Human Sexuality
17.1 Normal Sexuality
Sexuality has been a focus of curiosity and interest to humankind. Throughout history, depictions of sexual behavior have existed, from prehistoric cave drawings through Leonardo da Vinci’s anatomical illustrations of intercourse to current pornographic sites available on the Internet.
Sexuality is determined by anatomy, physiology, the culture in which a person lives, relationships with others, and developmental experiences throughout the life cycle. It includes the perception of being male or female and private thoughts and fantasies as well as behavior. To the average normal person, sexual attraction to another person and the passion and love that follow are deeply associated with feelings of intimate happiness.
Normal sexual behavior brings pleasure to oneself and one’s partner and involves stimulation of the primary sex organs including coitus; it is devoid of inappropriate feelings of guilt or anxiety and is not compulsive. Recreational as opposed to relational sex—that is, sex outside a committed relationship— masturbation, and various forms of stimulation involving other than the primary sex organs constitute normal behavior in some contexts.
SEXUAL IDENTITY AND GENDER IDENTITY
Sexual identity is the pattern of a person’s biological sexual characteristics: chromosomes, external genitalia, internal genitalia, hormonal composition, gonads, and secondary sex characteristics. In normal development, these characteristics form a cohesive pattern that leaves a person in no doubt about his or her sex. Gender identity is a person’s sense of maleness or femaleness. Sexual identity and gender identity are interactive. Genetic influences and hormones affect behavior, and the environment affects hormonal production and gene expression.
Sexual Identity
Modern embryological studies have shown that all mammalian embryos, whether genetically male (XY genotype) or genetically female (XX genotype), are anatomically female during the early stages of fetal life. Differentiation of the male from the female results from the action of fetal androgens; the action begins about the sixth week of embryonic life and is completed by the end of the third month. Recent research has focused on the possible roles of key genes in fetal sexual development. A testis develops as a result of the action of the proteins SRY and SOX9 and an ovary develops in the absence of such action. The DAX1 protein plays a part in the fetal development of both sexes, and the action of the protein WNT4 is needed for the development of the mullerian ducts in the female. Other studies have explained the effects of fetal hormones on the masculinization or feminization of the brain. In animals, prenatal hormonal stimulation of the brain is necessary for male and female reproductive and copulatory behavior. The fetus is also vulnerable to exogenously administered androgens during that period. For instance, if a pregnant woman receives sufficient exogenous androgens, her female fetus possessing ovaries can develop external genitalia resembling those of a male (See Chapter 18, Gender Identity Disorders).
Gender Identity
By 2 to 3 years of age, almost everyone has a firm conviction that “I am male” or “I am female.” Yet, even if maleness and femaleness develop normally, persons must still develop a sense of masculinity or femininity.
Gender identity, according to Robert Stoller, “connotes psychological aspects of behavior related to masculinity and femininity.” He considers gender social and sex biological: “Most often the two are relatively congruent, that is, males tend to be manly and females womanly.” But sex and gender can develop in conflicting or even opposite ways. Gender identity results from a very large series of cues derived from experiences with family members, teachers, friends, and coworkers and from cultural phenomena. Physical characteristics derived from a person’s biological sex—such as physique, body shape, and physical dimensions—interrelate with an intricate system of stimuli, including rewards and punishment and parental gender labels, to establish gender identity.
Thus, formation of gender identity arises from parental and cultural attitudes, the infant’s external genitalia, and a genetic influence, which is physiologically active by the sixth week of fetal life. Although family, cultural, and biological influences may complicate establishment of a sense of masculinity or femininity, persons usually develop a relatively secure sense of identification with their biological sex—a stable gender identity.
Gender Role.
Related to, and in part derived from, gender identity is gender role behavior. John Money and Anke Ehrhardt described gender role behavior as all those things that a person says or does to disclose himself or herself as having the status of boy or man, or girl or woman, respectively. A gender role is not established at birth but is built up cumulatively through (1) experiences encountered and transacted through casual and
unplanned learning, (2) explicit instruction and inculcation, and (3) spontaneously putting two and two together to make sometimes four and sometimes five. The usual outcome is a congruence of gender identity and gender role. Although biological attributes are significant, the major factor in achieving the role appropriate to a person’s sex is learning.
unplanned learning, (2) explicit instruction and inculcation, and (3) spontaneously putting two and two together to make sometimes four and sometimes five. The usual outcome is a congruence of gender identity and gender role. Although biological attributes are significant, the major factor in achieving the role appropriate to a person’s sex is learning.
Research on sex differences in children’s behavior reveals more psychological similarities than differences. Girls, however, are found to be less susceptible to tantrums after the age of 18 months than are boys, and boys generally are more physically and verbally aggressive than are girls from age 2 years onward. Little girls and little boys are similarly active, but boys are more easily stimulated to sudden bursts of activity when they are in groups. Some researchers speculate that, although aggression is a learned behavior, male hormones may have sensitized boys’ neural organizations to absorb these lessons more easily than do those of girls.
Persons’ gender roles can seem to be opposed to their gender identities. Persons may identify with their own sex and yet adopt the dress, hairstyle, or other characteristics of the opposite sex. Or, they may identify with the opposite sex and yet for expediency adopt many behavioral characteristics of their own sex. A further discussion of gender issues appears in Chapter 18.
SEXUAL ORIENTATION
Sexual orientation describes the object of a person’s sexual impulses: heterosexual (opposite sex), homosexual (same sex), or bisexual (both sexes). A group of people have defined themselves as “asexual” and assert this as a positive identity. Some researchers believe this lack of attraction to any object is a manifestation of a desire disorder.
SEXUAL BEHAVIOR
Physiological Responses
Sexual response is a true psychophysiological experience. Arousal is triggered by both psychological and physical stimuli; levels of tension are experienced both physiologically and emotionally; and, with orgasm, normally a subjective perception of a peak of physical reaction and release occurs. Psychosexual development, psychological attitudes toward sexuality, and attitudes toward one’s sexual partner are directly involved with, and affect, the physiology of human sexual response.
Normally, men and women experience a series of physiological responses to sexual stimulation. In the first detailed description of these responses, William Masters and Virginia Johnson observed that the physiological process involves increasing levels of vasocongestion and myotonia (tumescence) and the subsequent release of the vascular activity and muscle tone as a result of orgasm (detumescence). The text revision of the fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines a four-phase response cycle: phase 1, desire; phase 2, excitement; phase 3, orgasm; phase 4, resolution. However, the sexes differ, with men responding in sequential fashion, whereas women may respond out of sequence (e.g., arousal may precede desire) and their response phases may overlap. It is important to remember that the sequence of responses can overlap and fluctuate. In addition, a person’s subjective experiences are as important to sexual satisfaction as the objective physiologic response.
Phase 1: Desire.
The classification of the desire (or appetitive) phase, which is distinct from any phase identified solely through physiology, reflects the psychiatric concern with motivations, drives, and personality. The phase is characterized by sexual fantasies and the desire to have sexual activity.
Phase 2: Excitement.
The excitement and arousal phase, brought on by psychological stimulation (fantasy or the presence of a love object) or physiological stimulation (stroking or kissing) or a combination of the two, consists of a subjective sense of pleasure. During this phase, penile tumescence leads to erection in men and vaginal lubrication occurs in women. The nipples of both sexes become erect, although nipple erection is more common in women than in men. A woman’s clitoris becomes hard and turgid, and her labia minora become thicker as a result of venous engorgement. Initial excitement may last from several minutes to several hours. With continued stimulation, a man’s testes increase 50 percent in size and elevate. A woman’s vaginal barrel shows a characteristic constriction along the outer third, known as the orgasmic platform. The clitoris elevates and retracts behind the symphysis pubis, and as a result is not easily accessible. Stimulation of the area, however, causes traction on the labia minora and the prepuce and intrapreputial movement of the clitoral shaft. Women’s breast size increases 25 percent. Continued engorgement of the penis and the vagina produces color changes, particularly in the labia minora, which become bright or deep red. Voluntary contractions of large muscle groups occur, heartbeat and respiration rates increase, and blood pressure rises. Heightened excitement lasts from 30 seconds to several minutes.
Phase 3: Orgasm.
The orgasm phase consists of a peaking of sexual pleasure, with the release of sexual tension and the rhythmic contraction of the perineal muscles and the pelvic reproductive organs. A subjective sense of ejaculatory inevitability triggers men’s orgasms. The forceful emission of semen follows. The male orgasm is also associated with four to five rhythmic spasms of the prostate, seminal vesicles, vas, and urethra. In women, orgasm is characterized by 3 to 15 involuntary contractions of the lower third of the vagina and by strong sustained contractions of the uterus, flowing from the fundus downward to the cervix. Both men and women have involuntary contractions of the internal and external anal sphincters. These and the other contractions during orgasm occur at 0.8-second intervals. Other manifestations include voluntary and involuntary movements of the large muscle groups, including facial grimacing and carpopedal spasm. Blood pressure rises 20 to 40 mm Hg (both systolic and diastolic), and the heart rate increases up to 160 beats per minute. Orgasm lasts from 3 to 25 seconds and is associated with a slight clouding of consciousness.
Phase 4: Resolution.
Resolution consists of the disgorgement of blood from the genitalia (detumescence), which brings the body back to its resting state. If orgasm occurs, resolution is rapid and is characterized by a subjective sense of well-being, general relaxation, and muscular relaxation. If orgasm does not occur, resolution may take from 2 to 6 hours and may be associated with irritability and discomfort. After orgasm, men have a refractory period that may last from several minutes to many hours; in that period they cannot be stimulated to further orgasm. Women do not have a refractory period and are capable of multiple and successive orgasms.
HORMONES AND SEXUAL BEHAVIOR
In general, substances that increase dopamine levels in the brain increase desire, whereas substances that augment serotonin
decrease desire. Testosterone increases libido in both men and women, although estrogen is a key factor in the lubrication involved in female arousal and may increase sensitivity in the woman to stimulation. Progesterone mildly depresses desire in men and women, as do excessive prolactin and cortisol. Oxytocin is involved in pleasurable sensations during sex and is found in higher levels in men and women following orgasm.
decrease desire. Testosterone increases libido in both men and women, although estrogen is a key factor in the lubrication involved in female arousal and may increase sensitivity in the woman to stimulation. Progesterone mildly depresses desire in men and women, as do excessive prolactin and cortisol. Oxytocin is involved in pleasurable sensations during sex and is found in higher levels in men and women following orgasm.
MASTURBATION
Masturbation is usually a normal precursor of object-related sexual behavior. No other form of sexual activity has been more frequently discussed, more roundly condemned, and more universally practiced than masturbation. Research by Alfred Kinsey into the prevalence of masturbation indicated that nearly all men and three fourths of all women masturbate sometime during their lives.
Longitudinal studies of development show that sexual self-stimulation is common in infancy and childhood. Just as infants learn to explore the functions of their fingers and mouths, they learn to do the same with their genitalia. At about 15 to 19 months of age, both sexes begin genital self-stimulation. Pleasurable sensations result from any gentle touch to the genital region. Those sensations, coupled with the ordinary desire for exploration of the body, produce a normal interest in masturbatory pleasure at that time. Children also develop an increased interest in the genitalia of others—parents, children, and even animals. As youngsters acquire playmates, the curiosity about their own and others’ genitalia motivates episodes of exhibitionism or genital exploration. Such experiences, unless blocked by guilty fear, contribute to continued pleasure from sexual stimulation.
With the approach of puberty, the upsurge of sex hormones, and the development of secondary sex characteristics, sexual curiosity intensifies, and masturbation increases. Adolescents are physically capable of coitus and orgasm, but are usually inhibited by social restraints. The dual and often conflicting pressures of establishing their sexual identities and controlling their sexual impulses produce a strong physiological sexual tension in teenagers that demands release, and masturbation is a normal way to reduce sexual tensions. In general, males learn to masturbate to orgasm earlier than females and masturbate more frequently. An important emotional difference between the adolescent and the youngster of earlier years is the presence of coital fantasies during masturbation in the adolescent. These fantasies are an important adjunct to the development of sexual identity; in the comparative safety of the imagination, the adolescent learns to perform the adult sex role. This autoerotic activity is usually maintained into the young adult years, when it is normally replaced by coitus.
Couples in a sexual relationship do not abandon masturbation entirely. When coitus is unsatisfactory or is unavailable because of illness or the absence of the partner, self-stimulation often serves an adaptive purpose, combining sensual pleasure and tension release. Kinsey reported that when women masturbate, most prefer clitoral stimulation. Masters and Johnson stated that women prefer the shaft of the clitoris to the glans because the glans is hypersensitive to intense stimulation. Most men masturbate by vigorously stroking the penile shaft and glans.
Moral taboos against masturbation have generated myths that masturbation causes mental illness or decreased sexual potency. No scientific evidence supports such claims. Masturbation is a psychopathological symptom only when it becomes a compulsion beyond a person’s willful control. Then, it is a symptom of emotional disturbance, not because it is sexual but because it is compulsive. Masturbation is probably a universal aspect of psychosexual development and, in most cases, it is adaptive.
Several studies found that in men, orgasm from masturbation raised the serum prostate-specific antigen (PSA) significantly. Male patients scheduled for PSA tests should be advised not to masturbate (or have coitus) for at least 7 days prior to the examination.
HOMOSEXUALITY
In 1973 homosexuality was eliminated as a diagnostic category by the American Psychiatric Association, and in 1980, it was removed from DSM. The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) states “Sexual orientation alone is not to be regarded as a disorder.” This change reflects a change in the understanding of homosexuality, which is now considered to occur with some regularity as a variant of human sexuality, not as a pathological disorder. As David Hawkins wrote, “The presence of homosexuality does not appear to be a matter of choice; the expression of it is a matter of choice.”
Definition
The term homosexuality often describes a person’s overt behavior, sexual orientation, and sense of personal or social identity. Many persons prefer to identify sexual orientation by using terms such as lesbians and gay men rather than homosexual, which may imply pathology and etiology based on its origin as a medical term, and refer to sexual behavior with terms such as same sex and male-female. Hawkins wrote that the terms gay and lesbian refer to a combination of self-perceived identity and social identity; they reflect a person’s sense of belonging to a social group that is similarly labeled. Homophobia is a negative attitude toward, or fear of, homosexuality or homosexuals. Heterosexism is the belief that a heterosexual relationship is preferable to all others; it implies discrimination against those practicing other forms of sexuality.
Coming Out
According to Rochelle Klinger and Robert Cabaj, coming out is a “process by which an individual acknowledges his or her sexual orientation in the face of societal stigma and with successful resolution accepts himself or herself.” The authors wrote
Successful coming out involves the individual accepting his or her sexual orientation and integrating it into all spheres (e.g., social, vocational, and familial). Another milestone that individuals and couples must eventually confront is the degree of disclosure of sexual orientation to the external world. Some degree of disclosure is probably necessary for successful coming out.
Difficulty in negotiating coming out and disclosure is a common cause of relationship difficulties. For each person, problems resolving the coming-out process can contribute to poor self-esteem caused by internalized homophobia and lead to deleterious effects on the person’s ability to function in the relationship. Conflict can also arise within a relationship when partners disagree on the degree of disclosure.
LOVE AND INTIMACY
Sigmund Freud postulated that psychological health could be determined by a person’s ability to function well in two spheres, work and love. A person able to give and receive love with a minimum of fear and conflict has the capacity to develop genuinely intimate relationships with others. A desire to maintain closeness to the love object typifies being in love. Mature love
is marked by the intimacy that is a special attribute of the relationship between two persons. When involved in an intimate relationship, the person actively strives for the growth and happiness of the loved person. Sex frequently acts as a catalyst in forming and maintaining intimate relationships. The quality of intimacy in a mature sexual relationship is what Rollo May called “active receiving,” in which a person, while loving, permits himself or herself to be loved. May describes the value of sexual love as an expansion of self-awareness, the experience of tenderness, an increase of self-affirmation and pride, and sometimes, at the moment of orgasm, loss of feeling of separateness. In that setting, sex and love are reciprocally enhancing and healthily fused.
is marked by the intimacy that is a special attribute of the relationship between two persons. When involved in an intimate relationship, the person actively strives for the growth and happiness of the loved person. Sex frequently acts as a catalyst in forming and maintaining intimate relationships. The quality of intimacy in a mature sexual relationship is what Rollo May called “active receiving,” in which a person, while loving, permits himself or herself to be loved. May describes the value of sexual love as an expansion of self-awareness, the experience of tenderness, an increase of self-affirmation and pride, and sometimes, at the moment of orgasm, loss of feeling of separateness. In that setting, sex and love are reciprocally enhancing and healthily fused.
Some persons suffer from conflicts that prevent them from fusing tender and passionate impulses. This can inhibit the expression of sexuality in a relationship, interfere with feelings of closeness to another person, and diminish a person’s sense of adequacy and self-esteem. When these problems are severe, they may prevent the formation of, or commitment to, an intimate relationship.
17.2 Abnormal Sexuality and Sexual Dysfunctions
In the text revision of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), sexual dysfunctions are categorized as Axis I disorders. The syndromes listed are correlated with the sexual physiological response, which is divided into the four phases as described in the preceding section. The essential feature of the sexual dysfunctions is inhibition in one or more of the phases, including disturbance in the subjective sense of pleasure or desire or in the objective performance. Either type of disturbance can occur alone or in combination with others. Sexual dysfunctions are diagnosed only when they are a major part of the clinical picture. They can be lifelong or acquired, generalized or situational, and result from psychological factors, physiological factors, or combined factors. If they are attributable entirely to a general medical condition, substance use, or adverse effects of medication, then sexual dysfunction due to a general medical condition or substance-induced sexual dysfunction is diagnosed.
Seven major categories of sexual dysfunction are listed in DSM-IV-TR: sexual desire disorders, sexual arousal disorders, orgasm disorders, sexual pain disorders, sexual dysfunction caused by a general medical condition, substance-induced sexual dysfunction, and sexual dysfunction not otherwise specified.
Sexual dysfunctions can be symptomatic of biological (biogenic) problems or intrapsychic or interpersonal (psychogenic) conflicts or a combination of these factors. Sexual function can be adversely affected by stress of any kind, by emotional disorders, or by ignorance of sexual function and physiology.
In considering each of the disorders, clinicians need to rule out an acquired medical condition and the use of a pharmacological substance that could account for, or contribute to, the dysfunction. If the disorder is biogenic, it is coded on Axis III unless substantial evidence indicates dysfunctional episodes apart from the onset of physiological or pharmacological influences. In some cases, a patient has more than one dysfunction—for example, premature ejaculation and male erectile disorder.
SEXUAL DESIRE DISORDERS
Sexual desire disorders are divided into two classes: hypoactive sexual desire disorder, characterized by a deficiency or absence of sexual fantasies and desire for sexual activity (Table 17.2-1), and sexual aversion disorder, characterized by an aversion to, and avoidance of, genital sexual contact with a sexual partner or by masturbation (Table 17.2-2). The former condition is more common than the latter and more common among women than among men. Minimal spontaneous sexual thinking or minimal desire for sex ahead of sexual experiences does not necessarily constitute a desire disorder in women, particularly if desire is triggered during the sexual encounter. Low desire has been reported by 10 to 15 percent of women in various countries. In the United States, an estimated 20 percent of persons have hypoactive sexual desire disorder.
A variety of causative factors are associated with sexual desire disorders. Patients with desire problems often use inhibition of desire defensively, to protect against unconscious fears about sex. Sigmund Freud conceptualized low sexual desire as the result of inhibition during the phallic psychosexual phase of development and of unresolved oedipal conflicts. Some men, fixated at the phallic state of development, are fearful of the vagina and believe that they will be castrated if they approach it. Freud called this concept vagina dentata; because men unconsciously believe that the vagina has teeth, they avoid contact with the female genitalia. Equally, women may suffer from unresolved developmental conflicts that inhibit desire. Lack of desire can also result from chronic stress, anxiety, or depression.
Table 17.2-1 DSM-IV-TR Diagnostic Criteria for Hypoactive Sexual Desire Disorder | ||||||||||||||||||||||||||
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Table 17.2-2 DSM-IV-TR Diagnostic Criteria for Sexual Aversion Disorder | ||||||||||||||||||||||||||
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Abstinence from sex for a prolonged period sometimes results in suppression of sexual impulses. Loss of desire may also be an expression of hostility to a partner or the sign of a deteriorating relationship. In one study of young married couples who ceased having sexual relations for 2 months, marital discord was the reason most frequently given for the cessation or inhibition of sexual activity.
The presence of desire depends on several factors: biological drive, adequate self-esteem, the ability to accept oneself as a sexual person, previous good experiences with sex, the availability of an appropriate partner, and a good relationship in nonsexual areas with a partner. Damage to, or absence of, any of these factors can diminish desire.
In making the diagnosis, clinicians must evaluate a patient’s age, general health, and life stresses and must attempt to establish a baseline of sexual interest before the disorder began. The need for sexual contact and satisfaction varies among persons and over time in any given person. In a group of 100 couples with stable marriages, 8 percent reported having intercourse less than once a month. In another group of couples, one third reported episodic lack of sexual relations for periods averaging 8 weeks. Married couples have coitus three times a month, on average. The diagnosis should not be made unless the lack of desire is a source of distress to a patient.
SEXUAL AROUSAL DISORDERS
The sexual arousal disorders are divided by DSM-IV-TR into female sexual arousal disorder, characterized by the persistent or recurrent partial or complete failure to attain or maintain the lubrication-swelling response of sexual excitement until the completion of the sexual act (Table 17.2-3), and male erectile disorder, characterized by the recurrent and persistent partial or complete failure to attain or maintain an erection to perform the sex act (Table 17.2-4). The diagnosis takes into account the focus, intensity, and duration of the sexual activity in which patients engage. If sexual stimulation is inadequate in focus, intensity, or duration, the diagnosis should not be made.
Table 17.2-3 DSM-IV-TR Diagnostic Criteria for Female Sexual Arousal Disorder | ||||||||||||||||||||||||||
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Female Sexual Arousal Disorder
The DSM-IV-TR defines female sexual arousal disorder in terms of the physiological arousal response. A subjective sense of arousal is often poorly correlated, however, with genital lubrication in both dysfunctional and normal women. A woman complaining of lack of arousal may lubricate vaginally but may not experience a subjective sense of excitement. Some studies using functional magnetic resonance imaging have revealed a low correlation between brain activation in areas controlling genital response and simultaneous ratings of subjective arousal.
Table 17.2-4 DSM-IV-TR Diagnostic Criteria for Male Erectile Disorder | ||||||||||||||||||||||||||
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