Normal sexualitySexuality is determined byanatomy,physiology,the culture in which a person lives,relationships with others,developmental experiences throughout the lifecycleNormal sexual behaviour brings pleasure tooneself and ones partner, involves stimulationof the primary sex organs including coitus.
PSYCHOSOICAL FACTORS• Sexuality depends on four interrelated psychosexual factors:sexual identity,gender identity,sexual orientation,sexual behaviour.
Childhood Sexuality• Most sexual learning experiences in childhood occur without the parents knowledge, but awareness of a childs sex does influence parental behaviour.• Male infants, for instance, tend to be handled more vigorously and female infants tend to be cuddled more.
Sexual Identity and Gender Identity Sexual identity is the pattern of a persons biological sexual characteristics: chromosomes, external genitalia, internal genitalia, hormonal composition, gonads, secondary sex characteristics Gender identity is a persons sense of maleness or femaleness.
Differentiation of male and female externalgenitalia from indifferent primordia.Male differentiation occurs only in the presence ofandrogenic stimulation during the first 12 weeks of fetal life.
Virilizing adrenal hyperplasia (adrenogenital syndrome)• Results from excess androgens in fetus with XX genotype; most common female intersex disorder; associated with enlarged clitoris, fused labia, hirsutism in adolescence
Turners syndrome• Results from absence of second female sex chromosome (XO); associated with web neck, dwarfism, cubitus valgus; no sex hormones produced; infertile
Klinefelters syndrome• Genotype is XXY; male habitus present with small penis and rudimentary testes because of low androgen production; weak libido; usually assigned as male
Androgen insensitivitysyndrome (testicular-feminizing syndrome)• Congenital X-linked recessive disorder that results in inability of tissues to respond to androgens; external genitals look female and cryptorchid testes present; in extreme form patient has breasts, normal external genitals, short blind vagina, and absence of pubic and axillary hair
Enzymatic defects in XY genotype (e.g., 5-α-reductase deficiency, 17-hydroxy-steroid deficiency)• Congenital interruption in production of testosterone that produces ambiguous genitals and female habitus
Hermaphroditism• True hermaphrodite is rare and characterized by both testes and ovaries in same person (may be 46 XX or 46 XY)
Pseudohermaphroditism• Usually the result of endocrine or enzymatic defect (e.g., adrenal hyperplasia) in persons with normal chromosomes; female pseudohermaphrodites have masculine- looking genitals but are XX; male pseudohermaphrodites have rudimentary testes and external genitals and are XY
Gender Role• 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,(3) spontaneously putting two and two together to make sometimes four and sometimes five.
• 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
Sexual OrientationSexual orientation describes the objectof a persons sexual impulses:•heterosexual (opposite sex),•homosexual (same sex),•bisexual (both sexes).•A group of people have definedthemselves as asexual and assert this asa positive identity.
Sexual Behavior The Central Nervous System and Sexual BehaviorThe BrainCortex - is involved both in controlling sexualimpulses and in processing sexual stimulithat may lead to sexual activityThe limbic system - is directly involved withelements of sexual functioning. The anteriorthalamic nuclei have all elicited penileerections.
• Brainstem - sites exert inhibitory and excitatory control over spinal sexual reflexes.• Brain Neurotransmitters - including dopamine, epinephrine, norepinephrine, and serotonin, are produced in the brain and affect sexual function. Dopamine - increase libido. Serotonin - inhibitory effect on sexual function.• Spinal Cord Sexual arousal and climax are ultimately organized at the spinal level.
Physiological 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).• A four-phase response cycle:phase 1 - desire;phase 2 - excitement;phase 3 - orgasm;phase 4 - resolution
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
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.
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 mens orgasms. The forceful emission of semen follows• 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
Excitement Orgasmic ResolutionPhase Phase PhaseLasts several 3 to 15 seconds 10 to 15 minutes;minutes to if no orgasm, Â½several hours; to 1 dayheightenedexcitementbefore orgasm,30 seconds to 3minutes
Organ Excitement Orgasmic Resolution Phase Phase PhaseSkin Just before orgasm: Well- Flush sexual flush developed disappears in inconsistently flush reverse order appears; of maculopapular rash appearance; originates on inconsistently abdomen and appearing spreads to anterior film of chest wall, face, and perspiration neck and can include on soles of shoulders and feet and forearms palms of hands
Organ Excitement Orgasmic Resolution Phase Phase PhasePenis Erection in 10 to 30 Ejaculation; Erection: partial seconds caused by emission phase involution in 5 to vasocongestion of marked by three 10 seconds with erectile bodies of corpus to four 0.8-second variable cavernosa of shaft; loss contractions of refractory period; of erection may occur vas, seminal full detumescence with introduction of vesicles, prostate; in 5 to 30 minutes asexual stimulus, loud ejaculation proper noise; with heightened marked by 0.8- excitement, size of second glands and diameter of contractions of penile shaft increase urethra and further ejaculatory spurt of 12 to 20 inches at age 18, decreasing with age to seepage at 70
Organ Excitement Orgasmic Resolution Phase Phase PhaseScrotum and Tightening and lifting of No change Decrease totestes scrotal sac and elevation of baseline size testes; with heightened because of loss of excitement, 50% increase in vasocongestion; size of testes over testicular and unstimulated state and scrotal descent flattening against perineum, within 5 to 30 signaling impending minutes after ejaculation orgasm; involution may take several hours if no orgasmic release takes place
Organ Excitement Orgasmic Resolution Phase Phase PhaseCowpers 2 to 3 drops of mucoid fluid No change No changeglands that contain viable sperm are secreted during heightened excitement
Organ Excitement Orgasmic Resolution Phase Phase PhaseOther Breasts: inconsistent nipple Loss of voluntary Return to baseline erection with heightened muscular control state in 5 to 10 excitement before orgasm Rectum: rhythmical minutes Myotonia: semispastic contractions of contractions of facial, sphincter abdominal, and intercostal Heart rate: up to muscles 180 beats a minute Tachycardia: up to 175 Blood pressure: up beats a minute to 40 to 100 mm Blood pressure: rise in systolic; 20 to 50 systolic 20 to 80 mm; in mm diastolic diastolic 10 to 40 mm Respiration: up to Respiration: increased 40 respirations a minute
Excitement Orgasmic ResolutionPhase Phase PhaseLasts several 3 to 15 10 to 15minutes to seconds minutes; if noseveral hours; orgasm, 1/2 toheightened 1 dayexcitementbefore orgasm,30 seconds to3 minutes
Organ Excitement Orgasmic Resolution Phase Phase PhaseSkin Just before orgasm: Well-developed Flush disappears in sexual flush flush reverse order of inconsistently appearance; appears; inconsistently maculopapular rash appearing film of originates on perspiration on abdomen and soles of feet and spreads to anterior palms of hands chest wall, face, and neck; can include shoulders and forearms
Organ Excitement Orgasmic Resolution Phase Phase PhaseBreasts Nipple erection in Breasts may Return to normal in two thirds of become tremulous about 30 minutes women, venous congestion and areolar enlargement; size increases to one fourth over normal
Organ Excitement Orgasmic Resolution Phase Phase PhaseClitoris Enlargement in No change Shaft returns to diameter of glands normal position in 5 and shaft; just to 10 seconds; before orgasm, detumescence in 5 shaft retracts into to 30 minutes; if no prepuce orgasm, detumescence takes several hours
Organ Excitement Orgasmic Resolution Phase Phase PhaseLabia majora Nullipara: elevate No change Nullipara: decrease and flatten against to normal size in 1 to perineum 2 minutes Multipara: Multipara: decrease congestion and to normal size in 10 edema to 15 minutes
Organ Excitement Orgasmic Resolution Phase Phase PhaseLabia minora Size increased two Contractions of Return to normal to three times over proximal labia within 5 minutes normal; change to minora pink, red, deep red before orgasm
Organ Excitement Orgasmic Resolution Phase Phase PhaseVagina Color change to 3 to 15 contractions Ejaculate forms dark purple; vaginal of lower third of seminal pool in transudate appears vagina at intervals upper two thirds of 10 to 30 seconds of 0.8 second vagina; congestion after arousal; disappears in elongation and seconds or, if no ballooning of orgasm, in 20 to 30 vagina; lower third minutes of vagina constricts before orgasm
Organ Excitement Orgasmic Resolution Phase Phase PhaseUterus Ascends into false Contractions Contractions cease, pelvis; labor-like throughout orgasm and uterus contractions begin descends to normal in heightened position excitement just before orgasm
Organ Excitement Orgasmic Resolution Phase Phase PhaseOther Myotonia Loss of voluntary Return to baseline A few drops of muscular control status in seconds to mucoid secretion Rectum: rhythmical minutes from Bartholins contractions of Cervix color and glands during sphincter size return to heightened Hyperventilation normal, and cervix excitement and tachycardia descends into Cervix swells seminal pool slightly and is passively elevated with uterus
Phase 4: Resolution• Resolution consists of the disgorgement of blood from the genitalia (detumescence), which brings the body back to its resting state.• Women do not have a refractory period and are capable of multiple and successive orgasms.
Hormones and Sexual Behavior• Substances that increase dopamine levels in the brain increase desire, whereas substances that augment serotonin decrease desire.• 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 behaviour.• 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.
homosexuality• The term homosexuality often describes a persons overt behaviour, 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.
Prevalence• 2 to 4 percent of the population• According to Kinseys data, about half of all prepubertal boys have had some genital experience with a male partner.
Theoretical Issues Psychological Factors• According to psychodynamic theory, early-life situations that can result in male homosexual behaviour include, a strong fixation on the mother lack of effective fathering inhibition of masculine development by the parents; fixation at, or regression to the narcissistic stage of development losses when competing with brothers and sisters
New Concepts of Psychoanalytic Factors• According to Richard Isay, gay men have described same- sex fantasies that occurred when they were 3 to 5 years of age, at about the same age that heterosexuals have male- female fantasies.• The childs perception of, and exposure to, these erotic feelings may account for such atypical behaviour as greater secretiveness than other boys, self-isolation, excessive emotionality
Biological Factors• Gay men - lower levels of circulatory androgens• higher incidence of homosexual concordance among monozygotic twins• a familial distribution• a group of cells in the hypothalamus was smaller in women and in gay men• Women with hyperadrenocorticalism are lesbian and bisexual
Sexual Behavior Patterns• The behavioural features of gay men and lesbian women are as varied as those of heterosexuals
Taking a Sex History• Identifying data – Age – Sex – Occupation – Relationship status single, married, number of times previously married, separated, divorced, cohabiting, serious involvement, casual dating (difficulty forming or keeping relationships should be assessed throughout the interview) – Sexual orientation heterosexual, homosexual, or bisexual (this may also be ascertained later in the interview)
Taking a Sex HistoryCurrent functioning•Unsatisfactory to highly satisfactory•If unsatisfactory, why?•Feeling about partner satisfaction
Taking a Sex HistoryDysfunctions?–e.g., lack of desire, erectile disorder, inhibited femalearousal, anorgasmia, premature ejaculation, retardedejaculation, pain associated with intercourse(dysfunction discussed below)–Onset lifelong or acquired – If acquired, when? – Did onset coincide with drug use (medications or illegal recreational drugs), life stresses (e.g., loss of job, birth of child), interpersonal difficulties
Taking a Sex History• Dysfunctions?Generalized occurs in most situations or with mostpartnersSituationalOnly with current partnerIn any committed relationshipOnly with masturbationIn socially proscribed circumstance (e.g., affair)In definable circumstance (e.g., very late at night, inparental home, when partner initiated sex play)
Frequency partnered sex (coital and noncoital sex play)Desire/libido how often are sexual feelings, thoughts, fantasies, dreams, experienced? (per day, week, etc.)
Description of typical sexual interaction • Manner of initiation or invitation (e.g., verbal or physical? Does same person always initiate?) • Presence, type, and extent of foreplay (e.g., kissing, caressing, manual or oral genital stimulation) • Coitus? positions used? • Verbalization during sex? if so, what kind? • Afterplay? (whether sex act is completed or disrupted by dysfunction); typical activities (e.g., holding, talking, return to daily activities, sleeping)
• Sexual compulsivity?• intrusion of sexual thoughts or participation in sexual activities to a degree that interferes with relationships or work, requires deception and may endanger the patient
• Past sexual history• Childhood sexuality Parental attitudes about sex degree of openness of reserve (assess unusual prudery or seductiveness) Parents attitudes about nudity and modesty
Learning about sex From parents? (initiated by childs questions or parent volunteering information? which parent? what was childs age?) subjects covered (e.g., pregnancy, birth, intercourse, menstruation, nocturnal emission, masturbation) From books, magazines, or friends at school or through religious group? Significant misinformation Feeling about information
• Viewing or hearing primal scene reaction?• Viewing sex play or intercourse of person other than parent• Viewing sex between pets or other animals
– Childhood sex activities • Genital self-stimulation before adolescence; age? reaction if apprehended? • Awareness of self as boy or girl; bathroom sensual activities? (regarding urine, feces, odor, enemas) • Sexual play or exploration with another child (playing doctor) type of activity (e.g., looking, manual touching, genital touching); reactions or consequences if apprehended (by whom?)
• Adolescence – Age of onset of puberty development of secondary sex characteristics, age of menarche for girl, wet dreams or first ejaculation for boy (preparation for and reaction to) – Sense of self as feminine or masculine body image, acceptance by peers (opposite sex and same sex), sense of sexual desirability, onset of coital fantasies
• Sex activities Masturbation age begun; ever punished or prohibited? method used, accompanying fantasies, frequency (questions about masturbation and fantasies are among the most sensitive for patients to answer) Homosexual activities ongoing or rare and experimental episodes, approached by others? If homosexual, has there been any heterosexual experimentation? Dating casual or steady, description of first crush, infatuation, or first love Experiences of kissing, necking, petting (making out or fooling around), age begun, frequency, number of partners, circumstances, type(s) of activity Orgasm when first experienced? (may not be experienced during adolescence), with masturbation, during sleep, or with partner? with intercourse or other sex play? frequency? First coitus age, circumstances, partner, reactions (may not be experienced during adolescence); contraception and/or safe sex precautions used
• Adult sexual activities (may be experienced by some adolescents)Premarital sex• Types of sex play experiences frequency of sexual interactions, types and number of partners• Contraception and/or safe sex precautions used• First coitus (if not experienced in adolescence) age, circumstances, partner• Cohabitation age begun, duration, description of partner, sexual fidelity, types of sexual activity, frequency, satisfaction, number of cohabiting relationships, reasons for breakup(s)• Engagement age, activity during engagement period with fiance, with others; length of engagement
Marriage (if multiple marriages have occurred, exploresexual activity, reasons for marriage, and reasons fordivorce in each marriage)•Types and frequency of sexual interaction describe typical sexualinteraction, satisfaction with sex life? view of partners feeling•First sexual experience with spouse when? what were thecircumstances? was it satisfying? disappointing?•Honeymoon setting, duration, pleasant or unpleasant, sexually active,frequency? problems? compatibility?•Effect of pregnancies and children on marital sex•Extramarital sex number of incidents, partner; emotional attachment toextramarital partners? feelings about extramarital sex•Postmarital masturbation frequency? effect on marital sex?•Extramarital sex by partnerâ€”effect on interviewee•Manage trois or multiple sex (swinging)•Areas of conflict in marriage (e.g., parenting, finances, division ofresponsibilities, priorities)
• Sex after widowhood, separation, divorce celibacy, orgasms in sleep, masturbation, non coital sex play, intercourse (number of and relationship to partners), other
• Special issues• History of rape, incest, sexual or physical abuse• Spousal abuse (current)• Chronic illness (physical or psychiatric)• History or presence of sexually transmitted diseases• Fertility problems• Abortions, miscarriages, or unwanted or illegitimate pregnancies• Gender identity conflict (e.g., transsexualism, wearing clothes of opposite sex)• Paraphilias (e.g., fetishes, voyeurism, sadomasochism)
Psychopathology The range of psychopathology that may befound among distressed lesbians and gay menparallels that found among heterosexuals. Some gay men and lesbians with majordepressive disorder may experience guilt and self-hatred that become directed toward their sexualorientation
Love and Intimacy• Mature love is marked by the intimacy that is a special attribute of the relationship between two persons• 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
• Sex and the Law Medicine and the law both assess the impact of sexuality on the individual and society and determine what is healthy or legal behaviour. include abortion, pornography, prostitution, sex education, the treatment of sex offenders, and the right to sexual privacy, among other issues.