestation of arterial disease, and the vessels supplying the penis may be especially vulnerable, possibly because they undergo frequent straightening and convoluting as erections come and go.

Men with ischaemic heart disease (IHD) have up to four times as much chance of developing ED. In women, probably the most direct effect of IHD we can see is impaired vaginal lubrication. Those who suffered heart attacks have more sexual problems than those who have only suffered from angina (chest pains), possibly because the experience of a heart attack increases fear of death from a further infarction. This also explains any reaction of the partner: the prospect of one’s spouse dying during love-making is horrifying. At the moment, there is no reason to believe that hypertension per se impairs erectile function or genital response in women, the effects of hypertension on sexual function are not certain. It is possible that psychological factors play a role (the fear of raising blood pressure to dangerous level during sexual activity).

For middle aged men, there is some suggestion that regular sexual activity may reduce the likelihood of a fatal heart attack. Advising women with cardiovascular disease has received little attention, but we can assume that the guidelines for men are also relevant to women. Blood pressure and heart rate are lower during sexual activity than during modest physical activity, but higher when the sexual act has stressful circumstances (extramarital encounters). It is sensible to avoid more athletic sexual performances. But in general, if climbing two flights of stairs or a short brisk walk can be managed without difficulty, sexual activity of a calm, non-athletic kind should be equally manageable.

What is done in neurology?

A link between epilepsy and sexuality has always been thought to exist. In earlier days, masturbation was seen as a cause of epilepsy and the similarity between orgasm and an epileptic seizure has often received comment. In modern medicine, the sexual implications of epilepsy are threefold: (1) the sexual manifestations of epileptic seizures: erection, ejaculation or orgasm can occur as part of a seizure; (2) the provocation of a seizure by sexual activity; and (3) the sexuality of epileptic individuals in between their seizures: many epileptic men and women report sexual problems.

Patients with temporal lobe epilepsy often have ‘hyposexuality’, a lack of interest in intercourse and a lack of sexual curiosity, erotic fantasies or sensual dreams, and often inability to achieve orgasm. Occasionally however, we see a case of hypersexuality, usually episodic and manifested as excessive masturbation. Children with epilepsy are more likely to lack self-confidence, fear rejection or failure, and fear the effects of sexual excitement because of its similarity to epileptic phenomena. Excessive neuronal activity in some parts of the temporal lobe may lead directly to a suppression of sexual behaviour too. There is some evidence of improvement in hyposexuality as fits are brought under control. Epilepsy medicine may also influence hormone levels by reducing T.

In multiple sclerosis (MS), the basic lesion is demyelination of nerve fibres and most commonly starts in the 20s or 30s. Sexual problems are common in MS patients, stemming from consequences of physical handicap and the strains that these impose on sexual relationships. MS sufferers are also more prone to anxiety and depression, taking its toll on sexual happiness. When the nerves in the spinal pathway are affected, this may lead to failure of genital responses. Anorgasmia in MS correlated significantly with brain stem and pyramidal abnormalities, and with the total area of lesions or plaques observed on the MRI.

Parkinson’s disease is a progressive degenerative disease of the central nervous system, common in those beyond middle age. It specifically involves degeneration of the substantia nigra, in the mid brain, and its dopaminergic connection with the striatum of the basal ganglia. Sexual problems are common in men and women, mostly in arousal, orgasm, sexual desire, ED, premature ejaculation and retarded ejaculation. Muscle rigidity may be a direct cause for most of these symptoms, together with psychological reactions to the disease. Sometimes treatment with L-dopa leads to normalisation of sexuality.

Spinal cord injuries (SCI) result most commonly from traffic accidents and mostly affect men. Lesions low in the spinal cord result in paralysis and loss of sensation in the lower limbs, higher up they may lead to paralysis and loss of sensation in all four limbs. In many men, reflexive erections occur in reaction to (visual) stimuli, even though the man is not able to feel the response. Ejaculatory capacity tends to be more impaired, usually absent unless with some incomplete lesions. Many men do describe orgasmic experiences without necessarily ejaculating. A heightening of erotic sensitivity in areas above the lesion is not unusual.

It seems that women with spinal injuries have less affected sexuality than men. Some even mention experiencing orgasm, though different from their pre-injury experiences. Orgasm is significantly less likely in women with SCI, and if possible, it takes longer to reach orgasm. Fertility is relatively unaffected, and menstruation usually resumes within 6 months of the injury. Women with SCI may even experience menstrual pain. Pregnancy is possible and normal delivery is too, although with a risk of urinary infection, anaemia and premature labour. For the male however, fertility is much less likely, as few ejaculate and spermatogenesis is not always normal.

What are the sexual side effects of medication?

Sexual side effects are of fundamental clinical importance as they may determine whether patients continue to take their medication. A challenge is the distinction between an effect of a drug and a symptom of the condition treated by the drug. The likelihood of a drug-induced sexual effect depends on several factors: (1) the proportion of people taking the drug who are affected in this way: the higher the proportion, the more likely the drug is responsible; (2) the specificity of the observed effect: if a discrete mechanism is affected, a drug effect is more likely; and (3) whether there is a pharmacological basis for the suspected drug effect.

People who take medication for hypertension show significantly more ejaculatory problems than people with hypertension who aren’t treated. ED is seen both in treated and untreated people, so it isn’t certain whether this is caused by hypertension in itself, or by the medicine. Both men and women on a weight-losing diet experienced minimal sexual side effects on the medicine, as compared to people with normal diet or low salt diet. Women sometimes experience loss of libido. Different drugs for hypertension may have different side effects.

Drugs used to influence psychological states (psychotropic drugs) are difficult to evaluate from the sexual point of view. Benzodiazepines are the most commonly used tranquillizers and hypnotics and they have inconsistent effects on sexual function. Delayed orgasm has been found in women. Of anti-depressants, there are two types: tricyclics and selective serotonin re-uptake inhibitors (SSRIs). Sexual side effects are commonly reported with both types. One side effect stands out: delayed ejaculation or orgasm in both men and women, an effect more evident in SSRIs than tricyclics. What is puzzling is why this effect on orgasm is so much more predictable than inhibition of erection or other components of genital response. In anti-psychotics, dopamine antagonism is the key factor, but works on the same system that is involved in sexual behaviour. Here, ED and ejaculatory dysfunction in men, and orgasmic dysfunction in women, were significantly more prevalent.

Other drugs that may affect sexuality are anti-convulsants, causing mostly problems with lack of interest amongst epileptics. Another drug is cimetidine, an H2 receptor antagonist widely used for the treatment of peptic ulceration, of which there are several reports of sexual side effects.

What are the sexual aspects of alcohol and drug addiction?

It is widely believed that alcohol enhances sexual pleasure or at least reduces sexual inhibitions. Evidence shows that alcohol in the blood suppresses erection and delays ejaculation. Women show the same effects: suppression of vaginal blood flow and delayed orgasm. However, men who think they have been given alcohol expect a certain reaction, and they show greater erectile response and subjective arousal. These expectancy effects are less evident in women, but actual increasing blood levels of alcohol are associated with more subjective arousal in women, but lower vaginal blood flow, as mentioned above. As a result of alcohol, attention is focused on positive, sexually arousing or rewarding aspects of the situation and turned away from appraisal of negative consequences, leading to more sexual risk taking.

The relationship between chronic alcoholism and sexuality is complex. In some cases, alcohol is used to cope with socio-sexual anxieties in people already prone to develop sexual problems for personality reasons. However, the consequences of alcoholism on sexual relationships and marriage are likely to be considerable. These conflicts may then worsen the drinking pattern. Alcohol abuse may have negative effects on testicular function, possibly leading to hypogonadism, or ovarian atrophy in women. Alcohol tolerance does not protect against negative effects like erectile failure at high blood levels of alcohol. Alcoholics are more likely to lose erections during intercourse, but did not differ from controls in other measures of sexual function. Alcoholism does not cause irreversible damage to sexual function in men.

Drugs of addiction have very varied effects, but are difficult to do controlled research on because of their illegal status. Opiates like morphine and heroin cause a reduction in sexual interest and response, while the ‘rush’ caused by the drug increases pleasure of orgasm. In women, infertility is common. Cocaine is a powerful re-uptake inhibitor of DA and seems to have positive sexual effects with early use, but negative effects with chronic use, indicating some degree of tolerance. Marijuana is commonly regarded as a sexually enhancing drug, as shown by the early onset of sexual activity amongst young people. However, this may just reflect a more liberal attitude rather than a causal link between the two. Increased enjoyment during intercourse while under the influence of marijuana is often reported. There is a relatively high incidence of erectile problems in men using marijuana on a daily basis. Amphetamine is sexually enhancing, but it is not clear whether this is due to a specific DA effect or a less specific activation effect.

Practice questions CH.13

1. In what way can a sexual problem be related to medical illness?

2. In men, what medical issues most often cause sexual problems?

3. In women, what medical issues most often cause sexual problems?

4. What psychiatric issues most often cause sexual problems?

5. What general medicinal issues most often cause sexual problems?

6. What neurologic issues most often cause sexual problems?

7. What medication most often cause sexual problems, due to side effects?

8. Which drugs of addiction most often cause sexual problems?

What are sexually transmitted infections and the HIV/AIDS pandemic? - Chapter 14

What is the historical background of venereal disease?

At the end of the 15^th century, syphilis appeared in Europe, leading to a pandemic during the 16^th century. Times of war have been particularly associated with transmission of venereal disease, resulting from the separation of young men from their wives, and the chaos of war. Scientific understanding of sexually transmitted infections (STIs) started in the late 19^th century, when it was discovered that micro-organisms caused infectious diseases. The big breakthrough in treatment happened with the introduction of penicillin in 1944. Long before this, people believed STIs were God’s punishment for the sinner. This stigma led to victims being excluded or separated. The attitude was that information about sex should not be given to the general public, as this might ‘put ideas in their heads’. Women, especially prostitutes, were mostly blamed for venereal disease.

The story of HIV and AIDS started in 1981, when the first indications were seen of what turned out to be a worldwide pandemic, many people had already become infected before 1980. It was initially regarded as a ‘gay disease’, echoing earlier attitudes that STIs where God’s punishment for sin.

What is the nature of sexually transmitted infections and associated diseases?

A wide variety of pathogens can be transmitted by sexual activity, the most important being bacteria (gonorrhoea, syphilis, chlamydia), parasites, fungi, and viruses (herpes, genital warts, hepatitis B, HIV/AIDS). HIV is the least contagious, but once transmitted, potentially the most serious. Viral infections are much less treatable than the others. The non-HIV infections all have a tendency to increase vulnerability to HIV transmission, while the effect HIV has on the immune system makes one more vulnerable to other infections, including STIs. Women are often more susceptible than men to genital and urethral infections, due to the anatomy of their genitals.

In women, a bacterial infection may lead to vaginal discharge with an unpleasant odour, burning during urination or itching of the vulva. Often this kind of infection is not caused by sexual transmission, but is kept going by being passed back and forth between partners. More serious is pelvic inflammatory disease (PID): the infection spreads internally and affects the reproductive organs. This can eventually lead to infertility. In men, we often see no symptoms, but the most frequent ones are urethral discharge and burning during urination. This may eventually also lead to infertility.

What bacterial infections in sexology are there?

Gonorrhoea is caused by the gonococcus bacteria, typically transferred sexually. In women infection is initially in the cervical canal or urethra. PID occurs in up to 5% of cases, often leading to infertility. In men, the infection is often more obvious, but has less serious consequences than in women. Treatment is quite possible with antibiotics. Syphilis can affect the cardiovascular and central nervous systems. It starts with a single skin lesion, then a rash, fever, sore throat, headaches, weight loss, muscle aches and fatigue. These symptoms may go away, but the infection may persist for years and may lead to heart problems, dementia, possibly even death. During the first year it can well be treated with antibiotics. Chlamydia is the most common STI in the Western world, it often does not have symptoms, but may lead to infertility due to PID. Chancroid is a genital ulcer that responds to appropriate antibiotic treatment.

What other type of infections do exist?

Trichomonas is a parasite that causes a painful vaginitis and frothy discharge, although in many cases it shows no symptoms at all. In men, we often see no symptoms at all. Candida albicans are commonly present in the vagina and become a problem when normal flora is suppressed by antibiotics. These infections are more common in diabetics, obese, pregnant and immune-suppressed women. Also known as ‘thrush’, the main symptom is intense burning or itching. This infection is a fungal infection. Genital herpes has two types, type 1 is common around the mouth, causing sores. Type 2 causes genital herpes, which may be very painful and is very difficult to treat. It lies dormant and breaks out from time to time. The virus has been implicated as a possible causative factor in cervical cancer. Human papilloma virus has more than 100 different kinds, some are associated with cervical cancer. The main symptom is ano-genital warts. The hepatitis B virus varies in its effects, some people have no symptoms but can still infect others. Others have an acute episode of hepatitis that then resolves, and others end up with chronic liver disease, which can be fatal. These infections are viral infections.

HIV is complex. It binds to receptors on T-helper cells and other cells involved in immune reactivity of the skin and mucous membranes, as well as cells in the brain that are crucial to the immune system in the central nervous system. Hence, most manifestations of HIV infection are consequences of resulting defects of the immune system. Infection results from exchange of bodily fluids, in particular blood. Once infected, people experience flu-like symptoms after 2-6 weeks, sometimes with rash on the face and trunk. This lasts a week or two, and is followed by the symptom-free latency period. The progression to AIDS is marked often by respiratory infections, tuberculosis and direct damage of the nervous system, resulting in dementia and loss of control of the body and bodily functions. Death follows within 2 years. Some drugs can slow the advance of the virus, but they have severe side effects. HIV is also e viral infection.

What is the prevalence of sexually transmitted infections in community surveys?

Around 15-17% of men and women report at least one lifetime STI, men fewer than women. African Americans had more bacterial, but fewer viral STIs. The strongest predictor for both kinds of STI was number of life time sexual partners. African Americans have substantially higher rates of STIs than other ethnic and racial groups in the USA. Hispanics reported higher rates than whites. Higher rates were related to relative poverty, limited access to health care, drug use and living in high STI prevalence communities. Strong predictors for STI infection in men are at least one new partner in the past year, the number of partners in the past year, and the number with whom no condom had been used. For women, the number of sexual partners and the number with whom no condom was used were the strongest predictors.

What was the HIV/AIDS pandemic?

HIV/AIDS has become the fourth most frequent cause of death in the world, and is most frequent in sub-Saharan Africa. An estimated 60 million men, women and children have become infected worldwide. By the time the UN saw there was a need for action, ARV treatments were still too expensive. Many political leaders in Africa were still in total denial, delaying the establishment of effective programs. An important campaign, PEPFAR, by George W. Bush, was structured around moral values (abstinence until marriage, restricted promotion of condom use), rather than scientifically-based principles of prevention.

Married women in South Africa are most likely to be HIV-positive, quite often their husbands are reluctant to use condoms, and because they are often away for work for long periods of time, this may lead to a polygamous lifestyle in the men. Women are also seen as their husband’s property and are not very independent of their partners. For these women, the abstinence that is often promoted is of no use. In the Western world, women are much more able to stray from their traditional social roles in the area of sexuality, especially with higher social status.

What prevention programmes for HIV/AIDS exist?

So far, progress has been modest, but in Uganda and Thailand we have seen more substantial improvement. In Uganda, the objectives were an educational campaign, checking blood before transfusion and establishing a careful case surveillance process. A strength in this programme was a continued and increasing political commitment by both the government and the president. The emphasis was on monogamy, delaying onset of sexual activity and condom use. Condom use increased significantly, casual partners decreased, and sexual debut was delayed by 1 or 2 years. It’s important to keep in mind that knowledge is not enough, people will continue to deny their own danger of becoming infected.

The programme in Uganda can be seen as an example of the ABC approach (Abstinence, Be faithful, use Condoms). Delaying sexual debut is mainly based on evidence that shows a link between early onset of sexual activity and later sexual risk taking. Be faithful means people should at least try for serial monogamy. However, the religious often argue that condom promotion may entice young people to become sexually active for the first time. It’s important that messages suitable for the West should not be stamped into African settings without consideration of indigenous culture, and that prevention messages are focused for specific audiences.

The individual approach is based on how an individual assimilates information about risk, risks are taken by not correctly evaluating this information. This led to the study of various defining individual characteristics to see to what extent they were predictive of risk taking. These included cultural group, socio-economic status, age, alcohol and drug use, knowledge of health guidelines, perceived threat and peer support. The relation-based approach focuses on the interactive behaviour between the partners in a sexual interaction and the meanings attributed to such behaviour. This involves ideas about the nature of a woman’s social status, relationship characteristics at first sexual contact, the balance of power or a threatened breakup of the relationship.

Condom use has always been controversial, especially in religious circles, as mentioned above. Another problem is that condoms can interfere with sexual pleasure, in either or both partners. The question of prevalence of condom use is not easily answered, due to methodological difficulties in keeping track. It seems young males, blacks, the unmarried, those living in cities and those reporting more lifetime sexual partners seem to have made more changes in their sex life to protect themselves from AIDS infection. Increased condom use was also found in the early 1990s, especially in those with high risk partners.

Predictors of male condom use were not found to be related to knowledge of the risks involved. However, the nature of the sexual relationship involved was relevant, as is perception of one’s partner’s attitude towards condoms, and the ability and preparedness of two people in a relationship to discuss whether to use condoms. This last was more predictive than their ability to discuss HIV risk. Another strong predictor was the use of a condom during the first occasion of sexual intercourse, particularly for women. Attitudes toward condom use are also important predictors. Sexual arousal during an encounter is negatively associated with condom use, while intention to use condoms immediately before the encounter and communication with the partner about condom use were positively associated with condom use. Many people only use condoms when ejaculation is expected, and not all the time, because of the negative effect condoms can have on sensitivity and maintaining the erection. Lack of confidence in one’s erectile function may undermine one’s determination or ability to use a condom. A possible solution could be the use of female condoms.

In a group of HIV-positive gay males, high-risk sexual behaviour was predicted by young age, less education, less distress and greater feelings of mastery, less use of active coping strategies and heavier use of alcohol. More erectile problems were found in HIV-positive gay men, but whether this is a consequence of their sero-status of its treatment, or a cause of it (because of its associated increased risk taking in condom use) is not clear.

Male circumcision was initially used as a means to ‘cure’ masturbation, but the current controversy is about whether circumcision reduces the likelihood of HIV infection. It was proposed that it could be protective against infection, because the Langerhans cells in the inner lining of the foreskin provide an entry for HIV into the body. Whatever the reason, the evidence that circumcision does protect against HIV-infection is becoming persuasive, it seems to protect mostly HIV-negative men from infection by HIV-positive women. However, just circumcision is not sufficient to prevent HIV, it merely reduces the chance of infection.

What is the role of the ‘individual differences’ component in sexual risk taking?

Situational factors, many of which reflect the socio-cultural context, are clearly important. Aspects of the personality, on the other hand, could account for the fact that, in the same type of situation, individuals differ in how they respond. Whether someone takes a risk depends on risk appraisal (how much risk does a situation involve?) and risk management (how is the risk actually dealt with when the time comes?). Appraisal can be influenced by cultural norms and personal beliefs and attitudes. Personality factors may also be relevant here. Appraisal may however result in misperception of risk. No one performs a given behaviour unless the advantages are seen to outweigh the disadvantages. By risk management, we mean the implementation of this trade-off process and how it is affected by the state of mind at the time (which is not necessarily rational).

In a state of sexual arousal, normal ‘rational’ decision making is impaired. The need for orgasmic release largely determines how the situation is handled. HIV prevention efforts should take this into account. But if sexual arousal can have this effect on sexual risk management, how does anyone avoid sexual risk? In heterosexual men, the trait of sexual inhibition was strongly predictive of the number of partners in the past 3 years with whom no condoms were used. Sexual excitation was not predictive, pointing to the importance of inhibition in limiting sexual risk taking. In gay men, the same was found, though also that the tendency to lose one’s erection influenced a man’s risk management adversely. In women, higher propensity for sexual inhibition is also predictive for less sexual risk taking. Some people experience that sexual arousal makes it more likely for them to take risks, others recognise this and plan ahead (always have a condom with them), others feel like sexual arousal does not affect their risk management. A good way for men to assess their potential behaviour is to ask themselves how they will feel after they ejaculate. Some men, after taking a risk, report instantly regretting their actions after they ejaculate (and so are no longer aroused).

Bearing in mind the fact that sexual interest and responsiveness are reduced in states of negative mood, one would expect less sexual risk taking in negative mood states. However, no support for this hypothesis was found, negative affect could have different effects on sexual risk taking in different people. It was found that state-positive affect had a negative association with sexual risk taking, but neither state- nor trait-negative affect had any association with sexual risk taking. Also, those who are likely to be less aroused in the face of risk find it easier to assert safer sex. Confidence in one’s capacity for sexual response, particularly in a low-risk situation, is necessary for a clear determination to practice safer sex, especially condom use.

Personality characteristics are after all regarded as less important than situational factors in HIV prevention, mainly because they reflect genetic determinants and early learning, and are therefore not easy to change. However, it remains important to research individual differences, as this knowledge may help awareness of the influence these factors have on the prevention programmes, and because prevention messages can be better tailored to the individual. It may also help in identifying those young people who are likely to engage in high-risk sexual behaviour later, if they are not yet doing so now.

What is the impact of HIV/AIDS on sexual behaviour?

With the rise of the HIV/AIDS epidemic, many gay men showed substantial reductions in casual sexual contacts, whereas men in monogamous relationships showed little change in sexual behaviour within their relationships. Certain forms of sexual activity were also reduced, especially the oral or anal ingestion of semen, anal genital sex and oral-anal sex. We should, in any case, expect relevant individual differences in how people, heterosexual or homosexual, react to the threat of HIV/AIDS, and how they interpret the availability of treatment in relation to the need for safer sexual behaviour.

Practice questions CH.14

1. When did science start to understand STIs? What was the first effective form of treatment?

2. When and how did the story of HIV and AIDS start?

3. What are the most important pathogens that can be transmitted by sexual activity?

4. What are examples of the pathogens from question 3?

5. What is the prevalence of STI? And what is the strongest predictor?

6. What is the difference between the individual approach to risk taking and the relation-based approach?

7. What effect can circumcision have on the chance of infection with HIV?

8. What do risk appraisal and risk management mean?

9. What effect can sexual arousal have on sexual risk taking? Which personality-factor is important in predicting this?

What are fertility, fertility control and infertility? - Chapter 15

There is a fundamental need to understand the sexual implications and consequences of fertility regulation. Not much attention has gone to researching these consequences. In this chapter, we will discuss fertility control in the form of contraception, sterilisation and induced abortion. We will also consider the sexual aspects of infertility and pregnancy.

How is pregnancy during the post-partum period?

Pregnancy is physiologically different because of the impact of the placenta, which produces large amounts of reproductive hormones and is not under normal feedback control. We usually see a decline in sexual activity and interest during the third trimester of pregnancy. In the first and second trimester we see more variability, just like in the post-partum period. Nearly all women resume sexual intercourse by the 12^th week post-partum.

A factor that may be of influence on sexuality during pregnancy and post-partum can be concerns about harming the foetus. It seems women who have a tendency to abort towards the end of the first trimester should indeed avoid orgasm until that phase has passed. Several other complications, like cervical incompetence, bleeding or the threat of premature labour, may be cause to avoid orgasm and sexual intercourse during the second and third trimester. Pregnancy can also positively or negatively affect intimacy in the relationship, and post-partum is definitely a challenging time, with many adjustments required. An important factor influencing the quality of the post-partum experience is pain, especially in women who have had an episiotomy to prevent uncontrolled tearing during delivery. Mood change, starting around day 5 post-partum and lasting for 12-14 days, is very common and is called ‘post-partum blues’. Clinically more significant is post-natal depression, starting around the fourth week post-partum and occurring in 10-15% of women. It can have negative effects on the evolving mother-infant relationship and can cause low sexual interest.

Mothers vary substantially in the period of time they continue breastfeeding, but a typical duration is about 6 months. Breastfeeding mothers are less sexually active and have less sexual interest than bottle-feeding mothers, because she likely has ovarian suppression, raised prolactin levels and relative oestrogen deficiency. The raised prolactin may be directly associated with reduced sexual interest and the low E with lack of vaginal lubrication. The emotional involvement of the mother in the breastfeeding process may also be at the expense of her usual level of involvement and intimacy with her partner.

How to control fertility with contraception?

Female sterilisation and intrauterine devices (IUDs) are more frequently used in the developing world, and oral contraceptives and condoms more in the developed world. However, fertility control is a long way from being sufficient; around 46 million unwanted pregnancies are terminated each year, about 20 million carried out in unsafe conditions.

Of considerable importance is the morality of contraception. The Catholic Church in particular deems any artificial method of avoiding conception to be immoral. However, in the face of changing modern attitudes, an increasing number of Catholics are rejecting this particular part of the Church’s teaching. Yet still, the idea that sex is only acceptable as a means of reproduction is still fostered by such religious beliefs and goes deep in many individuals. Problems may also reflect difficulties in male/female relationships, conflict may lead to reluctance in one of the partners to take responsibility. Any method of contraception that substantially alters the enjoyment or interest of the user may cause repercussions in the sexual relationship, this can be both positive or negative. A woman may enjoy sex more if she knows she is safe from unwanted pregnancy.

Oral contraception became available in the 1960s and from the 1970s there was an increased interest in surgical methods of sterilisation. Since the late 1980s, as a result of the HIV/AIDS pandemic, there is an increased attention to the use of condoms. Single women are nearly twice as likely to use oral contraception as married or co-habiting women. Number of partners is predictive of contraceptive use, but more so in men than women. Use of contraception decreases with age. Three stages of birth control behaviour are suggested: the ‘natural stage’ when no contraceptives are used, the ‘peer stage’, when methods learned from peers are used, and the ‘expert stage’, when experts or professionals are consulted. Parent-child and peer group influences are important to contraceptive use. The peer group impact that is relevant requires an understanding of normal fertility and how this relates to the menstrual cycle. More attention has been paid recently to fostering responsibility for contraception in the adolescent male, and this may be having some effect. Parental attitudes are highly significant here.

What is hormonal contraception?

Oral contraceptives are of three main types: combined, sequential and progestagen only. Combined pills contain both E and progestagen and are taken for 21 days, followed by 7 pill-free days during which a monthly withdrawal bleed occurs. The sequential pill often has a fixed dose of E, combined with a low dose of progestagen for the first 7 days, a slightly higher dose for the next 7 days and the highest dose for the last 7 days. Again, there are then 7 pill-free days. The main effect is suppressing of ovulation. Injected forms of contraceptives have mainly contained progestagen only.

Oral contraceptives may reduce libido as a consequence of dyspareunia caused by lowered oestradiol and impaired vaginal lubrication, or more directly by lowering testosterone. The issue of negative effects of OCs on the sexuality of women is complex, which may account for the prevailing tendency therefore to dismiss it as unimportant. However, discontinuation of oral contraception is common. In IUD users, breakthrough bleeding was the most common reason for discontinuation. When asked for reasons to discontinue with OCs, women cite reasons including physical side effects, emotional side effects, bleeding problems, end of the relationship and sexual side effects. However, when looking at which side effects are predictors of discontinuation, the frequency of sexual thoughts, sexual arousability and the emotional side effects were the only ones.

One study found that the pill appears to be having a direct effect on sexuality, independently of its effects on mood. Pill-using women were less likely to report either highs or lows, and are more likely to report high sexual interest either during menstruation or the week before. Sexuality and mood are closely related to each other. Another study found that women with higher levels of pre-menstrual irritability show more negative mood change when low progestagen dosage is administered, while women with little or no pre-menstrual irritability show more negative mood change with the low progestagen dosage. Negative effects on sexuality were infrequent and possibly secondary to negative mood changes. It seems those women already experiencing pre-menstrual mood change, experience more lowering of mood when they’re on triphasic oral anticonception, than if they’re on the combination pill.

More attention has been paid to the effects of OCs on mood than on sexuality. Mood change, though not sufficient to be diagnosed as a depressive illness, is still relevant to quality of life, and has an impact on sexual interest and response as well as discontinuation of the OCs. Literature suggests a variable impact of OCs on mood: some women experience improved mood, some worse mood and the majority no change. For pre-menstrual mood, we see the same variability. However, just because we often see worsening of mood and reduction of sexual interest in users of OCs, it does not mean that one causes the other. Reduction of sexual interest has also been found when no worsening of mood was evident.

Regarding testosterone, a predictable association between T level and sexual interest in women has so far only been observed in women on OCs, whose T levels are in the lower part of the physiological range. It is possible that once a sexual problem becomes established in a woman, with all of the interpersonal and intrapersonal repercussions that tend to result, the subtle relationship between T and sexual interest becomes obscured. There is also, as has previously been established, a considerable variation among women in their behavioural responsiveness to T.

With all these studies, we have to keep in mind that minimal group changes in either sexuality or mood measures often conceal a considerable variability. There is sufficient evidence across studies of significant proportions of women who show either positive or negative changes in these regards after starting on OCs. It is possible that there is a direct effect of OC-induced negative mood on sexuality, where some women are more likely to experience reduced sexual interest in negative mood states. There is also a possibility that a substantial minority of women are dependent sexually on T and experience negative changes because of the OC-induced reduction in T.

What are long-acting reversible methods?

Intrauterine devices (IUDs) have become smaller over the past years. The copper device works by impairing sperm function and preventing fertilisation. Another IUD releases the hormone LN (levonorgestrel) and works in a number of ways, localised to the reproductive tract: thickening the cervical mucus, inhibiting sperm capacitation and survival, and suppressing the endometrium. The amount of LN released daily is about 10% that of an OC. Another option is systemic long-acting use of progestogens by implant or injection, this way progestogen inhibits ovulation. A higher rate of discontinuation in hormonal IUDs was found because of depression, this may be the case for some vulnerable women. With one of the implants, Implanon, 11% of women reported mood changes associated with the implant (emotional lability and loss of libido), and in 9% these were severe enough to require removal.

What is hormonal contraception in the male?

The possibility of using reversible hormonal methods to suppress fertility in men has been receiving attention in the past decade. The most feasible way to do this is to suppress spermatogenesis by inhibiting LH and FSH, but this is not possible without also suppressing T production. This is very likely to have an adverse effect on the man’s sexuality. The problem is also the uncertainty about the predictability of suppression of spermatogenesis. In the female, you either suppress ovulation in a cycle or you do not. With spermatogenesis, it is a question of how much the sperm count has to be lowered to ensure infertility.

Male condoms have been considered closely previously. For women, the two main barrier methods are the diaphragm and the female condom. Both require careful application to achieve effectiveness. The failure rate with ‘perfect use’ is 6% for the diaphragm and 5% for the female condom.

What are natural methods to control fertility?

The ovulation method involves taking a daily temperature and identifying the day of ovulation by the rise in temperature, or the woman learning to observe the nature of her cervical mucus and, by this means, to recognise when she is getting close to ovulation. Intercourse is then avoided until the safe period is reached. With ‘perfect use’ of this method, the failure rate has been estimated as 3.2%. The infertility associated with breastfeeding is probably the most natural method of birth spacing. It is not fool proof, but reduction of breastfeeding and increased use of artificial methods of feeding have led to reduced birth intervals in many parts of the world.

What is the process of sterilisation?

Surgical methods of contraceptive sterilisation are by now well established. In the female, various techniques are used to cut or obstruct the fallopian tubes, most frequently by laparoscopy. In the male, vasectomy is normally carried out under local anaesthetic and is a relatively simple and quick surgical procedure. There is a predominance of male sterilisation in the UK, New Zealand, The Netherlands and Bhutan, but in most parts of the world, female sterilisation is more common than male, particularly in developing countries. Socio-economic factors are relevant: vasectomy is more likely to be chosen by men from higher socio-economic groups or higher education groups. Female sterilisation requires a full anaesthetic and is substantially more expensive than the male method. The chances of reversal are small with both procedures, but somewhat greater and surgically less demanding in the male. The fact that despite that, women still have more sterilisations than men all over the world is probably due to the tendency to see the woman as responsible for fertility and its regulation, and to attach less importance to the sexual wellbeing of the woman compared to the man.

The number of women who regret being sterilised has been small. One of the most obvious reasons for regret is marital breakdown and the wish for further children with a new partner. There is no reason to believe that female sterilisation procedures have any direct effect on sexual function. Adverse effects are more likely to stem from psychological reactions to the sterilisation, either in the woman or her spouse. Improvement or no changes in the sexual relationship are a lot more common than deterioration.

Evidence about the effects of vasectomy on men’s sexuality has been reassuring, also with a lot more improvement or lack of change in the sexual relationship than deterioration. Principal reasons for men to seek vasectomy are prevention of further pregnancies because of completed family size and protection of the wife from the health hazards of other contraceptive methods, from the dangers of childbearing or from the fears of pregnancy. Some men indicate that they are hoping for an improvement in their sex life.

What is induced abortion?

During the 19^th century, concerns about declining birth rates led to induced abortion and contraception being made illegal. Not until the mid-20^th century was there a move to legalise both contraception and abortion. This process of liberalisation has met with considerable resistance, most notably from the ‘pro-life’ movement in the USA. For the most part abortion within the first trimester is legal, with increasing restrictions for later in pregnancy. Abortion is mainly seen in either unmarried, nulliparous women (those who have not had children) or women who are married and have already had enough children or wish to space their childbearing. Restriction of legal adoption is often followed by an increased use of illegal abortion and a substantial rise in maternal deaths from abortion.

It is of course difficult to distinguish between the effects of the abortion per se and the impact of an unwanted pregnancy. Early follow-up studies however, consistently failed to find evidence of adverse psychiatric consequences, though short-lived emotional reactions were not unusual. It is also not unusual that women who have had an abortion report sexual problems. The experience of abortion may lead to some problematic changes in their sexual self-image, which may not simply be attributed to the abortion itself. Yet it is still best, of course, to prevent unwanted pregnancies in the first place.

What is the effect of infertility?

The average time required for pregnancy to occur in normal couples not using contraception is 5.3 months. After 1 year of unsuccessful attempts to conceive, a couple may be regarded as potentially infertile. With a shift from having children as taken for granted towards more voluntary childlessness, mostly due to the increased availability of alternative roles for the woman, it may be easier for a woman to accept infertility with little distress. However, it would not be surprising if women prefer to choose not to have children, rather than have infertility thrust upon them. For men, it might be different. For some men, fatherhood is clearly important for their sense of masculinity, but it’s also easier for them to have ambitions that are not dependent on fatherhood. However, for a man to discover that he lacks fertile sperm, whereas his wife is reproductively normal, can be damaging to his self-esteem. Many infertile couples weather the initial stress of infertility and emerge with their relationship in some sense strengthened.

Sexual difficulties are common amongst infertile couples. Especially the women have more disturbances of sexual identity and problems of sexual adjustment. In some cases the sexual problem can be the direct cause of the infertility, often a problem that interferes with the deposition of semen in the vagina. Intervals between ejaculation of less than 12 hours or greater than 7 days result in reduced fertility of the ejaculate. Also, if intercourse is less than once weekly the likelihood of ovulatory cycles is reduced. Usually when stress declines, conception occurs, so for example when the sexual relationship improves.

After the diagnosis of infertility, many men suffer from ED and hostility and guilt may be common in the wives. The pressure of having to conceive and therefore having to perform at the right moment may also have negative consequences for the enjoyment of intercourse. Sperm donors are often used when the man is infertile, but because the child is then of another man, this may cause some adverse effects on the marital or sexual relationship. In women, IVF is used, where fertilised eggs are placed inside the uterus. This is less controversial and, if successful, has a significant positive effect on the couple’s happiness.

Practice questions CH.15

1. Which factors may be of influence on sexuality during pregnancy and post-partum?

2. What effect can breast-feeding have on sexuality and why?

3. What can contraception do to the sexual relationship? Name one effect?

4. What are some negative effects that oral contraceptives can have on sexuality?

5. What is something we have to keep in mind when we find that there are only small group changes in sexuality or mood changes as a result of the use of OCs?

6. What is the main problem in the development of male hormonal contraceptives?

7. Wat does sterilisation entail in women? And in men?

8. Which two groups of women are most likely to have abortions?

9. What is the average time needed for a couple to conceive? After how much time may they be regarded as potentially infertile?

10. What is a positive consequence for the couple when they get through the problems of infertility? And what is a negative consequence?

What are sexual offences? - Chapter 16

The most controversial function of the law is the ‘declarative’ function, that discourages certain forms of behaviour, considered to be undesirable. This changes constantly. Adultery or fornication has in the past been punishable in Western societies and in some Islamic countries this is still applied with considerable severity. A more recent change is homosexuality. However, legal proscription of certain forms of sexual behaviour on the grounds of immorality also has indirect consequences that are undesirable: when the behaviour is a source of pleasure, a ‘black market’ develops based on organised crime.

How are sexual offences defined in the UK?

There was much concern in the UK because it was believed, not just in the UK, that the majority of women who suffered rape or sexual assault did not report this to the police. The victims often received very unsympathetic, if not humiliating, treatment at the hands of the police and the courts, and often felt stigmatised by the experience in the eyes of their spouses or families. The collection of evidence was often carried out insensitively at a time of considerable emotional distress. Some officers tried to challenge the truth of the victim’s story as a way of testing its validity, an approach which would seldom be used with the victims of other types of crime. One-third of the cases were not prosecuted, mainly because of lack of independent third-party evidence, which must be extremely distressing for the victim. In court, the cross examination by the defence often made women feel as if it was their character that was judged. Another cause of concern was that a man could not be accused of rape of his wife; she was not entitled to refuse him sex, a horrendous principle. Many of these concerns have since been addressed.

There are now three categories of sexual assault: (1) rape, involving penetration of the vagina, anus or mouth with a penis, without consent; (2) sexual assault by penetration, involving penetration of the vagina or anus by a body part (finger or tongue), or some object; and (3) less serious sexual assault (without penetration), which has a minimum threshold that the event caused ‘fear, alarm or distress’, this can be touching without consent, indecent exposure or sexual threats. Factors that may make the act more serious in legal terms, include abuse of one’s position (employer or teacher), use of force or coercion and repeated offending.

Another offence is to cause another person to engage in some form of sexual activity, without consent. This may not involve contact with the offender, but may be masturbation or sex with a third person. Sexual offences against children have three categories: (1) offences against children under 13; (2) offences against children under 16; and (3) offences against children under 18. The act of consent is 16, before that a child does not, under any circumstances, have the legal capacity to consent to any form of sexual activity. Consent does not have to be proven. It is also an offence to arrange and facilitate a child sex offence (sex tourism).

Abuse of children through prostitution or pornography is also an offence, including paying for sexual services of a child, causing or inciting child prostitution or pornography, controlling a child prostitute or a child involved in pornography and arranging or facilitating child prostitution or pornography. Consent is not relevant. There are also offences against persons with a mental disorder, who are not able to give consent or are vulnerable because of their position of dependency on the person who sexually interacts with them.

The crime of incest was replaced in 2003 by a new offence of familial sexual abuse, to cover not just assaults by blood relatives, but also by foster and adoptive parents and live-in partners.

What is the true incidence of sexual offences?

A problem here is that victims often do not report the sexual crimes, because of the distressing nature of the legal process. Also, the official statistics do not show all information, for example, it is impossible to distinguish between children under 10 and those over 14. After the change in the law in the UK to include indecent exposure, there was a huge increase in sexual offences. Notifications of child abuse, of either sex, more than doubled between 1985 and 1995. Males and females between the ages of 10 and 15 are at greatest risk. The percentage of women who say they have been raped since the age of 16 has declined, which seems to be the opposite from the crime statistics. The number of offenders convicted of incest was reported for the years 1990-2000 and showed a decline. Most offences involving paternal incest that lasted for a year, only a fraction were isolated incidents. The majority of sibling cases were isolated incidents. There was an increase in indecent exposure offenders between 14-17 years, linked to an increase in juvenile delinquency.

In the USA, estimates are that 30-50% of sex offences against children in the 1980s were committed by adolescents. Sexual offenders were most often found to be familiar to the victim. Substantial changes in the laws relating rape and sexual assault, similar in their intentions to those for the UK, took place in the USA earlier than in the UK, though varying from state to state. As a result, rapes were more likely to be reported, but is always more likely when the rape offender was a stranger (who may have used a weapon). In spite of increased rates of reporting, overall prevalence rates of childhood sexual abuse appeared to be similar to those from before the legal changes. Girls were mainly touched by men over 18, boys most often by teenage girls, but also by males. Incest can happen with any family member, but in terms of the seriousness of the abuse, stepfathers were the worst offenders.

What impact does the socio-cultural context have on sexual offending?

The large majority of rapes and sexual assaults are perpetrated by men on women. Cultures that are rape-prone promoted male-female antagonism, while rape-free societies showed sexual equality, with low levels of interpersonal violence. Acceptance of violence in a society is significantly related to the frequency of rape. Often, people blame the victim for the assault. However, it is difficult to identify a meaningful stereotype of the typical rapist. It is possible that a rapist is a relatively normal male who, as a result of socially learned attitudes to women, is likely to rape in certain circumstances. War can be an example of such circumstances. When this happens in Muslim countries, often the men will not take their wives back after they have been touched by another man and may disown them, even if they were subdued by force. But even in most modern cultures, attitudes that the raped women is defiled or spoiled in some way do play a part in the traumatic consequences. Focusing on the individual, and looking for ways to stop that individual from re-offending, may divert attention from considering ways in which socio-cultural factors could be changed to make rape less likely in the first place. Feminist theories have focused on how societal change might reduce this likelihood, by changing the view of male dominance and the view that women will say no, even when they do desire sex, and will ‘ask for it’ by wearing certain clothes. Also if we shift the focus from rape as a sexual act to rape as a violent act, this may lead to viewing the act as more terrifying and humiliating, rather than sexually arousing.

From historical records there are indications that sexual activity with young boys was widespread in ancient Greece and accepted in various parts of the world during the 18^th century, as was sexual activity with young girls in ancient Rome. In researching this in modern cultures, difficulties arise when trying to define childhood socio-culturally. However, we do know childhood sexual abuse (CSA) is an international problem. With exploitation of children, often families knowingly benefit from the commercial aspect. This is mainly manifested in ‘sex tourism’. Child prostitution is often seen in third-world countries, but is at least still found in the USA as well. Cultural factors are often at play, involving religious practice or child marriage, but also female genital circumcision.

It is important to consider how ‘childhood’ is defined, because there are cultural differences in this respect. The law often imposes ‘cut offs’ by age. However, the age of puberty has fallen and in many pre-industrialised cultures, the age of consent is still based on pubertal stage. This then takes us to how the ‘mature adult’ fits sexual attributes into the concept of an ‘appropriate sexual partner’, and what other factors should be taken into account. If that does not limit the adult’s attraction, then the crucial issue is the adult’s ability to behave in a responsible manner, influenced by social norms. But when we consider sexual involvement with a pre-pubertal child, we are probably dealing with a fundamentally different set of sexual signals, more likely to be a ‘deviant’ sexual preference.

While CSA is a long-standing issue that has not increased or reduced over time, public reactions to it have changed dramatically since the latter part of the 19^th century. Over the 20^th century, we see ‘peaks of concern’ about every 35 years, but not much attention was paid to CSA in between. Around 1999, when politicians got involved, the public mind changed, seeing CSA as bad, regardless of what form it takes and regardless of whether or not the child is damaged by the experience. This does make unbiased research into the effects of CSA hazardous, because a study claiming CSA does not have many negative results on children is not likely to be received in a positive manner. Also, there has been a dangerous tendency to assume that anyone accused of sexual involvement with a child is guilty until proven innocent.

Child pornography increases the likelihood that the viewer will abuse a child, encourages abusers to see children as seductive and always involves participation of the child, legally unable to give consent. Because of growing concern about this industry, there has been an increasing move towards using children from the developing world. Usually, it is illegal to produce and distribute child pornography, often also to possess it.

Regarding incest, the taboo against mother-son incest is more or less universal; with father-daughter and brother-sister relationships there are exceptions, this and the sanctions vary across cultures. If a relationship is deemed incestuous, it will not be considered marriageable, but this does not prohibit someone to have sex with close family members. Biologically however, we see a marked lack of erotic feeling between people who lived closely together from childhood. The taboo is still necessary, to keep those who do have erotic feelings for family members from committing incest. Sometimes brothers and sisters are raised away from each other, and this may cause problems. It seems inescapable that across species there is a basic genetic disadvantage to inbreeding, resulting in ‘incest avoidance’.

What are characteristics of the sexual offender?

Adolescents may be responsible for up to a third of all sexual offences. The victim is often not much younger than the offender, so the interest could be seen as ‘age appropriate’. Many adult offenders first offended in adolescence, but only a small minority of adolescent sex offenders continue to do so as adults. The three strand model may be relevant here, and there are at least three ways in which sexual development can go wrong: (1) the establishment of sexual preferences leading to sexual identity can be derailed during the developmental phase, leading to various patterns of deviant sexual responsiveness; (2) problems during childhood with the ‘dyadic relationship’ strand, a consequence of negative parent-child relationships, result in barriers to intimacy and incorporation of sexuality into a dyadic sexual relationship; and (3) maladaptive patterns of behaviour, evident from early childhood, lead to various types of delinquency during adolescence and early adulthood. Especially parent-child attachments are very important in the developmental process leading to sexual offending. Being sexually abused themselves may lead children to early onset of masturbation and the use of sex as a coping strategy. The psychogenic perspective sees the original trauma and its severity as the key determinants of the final outcome of development. The life-course perspective states that an early negative experience may influence the next stage of development, which then interacts with other factors to determine the next stage, etc. Both perspectives are relevant and complement each other.

When we look at inhibition, it seems that in normal men, sexual arousal would be inhibited in circumstances where sexual behaviour would have disastrous consequences. This may not be the case when someone has a low propensity for inhibition, and a high propensity for excitation, tipping the balance even in these high-risk situations. Studies find that inhibition can be lessened by cognitive manipulations, a mechanism that features commonly in the literature on sexual offences.

Whereas most people report a reduction or no change in states of depression or anxiety, a minority report increased sexual interest or arousability. This ‘paradoxical’ pattern has been shown to be related to some aspects of high-risk sexual behaviour in men, and is therefore likely to be highly relevant to sexual offence behaviour. In sexual offenders, negative mood and interpersonal conflict were found to be associated with increased deviant sexual fantasies and often masturbation, indicating the use of sex as a coping strategy in these mood states. Also, sexual offenders on average have a lower IQ than non-sexual offenders. The best predictors of re-offending, apart from previous offending, are young age and evidence of deviant sexual preferences.

Rape is often either seen as a deviant sexual act, or an act of hostility or humiliation, or an expression of power over women. In high-aggression offences, we can make a distinction between explosive anger getting out of control, and sadism, in which hurting the victim is sexually arousing. Sexually aggressive men may be less able to suppress sexual arousal, and rapists are able to be aggressive and sexually responsive at the same time, while usually these two responses are mutually inhibitory. Rape is sometimes seen as an act or aggression rather than a sexual act, as it may carry the excuse that men cannot be entirely responsible for their sexual behaviour (as such individuals would believe).

In the majority of child molestation cases, the child is known to the offender, around 80% of offences take place in the home of either the offender or the victim. Child sexual offenders are less often convicted for non-sexual crimes than rapists and other sexual offenders. Sex offenders often have problems in establishing satisfactory adult relationships, possibly resulting from an inadequate attachment style. However, no consistent picture of sexual offenders against children emerges in terms of personality characteristics, although clear evidence of psychopathology is less apparent in this group when compared to other types of offender. Extra-familial offenders are more likely than incest offenders to report a sexual interest in children before the age of 18. Family is likely to be important, and women who have been sexually abused themselves during childhood are more likely to have children who are sexually abused. However, there is a more specific link with subsequent sexual offending in those who themselves offend against children, than in those who have been abused.

Finkelhor proposed a model in which there are four preconditions for CSA to occur: (1) There is some form of motivation to sexually interact with a child; (2) there are factors that counteract internal inhibitors (such as alcohol or psychotic illness); (3) there are factors overcoming external inhibitors; and (4) there are factors reducing the child’s resistance to abuse. We find four clusters of problems: emotional regulation problems, intimacy and social skill deficits, deviant sexual arousal or ‘sexual scripts’, and cognitive distortions.

‘Paedophilia’, according to the DSM IV, indicates the presence of ‘recurrent, intense sexually arousing fantasies, sexual urges, or behaviours involving sexual activity with a prepubescent child or children. There has been strong debate about whether this should be a mental disorder, because with many of the offences against children, the ‘child’ is a young teenagers who may well be sexually attractive, at least in some respects, to adults. The issue is then one principally of lack of responsibility and exploitation. It may be more appropriate to think of ‘deviant’ sexual interest when the victim is pre-pubertal. It is possible that a paedophile shows less plasticity and becomes fixated on what is learnt early in the sexual development process: attraction to similar-aged peri-pubertal children. ‘Normal’ progression through this process may also be influenced by cultural norms of acceptable age for a sexual partner. In much of the literature, the term paedophile is used to describe any offender against children, while in reality the majority of child molesters does not in fact have a sexual preference towards children.

A possible link was found between tendencies towards exhibitionism and towards voyeurism. Both were associated with having more psychological problems, lower satisfaction with life, greater alcohol and drug use, and greater sexual interest and activity in general. Voyeurism is reported more often, and is also less clearly abnormal. For most exhibitionists, genital display to members of the opposite sex is an end in itself. Others do it while drunk, or as an expression of hostility. The mentally defective may believe or hope the female will be sexually excited. Variables that are important are the age of the victim (often around puberty), the nature of the act (sexual or not: with erect penis?), the frequency of the behaviour (only during crisis or emotional distress, or always?) and risk-taking (avoid being caught, or like taking the risk). Though the victim’s initial reactions are often unpleasant, any continuing reaction seems to be unusual. Voyeurs may prefer to watch others engaging in sexual behaviour because real contact is too threatening for one reason or another. The most obvious explanation for this is that it provides a form of sexual stimulus without the threat of sexual contact or rejection. Risk and excitement may also be an incentive.

The large majority of sexual offenders are men, but a small percentage are women. Juvenile female sex offenders often show this behaviour because they are naïve experimenters, misusing their position as, for example, a babysitter. Sometimes they act out more extensively, with one or more children over time. When psychopathology, like PTSD, is involved, their abuse is more likely to involve force. Women may co-offend with a male they are emotionally dependent on, or abuse pre-pubescent children, or sexually interact with teenage males, seeing it more as an affair than exploiting.

Who are the victims of sexual offences?

Most rape victims are teenagers or young adult women, though no age group is immune. Black women and women with low socio-economic status are more likely to be raped. Substantial psychological after-effects of rape often occur, influenced by personality and resilience of the victim and characteristics of the situation during and after the rape. Chronic problems may include fear and PTSD, depression, loss of self-esteem, social adjustment problems, sexual problems and anxiety disorders. Sexual problems are often experienced as a need for avoidance of sexual activity and an impairment of sexual arousal when sexual activity does occur. There is no consistent evidence as to whether ‘stranger’ rape or rape by a familiar person is more traumatic. Confusion or disorientation during the rape was found to be a strong predictor for subsequent PTSD. Often, in those cases where rape occurs between friends or casual acquaintances, the victim finds herself under suspicion or held to be responsible to an extent. If a girl got involved in limited love-making but refused to go all the way, she may find it difficult to have her charge of rape taken seriously, the same as when a girl is ‘asking for it’ by dressing in a certain way. Many women put up minimal physical resistance because they fear they will otherwise be more likely to be hurt or disfigured. In the meantime, women who scream or fight back during the rape are more likely to be believed. Some rapists may be discouraged by resistance, while others get more aroused by it.

The victim of rape needs help immediately following the rape, in the days and weeks after, and to cope with the long-term consequences. Immediately following the rape, it is important that the physical police investigation is conducted in a supporting manner, so as not to add to the trauma. In the aftermath of the trauma, during the following weeks, crisis intervention needs to take place. Sometimes the victim is so shocked that she cannot take care of herself and needs someone else to temporarily take over her day-to-day responsibilities. Someone needs to stay with her until she starts to settle down. After this shock phase, counselling can start, to deal with the emotional reaction. The principal losses following rape are of trust, freedom and identity. It is important to also include the partner or family of the victim in counselling. Long term reactions often occur because the victims did not work through their feelings adequately at the time, and these feelings may be triggered by some subsequent event.

The effects that CSA may have shortly after the abuse range from anxiety or fear, PTSD, depression, low self-esteem, aggression, ‘sexualised’ behaviour, and behavioural problems. They did not, however, combine to present any ‘syndrome’, which could be regarded as characteristic of CSA. The symptom profile did vary with age, as children get older, the symptoms are more related to problematic behaviour. Anxiety-related symptoms tend to abate, whereas aggressive behaviour patterns tend to persist or get worse. Strong family support enhances recovery. The consequences of reporting incidents to the police can have further traumatic effects on the child, so supportive parents will protect their child by not reporting. There are not many reports about children who show no symptoms, quite possibly because stating that CSA may not always be damaging to the child will not be received at all well by the public. CSA in boys is less likely to cause long-term negative effects than CSA in girls. It is even possible that a boy around pubertal age finds the experience positive.

Factors that might increase the likelihood of CSA are low income of the family, social isolation of the child, presence of a stepfather, conservative ‘family’ values held by the father, little physical affection shown by the father, absent mother, detached mother, mother never finished high school and mother with punitive attitudes towards sexual matters. In subjects with none of these risk factors, sexual abuse was almost non-existent. If five or more factors were present, two-thirds of the subjects had suffered abuse.

When one considers the substantial variation in the nature of CSA, the differing ages at which it occurs, varying degrees of ‘closeness’ to the perpetrator, variability in responses to stress and coping strategies used, as well as the level of support available to the young person, the variability of CSA effects that we find seems hardly surprising. Summit described a syndrome that helps the child with the immediate survival within the family, but which tends to isolate the child from eventual acceptance, credibility or empathy within the larger society. There are five components: (1) secrecy; (2) helplessness; (3) entrapment and accommodation; (4) delayed, conflicted and unconvincing disclosure; and (5) retraction of the disclosure. Children are often confronted with four trauma-causing factors: traumatic sexualisation, betrayal, powerlessness and stigmatisation.

Part of the current reaction to CSA involves a need to see any child, however defined, as asexual. Therefore it is not currently acceptable to even consider whether a child may have consented to a sexual interaction, or in any way found it pleasurable, even though evidence of consent may influence the legal sentencing. This does not affect the moral and legal unacceptability of an older person exploiting the child, but could have a considerable bearing on how the child reacts to the experience. It is also possible that a child encourages yet ends up being frightened or disturbed by the experience, but the child may also gain some emotional reward (more likely when the offender is a stranger than a family member). The major psychological trauma may also develop later, even if the experience itself was not felt to be negative.

If we are to understand the impact of CSA on sexual development, we should pay particular attention to the stage of sexual development at which it occurred, or started. Preschool children often show sexually inappropriate behaviour, this is less evident in school-age children. CSA before puberty was associated with sexual arousal problems in women and PE, ED and low sexual desire in men. Women with a history of CSA show earlier onset of ‘voluntary’ sexual intercourse, more sexual partners, more unprotected sex, a higher pregnancy rate, more STDs and more sexual revictimisation. Men are more likely to engage in high-risk sexual behaviour as adolescents and adults, to have more sexual partners and to become victimisers themselves. They are also more likely to develop homosexual identity, but whether this is cause or effect is not yet clear. Girls abused by their biological father over a long period experience greater self-blame, possibly because they kept complying while not much force was used. They are most likely to show sexual aversion as a result. Negative emotional experiences, such as CSA, might result in the development of maladaptive ‘emotion schemes’ that may be activated inappropriately, e.g. by the partner’s intimate physical touching in an adult relationship, resulting in sexual relationship problems.

‘Traumatic sexualisation’ may occur when a child experiences early sexual arousal and pleasure as a result of CSA, which may then be further pursued in ways which are usually inappropriate. Girls also sometimes start using sex in an instrumental way, to achieve non-sexual goals and gratifications. This is more likely when there is some degree of consent by the child and when the adult’s behaviour is not frightening, threatening or physically painful.

In helping the child once abuse by a stranger has been established, it is important to work with the family, as their reactions may be important in determining whether the child suffers long-term consequences. When abuse involves an acquaintance or a family member, intervention becomes much more problematic, there is often a need for individual support for the child. Someone needs to believe the story and affirm the child’s innocence. Treatment of sexual problems in adults with a history of CSA addresses some of the key issues that may be involved in the sexual aftermath. Group therapy may help in dealing with emotional consequences. Other problems may be dealt with in sex therapy. Cognitive behaviour therapy (CBT) may help by focusing on the sequence typically leading from negative mood to sexual ‘acting out’, paving the way for behavioural change.

How to manage sex offenders?

The most effective method of discouraging sexual offences is the threat of legal sanctions. The large majority of first-time convicted sex offenders are not re-convicted of sex offences. These offenders are also most receptive to psychological treatment, while recidivists present a treatment problem. It is essential, for ethical reasons, to distinguish between social control, which is control of the offender for the benefit of society, and treatment aimed at helping the offender. Drugs that lower sexual drive can be used as part of medical treatment.

Sexual drive can be reduced by lowering androgens or in some way blocking their action. Whether this works on any given sexual offender depends on the extent to which his behaviour is determined by the sexual drive. Oestrogens were used for this purpose for many years. These are unpleasant for men to take, causing nausea and other side-effects. Progestagens have also been used, side-effects seem less troublesome, but with long time use there is a risk of diabetes, high blood pressure and gallstones. Most widely used outside the USA is cyproterone acetate (CPA), which is found to reduce re-offending in offenders with previously high recidivism rates. Depression may be a side-effect.

For pharmacological, rather than hormonal, reduction of sexual interest, various tranquillisers and psychotropic drugs have been tried. They may reduce libido, but the endocrine effects are not the same as those produced by CPA or oestrogens. SSRIs have been used for this purpose recently. There is a possibility that much of the beneficial effects of SSRIs in relation to unwanted sexuality relate to the underlying paradoxical relationship between negative mood and sexuality. When these drugs are used for social control rather than genuine treatment, it is difficult to ensure that they are really taken by the offender.

Far more controversial was the earlier use of irreversible surgical procedures, like castration and psychosurgery. Because of many ethical objections, both these procedures are no longer used. Psychological treatment is less problematic from this point of view. Change is only likely to occur if it is desired and actively sought by the offender. It is very difficult to achieve a good therapeutic relationship when the offender is under pressure from the legal system to be compliant. Group therapy may help. It is preferable to help the individual build up or reinforce new and more adaptive behaviours rather than simply to eliminate old, undesirable ones. For men with established relationships, couple counselling is often appropriate. The most obvious goal of treatment is the improvement of self-control over antisocial sexual urges or a reduction in the strength of those urges.

If the offence usually occurs at the end of a specific sequence of events, a point early in the sequence may be chosen to induce some alternative, well-rehearsed behaviour. Aversive techniques may also still have a place, where a stimulus that would provoke antisocial behaviour is associated with a negative stimulus. This may work in the same way the fear of re-conviction keeps most convicted offenders from recidivism. These counselling approaches could be combined with the use of libido-lowering drugs.

Practice questions CH.16

1. Which three categories of sexual assault are now recognised? What do they entail?

2. Which three categories of sexual offences against children does the law recognise?

3. Who most commit 30-50% of sex offences against children? What can we say about sex offenders and their relation to the victim?

4. How can we explain that in some countries/cultures, it is acceptable to have a sexual relationship with a post-pubertal child.

5. In which three ways can sexual development go wrong and lead to sexual offences?

6. What are the differences between the psychogenic perspective and the life-course perspective of sexual development?

7. Why is it incorrect to call all child sexual offenders paedophiles?

8. What are the long-term psychological after-effects of rape that a victim often experiences?

9. Which methods can be used to prevent re-offending?

Human sexuality and its problems by Bancroft - BulletPoints

1. What is human sexuality?

• In the twenty to thirty years before 1989, the changes in the sexuality of women were the most marked. Since 1989, these changes in women’s sexuality have not been so evident. The trend towards more sexual experience before marriage has continued in the western world since 1989.

• More recent attention in the field of HIV/AIDS has focused on the vulnerabilities of heterosexual women as a demonstration of the consequences of gender equality. HIV/AIDS has added further complexity to the issues of responsible sexual behaviour. The HIV/AIDS pandemic has led to a new phase of sex survey research. The need for such surveys has been acknowledged, but lack of funding and persisting fear of the subject makes it difficult to do the research.

• The past 20 years have seen a huge increase in the literature relating to human sexuality and its problems.

• Human sexuality results from an interaction between the psychobiological mechanisms inherent in the individual and the culture in which he or she lives.

• In the clinical field, there has been a shift away from surgical interventions (since the start of the ‘Viagra-era’), for example for erectile dysfunction.

• The internet is a major new factor in the modern sexual world, crossing age, cultural and geographic boundaries.

2. What are models and theories of human sexuality?

• Anthropologist Tuzin saw human sexuality as an interaction between biological mechanisms and cultural processes.

• In recent years we have seen a growing divide between conventional sex researchers (who attribute reality to the biological basis of sexuality) and social constructionists (who point to the social construction of sexuality and its changes throughout history).

• Harris makes a distinction between ‘emic’ knowledge – that which the native accepts as real, meaningful and appropriate – and ‘etic’ knowledge: concepts and categories used by experts and scientists.

• Many postmodernists believe that conventional science is used to gain social control, particularly control of sexual aspects of life, and is therefore politically suspect. Much of the social control of sexuality is imposed on women and is used to suppress homosexuality. Here we have a challenge of sorting out the scientific from the political.

• Conventional sex research often focused on the individual, but it’s good to keep in mind that situational factors can increase the likelihood of risky sexual behaviour and that we should be looking for ways to promote less problematic socio-cultural contexts.

• Sexual Strategy Theory (SST) is an application of evolutionary psychology principles. It focuses on desire and all of its interpersonal ramifications: attraction tactics, conflict between the sexes, mate expulsion tactics, causes of conjugal dissolution, mate retention tactics, and harmony between the sexes. Psychological mechanisms (both short-term and long-term) dealing with these ramifications can each be regarded as an adaptation and are activated depending on context.

• Sexual Scripting Theory uses the metaphor of ‘script’ to describe the sequence followed by an ‘actor’ engaged in sexual behaviour. According to this theory, all sexual meanings and desire are embedded in the social context.

• Marvin Harris’s account of cultural materialism deals with the material resources around which culture and social structure are created. This model explains differences and similarities between different cultures, but not yet between individuals within those cultures, something that is needed in a model describing human sexuality.

• The Dual Control Model states that whether sexual response and arousal occurs in an individual, is ultimately determined by the balance between two systems in the brain: the sexual activation or excitation system, and the sexual inhibition system.

3. What is sexual differentiation and gender identity in humans?

• There are two main chemical types of hormone. Steroids are to some extent stored in the blood since they are bound to plasma proteins (for example testosterone). Peptides on the other hand are stored in the cell or gland that makes them and are released when required.

• The hypothalamus mediates control of the anterior pituitary-gonadal system by other parts of the brain, such as the cortex and pineal gland. It directly influences the system by controlling hormones, which it secretes and transports to the anterior pituitary gland.

• Sex steroids (oestrogens, progestogens and androgens) are produced mainly by the gonads and the adrenal cortex. They all have a specific role in reproduction.

• The most basic manifestation of gender lies in our sex chromosomes, present in every cell of the body. The normal female has two X chromosomes, the normal male has one X and one Y.

• In the male, the increases in androgens are responsible for the male sexual characteristics, both primary and secondary. For girls, oestrogens are responsible for these changes.

• The female genitalia consist of the clitoris, the vulva is what can be seen on the outside, the labia majora and minora. The vagina is a tube, closely invested by the surrounding pelvic floor muscles. The uterus is a pear-shaped organ with a thick muscular wall, with a narrow lower part: the cervix or neck, which protrudes into the vagina. The fallopian tubes enter the upper part of the uterus, the ovaries lie below the fallopian tubes.

• The shaft or body of the penis is formed principally by a fused pair of corpora cavernosa, filled with erectile tissue, which inflates with blood during erection. Beneath the two fused corpora cavernosa lies another erectile column, the corpus spongiosum, which envelops the urethra. The gonads or testes lie in a superficial pouch of skin and muscle, the scrotum.

• Sex chromosome aneuploidies are problems caused by sex-chromosome anomalies, such as too many X, too many Y. Inborn errors of metabolism have no influence on the sex chromosomes, but cause similar problems with gender development- and identity.

• In the absence of pre-natal androgen effects, particularly if there are unambiguous female external genitalia, a stable female gender identity develops. Pre-natal exposure to androgens results in some masculinisation of behaviour. Problems with gender identity are slightly more likely in such cases.

4. What is the psychosomatic circle of sexual arousal and response?

• The central nervous system has seven main structural divisions: (1) the cerebral hemispheres, (2) diencephalon, (3) cerebellum, (4) midbrain, (5) pons, (6) medulla, and (7) spinal cord. The midbrain, pons and medulla together form the brain stem.

• The concept of a balance between excitation and inhibition is fundamental to neurophysiology. Gray has proposed three fundamental emotion systems: a behavioural approach system (BAS), a fight/flight system (F/FLS) and a behavioural inhibition system (BIS).

• There is some evidence that oxytocin (OT) plays a role in the sexual excitation system, just like dopaminergic mechanisms: three of the five DA systems impact on sexual behaviour. The noradrenaline (NA) system is involved in inhibition of male genital response in the periphery, but central effects of NA on sexual response are excitatory. Serotonin has a role in the inhibitory system.

• The caudal anterior cingulate cortex processes contradictory signals or intentions, including the conflict between ‘go’ and ‘no-go’ signals in response to sexual stimuli. The putamen is a basal ganglion that is correlated with penile erection. The amygdala is also activated in response to visual sexual stimuli (VSS).

• The book conceptualises orgasm as follows: an increase in both the central and the peripheral aspects of sexual arousal to a peak, where a neurophysiological process is triggered with several manifestations (intense feeling of pleasure, altered consciousness, reduced awareness, genital sensations, muscle contractions and other non-genital changes), followed by a post-orgasmic state resulting in a ‘refractory period’ when further sexual arousal is inhibited.

• For the function of female orgasm, the book uses the by-product explanation, which sees orgasm as a pattern that has evolved to allow orgasm and ejaculation in the male, but occurs as a ‘potential’ response pattern in the female because there has not been any evolutionary reason selectively to suppress its development.

• Negative mood (anxiety, depression or anger) has a negative impact on sexual arousability. Depressed women were found to report more inhibited sexual arousal and orgasm and less satisfaction and pleasure.

• Men experiencing testosterone (T) withdrawal predictably show a reduction in the level of sexual interest. In the female we find inconsistent and often contradictory evidence for the key role of T for sexual arousability. In the male, evidence points to a threshold, above which increased T levels have only subtle behavioural effects, and below which signs of androgen deficiency action on sexual desire are likely to occur. Women have circulating levels of T on average around a tenth of those found in males, whether there is a threshold is uncertain.

5. What is sexual development?

• The interactional model of sexual development used in this chapter attempts to integrate both biological and socio-cultural factors. There are three main strands: (1) sexual differentiation into male or female and development of gender identity; (2) sexual responsiveness, and; (3) the capacity for close, dyadic relationships. During most of childhood, the three strands are developing in relative independence of one another, but in early adolescence they start to be woven together to form the young sexual adult.

• Eighty percent of males starts masturbating within 2 years either side of the age at puberty. For women, the age of onset was much more widely spread, but looking at pre-pubertal onset, females on average started 2 years earlier than males. It is possible that girls who are highly sensitive to the behavioural effects of androgens experience onset of sexual interest and masturbation early, while those who are relatively insensitive to such effects develop sexual arousability more gradually, in late adolescence or early adulthood.

• Sexual arousal first occurs before puberty, with an average age of 9.7 for boys and 10.8 for girls. First sexual attraction occurs around the age of 11.4 in boys and 12.4 in girls. The onset of sexual fantasies is about 11.6 in boys and 13.3 in girls. This shows again the wider variability in girls, just like in onset of masturbation.

• The peri-pubertal pattern is intrinsically about normal sexual development, although individuals clearly vary in how they experience this process, reflecting the interaction between hormonal changes and evolving brain function.

• Sexual identity, a key element among the sexual meanings, emerges at the start of adolescence, defining what kind of person someone is sexually attracted to and what kind of sexual person they are themselves.

• For both heterosexual and homosexual women, emotional attraction often precedes erotic attraction, whereas the reverse applies for men. In men, sexual identity is most predictably related to the gender of those found sexually attractive. In women, the emphasis is on emotional involvement and closeness.

• There is a strong association between gender non-conformity during childhood and subsequent homosexual identity in both men and women, though much more in men.

• We can speculate that if there was no cultural control of the gender of sexual partners, but rather an acceptance of diverse types of sexual relationship, we would, by nature, have a widespread capacity for sexual interaction with either same or opposite sex partners, until the time that we chose to settle into a reproductive phase and rear a family.

6. What does heterosexuality mean?

• Kinsey is the biologist who has probably had the biggest influence on sex survey research. His primary objective was to demonstrate the extraordinary individual variability in human sexuality, no two people were the same and there was no cut-off that would justify the concept of ‘normal’ versus ‘abnormal’.

• Surveys conventionally have used self-report questionnaires, interview methods, or a combination of the two. There are advantages and disadvantages. In interviews, the meaning of questions can be clarified, but can also differ between interviewers, and we see under-reporting of sexual problems due to concerns about stigmatisation.

• Although masturbation is compatible with sexual health and can play a positive role in our sexual development, we should also look at the negative outcomes. Using sex as a mood regulator for example, may not lead directly to developing ‘out of control’ sexual behaviour, but may serve to reinforce this.

• Important dimensions when looking at cultural variations in sexual behaviour and marriage are importance of wealth and inheritance, the degree of differentiation of sexual roles, sexual segregation and sexual stratification (when one gender group has greater access to rewards, prestige and power), and the complexity of social structure.

• Following 1938, the birth rate amongst teenagers rose, reaching a peak in the early 1970s and then showing an unsteady decline since. Abortion rates increased and by 1975 nearly one in three pregnant adolescents elected to have their pregnancy terminated.

• Sexual attraction involves visual signals of how a person looks and how he or she behaves. Smell may also be important for some people, but could operate without their knowledge. Once two people begin to interact, personality factors will also operate.

• We see an earlier average age at puberty in African Americans than European Americans, applying to both males and females, consistent with earlier onset of sexual activity in African American individuals.

• Sexual fantasy therefore has the potential for being both stimulus and response, and is likely an interaction of both. These fantasies provide a whole new level of information about what an individual ‘desires’ or finds arousing.

• Overall, there have been substantially more changes in the sexuality of women than of men during the 20^th century. This is consistent with a reduction in the socio-cultural suppression of women’s sexuality.

7. What are the ageing effects on sexuality?

• Kinsey concluded that in males, from the early and middle years the decline in sexual activity is remarkably steady and there is no point at which old age suddenly enters the picture. In females however, there is little evidence of any ageing in the sexual capacities, until late in life.

• It was found that, in men, the extent of the decline was a function of the level of sexual activity during early adult life. Higher levels of sexual activity when younger means less decline.

• With age, brain function declines, associated with loss of neurons in various parts of the brain. There has been no clear evidence of such loss relating directly to declining sexual function, but it does affect areas in the brain that are also associated with sexual function.

• We saw a more complex, and to some extent less predictable, ageing pattern in women than in men.

• So far, there is inconclusive evidence as to whether decline in sexual functions is caused mainly by age or mainly by menopause.

• Lubrication difficulties were found to be the only sexual problem clearly related to age in women across most countries. The problem is not confined to women in the menopausal transition and later, and many post-menopausal women do not complain of vaginal dryness during sexual activity.

• Older women show a lower baseline VPA in post-menopausal women, but the increase following stimulation was similar to that of younger women. Baseline VPA is correlated with oestrogen level, but the VPA increase in response to sexual stimulation is not.

• It seems the menopausal transition appears to be a phase of increased vulnerability to depression. Depression is also an important cause of loss of sexual desire and other forms of sexual impairment, and is therefore likely to be contributing to the increase in sexual problems during the menopausal transition.

8. What are homosexuality and bisexuality?

• The idea that the homosexual individual comes, in some sense, between the typical male and the typical female, prevailed for some time. This idea was disproven in the 1940s.

• In the 20^th century, we see four particular themes: (1) the continuing persecution and suppression of homosexuality, (2) the medicalisation of homosexuality (particularly in the male), (3) the gradual emergence of a campaign by homosexual men and women to protect their human rights and by some professionals to de-pathologise homosexuality, and (4) the legal status of homosexuality and homosexual relationships.

• The emergence of homosexual activist groups brings with it an interesting conflict: those who wanted gently to bring the medical profession and general public to see the positive features of the homosexual community, and those who lost patience and pursued a more confrontational approach.

• Kinsey stated that nature rarely works with discrete categories, this is exclusive to the human mind. He therefore developed his ‘scales’, that were designed to indicate the proportion of behaviour that was homosexual or heterosexual during a specific period in an individual’s life.

• Cass described six stages of sexual identity development: (1) identity confusion, (2) identity comparison, (3) identity tolerance, (4) identity acceptance, (5) identity pride, and (5) identity synthesis.

• Kinsey disapproved of the term ‘bisexual’, partly because it described an individual rather than a behaviour and was in conflict with his determination to avoid categorisation of individuals in terms of their sexual behaviour.

• Usually, when changes in the law regarding homosexuals have occurred, they have been associated with some recorded changes in public opinion. Therefore, we can perhaps take the legal status of homosexuals, and how it varies cross-culturally, as one indicator of cross-cultural attitudes to homosexuality.

• From the 1970s, masculinity was defined in terms of instrumentality and femininity in terms of expressiveness. Homosexual men were similar to heterosexual men in terms of instrumentality, but scored higher in terms of expressiveness. Lesbian women were similar to heterosexual women in terms of expressiveness, but higher in instrumentality.

• Although it can be confidently concluded that homosexuality is not a manifestation of psychopathology, there is increasing evidence that homosexual men and women are more likely to experience depression and other negative mood states.

9. What are sexual variations in humans?

• Sexual minorities refers to the many minority groups in society defined by their sexuality, such as homosexuals.

• Sexual deviance can be seen in three main forms; normal deviance (frowned upon behaviours that are nonetheless carried out by large numbers of people), subcultural deviance (the more obvious sexual minorities) and individual deviance (including sexual behaviours that are not clearly organised into subcultures or minority groups).

• Sexual variations are patterns of sexuality that, while abnormal, are not necessarily problematic for the individuals involved.

• An asexual just does not experience sexual attraction, but may experience non-sexual attraction and may therefore identify as gay, straight or bisexual.

• The concept ‘fetishism’ becomes more relevant as the subject becomes more preoccupied with the signal itself and less concerned with the associated partner. The fetish serves to weaken rather than strengthen the sexual bond with the sexual partner and, in extreme forms, makes the partner as a person sexually redundant.

• There are three principal categories of sexual signal or stimulus to consider in fetishism: a part of the body (partialism), an inanimate extension of the body (e.g. clothing) or a source of specific tactile stimulation.

• It is often assumed that fetishism results from the specific conditioning of sexual response to particular stimuli. In the male, the capacity for classical conditioning of erections to unusual stimuli has been demonstrated experimentally.

• An important aspect of BDSM is the strict setting of rules and limits, allowing participants to enjoy the experience without fear that it might go too far. Interestingly, coitus or genital stimulation to induce orgasm is unusual.

• Although the various kinds of sexual variations discussed in this chapter are scattered fairly widely through the population, they have a striking tendency to occur together. This is called ‘multivariant sexuality’.

10. What is transgender, gender non-conformity and transvestism?

• Variations in gender identity, with individuals not fitting clearly into socially prescribed male or female roles, are evident in most cultures, though with considerable differences in how these individuals are received.

• The use of medical interventions to treat gender dysphoria, both hormonal and surgical, has been strongly opposed by some. However, the persuasive evidence that gender reassignment has a positive outcome in the large majority of cases has, to some extent, countered this opposition.

• We see that in cultures that reinforce clearly distinct gender stereotypes more than other countries, people more often seek help in the form of a gender reassignment, as these expectations about being male or female may generate greater anxiety and insecurity.

• It is possible that fetishistic transvestites live a dual-role pattern, where they spend most of their time as a male, and only some time dressed as a female. It is also possible that they develop a stronger wish to change into a woman permanently, with associated bodily change.

• The greatest improvements were in self-satisfaction, interpersonal interaction and psychological well-being. Sexual functioning is often impaired, but given the extent of overall satisfaction, this underlines the primary importance of gender identity over sexuality.

• The ‘real-life test’ challenges the ability of the transgendered individual to live fully in the chosen gender role for a reasonable period of time before anything irreversible like surgery is undertaken. After all, many day-to-day problems that must be overcome first require patience and relearning, not surgery.

• Hormone treatment: in male-to-female transsexuals, oestrogens and progestogens are used, which cause some breast enlargement, redistribution of fat in a more feminine pattern, softening of the skin and usually a reduction in sexual interest. In female-to-male transsexuals, the appropriate hormone is testosterone, which will increase body and facial hair, some enlargement of the clitoris and increase of clitoral sensitivity, increase muscle bulk and body weight and deepen the voice.

11. In what way can sexuality be problematic?

• Arousal is a physiological response, that involves interaction with another person. We can get sexually aroused when alone, but problems with our arousal responses are most often experienced in the context of a relationship.

• Men and women who score high with inhibition scores are more likely to report problems of impaired sexual response, while those at the low end are more likely to engage in high-risk or otherwise problematic sexual behaviour.

• The three windows approach is a way of conceptualising the approach to careful clinical assessment of sexual problems. Through the first window, we look at the extent in which the current situation or relationship is likely to result in ‘adaptive’ inhibition of sexual interest and response. Through the second window, we look for evidence that the individual with a problem has experienced that type of problem periodically through his or her sexual life, or whether it is of long duration. Through the third window, we look for any evidence of physical or pathological factors of relevance.

• Persistent genital arousal disorder (PGAD) is a problem where a woman is continuously sensitive in genitals and breasts, but this is unassociated with any sense of sexual desire and is intrusive and disturbing. It is only temporarily resolved following orgasm. Orgasms may occur spontaneously and maybe frequently.

• When looking at aspects of the current situation that may impact on an individual’s sexual responsiveness, we see expectations of sex, communication, misunderstandings, unsuitable circumstances, concerns about pregnancy, concerns about sexually transmitted infections, low self-esteem and relationship problems.

• Physical or pathological factors that may impact on an individual’s sexual responsiveness are effects of ageing, health problems, sexual side effects of medication and mental health problems.

• High-risk sexual behaviour (HRSB) can lead to unwanted pregnancy, sexually transmitted infection, negative consequences for the primary relationship, or legal consequences.

• ‘Out-of-control’ sexual behaviour is seen in the form of ‘compulsive sexual behaviour’ or ‘sexual addiction’.

• A very dangerous type of sexual behaviour is autoerotic asphyxia, which involves self-strangulation or suffocation. In some way, this has a sexually enhancing effect, but is usually done in secret and is only discovered when the person fails to stop in time and dies accidentally.

• Sexual activity can lead to three types of benefit: (1) reproduction; (2) a rewarding sexual relationship, and (3) sexual pleasure.

12. What are the assessment and treatment options for sexual problems?

• The dominant influence in the first half of the 20^th century was psychoanalysis, which was countered by a more pragmatic view in which learning or relearning or the acquisition of healthy habits has been the basic theme. Modern behaviour therapy became established in the 1950s and 1960s. The 1940s saw the first attempts at inserting penile implants or prostheses, methods that increased dramatically in the 1970s and 80s.

• From a theoretical perspective, the main objective of psychological treatment is to identify and reduce inhibition of sexual response. Therapy may reduce inhibition by identifying factors relevant to the individual or the couple, which invoke inhibition, and finding ways to make them less inhibiting.

• In couple’s therapy, the first two stages of treatment are the non-genital phase, in which each partner practises self-asserting: making clear what they like, or find threatening. Stage 3 involves touching, but now with genitals and breasts included, still applying the alternation of who initiates and who touches. In stage 4 touching is done by both partners simultaneously. In stage 5 vaginal containment is introduced, but movement and thrusting only occur in stage 6.

• For individual therapy, it is crucial that there are treatment goals that are not dependent on interaction with a partner. If problems only occur in interaction with a partner, but not during masturbation, that person will not benefit from individual therapy.

• There are many difficulties in defining success when evaluating sex therapy. More often than not the specific dysfunction is only one aspect of the sexual relationship and therapy can achieve substantial improvement in the quality of the relationship whilst leaving the dysfunction largely unaltered.

• For the initial assessment interview, one hour is normally allowed, to set the patient or couple at ease and discuss the contents of the referral letter. The couple is then interviewed separately, and points are addressed concerning the sexual problem, the relationship, their history, attitudes, and use of medicine or other substances.

• Physical examination of the genitalia is done in case of complaints about pain, history of ill-health, recent onset of loss of desire, approaching menopause (in women), age older than 50 (in men), menstrual irregularity (in women), abnormal puberty or if the patient believes a physical cause is most likely.

• The sexual problems encountered by same-sex couples are to a large extent similar to those in opposite sex relationships, and the treatment approaches, as outlined above, are equally appropriate. Obviously, there are likely to be some differences in the relevant factors, resulting from a different dynamic in the relationship.

13. What medical practice is common in sexual behaviour?

• A sexual problem may be the presenting symptom of an illness, or the medical problem may be linked to sexual activity (STD’s for example). In men, sexual problems are often caused by penile problems, prostate disease, chronic pelvic pain syndrome or other causes of pain or abnormalities of pelvic and penile blood flow. In women, sexual problems are often caused by Vulvular vestibulitis syndrome or vulvodynia, chronic pelvic pain, hysterectomy, malignancies (cancer) in the genitalia, or breast cancer.

• Psychiatric issues that may cause sexual problems can be depression, anxiety disorders, schizophrenia and learning disability. General medicinal issues that may cause sexual problems can be diabetes mellitus (both type I and type II), or cardiovascular disease, mostly ischaemic heart disease. Neurologic issues that may cause sexual problems can be epilepsy, multiple sclerosis (MS), Parkinson’s disease, or spinal cord injuries (SCI).

• Medication that may cause sexual problems due to its side effects can be medication for hypertension, psychotropic drugs (anti-depressants and anti-psychotics), or anti-convulsants.

• Drugs of addiction that commonly cause sexual problems are alcohol, opiates (morphine and heroin), cocaine, marijuana and amphetamine.

14. What are sexually transmitted infections and the HIV/AIDS pandemic?

• Scientific understanding of sexually transmitted infections (STIs) started in the late 19^th century, when it was discovered that micro-organisms caused infectious diseases. The big breakthrough in treatment happened with the introduction of penicillin in 1944.

• The story of HIV and AIDS started in 1981, when the first indications were seen of what turned out to be a worldwide pandemic, many people had already become infected before 1980.

• A wide variety of pathogens can be transmitted by sexual activity, the most important being bacteria, parasites, fungi, and viruses.

• The most seen bacterial infection is gonorrhoea. A parasitic infection is trichomonas. A fungal infection is candida albicans. Viral infections are genital herpes, human papilloma virus, hepatitis B and HIV/AIDS.

• Around 15-17% of men and women report at least one lifetime STI, men fewer than women. The strongest predictor was number of life time sexual partners.

• The emphasis in a good HIV/AIDS prevention programme is on monogamy, delaying onset of sexual activity and condom use.

• The individual approach is based on how an individual assimilates information about risk, risks are taken by not correctly evaluating this information. The relation-based approach focuses on the interactive behaviour between the partners in a sexual interaction and the meanings attributed to such behaviour.

• The evidence that circumcision does protect against HIV-infection is becoming persuasive, it seems to protect mostly HIV-negative men from infection by HIV-positive women. However, just circumcision is not sufficient to prevent HIV, it merely reduces the chance of infection.

• Whether someone takes a risk depends on risk appraisal (how much risk does a situation involve?) and risk management (how is the risk actually dealt with when the time comes?).

• In a state of sexual arousal, normal ‘rational’ decision making is impaired, which can lead to more risky behaviour. In heterosexual men, the trait of sexual inhibition was strongly predictive of the number of partners in the past 3 years with whom no condoms were used.

15. What are fertility, fertility control and infertility?

• Factors that may be of influence on sexuality during pregnancy and post-partum can be concerns about harming the fetus; the adjustments needed in the relationship and the couple’s life; pain after giving birth; and mood change/post-natal depression.

• Breastfeeding mothers are less sexually active and have less sexual interest than bottle-feeding mothers, because she likely has ovarian suppression, raised prolactin levels and relative oestrogen deficiency.

• Any method of contraception that substantially alters the enjoyment or interest of the user may cause repercussions in the sexual relationship, this can be both positive or negative. A woman may enjoy sex more if she knows she is safe from unwanted pregnancy.

• Oral contraceptives may reduce libido as a consequence of dyspareunia caused by lowered oestradiol and impaired vaginal lubrication, or more directly by lowering testosterone. They may also adversely affect sexuality through causing changes in mood.

• With all these studies, we have to keep in mind that minimal group changes in either sexuality or mood measures often conceal a considerable variability. There is sufficient evidence across studies of significant proportions of women who show either positive or negative changes in these regards after starting on OCs.

• The most feasible way to suppress fertility in men through hormonal contraceptives is to suppress spermatogenesis by inhibiting LH and FSH, but this is not possible without also suppressing T production. This is very likely to have an adverse effect on the man’s sexuality.

• Sterilisation: in the female, various techniques are used to cut or obstruct the fallopian tubes, most frequently by laparoscopy. In the male, vasectomy is normally carried out under local anaesthetic and is a relatively simple and quick surgical procedure.

• Abortion is mainly seen in either unmarried, nulliparous women (those who have not had children) or women who are married and have already had enough children or wish to space their childbearing.

• The average time required for pregnancy to occur in normal couples not using contraception is 5.3 months. After 1 year of unsuccessful attempts to conceive, a couple may be regarded as potentially infertile.

• Many infertile couples weather the initial stress of infertility and emerge with their relationship in some sense strengthened, but many infertile couples suffer from sexual difficulties, either as a cause or as a result of the infertility.

16. What are sexual offences?

• There are now three categories of sexual assault: (1) rape, involving penetration of the vagina, anus or mouth with a penis, without consent; (2) sexual assault by penetration, involving penetration of the vagina or anus by a body part (finger or tongue), or some object; and (3) less serious sexual assault (without penetration), which has a minimum threshold that the event caused ‘fear, alarm or distress’, this can be touching without consent, indecent exposure or sexual threats.

• Sexual offences against children have three categories, according to the law: (1) offences against children under 13; (2) offences against children under 16; and (3) offences against children under 18.

• In the USA, estimates are that 30-50% of sex offences against children in the 1980s were committed by adolescents. Sexual offenders were most often found to be familiar to the victim.

• The law often imposes ‘cut offs’ by age. However, the age of puberty has fallen and in many pre-industrialised cultures, the age of consent is still based on pubertal stage. This may explain why, in some countries, it is seen as acceptable to have sexual intercourse with a post-pubertal child.

• There are at least three ways in which sexual development can go wrong: (1) the establishment of sexual preferences leading to sexual identity can be derailed during the developmental phase, leading to various patterns of deviant sexual responsiveness; (2) problems during childhood with the ‘dyadic relationship’ strand, a consequence of negative parent-child relationships, result in barriers to intimacy and incorporation of sexuality into a dyadic sexual relationship; and (3) maladaptive patterns of behaviour, evident from early childhood, lead to various types of delinquency during adolescence and early adulthood.

• The psychogenic perspective sees the original trauma and its severity as the key determinants of the final outcome of development. The life-course perspective states that an early negative experience may influence the next stage of development, which then interacts with other factors to determine the next stage, etc.

• In much of the literature, the term paedophile is used to describe any offender against children, while in reality the majority of child molesters does not in fact have a sexual preference towards children.

• Substantial psychological after-effects of rape often occur, influenced by personality and resilience of the victim and characteristics of the situation during and after the rape. Chronic problems may include fear and PTSD, depression, loss of self-esteem, social adjustment problems, sexual problems and anxiety disorders.

• The most effective method of discouraging sexual offences is the threat of legal sanctions, but hormone treatment, pharmacological treatment and psychological treatment can also be used, if the offender still has a tendency towards recidivism.