Lecture notes with Sexology at Leiden University

Lecture 1, What are the general topics covered by Sexology and what is the History of Sexology?

In the book, different theories on sexuality are described. The psychological theories that are mentioned are psychoanalytic theories, learning theories and cognitive theories. The book focuses on criticism on these theories as well. Evolutionary and sociological theories are described as well.

What is sexuality?

Sexuality is a central aspect of human being throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sex has different functions: Procreation (fertility), relationship (bonding of individuals, intimacy, confirmation of being human/a man/a woman), or recreation (pleasure, relaxation, dealing with emotions, et cetera). Sexuality evolves around psychological factors, biological/physical factors, and social factors. They all have influence on sexuality and they influence one another (the bio-psycho-social model of sexuality). Sexology is the scientific interdisciplinary study of sexuality.

What is the sexual health perspective?

Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; and it is not merely the absence of disease, dysfunction or disability. Sexual health is the ability to sexually adapt and self-manage in the face of life’s physical, psychological and social challenges.

What is our perception of sexuality?

Values and norms influence how people view sexual behavior, desires, and also problems. Sexuality has time- and culture-specific issues. For example, in the 18^th century, masturbation was perceived as a cause for disease. However, in the 20^th century, we started to perceive masturbation as an effective treatment; in this case to solve female orgasmic disorders. Sigmund Freud was the first to make the transition to a more scientific study of sexuality. His ideas on sexuality, though nowadays controversial, are and have been influential.

What are the general ideas of Freud?

Freud introduced the term libido; it is the subjective experience of a physical need for sex. According to Freud, the libido is fuelled by the sexual instincts. “Its source is a state of excitation in the body”. A sexual instinct was, according to him, an internal mechanism. Freud perceived it as a constant force in the body. This drive pushes one towards sexual activity. Freud also described several stages of development: The pre-genital stages; the oral, anal and phallic/oedipal stages (1-6 years), the latency stage (6-12 years), and the genital stage (from 12 years onwards). Freud received a lot of criticism because of the following ideas: He claimed that sexual pleasure is transferred from the clitoris to the vagina. A healthy woman was presumed to experience a vaginal orgasm. If a woman could only have a clitoral orgasm, this would be a sign of dysfunction. Nowadays, we know that the bodily response during a clitoral and vaginal orgasm are in fact the same.

What are were other first studies of sexuality?

Marie Bonaparte, a patient of Freud, was unable to reach a vaginal orgasm. She researched the distance between the clitoris and vagina. The smaller the distance between the two, the easier a female would be able to get a vaginal orgasm. Haldan performed clitoris relocation surgeries based on this idea. In the early 1900s, there were a lot of German psychiatrist involved in sexology; Krafft-Ebing, Bloch, and Hirschfeld. Research was primarily focused on case studies. There was a common belief in a universal sexual instinct. It was also thought that sexual deviations were a result of a disease (a medical point of view). After WW-II, there were a lot of important developments in the US in the field of sexology. Kinsey was the first researcher to conduct a large-scale interview research on the topic of sexuality. He collected a lot of data and reported his results in his books Sexual Behavior in the Human Male and Sexual Behavior in the Human Female. Until the third version of the DSM of 1974, homosexuality was considered a mental disorder. 

What was the case of David? 

John Money was a psychologist who studied the development of gender identity in children. He was convinced that this development is a matter of learning from the environment; nurture rather than nature. John Money studied the case of David, who was born as Bruce, but due to a failed circumcision surgery, was raised as Brenda. David was very unhappy. When David found out, he decided to transition to a male again. The case of David proved that gender identity is in fact also dependent on nature, and not only nurture. We should not conclude that gender transition will always be unsuccessful: The case of David is different from intersex children; because the abnormalities in intersex children already occur in the womb. David was a ‘regular’ boy. Nowadays, transition surgeries are often postponed until adulthood.

What was the research by Masters and Johnson about?

Masters and Johnson were the first to conduct psychophysiological laboratory research towards sexual responses. They studied the human sexual response cycle by observing and measuring responses in people who performed sexual actions in their lab. Masters and Johnson discovered that there are a variety of possible sexual responses; dependent on the person and the situation. Masters and Johson developed a three-step sex therapy for couples to resotre the natural sexual response: 1) non-genital touching, 2) touching with genitals, 3) coitus position and movement. Masters and Johnson were convinced that a sexual problem was the result of a problem of the couple; and not just the individual.

What did the first studies towards female sexuality discover?

Helen Singer Kaplan was an American therapist. She used integration of psychodynamic orientation together with behavioral therapy. She noticed that problems with sexual desire are quite common. Based on her studies; the human sexual response cycle was extended by adding a desire phase. It was one of the first more feminist approaches to sexuality. Lonnie Barbach wrote many self-help books for females, and she designed a group therapy for women with orgasm problems (1974). She believed that many women who are unable to reach orgasm, are in fact having problems with the pre-orgasmic stage; they do not know what stimulation they find pleasurable. Bernie Zilbergeld wrote a male self-help book and designed group therapy for males with sexual dysfunction. He came up with the so-called sexual myths; biased ideas about male sexuality. Susan Brownmiller put emphasis on power mechanisms within sexuality. She wrote about differences in power between men and women and how this can affect sexuality. She also focused on sexual abuse. This was also a feminist approach. Shere Hite interviewed 3000 women about their sexual experiences. Her focus was to reduce black-and-white ideas about normal and abnormal sexual experiences; she collected very diverse stories.

What is the sexual scripting theory?

The sexual scripting theory by Gagnon and Simon states that sexual behavior is social role behavior, generated by culturally determined scripts. A script is a scenario that defines a situation as sexual, designates the actors and specifies roles. A script distinguishes two dimensions: 1) an interpersonal dimension; through which people interact sexually, and 2) an intrapsychic dimension; through which a person has a psychological interpretation of sexuality, a schema, and strives for specific sexual behavior. This theory puts a lot of emphasis on the influence of culture and environment; stating that it affects the way people behave.

What is the sexual strategy theory?

David Buss came up with the sexual strategy theory; related to evolutionary psychology. This theory states that there are different mating strategies, which can be divided into short-term and long-term strategies, and differ between men and women. For men, it can be adaptive to have sex in short-term relationships; they spread their genes effectively. For women, it is more adaptive to be more selective in their partner choice; because of the greater investment and risk of becoming pregnant. Together with Meston, Buss researched the reasons for having sex.

What is the dual control model of sexuality?

John Bancroft came up with the dual control model: It states that the sexual response is dependent on the central excitatory mechanism and the central inhibitory mechanism. Some psychosocial or physical factors are stimulating for sex, others are inhibiting.

What are recent theories and development in the field of sexuality?

More recently, there is a lot of attention for the role of mass media in sexuality. Cultivation is the idea that people begin to think what they see on television and other media represents the mainstream of what happens in our culture. Agenda setting is the idea that reporters select what they report, what they ignore, and what they emphasize. Social learning is the idea that people learn about sex and gender in part by imitation and identification.

Viagra was a recent invention to treat erectile dysfunction. It was the first medicine for sexual dysfunction. Nowadays, pharmaceutical companies are trying very hard to come up with medication for female sexual dysfunction as well. However, we should remember that taking a pill is not the only solution to sexual problems; as these are dependent on social and psychological factors as well. Very recently, a female libido pill was invented. There is a lot of discussion about the efficacy, risks and cons to this new drug. Another “hot topic” nowadays is the discussion about sexual and gender identity disorders. 

In clinical practice, we look for a balance in the bio-psycho-social model of sexuality.

Bullet-point summary:

• Sexuality evolves around psychological factors, biological/physical factors, and social factors. They all have influence on sexuality and they influence one another (the bio-psycho-social model of sexuality).
• Sexuality has time- and culture-specific issues.
• Sigmund Freud was the first to make the transition to a more scientific study of sexuality. He introduced the terms libido, the stages of development (pre-genital, latent and genital stages), and studied the relationship between clitoral and vaginal orgasms.
• German psychiatrists in the early 1900s believed in a general sexual instinct, and thought that sexual deviations were caused by disease.
• Kinsey was the first to conduct a large-scale interview study.
• John Money studied gender identity development in children. The case of David was an example: Bruce (m) transitioning to Brenda (f), and then again to David (m).
• Masters and Johnson were the first to conduct laboratory research towards sexual responses in couples and through their results, they came up with the human sexual response cycle. They devised a three-step treatment to solve sexual problems.
• Through the research of Kaplan, the sexual response cycle was extended with a desire-phase.
• The sexual scripting theory by Gagnon and Simon states that sexual behavior is social role behavior, generated by culturally determined scripts.
• John Bancroft devised the dual control model; stating that sexuality is influenced by excitatory and inhibiting factors.
• More recently, the role of mass media in sexuality is a hot topic. Cultivation, agenda setting, and social learning are important processes.

Five questions:

• What topics are covered in this lecture?

This lecture covers the very first theories of sexuality, and primarily the theories of Freud and the development of sex research. Contemporary theories of sexuality were also covered. The term sexuality is explained.

• What topics are covered that are not included in the literature?

n.a.

• What recent development are discussed?

The contemporary theories of sexuality are discussed and compared to the traditional theories of sexuality.

• What remarks are made about the exam?

No specific remarks were made about the exam.

• What questions are discussed that may be included in the exam?

The contents of this lecture were very similar to those of the chapters in the book; so it's important to know everything.

Lecture 2, What Sexual Disorders do we distinguish in Men: Diagnosis and Treatment

We watched a scene from the Netflix series ‘Sex Education’; in which a boy told he was having problems with getting erections. We discussed whether Viagra would be a good treatment option.

What sexual disorders are included in the DSM-V?

Sexual problems that are included in the DSM-V are sexual dysfunction, sexual problems due to use of substances, and paraphilia. For a diagnosis with sexual dysfunction, one must meet several criteria: The problems must cause significant distress, they occur in 75-100% of the occasions, the problems have a minimum duration of 6 months, and they not attributable to another disorder, and/or severe relationship distress, and/or the effects of medication or substances. 

There are different subtypes of sexual dysfunctions in the DSM-V. We make a distinction between lifelong and acquired sexual dysfunction. We also distinguish generalized and situational problems. We can also classify sexual disorders based on its severity; mild, moderate or severe.The different sexual dysfunctions in men are male hypoactive sexual desire disorder, erectile disorder, delayed ejaculation, premature ejaculation, other specified sexual dysfunction (sexual aversion, hyperactive sexual desire), body dysmorphic disorder, unspecified sexual dysfunction. 

How do drugs and medication influence male sexual behavior?

Psychiatric medication are often reported to have sexual problems as a side effect. Drugs such as cocaine, alcohol, MDA, XTC and GHB usually cause an increase in disinhibition in sexual behavior. Low sexual desire has a high correlation with depression. Sometimes it is difficult to distinguish whether problems with sexual desire stem from a true disorder, or the side effects of medication. 

What is male hypoactive disorder?

We reviewed the case of John; who is a male who never takes the initiative to have sex with his girlfriend. He has no sexual desire at all. We discussed what his diagnosis would be; which is probably a sexual desire disorder. Male hypoactive disorder is the persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. In assessment of this disorder must take into account factors such as age and lifestyle. A sexual response requires adequate sexual stimulus, genital response; a subjective experience of arousal, good situational factors, and physiological sensitivity (for which androgenic hormones and neurotransmitters are responsible).

What is the role of testosterone in male sexual behavior?

Testosterone plays an important role in sexual behavior. Testosterone is produced in the testes. The production is regulated by the pituitary gland that secretes LH and FSH. The level of testosterone peaks at age 35; which is the point from which it slowly declines. Testosterone makes the system ready for sexual activity. A minimum level of testosterone is already sufficient in order to function sexually. Low levels of testosterone can be caused by a disturbance in testosterone regulation in the hypothalamus, congenital functional disorders affecting the testicles, prolactinoma (a benign tumor in the pituitary gland), or late-onset hypogonadism. We discussed whether in the case of John, we would test for his testosterone level. This is quite a good approach; since sexual desire is dependent on testosterone.

When does the tendency to act occur?

Sexual stimuli in combination with sufficient physiological sensitivity can lead to the tendency to act. This tendency is subject to regulation; excitation and inhibition. These processes determine whether the tendency to act eventually leads to sexual activity.

Why do people have sex?

Meston and his colleagues researched the reasons for people to have sex (2007). The most frequently mentioned reasons to have sex are pleasure, wishing to orgasm, or intimacy and affection with a partner.

How are male sexual disorders treated clinically?

In diagnosing, the practitioner often uses physical measurement and discusses the sexual and medical history of the client. Treatment options could be testosterone supplements, sexual counseling, or both of these combined. Testosterone supplements in men with androgen insufficiency leads to improvement in the number of sexual fantasies, increased sexual arousal and desire, more spontaneous nocturnal and morning erections, increased sexual activity (as well as during masturbation as with sex with the partner), and an increased number of orgasms. Sex counseling, on the other hand, targets life-style changes (for example exercise), it aims to break the pattern of avoidance behavior (by looking for sexual cues, through porn for example, and sensate focus therapy for couples; during which there is a focus on sexual responses and erogenous zones), it focuses on cognitive restructuring (Rational Emotive Therapy), and it can implement couple therapy (including communication exercises).

What is erectile disorder and what causes it?

Secondly, we discussed the case of Bill. He has difficulty maintaining an erection, and if he manages to do so; he often suffers from premature ejaculation. Bill probably suffers from erectile dysfunction. The criteria for erectile disorder are 1) a marked difficulty in obtaining an erection during sexual activity, 2) marked difficulty in maintaining an erection, and 3) a marked decrease in rigidity. The prevalence of the disorder increases with age.

Trauma, a pelvic surgery, neurological or hormonal diseases, alcohol or drug use, age, cardiovascular diseases, hyperlipidemia, diabetes mellitus, side effects of medication, and smoking are all biological and physical risk factors for developing an erectile disorder. Erotophobia is the learned negative sexual attitude towards sexuality. Poor interpersonal relationships, a lack or communication and erotophobia form social risk factors for developing an erectile disorder (ED). Temporary episodes of stress, psychopathology, negative cognitive schemas, and fear of failure are psychological risk factors for developing ED. 

Barlow and his colleagues (1983; 1986) found that men with erectile disorders show negative affect in relation to sexuality, they underreport their level of sexual arousal, they have reduced perception of control in relation to sexual arousal, they are easily distracted by performance-related stimuli, and they show increased anxiety that inhibits their sexual arousal. The conclusion that we can draw from this is that the selective attention of men with erectile problems focuses on performance-related, task-irrelevant and therefore non-sexual cognitions. So, men with ED may have an attention bias. This selective attention increases when the pressure to perform increases, causing a decrease in attention to sexually arousing stimuli and a decrease in sexual arousal; a communication bias.

Cognitions, biological factors and relational factors influence the explicit or implicit demands for sexual performance; for example, the ability to have an erection. Apparently Bill drinks a lot of alcohol and uses drugs every now and then. His focus during masturbation is not sexual pleasure, but rather checking whether everything is working.

How do we assess the cause of an erectile disorder?

To determine whether erectile problems have an organic or psychogenic cause, practitioners have interviews with their client. They can also do a nocturnal penile tumescence (NPT) measurement; which registers erections that occur overnight. When the erectile problems have an organic cause; erections will also not occur during sleep. When there is a psychogenic cause; the NPT does register erections.

What are treatment options for erectile disorder?

Treatment options for erectile disorder are for example medication: Sildenafil (viagra), tadalafil (cialis), and vardenafil (levitra) all increase the quantity and quality of erections). Injection therapy is another treatment option. Androskat is injected into the penis; and it helps to relax the muscles. MUSE is injected into the urethral system; directly in the tip of the penis. A penile prosthesis can also be placed into the penis. With a surgery, malleable bars are placed against the penis and a pump; to straighten these bars, is implanted in the testes. This is a pretty permanent therapy; so it is generally one of the last options. Sex therapy is another treatment option. It includes formulation of goals, psychosexual education, relaxation training, sensate focus exercise, communication about sex, step-by-step introduction to intercourse, cognitive interventions. 89% of men improve from using Viagra. After drug therapy has stopped, 66% of men experience lasting gains.

What is premature ejaculation?

The average time after which a man ejaculates is 5.4 minutes after vaginal intercourse has started. Medical therapy targets premature ejaculation with SSRIs, dapoxetine, or local anesthetic creams. Sex therapy is usually implemented as well: It includes discussing goals, prohibition of coitus, pelvic floor muscle relaxation exercises (as an ejaculation control technique), stop-start exercises, acclimatization, cognitive therapy (RET), and communication about sex.

What is delayed ejaculation?

Case 3 was about Frank; who is currently having trouble ejaculating during intercourse. This is difficult for him and his partner, since they want to have children. This affects his sexual arousal and desire as well. We can probably diagnose Frank with delayed ejaculation. The criteria are 1) a marked delay in ejaculation, 2) infrequency or absence of ejaculation, and 3) it occurs in 75-100% of occasions. Causes are sometimes physical (because of spinal cord injury) and psychological. There can be a variety of additional factors. Treatment of anorgamsia (another term for delayed ejaculation) is targeted at increasing sexual arousal. 

What other problems with orgasming in males do we distinguish?

Others orgasm problems are unspecified sexual dysfunctions. These can be retrograde ejaculation (orgasm but no ejaculation; the ejaculate ends up in the bladder), anhedonic ejaculation (ejaculation but no orgasmic feeling), or post-orgasmic illness syndrome (characterized by exceptional fatigue and exhaustion after orgasm).

Bullet-point summary:

• This lecture focused on different sexual disorders that occur in men. 
• Different sexual problems have been included in the DSM-V: sexual dysfunction, sexual problems due to substance (ab)use, and paraphilia.
• For a diagnosis with any of these, one must meet several criteria: The problems must cause significant distress, they occur in 75-100% of the occasions, the problems have a minimum duration of 6 months, and they not attributable to another disorder, and/or severe relationship distress, and/or the effects of medication or substances.
• We distingsuish lifelong and acquired problems, generalized and situational problems, and differentiate between severity rates.
• Male hypoactive disorder is the persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. 
• A sexual response requires an adequate sexual stimulus, the subjective experience of arousal, good situational factors, and physiological sensitivity.
• Testosterone plays an important role in sexual behavior. A low level of testosterone can be causing male hypoactive disorder. Treatment using testosterone supplements and sex counseling are effective.
• Erectile disorder is characterized by a marked difficulty in obtaining an erection, maintaining it, and a marked decrease in rigidity. 
• Men with an erectile disorder often show negative affect in relation to sexuality.
• The sexologist is interested in whether the erectile disorder has an organic or a psychogenic cause. This can be measured using NPT.
• Treatment options are medication, such as Viagra, injection therapy, penile prothesis, and sex therapy.
• Premature ejaculation is when ejaculation occurs too quickly. It is rather subjective.
• Delayed ejaculation is characterized by a marked delay in ejaculation, infrequency or absence of it.
• There are other types unspecified sexual dysfunctions; retrograde ejaculation, anhedonic ejaculation, and post-orgasmic illness syndrome.

Five questions:

• What topics are covered in this lecture?

This lecture covers the different sexual disorders that are distinguished in males. It describes the symptoms, the causes, process of diagnosis and possible treatment options.

• What topics are covered that are not included in the literature?

This lecture includes different cases of men with different sexual disorders. The book does not describe these exact cases, although they will be very useful for the exam.

• What recent development are discussed?

No specific recent developments were discussed.

• What remarks are made about the exam?

For the exam, it is important to get familiar with case stories of sexual disorders and recognize them.

• What questions are discussed that may be included in the exam?

Examples of case stories were discussed; which will likely be useful on the exam.

Lecture 3, What Sexual Disorders do we distinguish in Women: Diagnosis and Treatment

Most of the female sexual complaints that the lecturer comes across in her practice are related to pain.

What female sexual disorders are distinguished in the DSM-V?

The female sexual disorders that are described in the DSM-V are 1) sexual desire disorders (hypoactive sexual desire and sexual aversion), 2) sexual arousal disorder (lubrication problem), 3) orgasmic disorders (anorgasmia), 4) sexual pain disorders (dyspareunia and vaginismus). All these problems should cause significant suffering and distress or relational problems. The disorder should not better be explained by another mental disorder or be a consequence of another somatic complaint. All these disorders can be lifelong or acquired, and generalized or situational. There is a high comorbidity between all different female sexual disorders. For men, there is a way lower comorbidity.

What is hypoactive sexual desire disorer?

We discussed the case of Mrs. Baker. She is not interested in having sex anymore, which also leads to relational problems. Hypoactive sexual desire disorder is the persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity. The judgment of deficiency should be made by the clinician, taking into account factors that affect sexual functioning; such as age and the context of the person’s life. It is hard to determine what frequency of sexual behaviors is normal. There are gender differences in sexual desire: Compared to women, men masturbate more often. Men fantasize about sex more often, experience sexual desire more often, and report fewer problems of a lack of sexual desire.

What is sexual arousal disorder?

Sexual arousal disorder is the persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication. When females become older, they experience less sexual desire; but this does not cause distress. Freud’s drive theory states that sexual desire comes spontaneously, from within. Nowadays, the incentive motivation model states that desire emerges through the interaction of a sensitive sexual system with stimuli that promise. So, first the system should be activated. Then, an adequately sensitive system should lead to physical arousal. Physical arousal and desire are different things, but as one increases, the other does as well.

What is sexual arousal disorder?

Sexual Interest / Arousal Disorder (DSM-V) is characterized by 1. absent or diminished interest in sexual activity; 2. absent or diminished sexual thoughts or fantasies, 3. no or reduced responsiveness to partner’s attempt to initiate sexual acitivity, 4. absent or diminished sexual excitement/pleasure during sexual acctivity. 5. absent or diminished sexual interest/arousal in response to any internal or external sexual cues, and 6. absent or diminished genital and non-genital sensations during sex. One should meet at least 3 of these criteria, they must be present for at least 6 months, it should cause distress in the women, not be due to another disorder, and cause severe relational problems.

What leads to motivation to have sex?

Men report that feeling attracted and experience pleasure is the primary reason to have sex. Showing love and experience intimacy is the primary reason for women to have sex. Basson (2001) came up with a sexual motivation model. There should be willingness to be receptive to sexual stimuli. Then, sexual stimuli can come across. Biological and psychological factors influence the processing of these stimuli. When a physical response occurs, this leads to arousal and desire, which leads to sexual satisfaction and possibly orgasm, and it leads to non-sexual rewards; emotional intimacy. Memory of positive sexual experiences leads to increased willingness to be receptive to sexual stimuli. Biological factors that influence arousability are: 1) hormone levels (oestrogen and androgens), 2) somatic diseases, and 3) medication.

When is a women aroused?

A laboratory study by Laan and Jansen (2002) towards medically healthy women with sexual arousal disorder studied genital and subjective responses to an erotic film. The physical assessment is conducted through a photoplethymograph. It was found that the body reacts rather automatically to sexual cues. Subjective sexual responses were measured by questions towards sexual arousal, genital sensations, lust, pleasure, shame and disgust. It was found that there is no difference between groups in genital response, however there were less feelings of sexual arousal and more negative emotion in patients of sexual arousal disorders. There was found no evidence for diminished sexual arousability in somatically healthy women with sexual arousal/interest disorder. Women are not able to recognize their genital response. A stimulus leads to a genital response and independently is can also lead to sexual arousal. Men are able to recognize their genital response, after which sexual arousal can occur. When a woman says that she is sexually aroused, she thus means that the present situation is sexually appealing to her. In the case of Mrs Baker, both partners had little time for each other. The sexual desire problem was probably related to a lack of time together; so a lack of situations in which desire could occur.

What are factors influencing female sexual desire?

Psychological factors that are involved in sexual desire: 1) negative opinions and attitudes regarding sex, 2) negative sexual experience, 3) mood, 4) stress, 5) fear of failure, 6) negative body image, 7) relationship dissatisfaction. Desire and arousal problems depend on the sensitivity of the sexual system; dependent on hormones, diseases and medication. Possible intervention can be changing the medication or taking a lust pill. However, the relational context is also crucial in desire and arousal problems. Masters and Johnson advised clients with relational problems to first fix those, after which they could come back if sexual problems persisted. Possible intervention could be partner therapy, in which it is aimed to cease the pattern of pushing and avoiding,  promote positive intimate experiences, improve ocmmunication, discuss negative feelings, negotiate wishing and desires. An example is sensate focus therapy; in which there is a step-by-step increase in intimate actions. Desire and arousal problems also depend on the presence of stimuli. Is there adequate sexual stimulation? Do they have a positive meaning for the partner? What is the sexual history? Does habituation or boredom maybe occur? Intervention aims at cognitive restructuring.

What is sexual aversion disorder?

Sexual aversion disorder is characterized of persistent or recurrent extreme aversion to, and avoidance of , all (or almost all) genital sexual contact with a sexual partner. There is no tendency to engage in sexual actions, and no experience of arousal or desire. Females who suffer from this disorder often have negative sexual experiences, come from a more orthodox religious upbringing, received negative messages about sex during childhood. Treatment is focused on potential traumas, for example through EMDR therapy. Then, further sex therapy is implemented; cognitive behavioral therapy.

What is female orgasmic disorder?

We reviewed the cases of Suzan. She has never experienced an orgasm. Orgasmic disorder is characterized by a marked delay in and a marked infrequency or absence of orgasm. It can also be a marked reduced intensity of orgasmic sensations. It has to occur for a period of longer than 6 months and cause significant distress. An orgasm is “a transient peak sensation of intense pleasure, creating an altered state of consciousness, usually accompanied by involuntary, rhythmic contraction of the pelvic floor, uterus, and anus, that resolve the sexually-induced vasocongestion, usually with the induction of well-being and contentment”. Women can have complaints in several of these areas. There is a lot of variation in orgasmic complaints in females. Some orgasmic disorders are generalized, whereas others are situational. There is also a distinction between lifelong and acquired disorders.

What are the possible factors involved in orgasmic complaints?

Somatic factors that can be involved in orgasmic complaints are 1) damage to the central nervous system, spinal cord, or peripheral nerves, 2) there is no systematic associated with hormone levels, 3) medication. Psychosocial factors can be religiousness, feeling of guilt regarding sex, negative feelings towards sexual stimuli, fear of losing control, inability to focus on own physical sensation, negative interaction with the partner, a lack of communication.

How can orgasmic disorder be treated?

A possible treatment is step-by-step directed masturbation. This treatment is based on learning how to reach high arousal and possibly, consequently, orgasm. There is attention for cognitive restructuring. The steps in directed masturbation are: 1. body exploration, 2. exploration of sexual stimulation (exploration of the genitals by touching, pelvic floor exercises, sexual fantasies and enhancing sexual feelings by reading erotic books or watching erotic films), 3. overcoming fear of losing control (role-playing orgasm, and education to direct attention to yourself), and 4. assertiveness in partner sex (education of the partner about female anatomy and sexuality, sensate focus exercises, encourage self-touching during partner sex, stop focus at simultaneous orgasm). 

What is sexual pain disorder?

In the DSM-IV, sexual pain disorder was either a case of dyspareunia or vaginismus. However, there is also a group of women who experience volvodynia (chronic vulvair pain), which affects sex as well. In the DSM-V, vaginismus and dyspareunia combined are now named genito-pelvic pain / penetration disorder. It is characterized by 1. pain during vaginal penetration/intercourse, 2. vaginal or pelvic pain during penetration or attempt at penetration, 3. fear or anxiety about pain in anticipation of or during vaginal penetration, 4. tightening or tensing of the pelvic floor muscles during attempted penetration. You only need to meet one of these criteria to be diagnosed with the disorder. Provoked vestibulodynia (PVD) is characterized by a painful experience by only touching the vagina. The pain is located around the entrance of the vagina and provoked by pressure. 

What factors are possible involved in sexual pain disorder?

Psychosexual, cognitive/emotional, bio-medical and interpersonal factors can all be involved in dyspareunia. Half of the women started suffering from dyspareunia after an infection. The circle of pain is an explanatory model. Pain leads to catastrophizing thoughts, leading to pain-related fear, which leads to a lack of sexual desire (possibly also of the partner), decreased arousal, and increased muscle tension. This leads to decreased lubrication and increased pelvic floor muscle tension, leading to mechanical friction. This leads to irritation of the vulvar skin, leading to pain again. This circle continues. Women with PVD suffer from fear. Fear increases pelvic floor activity. Some women with the disorder even suffer from a constant higher activity of the pelvic floor muscles.

How is sexual pain disorder clinically assessed and treated?

When we look at a possible case of PVD, we want to know whether the pain occurs in other situation as well, whether it is acquired of lifelong, we want to know if intercourse is physically possible or has ever been possible, we want to know about the cognitive, emotional and behavioral consequences, we want to know how the relationship is affected, we want to know the medical history and previous treatments, and we want to know about current and past bowel and bladder functioning. These questions are all part of clinical assessment. Next to clinical assessment, we also do medical and psychosexual assessment.

Treatment options for PVD include medication, pain relievers, surgery, CBT, and physiotherapy. We tend to prefer CBT over surgery. Factors that can limit the effectiveness of CBT are severe psychopathology, relational problems, and PTSD related to touch. The goal of CBT is to reduce pain and focus on the relationship.

Bullet-point summary:

• During the anamnesis, make sure that all potential factors have been addressed before reaching a DSM diagnosis of the complaints.
• For women, the situational context and the relationship are very important in the experience of sexuality.
• In practice, time will tell what consequences the changes in the DSM-V will have for the clinical situation and in the area of research.
• We discussed the different sexual disorder that occur in females; sexual desire disorders, sexual arousal disorders, sexual pain disorders, and orgasmic disorders. We talked about the symptoms of each of these disorders, models relating to these disorders, treatment, and diagnosis.

Five questions:

• What topics are covered in this lecture?

This lecture covers the different sexual disorders that are distinguished in females. It describes the symptoms, the causes, process of diagnosis and possible treatment options. This lecture, in contrast to the one about male sexual disorders, also focused a lot on the cognitive processes involved in the maintenance of the disorder.

• What topics are covered that are not included in the literature?

This lecture includes different cases of women with different sexual disorders. The book does not describe these exact cases, although they will be very useful for the exam.

• What recent development are discussed?

No specific recent developments were discussed.

• What remarks are made about the exam?

For the exam, it is important to get familiar with case stories of sexual disorders and recognize them.

• What questions are discussed that may be included in the exam?

Examples of case stories were discussed; which will likely be useful on the exam.

Lecture 4a, What is the Anatomy and Physiology of the Male Sexual Response?

What is the anatomy of the male genitalia?

The external genitalia of the male consists of the scrotum, testes (gonads) and penis. The scrotum contains paired testes separated by a midline septum. Its external positioning keeps the testes 2C lower than the core body temperature; this is important to maintain the quality of the sperm. Sperm are produced in the testes within the seminiferous tubules. Leydig cells produce and secrete male hormones. Sertoli cells help in the process of spermatogenesis. The sperm is stored and matured in the epididymis, which is a long tube. Its head joins the efferent ductules and caps the superior aspect of the testis. The penis consists of three corpora, which are all connected to each other: The corpora cavernosa are located on either side of the penis. The corpus spongiosum is located on the inside of the penis. The head of the penis is called the glans. 

How does ejaculation work?

Spermatogenesis refers to the production of sperm. It begins at puberty and continues throughout the life of a male. The entire process, beginning with a primary spermatocyte, takes about 74 days. After ejaculation, it can stay and survive in the female for 48 hours. Sperm have three major regions: The head, which contains the DNA, the midpiece, that contains mitochondria, and the tail. During ejaculation, the epididymis contracts, allowing the sperm to move through the vas deferens, along the prostrate gland, and out of the urethral tract out of the penis. The seminal vesicles add seminal fluid to the sperm, for example containing fructose; to provide energy for the sperm. The vesicles are located behind the bladder. The prostrate continuously grows throughout life. The function of the prostrate is to add volume to the sperm as well as the seminal vesicles. The bulbourethral glands are pea-sized glans inferior to the prostate, which produce alkaline mucus prior to ejaculation that neutralizes traces of acidic urine in the urethra and help lubricate the urethra and the head of the penis. The volume of a typical ejaculation is 2.0-5.0 mL, with an average sperm count of 50-150 million spermatozoa per mL. Males need at leads 20 million spermatozoa per mL to be fertile. Sperm are produced in the seminiferous tubules in the testes, stored in the epididymis, and transported through epididymis along the seminal vesicles and prostrate, through the urethra.

What is the male sexual response?

The male sexual response consist of a desire phase, secondly the arousal stage, then the plateau phase, then the orgasm phase, and lastly the resolution stage. Various erotic thoughts and physical stimulation triggers the parasympathetic nervous system. Nitric oxide is released in the brain. An erection occurs when neurons release nitric oxide at their synaptic endings. It causes smooth muscles of the penile arteries to relax, vessels dilate, and blood flow to the erectile tissue increases. The vascular channels engorge with blood, resulting pressure causing the penis to erect. As the genitals become further engorged with blood, their color deepens. The testes can grow up to 50% larger. A feeling of warmth develops. During the plateau phase, changes that begin during arousal are sustained at an intense level. During ejaculation, sympathetic stimulation causes peristaltic contractions. The orgasm is a pleasurable feeling associated with ejaculation. During the resolution, the sense of profound relaxation, genital tissues, heart rate, blood pressure, breathing and muscle tone return to normal. The interest in sex disappears. Testosterone is produced by the Leydig cells in the testes, which help the sperm to grow. Testosterone stimulates the sex drive, and is associated with aggression.

What are possible organic sexual problems that can occur in males?

Sex is healthy, but much can go wrong. Sexual problems give rise to psychological problems and relational problems, and vise versa as well. Erectile dysfunction can have organic as well as psychological causes. In the case of organic causes, the beginning of the problems occurs gradually, the course is constant, at the start there is no conflict, it is constant, and there is no morning erection or erection during masturbation. In the case of psychological causes, the beginning of the problems occurs suddenly, the course is not constant, at at the start there is usually relationship conflict, it is not constant, and there are morning erections and erection during masturbation. Foreskin problems, penis fractures, and morbus peyronie can occur as well.

Bullet-point summary:

• The external genitalia of the male consists of the scrotum, testes (gonads) and penis.
• Spermatogenesis is the production of sperm. Sperm are produced in the seminiferous tubules in the testes, stored in the epididymis, and transported through epididymis along the seminal vesicles and prostrate, that add fluid to it, and then through the urethra.
• The male sexual response consist of a desire phase, secondly the arousal stage, then the plateau phase, then the orgasm phase, and lastly the resolution stage.
• Testosterone is produced by the Leydig cells in the testes, which help the sperm to grow. Testosterone stimulates the sex drive, and is associated with aggression.
• The male sexual problems that were discussed are erectile dysfunction, foreskin problems, penis fractures, and morbus peyronie. Erectile dysfunction are sometimes caused by organic factors, and sometimes by psychological factors.

Five questions:

• What topics are covered in this lecture?

This part of the lecture covers the anatomy and physiology of the male genitalia. It describes the function of all the parts of the male genitalia and how they work.

• What topics are covered that are not included in the literature?

This lecture elaborates a lot on the genitalia and the way they work. However, the greatest part of the contents of this lecture is directly derived from the book.

• What recent development are discussed?

No specific recent developments were discussed.

• What remarks are made about the exam?

No specific remarks were made about the exam.

• What questions are discussed that may be included in the exam?

No specific remarks were made.

Lecture 4b, What is the Anatomy and Physiology of Sexual Functioning in (adult) Women?

How does a healthy sexual development progress and what does it require?

Intact anatomy and endocrinology are necessary conditions for a healthy sexual development. Due to an absence of SRY, testosterone, and AMH, an embryo with XX chromosomes will develop into a female. During puberty, the secondary sexual characteristics develop. In females, puberty starts at 10 years and 8 months of age on average. Other conditions for a healthy sexual development are 1) a matching gender identity, 2) a warm pedagogical climate, 3) positive examples of relational behavior, 4) positive messages concerning sexuality and the own body, 5) the possibility to age-specific consensual sexual practice behavior, and 6) skin contact. In 10 weeks, an embryo will have developed into a male or female. Gender at birth is just based on the appearance of external genitals, yet gender identity is related to many more factors. Nowadays, when the gender is not 100% clear at birth, additional research is done. It used to be the case that the doctor would just make a choice. The hypothalamus directs the secretion of GNRH, stimulating the anterior lobe of the pituitary to secrete LH and FSH. The gonads secrete estrogen and testosterone. For the development of the fetus, secondary sex characteristic, and sexual desire testosterone and estrogen are essential.

What do we mean by a normal variation in female external genitalia?

There is a wide normal variation in the size of the external genital female organs. However, due to the influence of for example pornography, a lot of females are insecure about the size of primarily their inner lips. A reduction of the inner labia by a plastic surgeon is sometimes chosen for. There is controversy around the topic of cosmetic inner labia reconstruction. In other cultures in for example Africa, females engage in elongation of the labia. 

The clitoris consists of a glans and two corpus cavernosa alongside of the vagina. They become engorged with blood during sexual arousal. The pelvic floor muscle is essential for sexuality. These muscles contract during orgasm. However, when they are constantly hypertonic, this can cause problems to have intercourse. The breast have an erotic and reproductive function.

How does the female sexual response work?

The female sexual response is characterized by increased blood flow to the genitals, just as with males. The outer part of the vagina and labia minora swell. The vagina is elongated. Lubrication occurs, and the clitoris becomes erect. The uterus engorges and rises. Peripheral responses occur: the heart beat rises, the frequency of respiration increases, the skin blushes, and the nipples become stiff. An orgasm is an individual experience, characterized by an intense feeling of pleasure. There is some degree of an altered state of consciousness. Specific sensations occur in the genital region and pelvis. Muscles in the pelvic floor contract.

What can physically go wrong?

An example of congenital abnormal external genitals: The hymen can be half-moon shaped, which makes coitus difficult and painful. The MRKH syndrome is primary amenorrhoea in women with normal chromosomes. There is no vaginal bleeding, pregnancy is impossible, and coitus is not possible, because of the absence of a uterus. There are also various examples of acquired abnormal genital anatomy.

What is female genital cutting and why is it done?

Female genital cutting occurs for various reasons, which vary from one geographic region to another, as well as over time, and include a mix of sociocultural factors within families and communities. Reasons have no relation to religion and a non-medical. There are 4 types of surgeries. Citoridectomy is the removal of the clitoris. Infubulation is the most drastic procedure; the lips are removed, the clitoris is removed, and stitches are added to allow for only one small opening.

What disorders of sexual development can occur?

An example of an abnormal chromosomal pattern is the Tuner syndrome. These girls only have one X chromosome; causing the gonads to refuse to develop. An example of a disorder of sexual development is AIS. These people have normal male chromosomes. However, the receptors of androgens do not work. No armpit or pubic hair occurs and these people are infertile. Androgenital syndrome in women (AGS) is characterized by a defect in the enzyme 21-hydroxylase. The internal genitals are female, however, there are high testosterone levels causing clitoral and adrenal hyperplasia. Another disorder of sexual development is the intersex condition.

Bullet-point summary:

• Healthy sexual development occurs when there is intact anatomy and endicronology, however, factors such as a matching gender idenity are also important.
• Due to an absence of SRY, testosterone, and AMH, an embryo with XX chromosomes will develop into a female. Gender differentiation occurs 10 weeks after conception.
• There is a wide normal variation in the size of the external and internal genital female organs.
• The female sexual response is characterized by lubrication and increased blood flow to the vulva.
• We distinguish abnormal congenital and abnormal acquired sexual dysfunctions.

Five questions:

• What topics are covered in this lecture?

This part of the lecture covers the anatomy and physiology of the female genitalia.This part of the lecture elaborates a lot on sexual development and what can possibly go wrong. 

• What topics are covered that are not included in the literature?

No topics were discussed that are not covered by the book.

• What recent development are discussed?

It was discussed how recently there is a lot of controversy and discussion about hymen reconstruction in the Netherlands. 

• What remarks are made about the exam?

No specific remarks were made about the exam.

• What questions are discussed that may be included in the exam?

No specific remarks were made.

Lecture 5, How do Children and Adolescents develop Sexually & What is the Influence of Culture?

Sexual development starts with children observing each other; and they will keep on doing this for the entire lifetime. Around 12 years of age, a person starts getting an increase of hormones, which will change the way a child views sexuality.

How do foetuses and babies (0-1 years old) develop?

Even a fetus can have an erection. The purpose of this is that the body is trying to check whether everything is working. For baby’s from 0 to 1 years old, touching is an important way of making contact and building trust. Erection occur often based on pleasant, non-sexual stimuli. Gender identity is developed from birth, stimulated by the family and other people in the environment of the child. Babies engage in mobility; reflexive moves and touching their genitals.

How do toddlers (2-3 years old) develop?

 Toddlers are aware of their own sex and think this is fluid. Toddlers learn that touching their genitals feels pleasant and do this regularly on purpose. They become aware of the differences in genitals between boys and girls. Toddlers become interested in their own genitals and those of others, and want to see these and touch these. Toddlers develop their gender identity by expression and activities, such as the way they wear their hair, clothes, and the way they play with toys.

How do 2-6 year olds develop?

90% of the 2-6 year old touch their genitals regularly. Observations of 460 2-6 year olds has shown that 90% touch their own genitals, and 60% stimulate their own genitals by hand. A great proportion of these children also undresses others or shows their genitals to others. Pre-sexual games during pre-school (4-6 years old) consist of undressing and exposing, looking and touching in a public of private environment; in this way, children discover their own bodies and those of others. Children of this age often touch and stimulate their own genitals, and realize that their biological sex will not change. These children grow awareness of social norms of (pre-)sexual behavior. Focus on stereotypical male/female behavior as peers criticize non-specific gender behavior. Children from age 4 to 6 have a fascination for reproduction, nudity and pregnancy. They like to use sexual explicit language and make jokes about sex.

How do children from 7-9 years old develop?

Children of a school-age (7-9 years old) are ashamed of their naked bodies. They engage in more friendships with children from the same sex. They have fantasies about being in love, relationships and sex. They fall in love for the first time. They engage in pre-sexual play in private places, hidden from others.

How do children of a pre-puberty age (10-12 years old) develop?

Children with a pre-puberty age (10-12 years of age) experience their first minor physical changes. They start become insecure about their (changing) body and appearance. The first romantic relationships occur during this phase. 10-12-year-olds have increasingly interested in sexual media content. More than 80% of 10-12-year-olds have been in love, and 58% have been in a romantic relationship. Boys have an advantage in their sexual development compared to girls; as they can physically see their arousal a lot easier than girls. Dependent on culture, the norm is often that boys are allowed to touch their own genitals and engage in masturbation; and girls aren’t.

How do children develop during puberty?

In puberty (13-15 years old), the desire to be more independent arises. Teens of this age become curious about sexuality. They experience their first sexual feelings and talk about being in love and sexuality with peers. Their first sexual experiences occur during this phase. Approximately 60% of the adolescents (16-17 years) report curiosity as their main motivation for their first sexual intercourse. For girls, a main motivation can also be to be in love. For boys, “I was sexually aroused” is more often the reason. Adolescents from 16-18 years of age gain more relational experience. They start to communicate about what they like and don’t like. Their sexual orientation becomes (more) clear to them. The median age of very first sexual intercourse in the Netherlands is 18.6 years old.

How could we formulate sexual development in summary?

0-4 years: Discovering

4-6 years: Friendships start, playing games, learning rules

7-9 years: Embarrassment, fantasy, first infatuation

10-15 years; (Pre)puberty

16-18 years: Adolescence.

What did the research towards sexuality under the age of 25 discover?

The research by Rutgers “Sex under the age of 25” consists of a questionnaire. The research was conducted multiple times. A key finding is that the median age of first time of intercourse has gone up from 17.1 years old in 2012 to 18.6 years old in 2017. Another key finding is that both young men (94%) and young women (90%) enjoy sexual intercourse. Another finding was that 1 out of 8 young people have sent a nude picture or sex video of themselves to someone else. A growing number of young women have stopped or refuse to use the contraceptive pill. More young women have an IUD instead. 7 out of 10 young people used a condom first time they had sex. 4 out of 10 people do not use a condom during a one-night stand. 76% of young men and 63% of young women stop using condoms with their sex partner without getting both tested for STIs. 17% of young women in 2012, and 11% in 2017 have ever been forced to do something sexual they did not want to do. The same holds for 4% of young men in 2012, and 2% in 2017. According to this research, homophobia has also decreased and there is more tolerance for it. 2/8 young women and 4/8 young men disapproved of two young men kissing in public in 2012. In 2017, this was only 1/8 women and 2/8 young men.

How should we see sexuality?

Sexuality is much more than only sexual intercourse: self-esteem, fantasies, emotions, orientation, personal identification, and very important: communication. We can categorize sexuality in biological, psychological and sociological aspects. Sexual development is a very personal and lifelong process. A narrow perspective on sexuality is that it is aimed for reproduction, only consists of intercourse, it needs to be controlled, it is a voluntary action between adults of equal status, it is a men’s things and reproduction is a women’s thing, and it doesn’t exist in childhood. The newer comprehensive perspective on sexuality states that sexuality is a broad concept including thoughts and fantasies, emotions and feelings, and consists of a very broad range of acts; it is a private, personal issue and hardly to control by others, it is a source of pleasure, it should always be consensual and safe, and it is a fundamental human right to enjoy sex, independent of gender and sexual orientation. 

What is the influence of culture on sexuality?

In biological perspective, people have more similarities than differences than in different cultures. There are no universal sexual norms and values other than universal sexual and reproductive rights. Our values about sexuality are shaped by our personal values about sexuality and gender, and also our socio-culturally dependent values of sexuality and gender. Our individual sexual development is shaped from birth by our environment; family, friends and peers, geography, school, religion, et cetera. Medical science, other sciences, human rights, national and local laws, as well as personal experience, religion, culture and other social perspectives influence our sexual behavior.

What is hymen reconstruction and why is there controversy around this topic?

There is not a way for a doctor to check whether a girl is still a virgin. However, in some cultures, a female is ‘required’ to bleed during the wedding night so that the couple can prove that she was still a virgin. There is a current discussion in the Netherlands whether a hymen reconstruction surgery should still be allowed.

What is the influence of religion on sexuality?

Examples of religious influences on sexuality are 1) perspectives on body changes in puberty, 2) ideas and values about sexual behavior, 3) ideas and values about sexual responsibility, 4) the use of contraceptives, 5) the expression of sexuality, sexual orientation and gender, 6) the moment of first sexual intercourse, and the 7) physical, emotional and spiritual satisfaction.

What is the contemporary perspective on gender?

The Gender Unicorn is a figure to describe the major players in our sexual development. It displays the differences between biological sex and gender. ‘Gender’ is the psychological sex; social-cultural representations of femininity and masculinity, whereas ‘sex’ refers to the biological characteristics that define humans as male or female.

What are common myths about differences in sexuality between males and females?

Ancient myths about men and sex are 1) that men cannot express feelings, 2) men are always willing and able to have sex, 3) men should initiate sex, 4) sex is competitive, 5) sex is intercourse, 6) sex is good only if you have an orgasm, 7) no sex makes you ill, 8) no erection means that you can’t have sex, 9) carrying condoms means taking responsibility, and 10) gay men are perverts looking for sex with any man they can. Ancient myths about women and sex are 1) that women cannot demand sex, 2) women can’t have sex without romance or being in love, 3) never refuse sex if your partner wants to have it, 4) women should be passive, 5) women don’t masturbate, 6) once you’ve started kissing you can’t stop, 7) if you often talk about sex you sleep with many men, 8) healthy women have orgasms during sexual intercourse, 9) carrying condoms means being a slut or sex workers, and 10) lesbian women can be quickly converted into heterosexuals if they meet Mr Right.

What is the CSE approach?

Comprehensive Sexuality Education (CSE) consists of approaching sexuality positively, it is a gender-based approach, and it interlinks SRH&R and HIV/AIDS and integration in sexual health. CSE views youth as sexual being, decision makers and social actors. CSE uses a lot of participatory methods. 

Bullet-point summary:

• Sexual development starts with children observing each other; and they will keep on doing this for the entire lifetime. 
• Sexual development in the age period of 0-4 years is characterized by discovering. Between the age of 4 and 6 years old, children start to form friendships, play games, and learn rules about friendships. From 7 to 9 years of age, children fall in love for the first time and start being ashamed of their naked body. 10 to 15 years are labelled as the (pre-)puberty period. Adolescence occurs from the age of 16 years to 18 years.
• The research by Rutgers was conducted to study the experience of sex under the age of 25. The research was last conducted in 2017, and before that in 2012. Through this, interesting results can be compared to each other.
• Nowadays, we disregard the narrow perspective on sexuality and often replace it for the comprehensive perspective on sexuality.
• Our values about sexuality are shaped by our personal values about sexuality and gender, and also our socio-culturally dependent values of sexuality and gender.
• The Gender Unicorn is a figure to describe the major players in our sexual development. It displays the differences between biological sex and gender. 
• There are some myths about typical male and typical female sexual behavior, which have been presented for a long time.

Five questions:

• What topics are covered in this lecture?

This lecture covers the sexual development of children and adolescents of different ages. It gives another perspective on sexuality by including the cultural factors involved in this process.

• What topics are covered that are not included in the literature?

The lecturer talked about research from the institution where he works (Rutgers) that studied sexual behavior of Dutch adolescents under the age of 25.

• What recent development are discussed?

There has been a lot of discussion around the topic of hymen reconstruction recently.

• What remarks are made about the exam?

No specific remarks were made about the exam.

• What questions are discussed that may be included in the exam?

No specific remarks were made.

Lecture 6, How does Research in the field of Sexology take place?

The aim of the first part of this lecture is to learn how sex is studied in the laboratory, what the role of conscious and unconscious processing is in the sexual response, what factors determine sexual feelings in males and females, and to learn about the implication for clinical practice.

How can sexuality be measured physiologically?

Sex is physiological; for example erection, lubrication, breathing, heart rate, and muscle tension. Sex is emotional as well; for example excitement, desire, passion, ecstasy, and satisfaction. Measuring sex can be done through questionnaires and psychophysiological measurements. Specific physical measurements of sexual response are the increase in volume of the corpora cavernosa and erection in men, and an increase in volume of the corpora cavernosa, an increase in blood flow to the vaginal wall, and lubrication in women. For males, the penile strain gauge can be used to measure physical arousal. For females, a photoplethysmograph is used. Often, a female’s physical arousal is compared to her reported emotional arousal by asking questions such as; to what extent did you feel sexual arousal/pleasure/shame/anger/disgust? Examples of erotic stimuli are fantasy, photographs, tactile stimulation (such as vibration), or films.

What are issues in the field of sex research?

Issues in the field of psychophysiological sex research are the fact that there are often only small samples, there is a selection bias, there are ethical considerations since sex is a rather private subject, and it has to stick to objective measurement.

How is sexuality measured psychophysiologically?

Psychophysiological sex research focuses on 1) the effect of psychological and pharmacological manipulations, disease, and surgical interventions; 2) the differences between people with and without sexual dysfunctions; 3) sex differences; 4) the relationship between the genital response and sexual feelings; and 5) the underlying mechanisms of sexual desire, arousal, and orgasm; and disorders of these. 

An emotional stimulus leads to activation of the sensory thalamus. Via the “neat and slow pathway”, this leads to activation of the sensory cortex and hippocampus, and subsequent activation of the amygdala. Via the “quick and dirty pathway”, the amygdala is directly stimulated by the sensory thalamus. Stimulation of the amygdala leads to an emotional response. It was found that the conscious feeling of sexual arousal is conscious. Physiological responses are on the other hand unconscious.An fMRI study focused on the question of whether sexual stimuli can ‘automatically’ activate the emotion-motivation systems, and whether this activation is influenced by dopamine. In a study with 53 heterosexual men, three groups were distinguished. One group was treated 100mg of levodopa, the second group was prescribed 3mg of haloperidol, and the third group received a placebo. All groups were presented with an unconscious sex task.  The percentage of correct classification was below chance level for all target categories; so the target pictures displaying sexual imagery were not consciously perceived. Unconsciously processed sexual stimuli were found to activate emotion-motivation systems in the brain, and dopamine was found to influence this activity. More dopamine increases the activation, and less dopamine decreases the activity.

How does sexual arousal work differently in males and females?

Determinants of sexual arousal in women are related to the relationship between genital response and subjective experience.  Correlations between genital and subjective sexual arousal are low in women, and high in men. The hypothesis is that women’s sexual feelings are determined more by the evaluation of the context and nature of the stimulus. In men, a stimulus leads to sexual feelings via the conscious path, and a genital response via the unconscious path. The genital response has a major influence on the sexual feelings. In women, a stimulus has a major influence on conscious sexual feelings. The genital response, that occurs unconsciously, has little influence on sexual feelings. In men as well as women, there was found no significant difference in genital response between woman-friendly and man-friendly erotic films. Women however do have a significant stronger subjective sexual response for woman-oriented films; and prefer those over man-oriented films. The conclusions that can be drawn from this study are that in women,, the genital response does not predict sexual feelings. In women, sexual feelings are determined more by meanings associated with the stimulus context. Lastly, in men, sexual feelings are determined more by the intensity of the genital response. Implications to these types of research are firstly, that motivation processes have already been activated unconsciously before the individual is conscious of this. This however does help to understand why sexual responses can be difficult to control. A second series of implications is about the research on the relationship between the genital and subjective sexual response: 1) the automatic genital response is not evidence of positive sexual experience; 2) complaints of reduced sexual arousal does not necessarily indicate disturbed genital response; 3) the meaning of the stimulus and the context are important in women’s sexual feelings; and 4) pharmacological treatment aimed at increasing the genital response is an option for men, but not a solution for most women.

What are female sexual pain disorders?

The second part of this lecture will discuss clinical research towards female sexual pain disorders. In vaginismus, there are a lot of biopsychological factors involved. Vaginismus is not caused by a pelvic floor muscle dysfunction. Patients are fearful of penetration and display avoidance behavior. 

What is the cognitive vicious cycle these women experience?

Patients with vaginismus are often subjected to a vicious cycle: When penetration is attempted, these women have catastrophizing thoughts such as “it will not fit” and “it will be very painful”; which leads to fear, and subsequently avoidance, and also increased pelvic floor muscle tension. This leads to penetration being impossible, resulting in these women not wanting to try it again, and increasing all other factors in this cycle again.

How does cognitive behavioral therapy treat vaginismus?

Cognitive behavioral therapy (CBT) seems a very promising treatment for vaginismus. Out of the 43 observational studies, the success rate is 0.79. There was found no difference in effect among different kind of interventions. CBT consists of psycho-education, relaxation exercises and pelvic floor muscle training, and gradual exposure exercises. It includes the role of helpful and unhelpful cognitions and searches for sexual stimuli and arousal. Lastly, CBT includes sensate focus exercises with partner couples, sexual communication in relationship, and the search for new pleasurable sexual activities. CBT can also be applied in group therapy and bibliotherapy (such as self-help books). There is no difference in effectiveness between these two. Successful intercourse at one-year of treatment is often related to 1) less avoidance of penetration during treatment; and 2) a reduction in fear during treatment. 

How does exposure therapy treat vaginismus?

Therapist aided exposure aims to reduce avoidance behavior, increase successful penetration exercises, and disconfirm catastrophic beliefs. It is conducted by a female therapist, and the partner is often present as well. Exposure therapy reduces vaginistic complaints and negative penetration beliefs, it helps to strengthen positive penetration beliefs; yet is does not help with overall sexual functioning. Sexual abuse does not moderate the effect of treatment on vaginistic complaints, negative nor positive penetrations beliefs, or overall sexual functioning.

Bullet-point summary:

• Sex is physical as well as emotional. Measuring sex can be done through questionnaires and psychophysiological measurements.
• Psychophysiological sex research focuses on 1) the effect of psychological and pharmacological manipulations, disease, and surgical interventions; 2) the differences between people with and without sexual dysfunctions; 3) sex differences; 4) the relationship between the genital response and sexual feelings; and 5) the underlying mechanisms of sexual desire, arousal, and orgasm; and disorders of these.
• Physiological arousal is an unconscious process. Correlations between genital and subjective sexual arousal are low in women, and high in men.
• In vaginismus, there are a lot of biopsychological factors involved. Patients are subjected to a vicious cycle of events. Cognitive behavioral therapy (CBT) seems a very promising treatment for vaginismus.

Five questions:

• What topics are covered in this lecture?

This lecture discusses how research towards sexuality takes place and what the limitations are to these studies. It also focuses on female sexual pain disorders.

• What topics are covered that are not included in the literature?

This lecture elaborates a lot more on female sexual pain disorder and how it can be treated then the book does.

• What recent development are discussed?

No specific recent developments were discussed.

• What remarks are made about the exam?

No specific remarks were made about the exam.

• What questions are discussed that may be included in the exam?

No specific remarks were made.

Due to measures that were taken by the university to contain the spread of the corona virus, the seventh and eighth lectures were cancelled. Lecture notes of previous years are available.