Chapter 0 - What is the book Understanding Human Sexuality about?

The book Understanding Human Sexuality was written by Hyde and Delamater. It describes sociological, biological, and psychological perspectives on sexuality.

The first author, Janet Shibley Hyde, has done a lot of research towards sexuality; and mainly towards the topics of gender differences and gender development in adolescence. Hyde was married to John D. DeLamater, the co-author of this book. He focused his research on the influence of marital duration, attitudes about sex for elders, and illness and medication on sexual expression. Both Hyde and DeLamater are based at the University of Wisconsin. DeLamater passed away in December 2017.

The book starts by giving a broad introduction to the topic of sexuality and introduces common terms and their meaning (Chapter 1). It covers the early theories of sexuality (Chapter 2) and important research towards sex (Chapter 3). A few chapters will eloborate on the biological aspects of sexuality (Chapter 4-7). The topics of sexual arousal (Chapter 8), sexuality across the life cycle (Cahpter 9 & 10), and topics of attraction and love (Chapter 11) are discussed as well. Sexuality, sexual orientations and variations in these will be touched upon in Chapter 12 to 14. Sexual coercion (Chapter 15), sex for sale (Chapter 16) and sex diseases (Chapter 17 & 18) will then be discussed. Sociological perspectives on sexuality are covered as well (Chapter 19-20).

Chapter 1 - How can we put Sexuality in Perspective?

Sexual behaviour is a diverse phenomenon that occurs in several physical situations, social contexts and is experienced differently by everyone. Everyone has a complex set of motivations and external influences that determine the decision of whether or not to engage in sexual behaviour. It is difficult to answer all the questions about sexuality within one scientific discipline. The study of sexuality is important for the following reasons:

1. The exchange of sexual information is taboo in many societies.

2. For many people, sexuality is an important motivation in life.

3. Some people experience difficulties with sex and problems with their sexual functioning.

What is the difference between sex and gender?

The definition of gender is whether someone is male, female or something else; such as trans. However, sometimes the word sex is used to describe gender, for example on a job application form. However, most of the times sex refers to sexual behaviour or reproduction. The ambiguity in the use of the word sex causes confusion. In the context of this book, the term sex describes sexual activity and gender refers to being male, female or something else.

Besides the ambiguity in the use of the word sex, there are other problems with the difference between sex and gender. A lot of contemporary research is based on the gender binary, this is the notion that there are only two genders, being male and female. Also, the activities that are included in sex are debatable. Biologists describe sex as every behaviour that potentially lead to the union of an egg-cell and sperm-cell. However, sexual behaviour is not only used for reproduction, but also for recreation. Therefore, this book will stick to the definition of sexual behaviour as behaviour that cause arousal and increases the chance of an orgasm; although there are problems with this definition as well.

What is the history of sexuality in religion and science?

Until about one hundred years ago, the available knowledge on sexuality came from religious sources. The ancient Greek already told myths about the existence of hetero -and homosexuality. In this way, they could understand these sexual orientations. In ancient Christianity, they believed that having a “wet dream” was caused by having sex with the mythical creatures’ incubi ­and succubi. The person who had the wet dream was sometimes accused of witchcraft. Muslims believe that sex is one of the most pleasurable things in life, which reflects upon the teachings of the prophet Mohammed.

Scientific research towards sexuality started in the nineteenth century, even though at that time it was still illegal according to religion. In his book “Theoretical Perspectives on Sexuality” Freud described the cultural background of sexual behaviour for the first time. Norms concerning sex used to be very strict and rigid; causing sexual tension and conflict. The psychiatrist Richard von Krafft-Ebing (1840-1902) described the pathology of sexual behaviour for the first time. Hirschfeld was interested in research about homosexuality and introduced the term transvestite. Only in the twentieth century, there was a breakthrough in scientific research towards sexuality. It was the same period in which large-scale surveys were conducted in the United States. Because of this way of researching, sexual disorders and alternating sexual orientations were exposed for the first time. At the same time, scientists started investigating the biological processes of sexual behaviour.

What is the influence of mass-media on sexuality?

The mass media has had a significant influence on knowledge on sexuality comparable to religion. Especially television was of great importance, in only one hour of American television, adolescents were exposed to a mean of seventeen behaviours or conversations about sex. Only two percent of these images show sexual repercussions. Many of the American insights about sexuality therefore come from mass media, instead of scientific research. The concept of cultivation is the exposure to sexual behaviour in mass media where people believe this resembles reality.

Another major impact of mass media is called agenda setting. It is defined as the choices that news-creators make in what information they present to their audience. The framing theory states that the media draw attention to certain topics and not to others, suggesting how we should think about certain matters. In this way, the media provide a framework.

The third influence of mass media is social learning. In social learning, the characters in films serve as social models that people use to construct their ideas about the reality of sex. Besides television, the internet is an important source of sexual knowledge. There are both positive and negative norms displayed on the internet. Besides bad information about sexual behaviour, positive information about sexual health is widely available and promoted. This caused the number of sexual abuse over the internet to decrease over the last years.

However, we are also subject to the process of selectivity ourselves: People select and pay attention to certain media and not to others. We are prone to seek information that is consistent with our own beliefs and views.

What are cross-cultural perspectives on sexuality?

Culture is defined as the traditional norms and values that are transferred through group members by cultural symbols, such as language. These ideas and values are the basis for behavioural patterns for members of that group. Ethnocentrism influences this understanding of sexual behaviour, because most people experience sex through the eyes of their culture. The pattern in which people experience sex is therefore seen as correct. However, different cultures hold very different attitudes towards sex. There has not ever been a single society that has been able to guarantee complete freedom of sexual behaviour: There are always some rules concerning sex. For example, almost every society has incest taboos; meaning that it is illegal to have sex with a relative. Also, in most societies, rape and sexual assault are forbidden. Besides rules about incest and rape, many differences exist between cultural norms of sex:

1. Variations in sexual techniques resemble the differences in techniques of sex. Kissing of a partner is a very normal thing to do in the Western society, but is seen as disgusting by the Tonga Africans. Romantic kissing is in fact not present in 54 per cent of cultures. Also, cunnilingus, the stimulation of the female genitals is seen as completely normal in Western societies. In different cultures this is practiced in a very different way. The average amount of sex that people engage in deviates for each culture. The Irish natives have the least sex between couples on average; maybe only once a month, while the Mangaians are used to having sex several times a night. Almost every culture describes norms on postpartum sex, which is the taboo of having sex after giving birth.

2. Masturbation or self-stimulation is tolerated in some cultures while it is forbidden in others. Especially rules about female masturbation vary among different cultures.

3. Different cultures hold different attitudes towards topics like pre -and post marital sex. In the Pacific, pre-marital sex is completely normal and approved in 90% of the occasions. However, 73% of cases of premarital sex is disapproved in the Mediterranean area.

4. Homosexuality is often disapproved of in the United States. In other cultures, homosexuality among men is promoted. It seems there are two important universal rules about homosexuality. The first is that homosexuality exists in every culture. The second is that sex between two people of the same gender is never the most prevalent relationship form.

5. Attractiveness determines the choice for a sexual partner. The norms of attractiveness vary among cultures but there seems to be one conformity: a pale skin colour is seen as unattractive in most cultures.

What is the influence of differences in social class and ethnicity on sexual behaviour in the United States?

Some varieties in attitudes in the United States can be explained in terms of differences in social class, whereas others can be explained in terms of ethnicity. Social class is often determined by education. The influence on sexual behaviour is that women that had a higher-level education are more likely to use birth control. People with a lower education level are therefore also more likely to have children at a younger age. These children often have a lower education level as well. This means that sexuality might also influence social class.

Besides the influence of social class, there are ethnical differences in sexuality:

• In the Afro-Caribbean culture, the general norm is that women should be modest. They see the African Americans as being sexually undisciplined. The percentage of African Americans that engage in marriage is lower than in other ethnic groups. This is caused by the obstacles they face in finding a decent job to be able to take care of a family.

• Latinos are people from Latin American heritage. Researchers nowadays tend to stick to the term Latinx instead of Latinos; because the latter is rather gender-bound. They have a different view on sexuality compared to most Americans. Gender-roles are highly specific and are taught during childhood. The gender-roles in the Latinx culture are characterised by machismo or macho. It literally means masculinity and implicates that a man is responsible for the honour and well-being of his family. The female form is marianismo and mean that motherhood is highly valued. Also, keeping your virginity until marriage is an important consideration for a woman. Familismo means that family is important, and support, loyalty, solidarity and family-honour are central values in the Latinx culture.

• Asian Americans represent different cultural groups. They include Chinese, Japanese, but also Indians. Especially the Chinese have a repressive outlook on sex. The people from Cambodia believed that withholding information about sex would lead to a decrease in premarital sex. Their conservative cultural values, relevant for sexual attitudes are the following:

  1. Collectivism relates to a culture where people value others more than they value themselves. Openness of sexual behaviour could lead to discomfort in others, thus it is not tolerated. Individualistic cultures have the norm that people value themselves and their own opinions more than they do of others. Then there are honor cultures as well, which stress 'face', that is, individuals' reputation and the respect or honor that people show toward it.

  2. Conformity to norms means that people need to live up to high expectations of their family and society. Shame and loss of face are important conditions on how to behave.

  3. Emotional control means that emotions should not be publicly displayed. Love and passion should not be showed to the outside world.

• American Indians are the native Americans and exist from different tribes. Men of this culture are masculine and often pictured naked. Females from the native American culture are vulnerable, attractive and maidenly. They have strict rules about pre-marital sex.

• Nowadays, a lot of people are in fact biracial or multiracial; which makes the prior categorizations rather ambiguous.

Racial microaggressions are subtle insults that are displayed to people of another (racial) background. It happens unnoticed and unconsciously; but it can lead to stress for the victim. There are gender microaggressions, sexual orientation microaggressions and microaggressions against transgenders as well.

In ancient China, there were positive and open attitudes towards human sexuality. Modern China is however very repressive towards sex. Up until the 1980s, prostitution, premarital sex, homosexuality and variant sexual behaviors were illegal. A sexual liberation started in the 1980s and is still continuing.

What is the significance of cross-cultural research on sexuality?

Scientific research on human sexuality is important for two reasons:

1. It helps to determine the variation in sexual behaviour and help us to put this into perspective.

2. These studies provide important insights in the importance of cultural learning on sexual behaviour. Cultural differences show that sexual behaviour is not only caused by biological factors.

What are cross-species perspectives on sexuality?

People are just one of the different species. Every species is involved in sexual behaviour. We can learn about human sexual behaviour by studying sexual behaviour in animals.

1. Masturbation is present in many animal species. Especially apes often engage in masturbation. Not only male, but also female masturbation is observed in animal species.

2. Homosexuality is present in other animals and this may suggest that we are biologically bisexual. This is because homosexual behaviour is present in all animal species.

3. Sexual signalling or flirting happens across all species. It is an universal act.

4. Uniqueness of humans. In higher animal classifications, such as primates, sexual behaviour is guided more by hormones than by internal impulses. The environmental influence on sexual behaviour is more present in primates than in fish, for example. For humans, the environment also has an important influence on sexual behaviour. There is not much of human sexual behaviour that is unique to humans only, except for the cultural norms that are related to sexuality.

5. Non-sexual use of sexual behaviour is often described as using sex to express dominance. It happens in primates, but also in humans. For instance, rape is a desire for dominance that is expressed using sexual behaviour.

What is the sexual health perspective?

Sexual health is the political and social movement that is directed towards a shift of focus towards sexual health and sexual rights. Discussions about sexual health concern pathology, such as the infection with the HIV-virus. However, the concept is in reality a lot bigger and includes sexual rights. These are universal basic rights that people have regarding their sexuality. This includes self-determination, freedom from sexual abuse, and the right to express oneself sexually.

Study notes:

• Make sure that you can explain the sexual differences within the United States. What type of cultural groups exist and what influence does their culture have on their sexual behaviour?
• You should know what influence the mass media had on the development of knowledge about sexuality. One example would be what is meant with agenda setting and what is it’s influence on knowledge about sex?
• What is the difference between sex and gender?

Chapter 2 - What are the Theoretical Pespectives on Sexuality?

According to Freud, nothing is more important than the choice for a reproductive mate. He views sex in terms of libido, which can be expressed with sexual behaviour. On the other hand, Bandura would argue that sexual arousal leading to an orgasm is a positive reinforcement that will lead to the couple repeating this act more often.

What are the evolutionary perspectives on sexuality?

The evolutionary biology perspective that is used to understand social behaviour in animals is called socio-biology. The socio-biologist will study human sexual behaviour by examining patterns in other species. From the evolution perspective the most important function of sex is producing healthy offspring. This happens through sexual selection, in which animals that are best at adapting to their environment will survive. Humans choose their mates based on physical attractiveness, which according to the socio-biologist is a way of evaluating one’s health and vigor. This could indicate a better offspring. However, if people only chose mates based on maximum reproductive success, attractiveness should be a more important indicator of mate selection in unhealthy countries.

There are several hindrances that can occur in the process of reproduction, and two of those are infant vulnerability and maternal death. The risk on the first one is reduced when the mother is providing care continuously, including breastfeeding. Also, a pair-bond between mother and father and attachment between the child and its parents limit infant vulnerability. Parental investment means that parents are more interested in the survival of their own offspring and will invest significant resources to achieve this. Darwin proposed that sexual selection creates differences between females and males. There are two processes involved:

1. The competition of representatives from one gender (often males) for access to mating members of another gender.

2. Preferential choice by representatives from one gender (often females) for certain members of another gender.

This means that species compete among themselves in the mating process. The socio-biologic perspective has been criticized. Researchers argue that the biological determinism is an old-fashioned version of evolution and sex is no longer only reproductive.

What is the evolutionary psychology perspective on sexuality?

Evolutionary psychology focuses on psychological mechanisms, altered by natural selection. Behaviours that evolved as a result of sexual selection can be considered cognitive or emotional. People can have different strategies in choosing a partner for reproduction. A short-term strategy is when one chooses a partner based on immediate resources, such as food or money. A long-term strategy could be to choose someone who appears to provide resources for an indefinite future. Therefore, women with a long-term strategy should respond negatively to women who make sex easily available. On the other hand, females that pursue short-term strategies dress more provocatively. Researchers found that women pursue both long-term and short-term strategies. Another criticism is that in this view, every mating choice should have some kind of evolutionary purpose. The research also suggests that these strategies are universal, but the population studied are mostly Western Educated Industrialized Rich Democratic societies (WEIRD). It is not certain that these conditions hold when studies in other cultural societies.

Gowaty proposed a gender-neutral evolutionary theory as an alternative to other evolutionary psychological theories of sex. His gender-neutral evolutionary theory states that it is most adaptive for individuals to be flexible in their behavior. A flexible mating strategy is therefore most successful: In some situations, one may need to behave more male-typical, while in other situations, one might behave more female-typical.

What are psychological theories on sexuality?

There are several psychological theories that are relevant for the studying of sexual behaviour: These are the psycho-analytic theory, social exchange theory, learning theory and cognitive theory.

The psychoanalytic theory

The psychoanalytic theory is one of the most influential theories in psychology. Freud argues that sex drive, or in other words the libido, is the primary force in sexual behaviour. The libido is focused on erogenous zones on the body. These zones are sensitive to stimulation and provide feelings of pleasure. The second influence is thanatos, the death instinct. According to Freud, personality exists of three parts: the id, ego and superego. The id operates based upon the pleasure principle and includes the libido. The ego uses the reality principle to keep track of the irrational id. The superego is referred to as consciousness. It operates based upon the idealism principle. It exists from moral goals instead of realistic goals. The id, ego and superego develop in sequence where the id is present at birth, followed by the ego and lastly the superego. According to Freud’s principles, there are several stages of development.

1. The oral stage in which pleasure is evoked from sucking and stimulating the lips.

2. The anal stage in which interest is mostly focussed towards elimination.

3. The phallic stage where a child’s (male) attention is focused towards the penis (phallus). In this stage the oedipus complex is present, where the boy sexually desires his mother. The boy then feels castration anxiety which leads him to stop desiring his mother and identify with his father instead. The oedipus complex is considered a primary factor in human development. The third stage in a girl is different and is characterized by penis envy. She develops the electra complex where she desires her father. The resolution of the electra complex is dissimilar to the boy’s solution for the Oedipus complex. Therefore, Freud argues that girls remain immature compared to men.

4. After the phallic stage, the latency stage follows. It lasts until adolescence; sexual impulses are repressed and sexually there is not much happening.

5. The genital stage starts during puberty and sexual urges become more genital, oral and anal to promote their biological function of reproduction. It is possible that people remain fixed on one stage. For example, Freud argues that people that remain fixated on the oral stage have habits such as biting their fingernails.

There are some criticisms on the psychoanalytical theory. One of the major critiques is that scientific research is impossible. This is because most urges are unconscious and can not be studies using the currently available techniques. However, fMRI research has given some insight into Freud’s theories. Neuropsychoanalysis suggests bizarre imagery (from the id) is controlled by the prefrontal cortex. One of Freud’s main concepts is repression where people forget certain information as a defensive act. Even though this has been widely criticized, the social factors causing neural inhibition and impulse control could account for Freud’s idea of repression. Other criticisms are Freud’s study subjects consisting of mentally ill individuals meaning his theory is more likely to resemble disturbances in the human personality rather than healthy behaviour. Also, females tend to disagree with Freud because of his male-centered perspective. They argue that boys have womb envy (Horney, 1926/1973) and there is no distinction is made between a vaginal orgasm and a clitoral orgasm. Finally researchers argue that Freud overestimated the biological factors in sex.

Learning theory

It is apparent that much of sexual behaviour is learned. It is not only driven by biological forces. Research about (sexual) behaviour in different cultural environments resulted in various principles of modern learning theory.

• Classical conditioning is associated with Pavlov (1849-1936). It exists from an unconditioned stimulus, followed by an unconditioned response. The process of learning that elicits the response without the stimulus is called classical conditioning. It has proved to be useful in explaining several phenomena in sexuality. One example is the explanation of a fetish, where someone has sexual desire for an object rather than a person.

• Operant conditioning is associated with Skinner and refers to the reinforcement (positive versus punishment) after receiving a stimulus. If the behaviour is followed by a reward, the behaviour is likely to occur again. Punishment of sexual behaviour, such as pain during intercourse can lead to diminishing of the desire to have sex. However, other types of punishment can result in continuing the behaviour privately. One example is getting caught while masturbating.

• Behaviour modification exists from techniques derived from theories on conditioning to change behaviour. These methods also apply to solving problems with sexual behaviour. One technique is olfactory aversion therapy. Problematic behaviour is then punished using an aversive stimulus.

• Social learning is a complex learning theory involving the process of imitation and identification. They are useful in the explanation of gender identity. Once gender-specific behaviour is learned, the likelihood of occurrence is determined by its consequences. Creation of a sense of competence, or self-efficacy is achieved by promoting successful behaviour, such as anticonception.

Social exchange theory

The social exchange theory is based on reinforcement principles. It describes changes in relationships between people. Every behaviour comes with a certain cost or reward. According to the theory, humans behave hedonicand strive for optimal profits with our actions. Social relationships are characterized by the exchange of services and goods. The outcome of such a relationship is defined by its comparison level for alternatives. It also predicts when people change their relationships. The key concept is equity where people in a relationship believe the rewards weigh up to the costs. The matching hypothesis predicts that people choose mates based upon social characteristics and rewards on the dimensions of attractiveness, wealth and social status. The theory has been criticized because the applied ideas of rewards and costs do not always seem to apply in romantic relationships. Another criticism is that other motivations are downplayed by social exchange. The theory is unable to explain altruistic behaviour.

Cognitive theory

Cognitive psychologists believe that people’s thoughts and the way they think -and behave should be studied.

• Cognition can explain certain parts of sexuality. The basic notion is that thoughts shape what we feel. The cognitive approach states that psychological distress is caused by unpleasant thoughts. The labeling, evaluation and perception of events is crucial to our (sexual) experiences.

• The gender schema theory explains gender-role-development in terms of internal schemas. A schema is a framework that consists of general knowledge that someone has about a subject. The schema is used to organize one’s thoughts, feelings and emotions. It both helps -and distort our memories, especially when information is inconsistent with our schema. A gender-schema is a cognitive structure of behaviours, personality and appearance that is associated with either male or female. The gender schemas guide everyday behaviour and gender-stereotypes are very difficult to change.

What are critical theories about sexuality?

The theories that have been discussed so far are used to understand the nature of behaviour. The behaviours described in these theories are derived from groups, subcultures, associations and constructions of categories. The critical theories give a more in-depth description about the formation of these categories influenced by groups and subcultures.

Feminist theory

Feminist theory was proposed by many independent scholars and exists of four important assertions.

1. Gender as status and inequality: gender is a status characteristic where men often have greater status than women. It has allowed men to undermine the sexual expression of women.

2. Sexuality includes different topics, such as abortion, rape, birth-control, sexual harassment and pornography. According to feminists, women’s sexuality is repressed instead of expressed.

3. Gender roles and socialization: gender-roles display inequality and place restrictions on both women and men’s behaviour.

4. Intersectionality states that people should consider other’s group memberships, including gender, social class, sexual orientation and race.

Queer theory

Lately queer regained a positive attitude from homosexuals. The theory is broader than just homosexuals, it is about intersex and transgender too. The theory states that social categorization of sexual orientation should not fall into binaries (just two categories). It questions the gender binary that separates males and females. It also argues that sexual identities are not restricted for the individual. Another definition is that it challenges heteronormativity which is the belief that heterosexuality is the only normal and natural pattern of sexuality.

Performativity 

A concept that is present in both feminist theories as well as in queer theory, is performativity. This term refers to the ways in which we perform gender- or sexually based behaviors based on society's norms. We perform like actors do in a play.

What are sociological perspectives on sexuality?

Sociologists study the influence of society on the expression of sexuality.

• Symbolic interaction theory states that human nature and social order is derived from symbolic communication between individuals. Behaviour is based on interaction with others. The meaning of an object does not depend on its qualities, but also on what a person might do with it. The views on people are thus goal-oriented and proactive. Especially for sexuality, it alerts us to engage in mutual effort in order to define a situation, by conscious thought, whereas sexual behaviour is often dependent on emotional decision making.

• Sexual scripts are learned by the outcome of social influence. The idea behind it is that human behaviour is somehow scripted. Sexual behaviour in this sense comes from prior learning and teachings of sexual etiquette. Scripts are the plans that people carry around in their head that determine behavioural patterns. Besides that, it also conveys the meaning of how we should perceive certain events or what guidelines to follow.

Social institutions

Most sociologists view sexuality using three basic assumptions, the first is that every society regulates the sexuality of its citizens. The second is that the inappropriateness or appropriateness of sexuality depends upon the institutional context in which it happens. The third assumption is that basic institutions of society affect the rules that citizens are subjected to by the government. Each of the institutions explained below has its own view on sexuality and an ideology about beliefs and behaviours.

• Religion is powerful in shaping sexual norms. The traditions of asceticism (abstinence of sexual pleasure) practiced by monks and priests is seen as virtuous. Sexual legitimacy is only reachable with heterosexual marriage with the goal of having children. This is called a procreational ideology.

• The economy influences sexuality by permitting a kind of togetherness where before the industrial revolution sexuality was closely monitored by family members. After the industrial revolution people started to spend more time outside of the house, thus the surveillance became less. This increased rate of affairs and same-gender sex. It is still prevalent today, where unemployment has a big influence on sexuality.

• The family influences sexuality because of the interpersonal relationships. There exists a triple linkage between love, marriage and sex. The relational ideology means that the link between love and sex can exist without marriage. The family also influences sexuality through the socialization of children and teach them appropriate behaviours.

• Medicine has become a major influence over the past years. The predominance of medicine on sexuality in the biomedical model is called medicalization of sexuality. It has two components: the first is sexual behaviours and conditions that are caused by health habits. The second are problematic experiences where medical treatment is helpful.

• The law institution influences sex by restraining people’s sexual behaviours. Laws determine (sexual) norms and therefore people will have very different views on sexuality across different societies.

Study notes:

• You should be able to explain the evolutionary, psychological, sociological and critical theories about human behaviour and how they explain differences in sexuality.
• How can knowledge about learning theory contribute to psychological treatment of sexual problems?
• In the book several viewpoints on how to explain sexual behaviour. In the schema theory they talk about schemas on sexual behaviour and how stereotypes are difficult to change. The queer theory is a response to this schema theory. The scripting theory seems to be the social alternative to the cognitive schema theory. How are sexual scripts related to the queer movement?

Chapter 3 - What does the field of Sex Research entail?

Over the last few years there have been major improvements in sex research. These methods can differ on the following aspects:

1. The measurement of sexuality: this can be the form of a self-report, biological measures or observations.

2. The number of subjects that are studied, so either large or small groups of people.

3. Whether the studies take place in the field or in a laboratory setting.

4. Sex can be manipulated or studied in natural occurrence.

It is important to study and understand these techniques and their limitations. It gives a better understanding in current sex research, but also in the research that is yet to come.

How can we measure sexual behaviour?

The first thing that needs to be decided is how to measure sexuality. There are several methods available:

• Self-reports are the most common way and exist of questions about people’s sexuality. They can be conducted on paper, with interviews or online.

• Behavioural measures include direct observation where participants are observed, and the behaviour is described. Another behavioural measure is eye-tracking where participants’ eye movements are studied when they look at images on a computer. Illegal sexual behaviour is studies using police reports. In the FBI they use uniform crime reports to study illegal sexuality. However, it only detects cases that are reported to the police.

• Implicit measures include the implicit associations test in which the strength of associations to sexual content is measured. People tend to respond faster when an association is stronger. People are asked to divide sexual images or text into categories, such as pleasant and unpleasant.

• Biological measures are measures of response to sex. There are genital measures in which arousal is measured by vaginal changes in women and erection changes in men. MRI and fMRI are now increasingly being used, they look at autonomy and brain regions involved in sexual behaviour. Strengths are its normativity, but limitations are the complicated statistical research needed to read the results and there is a lot of noise if the participant does not lie completely still in the scanner. Also, the results depend on the choice of sets of stimuli.

What are issues in the field of sex research?

One important consideration is the population that is being used. The question here is who do we want to study? A scientist should always take a sample of the population. If the sample is a random sample, the results can be generalised to the population that was originally identified. However, random sampling is difficult because selecting a random one out of every fifty people in the United States can be tricky. Therefore, probability sampling is often used. Here, participants are selected based on characteristics meaning that the results are not generalizable to the whole population. Sampling exists from three stages:

1. Identification of the population.

2. Choosing a method for sampling.

3. Contacting the people in the sample. Here, researchers encounter the problem of refusal or non-response. The researcher needs to use volunteers, which causes the sample to contain volunteer bias, people that participate might be different from the ones that refused to participate. Moreover, women are less likely to volunteer for sex research than men.

Because there are some issues with sampling, convenience sampling can be used. It includes volunteers that came to sex’ therapist offices and volunteer to participate. It is chosen in a haphazard manner and relative to the population of interest. It differs from a probability or random sample.

Another issue is the accuracy of measurement. Participants in sex research often engage in purposeful distortion, when giving self-reports, they distort reality. They might exaggerate sexual behaviour (enlargement) or conceal certain things (concealment). To avoid distortion the participants are told that for scientific purposes, the information they give must be as accurate as possible, besides that anonymity must be guaranteed. However, even with these measures, there are two factors that impact the accuracy of responses:

• Memory recall is needed to retrieve information on sexual behaviours years ago. One solution is asking about current sexual behaviour. However, children cannot be asked due to ethical and practical problems. One alternative is to use daily diaries in which people report their behaviour.

• Difficulties with estimates arise when people are asked about frequencies. People cannot estimate very accurately which leads to inaccuracy in the self-report data.

• Evidence of the reliability of self-reports can be measured. One measure is test-retest reliability where the respondent is asked to answer a series of questions once, and again when some time has passed. The correlation between the answers is noted as test-retest reliability. Another option is using a computer-assisted self-interview (CASI) method. The questions can be read aloud in addition to written questions for people that are poorly in reading questions, while giving the same level of privacy.

• Accuracy of behavioural observations is an issue with natural observation of sexual behaviour. Direct observations have an advantage on self-report measures in accuracy but have their own problems. For example, they are expensive, time consuming and only a small sample can be studied. The sample that can be used probably consists of an unusual population that allows researchers into their bedroom.

• Extraneous factors can influence sex research, these factors include race, gender or age of the respondents and the researchers.

• Ethical issues arise when participants feel their privacy is being violated. A solution can be the use of an informed consent, where participants have the right to be told the purpose of the research. Another solution is the protection from harm where the levels of stress and discomfort are minimised. The principle of anonymity is an example of protecting participants from harm. The justice principle means that risks and benefits of participating should be equally distributed across research groups. A cost-benefit approach means that the stress of participants should be minimised and that what is left is the cost. Researchers should consider if the benefits outweigh the costs.

What are examples of major sex surveys?

When data is collected from a large sample of people by using questionnaires this is called a major sex survey.

The Kinsey reports

The first major sex survey was done by Alfred C. Kinsey between the late 1930s and 1940s. Even though the results are of historical interest, the research is a good example. The sample of the research was obtained by interviewing 5,300 males. Their responses were reported in a scale, called the sexual behaviour in the human male (1948). Females contributed to the sexual behaviour in the human female (1953). They chose not to use probability sampling because of non-response problems. However, there is currently no information about the accuracy of the used sample. College students, well-educated people, young people, protestants, people from Indiana and people from the Northeast were over presented. He used face-to-face interviewing by Kinsey himself or his well-trained colleagues. They cross-checked the participant’s reports for false information. The sample contained a unlikely high level of homosexuals and people with unusual sexual practices. Therefore, it is impossible to say how accurate the Kinsey statistics are.

The NHSLS

The National Health and Social Life Survey (NHSLS) used slipshod sampling. A large sample of the national population was needed to say what sexual behaviour looked like in America. The researchers used probability sampling for this purpose. It excluded only three percent of the population, which were institutionalised people. Data was obtained with interviews in addition to a written questionnaire. The NHSLS is one of the best surveys because outstanding sampling -and interview techniques were used.

The NSSHB

The National Survey of Sexual Health and Behaviour (NSSHB) is the most recent major survey done in the United States. A probability sample was used and 5,865 people participated. The method they used for sampling, which was based on the random selection of phone numbers was excellent. However, it caused the response rate to be low. Therefore, it is not possible to be sure the result can be generalised to the whole population. They obtained a good sample size and ethnic diversity though.

Sexual behaviour in Britain and Australia

Every ten years, a major sex survey is conducted in Britain called the National Survey of Sexual Attitudes and Lifestyle (Natsal). They use postal codes for sampling, which is an excellent method and the sample size is good (about 15,162 completed interviews). Interviewers went to participants homes to complete the survey. Also, urine samples were collected to test for sexual transmitted diseases. Another major research was done in Australia where computer-assisted telephone interviews were used to study health and relationships. Their findings were that the age of first intercourse has decreased over the last couple of years which is consistent with findings in the United States.

A survey of Latinx women

Latinas in the United States were interviewed to assess patterns of interpersonal victimization. This included sexual assault and violence by one’s partner. The study was called SALAS, meaning Sexual Assault among Latinas. Interviews were conducted over the phone in either English or Spanish. It used many methods suitable for investigating among minority populations. Sex research in minorities indicates sensitive issues and need additional consideration in language and ethnicity of the interviewer.

Magazine surveys

Magazine surveys are using samples that our out of their control. They are distributed among different clienteles and only to readers of the magazine. The response rate is about three percent, which is not even generalizable to the population of people reading the magazine. Ethnic backgrounds, marital status and age are unknown. These details are crucial in evaluation of the outcomes. Therefore, it would not be legitimate to infer conclusions based upon these statistics.

How do we study special populations?

An example of a study of a special population is the Coxon Study of gay men in the AIDS era. The project was called SIGMA and was used to understand the behaviour of men in the AIDS era. Participants were divided into two groups, one was the “out” and easy to administer gay people that were recruited in bars and pubs. The second, more difficult group consisted of “hidden” gays. After that respondents were asked to nominate persons in the other category. This technique of sampling is called snowball sampling or respondent-driven sampling. The study used the daily diary method where participants reported their sexual experiences. It resulted in a richer and contextualized overview of people’s sexual experiences. However, memory in self-reports is a major concern.

Nowadays, samples of special populations are often recruited via the Internet. There have for example been advertisements to take part in a research program on social and sexual networking websites for gays.

What are the advantages and disadvantages of web-based surveys?

A whole new era in sex research began by administering web-based surveys. Web-based surveys include recruiting participants using the Internet, and having participants complete questionnaires online. 

Advantages were that larger and broader samples could be recruited. They also have an advantage in studying specific populations defined by their sexual behaviour; especially when studying taboo behaviour. They also have the advantage that they eliminate extraneous factors, such as the ethnicity of the interviewer. A disadvantage is that the researcher does not have any control over the environment. Also, individuals might respond multiple times or sabotage the interview with fake answers.

What is media-content analysis?

The influence of mass media on sexuality can be analysed by content analysis, it consists of a set of procedures that are utilised to make valid inferences about text. It can be any text, an article in a magazine, a rap song or a romance novel. Again, sampling becomes an issue. The population must be defined an whether you want to analyse over a specific time period. Then, a coding protocol should be established. One important consideration is intercoder reliability, the correlation or percentage of agreement between different coders rating the same texts. It is a powerful scientific technique that allows people to know how the media is portraying sexuality.

What are qualitative methods?

Most research discussed so far uses quantitative measures, however qualitative measures can give useful insights into the subject as well. Qualitative research is done in a naturalistic, holistic manner which includes observation and in-depth interviewing of a participant. The results are conveyed into words instead of numbers. It seeks a complete picture of the participant and the context. Ethnography is a qualitative method that is used to provide a description of a social setting, society or human group. Participant-observer techniques include methods where the researcher becomes part of a community in order to observe its behaviour.

What are experimental methods?

The research discussed so far looks at natural occurrence of sexual behaviour. Such research is called correlational, meaning that the researcher does not manipulate variables, but studies the natural occurrence of relationships between variables. An experiment is another type of research where the experimenter studies an independent variable which is manipulated and its dependent variables that occur as a result of the manipulation of the independent variable. All other factors are held constant. The researchers is then permitted to make causal inferences about the behaviour observed in his participants.

What does the concept of meta-analysis entail?

Meta-analysis is a technique to create order among different studies on the same topic. It is a statistical technique where results from different studies are combined to determine what, taken together these studies say. There are three steps that need to be taken:

1. The researcher must locate all the previous studies based on the question that needs to be investigated.

2. For each study, the researcher must compute a statistic to measure the direction and difference between males and females. This is the value of d.

3. The researcher must average all the values of d over all the studies.

What statistical concepts are being used in research towards sex?

There are several important statistical concepts to understand before understanding reports of sex research.

• Average is used to summarise data. The mean is the average of scores of the respondents. The median is the middle score.

• Variability is an indication of the average of all the respondents. This can be used to judge the numbers in a single respondent or group of respondents.

• Average versus normal is an important consideration, conclusions based on a single average number are often mistaken. It is important to note that variability in (sexual) behaviour should be considered in classifying normal behaviour.

• Incidence versus frequency is another important consideration. Incidence refers to the percentage who engaged in a specific behaviour. Frequency is how often they do this. Cumulative frequency is the percentage of people who engaged in specific behaviour before a certain age. Prevalence refers to the percentage of people in a certain population who have engaged in a specific behavior.

• Correlation is the number that can be used to measure a relationship between two variables.

Study notes:

• In this chapter several difficulties in sex research have been described. The most difficult being sampling. What is sampling exactly and what kind of problems arise when sampling for sex research? Also, be sure to know what impact this can have on the interpretation of your results.
• Make sure to know the difficulties that can arise in using self-report measures in research on sexual behaviour. For example, can we trust people’s memory to be completely accurate?
• Understand the most important concepts in sex research, described in the final paragraph.

Chapter 4 - What is the Sexual Anatomy?

The purpose of this chapter is to provide information about the functionality of parts of the reproductive organs.

What are the female sexual organs?

The female sexual organs are divided into external -and internal organs.

External organs

The external organs are the clitoris, the inner lips, the mons pubis, the vaginal opening and the outer lips. Together they are called the vulva. Its appearance differs from one woman to another.

• The clitoris is a sensitive organ that is important in sexual response. It exists from the tip (glans), two copora cavernosa, a knob of tissue and two crura. They develop before birth and the gender organs of one gender are homologous. The clitoris of the female is homologous to the male’s penis because they exist from the same embryonic tissue. The clitoris is also erectile and fills with blood as the penis does. The clitoris is unique because it has no reproductive function.

• The mons pubis is the rounded and fatty part of tissue covered in pubic hairs. Nowadays, female pubic hair is often removed. Some say this norm has emerged due to the increased access to pornography. However, removing pubic hair leads to increased risk on injuries and STIs.

• The labia is the part along both sides of the opening of the vagina and also covered with pubic hairs. The Bartholin glands lie inside the inner lips and do not have a significant function. The perineum is the area between the anus and the vagina. The introitus is the opening of the vagina itself. Urine does not pass through the clitoris itself, but through the urethra, which is a separate opening.

• The hymen is a thin membrane that partly covers the opening of the vagina. It has some openings for menstrual fluid. It can be opened or stretched when the penis moves into the vagina. The hymen may be taken as a sign of virginity as it typically breaks when first having intercourse. However, a women without a hymen can still be a virgin, some girls are just born without.

Internal organs

The internal organs consist of the vestibular bulbs, the skene’s glands, the vagina, a pair of fallopian tubes and a pair of ovaries.

• The vagina is the organ in which the penis is inserted during sex. It is also referred to as the birth canal or introitus. The cervix at the lower part of the uterus is connected to the top. The walls of the vagina have three layers. The inner part of the vagina is sensitive to erotic stimulation. Around the vagina there is the pubococcygeus muscle, which is stretched during childbirth.

• The vestibular bulbs are two small organs that lie on either side of the vaginal wall.

• The skene’s gland or female prostate lies between the wall of the vagina and the urethra. This organ is the G-spot responsible for female ejaculation.

• The uterus or womb has the cervix which opens into the vagina. The major function is the development of a foetus.

• The fallopian tubes are the pathway by which the sperm reaches the egg.

• The ovaries lie on either side of the uterus and produce the eggs. They also produce estrogen and progesterone. They contain follicles, capsules that surround an egg.

Female genital cutting

There is worldwide controversy over female genital cutting. One type is clitoridectomy; the partial or total removal of the glans of the clitoris (Type 1). Type 2 is the removal of the clitoris and inner lips. The most extreme form, Type 3, is infibulation, in which the clitoris and all of the inner lips are removed, parts of the outer lips, and the edges of the outer lips are stitched together to cover the urethral and vaginal openings with only a small opening left for passage of urine and menstrual fluid. There are several critical health risks. The discussion is whether cultural relativism has limits. 

Nowadays, some women want to have surgery to make their labia smaller. There is controversy around this topic as well.

The breasts

Although they are not sex organs, they have a reproductive and erotic significance. They consist of fifteen to twenty clusters of mammary glands, all with a separate opening to the nipple. They are covered with a fibrous and fatty tissue. The nipple has a lot of nerves and is therefore sensitive to stimulation. The darker area around the nipple is called areola. The symbolical and psychological meaning of the breasts is enormous.

What are the male sexual organs?

The most notable parts of the sexual organs of the male are the scrotum, scrotal sac and the penis.

External organs

• The penis has an important function in reproduction, urination and sexual pleasure. The end or tip is called the glans. The opening at the end is called the meatus or urethral opening. Trough this opening pass urine and semen. The main part is called shaft and the raised ridge is called corona. The corona and the rest of the glans are most sensitive to stimulation. Inside the penis there are the corpora cavernosa and the corpus spongiosum. During the erection these tissues are swollen because they are filled with blood, making the penis stiff. The skin of the penis is usually not covered in hair.

• The foreskin is an additional layer of skin that covers the glans. In some adults this is absent if they are circumcised. Two small glands under the foreskin produce smegma. If the foreskin is not washed properly the smegma hopes up and can start to smell.

• Circumcision is the removal of foreskin. It can be done for religious or cultural reasons and symbolises the covenant between the Jewish people and god. It is also done for medical reasons; the chance of getting an HPV infection that causes genitals warts and predisposes women to cervical cancer is reduced, and the risk on prostate cancer is reduced as well. However, the foreskin is an erotic tissue, so the question is whether we should want to remove it. In Polynesia they use supercision, where they just make a small incision in the foreskin leaving the rest intact. In some tribes they do subincision, which is an incision in the lower side of the penis to the urethra. Urine is then coming from the base of the penis instead of the top.

Internal organs

• The testes or gonads are important in reproduction. They produce sperm and sex hormones, such as testosterone. In the internal structure, the seminiferous tubules are responsible for storing sperm and the interstitial cells produce testosterone. The cresmasteric reflex is the movement of the scrotum. When it is cold the scrotum moves closer to the body and when it is hot it moves further away to remain a constant temperature that is slightly lower than the body temperature.

• The male germ cells go through several stages of maturation: the spermatogonium, spermatocyte withspermatid as final stage. The sperm passes out of the testes into a single tube, the epididymis. While ejaculating, the sperm moves through vas deferens to the ejaculatory duct, which opens in the urethra. The sperm is then ejaculated out of the penis. The seminal vesticles are two structures that look like a sac and lie above the prostate. They produce about sixty percent of the seminal fluid or ejaculate. The other forty percent is created by the prostate.

• The prostate is situated below the bladder. It exists from glandular tissue and muscle. The prostate is small at birth and grows during puberty. It shrinks at old age. Sometimes it grows big enough to infer with urination, a surgical or medicinal procedure is then needed.

• Cowper’s glands or bulbourethral glands are just below the prostate. They empty into the urethra. The function is to neutralize the acidic urethra which allows safe passage of the sperm.

What kind of cancer exists in sex organs?

There are several kinds of cancer people can have in their sex organs. There is breast cancer, cancer of the cervix, endometrium -and ovaries, cancer of the prostate and cancer of the testes.

Breast cancer

This is the most common form of cancer in women. About five to ten percent is genetic. Other risk factors are long-term use of menopausal hormone therapy (MHT) and obesity. Self-exams of breasts can help to detect changes in an early stage. There are three kinds of breast lumps: cysts, fibroadenomas and malignant tumours. About eighty percent of lumps in breasts are not malignant. The technique used for early detection of breast cancer is mammography, also MRI scans can be used, but only recommended for high-risk cases. There are several forms of treatment including lumpectomy and radical mastectomy.

1. Lumpectomy is a surgical treatment where only the lump and surrounding tissue are removed.

2. Radical mastectomy is a surgical treatment where the entire breast is removed.

Both techniques have psychological consequences. The emotional response is often depression and anxiety. Relationship tensions can increase. However, most women show posttraumatic growth when they learn to live with their new body. Cognitive behavioural therapy can be useful in treatment of emotional responses to breast cancer.

Cancer of the cervix, endometrium and ovaries

About ninety-five percent of this type of cancer is caused by the HPV virus. Early heterosexual intercourse and multiple are known risk-factors. HPV interferes with the tumour suppressor genes. A pap test can detect this type of cancer early and helps to decrease the death rate. Diagnosis is difficult due to the varying symptoms. The symptoms such as vomiting and cramping can be related to many less serious conditions. Treatment, when detected early is cryotherapy that uses extreme cold to destroy the abnormal cells. For women with advanced cervical cancer, hysterectomy is used. This is the removal of the uterus. The vagina is left intact, so intercourse is quite possible.

Cancer of the prostate

Most cases of prostate cancer are not lethal. Most tumors are small and not widespread. The prostate cancer gene is called HPC1, but only accounts for three percent of the cases. Symptoms are frequent urination (especially at night), difficulties in urinating and prostate enlargement. The tumour presses onto the urethra causing these symptoms. In the beginning the disease may give a men frequent erections and increase in sex drive which results in problems with sexual functioning as the disease progresses. Rectal examination is the simple and best way for preliminary diagnosis. Treatment involves surgical removal of the prostate. Surgery can result in erection problems. The risk for prostate cancer increases with the number of sex partners.

Cancer of the testes

This is not a common form of cancer. It tends to happen to young men between the age of twenty-nine and thirty-five. The first sign is change in consistency of the testes or a painless lump. Many men do not discover the tumour. When the lump is early detected the survival rate is almost a hundred percent. When the tumour develops this is only seventy percent. Final diagnosis involves surgical removal of the testes. The other testicle can remain so hormone production and functioning can continue normally.

Study notes:

• Make sure you can name the most important internal and external organs of the female sexual anatomy
• Make sure you can name the most important internal and external organs of the male sexual anatomy
• What could be the psychological consequence of the treatment of different types of cancer on someone’s sexual functioning?

Chapter 5 - What are Sex Hormones, Sexual Differentation, and the Menstrual Cycle?

During the prenatal period most differences between men and women arise. This complex process is named: parental sexual differentiation. In this chapter the process of the menstrual cycle and sexual differentiation is discussed.

What are sex hormones?

The chemical substances that are created by the endocrine glands and secreted into the bloodstream are called hormones. The effects of hormones are felt rapidly through its secretion into the bloodstream. The hormones that are most important for sex are the following:

• Testosterone, this hormone belongs to the group called androgens.

• Oestrogens

• Progesterone

The endocrine glands that are of interest are those for sex, these are the testes in males and the ovaries in females. The pituitary gland is related to the hypothalamus. The hypothalamus regulates the pituitary, which regulates the ovaries and the testes. Therefore, it has the nickname of master gland. The hypothalamus plays a role in vital behaviours such as drinking, easting and having sex. The pituitary, hypothalamus and gonads (which are the ovaries and testes) work together to regulate the functions needed for sex.

What are sex hormone systems in males?

Both the testes and the pituitary produce hormones, the most important one in men is testosterone. It has a function in maintaining and stimulating the secondary characteristics of sex, such as beard growth. It also is responsible for maintaining genitals and their production of sperm and for stimulation of the bones and muscles. The pituitary produces two important hormones, both hormones influence the functioning of the testes.

1. Follicle stimulating hormone (FSH): controls sperm production.

2. Luteinizing hormone (LH): controls testosterone production.

Because of the negative feedback loop between the pituitary, the testes and the hypothalamus, the testosterone levels in males remain relatively constant. The level of the LH and FSH hormone is regulated by gonadotropin-releasing hormone or GnRH. This hormone is secreted by the hypothalamus. The feedback loop, where the hypothalamus monitors the testosterone levels and influences the level of GnRH, is called the HPG-axis. When testosterone levels are high, the hypothalamus produces GnRH to make sure the pituitary stops producing as much LH. This negative feedback loop is important for keeping the testosterone level constant. The hormone inhibin is produced by the Sertoli cells in the testes. It regulates FSH in a negative feedback loop, inhibin suppresses FSH, which suppresses sperm production. The hormone shows great potential to serve as a male anticonception method.

What are sex hormone systems in females?

Oestrogen and progesterone are the hormones produced by the ovaries. Oestrogen is responsible for the changes in puberty. It stimulates the growth of the vagina, uterus, pelvis and breasts. It also regulates membranes of the vagina and stops muscle and bone growth in females. The levels of these hormones fluctuate during pregnancy, menopause and the menstrual cycle. The two hormones produced by the pituitary, LH and FSH regulate the levels of progesterone and oestrogen. They are also controlled by the negative feedback loop of the hypothalamus, like the negative feedback loop for testosterone in men. Inhibin is produced by the ovaries instead of the testes. Besides this, the pituitary produces two other hormones: prolactin and oxytocin. The first is responsible for the production of milk after the pregnancy and the second stimulates the contractions of the uterus during childbirth. After birth, oxytocin seems to promote bonding with the child.

Levels of estradiol and progesterone actually do not differ between adult men and women, although most people think so. Only testosterone levels differ between men and women; as men have more of it.

What are prenatal sexual differences?

Sex chromosomes

A new human starts from a single cell and develops into a male or female. The specific chromosomes within that cell determine its gender. Two X chromosomes is typically a woman, an X and Y chromosome becomes a man. These chromosomes give instructions on which organs to develop. Some children are born with a different combination. This often results in the Klinefelter syndrome. A genetic male has the XXY chromosomes. Testosterone levels are low and there is no sperm being produced. The single cell duplicates many times during growth and turns into an embryo. By the seventh week you can tell whether it’s a male or female.

Gonads

After the seventh week, differentiation of the sex chromosomes begins. One important gene involved in differentiation is the SRY-gene, or sex-determining region, Y chromosome. This gene is responsible for the testes-determining factor (TDF). The X chromosome consists of genes that control ovary functions.

Prenatal hormones and the genitals

After differentiation, the sex hormones are produced and cause changes in the internal and external genitals. In females, the Mullerian ducts become fallopian tubes, the vagina and the uterus. The tubercle changes into the clitoris, inner -and outer lips. In men, the Wolffian ducts turn into the ejaculatory duct, the vas deferens and the epididymis. The tubercle becomes the glans of the penis and the scrotum.

Descent of the testes and ovaries

While these differentiations take place, the testes and ovaries change position and shape. Before shifting to the final position in the pelvis they remain at the upper end. The testes undergo a similar change going through the inguinal canal. There are two issues that can occur during this process:

1. Cryptorchidism meaning undescended testes

2. Inguinal hernia meaning an unfinished inguinal canal

Brain differentiation

Aside from differentiation in the genitals, there is also brain differentiation. Epigenetics refers to changes in DNA that does not alter the DNA code, but rather leads to changes in the expression of specific genes. Genes responsible for brain differentiation can be found in several genes. New studies using MRI reveal important insights in the androgen and oestrogen receptors responsible for gender differences. Studying the brain using fMRI revealed that there is an activation of a region in the hypothalamus in men when they were sexually aroused. Neuroscientists emphasise the brain’s plasticity and argue that it is continuously changing in response to certain experiences.

Homologous organs

Men and women have the same origins and develop the same embryonic tissue. The organs are called homologous. When two organs have a similar function, they are referred to as analogous.

Endocrine disrupters

Abnormal endocrine development is the result of endocrine disrupters; which are chemicals found in the environment that affect the endocrine system. An example is atrazine, which affects estrogen and testosterone and inhibits their binding to their receptors. It also depresses the LH surge that causes ovulation. Another example is DTT, which mimics estrogen and then binds to their receptors, and alters the metabolism of progesterone and testosterone.

Endocrine disrupters contribute to impaired reproduction, neurodevelopment, thyroid function, and metabolism and increased propensity for hormone-sensitive cancers. Plastic and pesticide residues on fruit and vegetables seem to form a dangerous risk in the Western society nowadays.

What are atypical differences between genders?

There are several variables of gender (Money, 1987) they are the following:

1. Chromosomal gender. This is XY in males and XX in females.

2. Gonadal gender. These are testes in men and ovaries in women.

3. Prenatal hormonal gender and prenatal and neonatal brain differentiation. The existence of MIS and testosterone in men, but not in women before birth. Testosterone is present for masculinization.

4. Internal organs. These include the uterus, the upper vagina, the fallopian tubes, the prostate, vas and seminal vesicles.

5. External genital appearance. This are the inner and outer lips, the clitoris, the vaginal opening, the scrotum and the penis.

6. Pubertal hormonal gender. Testosterone, oestrogen and progesterone.

7. Assigned gender. The announcement whether it is a boy or a girl.

8. Gender identity. The internal sense of female -or maleness.

A person is said to have an intersex condition or disorder of sex development when there are contradictions between several of the above biological factors (1 to 6). There are several syndromes that can cause an intersex condition. One is congenital adrenal hyperplasia, this is when a genetic female produces an excess number of androgens during prenatal sexual differentiation. The external genitals will then appear men. Another condition is androgen-insensitivity syndrome where a male develops normally including its testosterone levels, however the body is insensitive to them. This results in a feminized sexual development. The person is born with the external organs of a female.

What sexual differentiation happens during puberty?

The scientific definition of puberty is the period of sudden maturation and enlargement of the gonads, secondary sex characteristics and other genitalia leading to the capacity to reproduce. The psychological process that people endure during puberty is a result of increased hormone activity. Adolescence is defined as the period of transformation of behaviour, responsibilities and attitudes to become an adult. The timing for pubertal processes is very different between males and females. Boys begin about two years later than girls, who start around the twelfth year of age. Also, there are large individual differences in the age when puberty begins.

Changes in girls

The first sign of puberty in girls is breast development. This starts when a girl is about eight or nine years old. The changes are produced by increases in sex hormone levels. Besides the growth of the breast, another visible sign is the growth of pubic -and underarm (armpit) hair. Oestrogen is responsible for stopping the growth spurt in girls and causes the growth period to be shorter than in boys. The menarche happens around the age of twelve and is the first time of menstruation. There are some factors that contribute to the age of the menarche. One is body fat, leptin is the hormone that determines the onset of puberty and rises with body fat. Kisspeptin is another hormone to stimulate the onset of puberty. It does so by stimulating the hypothalamus to secrete is sex-hormone GnRH and later LH and FSH. The influence of body fat is important in describing two phenomena:

1. The cessation of menstruation in girls with anorexia nervosa.

2. The cessation of menstruation in runners or extreme athletes.

The adrenal glands are also important in puberty. They produce androgens that stimulate pubic -and axillary hair growth. It is also related to female sex drive. The adrenarche is the onset of increasing secretion of the adrenal androgens. The adrenarche is mostly around eight years.

Changes in boys

Puberty starts later in boys and begins with heightened levels of the hormones: LH and FSH. The first sign is growth of the scrotum and testes. Pubic hair growth starts about the same age, around nine. One year later the penis starts to grow, which is caused by testosterone stimulation. Erections increase in frequency and when a boy is around thirteen or fourteen years old, he can ejaculate. One year later, boys start having nocturnal emissions and for a boy that has never masturbated, that can be his first ejaculation. In boys, acne is quite normal during puberty cause by androgens. It is a shame that there is so little interest in the rites of passage for both boys and girls when they enter the stage of puberty. When there is more recognition, boys and girls might better understand the stage they are in.

How does the menstrual cycle work?

Fluctuating hormones in the body regulate the menstrual cycle. There are several phases involved in the menstrual cycle which are all characterised by different hormones.

1. The follicular phase is when high levels of FSH are secreted. This causes an egg to get to the state of final maturity. Oestrogen is secreted at the same time.

2. The ovulation is when the mature egg is released by the follicle. Oestrogen is risen to a level where it inhibits the secretion of FSH and increase produce of GnRH, which causes beginning of production of LH.

3. The luteal phase is when the follicle (caused by LH) turns into a corpus luteum. It manufactures progesterone and inhibits LH secretion causing the corpus luteum to degenerate. After this a sharp decrease of oestrogen and progesterone causes the stimulation of FSH and the cycle can be repeated.

4. The menstruation is when the inner lining of the uterus is passed out through the vagina. During this phase, FSH levels are rising, oestrogen and progesterone levels are low. These low levels of oestrogen and progesterone trigger the menstruation and end the luteal phase.

The menstrual cycle lasts from twenty to thirty-six days with an average of twenty-eight days. There can be menstrual problems, for example dysmenorrhea is the most common and is the experience of a painful menstruation. It is caused by prostaflandis, a hormone causing muscle contraction. The best treatment is NSAIDs or nonsteroidal anti-inflammatory drugs. Another proposed cure is masturbation because the discomfort is caused by the pelvic edema, which increases during an orgasm. The second problem is endometrosis, caused by growth of the endometrium. It should be treated by a physician, otherwise it can lead to sterility. The last menstrual problem is amenorrhea, which is the absence of menstruation.

What are the psychological aspects of the menstrual cycle?

• Fluctuation in mood is related to the premenstrual syndrome (PMS). It is the occurrence of psychological and physical symptoms that occur prior to menstruation. Symptoms are breast pain, water retention and depression and irritability. Researchers showed that only sadness and irritability showed significant changes throughout the menstrual cycle. It was not just prior to menstruation, which is the main concept of PMS. There is no scientific evidence of PMS. There is a premenstrual dysphoric disorder (PMDD) which is found in a small percentage of women. Symptoms are feelings of hopelessness, sadness, anxiety, fearfulness and tension in the luteal phase.

  In rural Nepal, religious Hindus consider a menstruating woman to be toxic. This leads to the custom of chhaupadi; which entails that women are not allowed to sleep in the family home during their periods. They go to crude animals sheds, in which they are exposed to harsh weather. The tradition is dangerous; as it has costs many lives.

• Fluctuations in performance can be a practical indicator of mood changes during the menstrual cycle. Researchers did not find any fluctuations in performance, there is no reliable evidence of performance decrease caused by the menstrual cycle. However, in one study there was found that elite female athletes had more testosterone during ovulation. Does this mean that more testosterone leads to performance benefits, or is it maybe the case that the experience of being an elite athlete leads to increased testosterone?

• Fluctuations in sex drive, there is a link between sex drive and menstruation and is associated with the testosterone levels. Therefore, women have a peak in sexuality while ovulating.

Study notes:

• Make sure you know the most important hormones that are important for puberty and sexual differentiation.
• The female changes of breast development and menarche, and changes in men which include growth of the penis and testes and beginning of ejaculation are important concepts described in this chapter.
• Women often complain about PMS. However, this has never been scientifically proven. Could you think of reasons of why people still believe in the existence of PMS?

Chapter 6 - How do Pregnancy and Childbirth work?

How does the process of conception work?

When a woman is ovulating, the egg is released from the follicle into the ovary and enters the fallopian tube. It starts its journey to the uterus when it is fertilized in about five days. If the egg is not fertilized it degenerates in forty-eight hours. When the sperm is inserted into the vagina it starts its way towards the egg. The sperm is a very tiny cell and exists from the head, midpiece and tail. Sperm contains both RNA and DNA carrying instructions for development of the embryo. Conception does not happen in the uterus, but in the outer part of the fallopian tube. The sperm is attracted to the egg by a chemical attractant. Sperm produces hyaluronidase, which dissolves the thin layer around the egg called zona pellucida. When an egg is fertilized it is called a zygote. In the first eight weeks the conceptus is called embryo and after that foetus.

What are the chances of successful conception and how can they be improved?

The most important way to improve conception is to have intercourse while the woman is ovulating. The best way to determine when a woman is ovulating is to measure body temperature. On the day of the ovulation the temperature drops, and the day after it rises again. Sperm can live in the woman’s body for five days meaning intercourse could also take place a few days before the ovulation. Also, regular intercourse (every day or every two days) is important for the male’s sperm count. The position of intercourse is important for an optimal flow of sperm into the vagina. Finally, lubricants should not be used as they might kill or block the sperm.

Fertility websites and apps are available that tell the user the best time to have sex if the goal is to become pregnant. However, most of these websites are inaccurate. 

How does the conceptus develop?

The “silent struggle” between conceptus and pregnant woman is about the competition for nutrients. The placenta determines the flow of nutrients to protect the foetus. The months of pregnancy are divided into three parts, or trimesters. After conception and the passing through the fallopian tube, the single and now divided egg cell arrives in the uterus for implantation. During the first eight weeks, the major organ systems of the embryo are formed. The ectoderm will become the entire nervous system plus skin. From there it develops into the digestive -and respiratory system. The mesoderm will become the skeleton and muscles, but also the circulatory ad reproductive system. The head develops at first, followed by the body. This is called a cephalocaudal order.

The placenta exists from a lot of tissue and exists from the trophoblast. This is the tissue surrounding the conceptus and matures the growth. The circulatory systems of the woman and conceptus are separate. The placenta serves as a barrier between these two systems. It produces oestrogen and progesterone and many of the physical symptoms occurring while pregnant are because of these elevated hormones. The placenta also produces human chorionic gonatropin (hCG), this is the hormone detected with a pregnancy test.

The umbilical cord is developed in the fifth week of embryonic development. It is attached to the placenta in order to interchange substances between the woman and the foetus. The two membranes around the foetus are called chorion and amnion filled with amniotic fluid in which the baby can float. It keeps the foetus at a constant temperature and provides protection against possible injury.

How does the foetus develop?

The foetus develops the fastest in the first trimesters. At the end of the first trimester, the foetus looks human and the development consists of enlargement of already present structures. By the eighteenth week the woman can feel movement and heartbeat. The baby should be born about twenty weeks after that. The foetus should turn in the uterus after seven weeks. If this does not happen, the baby will be born in a breech presentation.

What are the stages of pregnancy?

Trimester I

The first trimester (until week twelve) starts with the detection of pregnancy. The body-temperature chart can provide insights into pregnancy. The body temperature stays up after ovulation for about two or three weeks. Other symptoms in early pregnancy are morning sickness, sensitivity of the nipples and tenderness of the breasts. Pregnancy tests should be taken as early as possible. The accuracy of a home-pregnancy test depends on the sensitivity to hCG. There are three signs of pregnancy, presumptive signs, probable signs and positive signs. Positive signs cannot be detected until the fourth month and include beating of the heart, movement and the detection of the foetal skeleton (by ultrasound). The expected delivery date (EDC) is calculated using nӓgele’s rule. 

Physical changes during the first trimester include increased level of hormones, women urinate more frequently and the colour around the nipples turns darker. Also experiences of sleepiness and fatigue are common and caused by high levels of progesterone. Psychological changes vary with the attitude to the pregnancy. Social class also influences emotional state during pregnancy, where a low income can cause depression in pregnant women. Anxieties of women will often centre around miscarriage. The emotional state can influence the development of the foetus. Stress can cause stillbirth, the delivery of a death foetus. Intercourse is safe throughout the pregnancy. It is even related to a reduced risk of preterm birth.

Trimester II

In the second trimester (weeks thirteen to twenty-six) the woman is aware of the foetus’ movements. Most physical symptoms, such as morning sickness are down to a minimal level. Other physical problems arise, such as nosebleeds and constipation. Edema, or water retention and swelling can become a problem in hands and wrists. Around the middle of pregnancy, colostrum could already come out of the nipple, without milk. Psychological changes are that the woman becomes calmer, the discomforts of the first trimester start to disappear and the woman feels the movement of the foetus. Depression is less likely. Woman who experienced pregnancy before are more distressed than woman who did not.

Trimester III

The third trimester (weeks twenty-seven to thirty-eight) is characterised by the very large and hard uterus. The foetus is becoming more active and can keep the woman awake at night. The size of the uterus pressures other organs which can cause shortness of breath. Women often feel low on energy during this period. The amount of weight gain should be restricted because it can cause complications, the strain on blood pressure and the heart is much higher with women that gain an excessive amount of weight. During the third trimester, the uterus contracts painlessly, these contractions are called Braxton-hicks contractions. It helps to strengthen the uterus muscles for labour. The turning of the babies’ head and dropping into the pelvis is called dropping, engagement or lightening. Psychological influence comes from support during pregnancy. Women with less support in this period have a higher chance on a baby with a low birth-weight.

What is the experience of the father during pregnancy?

The father can experience pregnancy symptoms as well. This is called the couvade syndrome and are caused by hormonal changes in prolactin. In some cultures, the couvade ritual exists where the husband lays in bed while his wife is in labour. He suffers all the pains of delivery. Nowadays, men are expected to take an active part in fathering. A father instinct and bond to the child can be strengthened by the response to the infant. They also play a role in preparing for the baby, joint activities between partners increases the bond and provides a better foundation for their new family member.

What are the effects of using substances on pregnancy?

A drug taken during pregnancy will also circulate through the body of the foetus. Drugs that may cause severe consequences are called teratogens. The drugs that women should be cautious about are the following:

• Antibiotics can cause severe defects during birth and can cause foetal abnormalities.

• Alcohol can cause any foetal alcohol spectrum disorder. The severity and occurrence depend on substance and occurrence. The foetal alcohol syndrome (FAS) is a malfunction with prenatal and postnatal (brain) growth deficiencies. The most serious effect of FAS is intellect, children with FAS score about 2 standard deviations below the average. A meta-analysis of empirical studies found a relationship between binge drinking and diverse aspects of cognitive functioning in children aged 6 months to 14 years. There are no safe limits of alcohol consumption during pregnancy.

• Cocaine is related to the risk of premature birth and birth weight. Children exposed to cocaine can exhibit neurological defects and lower intelligence scores.

• Marijuana use can cause premature birth, reduces growth and reduced weight although the empirical evidence varies. Verbal skills and memory can be affected, but also hyperactivity, impulsivity and externalizing behaviour.

• Steroids also correlate to low birth weight but can also cause stillbirth.

• Other substances such as smoking causes cardiovascular disease or heart problems. The risk on asthma increases. The use of tricyclic antidepressants can result in birth defects, but the results are inconclusive. The use of psychiatric medication in general should be individually examined and discussed with a psychiatrist and an obstetrical services provider.

• Dads and drugs, drugs taken by the father even before conception may also cause birth defects. Drugs could damage sperm and its genetic content. A father who was smoking in the absence of the woman also increased the risk of childhood cancer.

What are the stages of labour?

Labour starts with contractions of the uterus. In ten percent of women, the water breaks. It means that the membranes with fluid rupture bursts. With most women, the sac does not break until the end of the first stage of labour. Contractions during labour are very irregular. The biological system causing labour to start is not completely clear. It could be a hormone that inhibits progesterone is released.

Labour often is divided into three stages:

1. First stage labour starts with the contractions and these cause two changes in the cervix. These are effacement, thinning out and dilation, opening up. The process of first stage labour consist of early first labour, late first stage labour and transition.

2. Second stage labour begins when the cervix is fully dilated. The head of the baby starts to move into the vagina or birth canal. With each contraction the baby can be pushed down and when the babies head can be seen it is called crowning. Many physicians perform an episiotomy, an incision in the skin behind the vagina. The incision prevents problems with later sexual functioning. After the first breath, the baby can be cut off from the placenta and the uterus of the mother.

3. Third stage labour is when the placenta comes loose from the wall of the uterus and the afterbirth is expelled. Contractions can be accompanied with the outburst of the placenta.

A caesarean section (c-section) is used when vaginal birth is impossible. Reasons could be that the vagina is too small, the labour has been very long and hard or the mother is near the point of total exhaustion. Other reasons could be that the health of the mother or baby is getting worse or the umbilical cord prolapses. Even though someone had a c-section, it does not mean vaginal birth after that is not possible.

What are the options for childbirth?

• Prepared childbirth by education about fears and relaxation techniques. The Lamaze method exists of controlled breathing and relaxation. There are numerous other exercises available to prepare for childbirth. It helped improve experiences, however unrealistic expectations could arise, especially for women having their first, or primiparas.

• The use of anaesthetics in childbirth had become common. A spinal block is used to relief pain in the first stage of labour. The epidural block numbs the body and may be given before a c-section. A pudendal block in and injection in the vaginal wall and gives pain relief short before delivery. It has some risks for the woman and the baby, but when a woman cannot control the pain, she should be able to request anaesthetics.
• Home birth versus hospital birth, home delivery is less stressful for the woman whereas if unforeseen emergency takes place, a hospital might be more comfortable and homebirth dangerous.

During the prenatal period most differences between men and women arise. This complex process is named: parental sexual differentiation. In this chapter the process of the menstrual cycle and sexual differentiation is discussed.

What does the postpartum period look like?

During the postpartum period (after childbirth) there are both physical and psychological changes happening to the woman. Attachment to the baby and sex with the partner also play an important role in the postpartum period.

• Physical changes include severe drops of hormones and exhaustion after labour.

• Psychological changes can include postpartum depression, a depression followed by the birth of a baby.

• Attachment to the baby begins even before the baby is born and feelings of nurturance increase after birth.

• Sex during postpartum can be impossible in the first period. After four months most couples resume intercourse as back to normal.

How does breastfeeding work?

The biological mechanisms of breastfeeding are based on two hormones, prolactin and oxytocin. Milk is produced a few days after delivery. It gives the baby high protein and temporary immunity to several diseases. Substances taken by the mother are transmitted to the infant through the milk. Breastfeeding is encouraged. The physical and mental health of the infant benefits greatly from breastfeeding.  

What problems can arise during pregnancy?

• An ectopic pregnancy is a misplaced pregnancy and happens when the egg implants in the fallopian tube instead of the uterus.

• In pseudocyesis (false pregnancy) signs and symptoms of pregnancy are happening without actual pregnancy.

• Pregnancy-induced hypertension has three serious conditions, the first hypertension, second is preeclampsia, an elevated blood pressure together with edema (fluid-retention) and proteinuria (urine with protein). It is related to foetal death and has serious implication for the woman such as vision problems. The third is eclampsia, where the woman goes into a coma or dies. These problems occur around the twentieth week of pregnancy and is a reflection of the struggle between mother and foetus for resources.

• Viral illness during pregnancy, for example measles cause fifty percent of infants to be born deaf or mentally deficient. A woman should get a vaccination before she gets pregnant. Herpes increases the risk of spontaneous abortion.

• Birth defects can be genetic or caused by taken substances during pregnancy. Two ways can examine possible birth defects: amniocentesis, where fluid around the baby is examined for defects, chorionic villus sampling (CVS) is a technique that takes a sample for cells and analyse them before birth.

• RH incompatibility when the babies blood type contains Rh+ while the mother has Rh-. It can cause stillborn of the baby or severe disabilities.

• Miscarriage (spontaneous abortion) is the termination of a pregnancy trough a natural cause. This does not include premature birth or induced abortion.

• Preterm birth is a major complication and happens when a baby is delivered before thirty-seven weeks. A premature infant is less likely to survive.

What are causes and treatment of infertility?

Infertility is the inability of a woman to give birth to a living child. It can be caused by both the female, such as by pelvic inflammatory disease (PID) or by the man by for example sexual transmitted diseases. There are several ways of treatment of infertility.

• Artificial insemination is when semen is placed artificially into the vagina, uterus or fallopian tubes. It is a means for getting pregnant without having intercourse.

• Sperm banks use sperm that has been frozen. For example, men can freeze their sperm for if they get cancer or a vasectomy and still have children later.

• An embryo transfer is done from one uterus to another and for women who can conceive but always miscarry. A surrogate mother is then used to carry the baby.

• Test-tube babies come from in vitro fertilization or IVF. The fertilized egg is implanted into the women’s uterus. It is also possible to freeze fertilized eggs, you get frozen embryos. The legal status is undergoing a debate because of the worry on embryo wastage. Intra-cytoplasmic sperm injection is an improved kind of in vitro fertilization in which a single sperm is injected directly into the cytoplasm of the egg. It has a high success rate. 

• In an embryo transfer procedure, a fertilized developing egg (embryo) is transferred from the uterus of one woman to another. The female of the first uterus is the surrogate mother.

• GIFT or gamete intrafallopian transfer is when sperm and eggs are inserted into the vagina together. ZIFT or zygote intrafallopian transfer involves the fertilization of the egg with sperm in a laboratory dish and then placing the developing zygote into the fallopian tube, again allowing natural implantation.

ART can often result in multiple births; for example, twins. There is controversy about whether ART should be available to everyone. Since 2015, transgender persons have become legally able to use ART.

What are the recent developments on the topic of gender selection?

There is much interest in techniques that can alter gender in unborn babies. However, there are many ethical consequences. The population balance might change drastically. There are wisdoms about how to conceive a boy, but research did not find any evidence to support certain claims. There are possibilities to manipulate the gender, but these techniques are still forbidden, expensive and risky.

Study notes:

• Make sure to have a broad overview of the different stages of pregnancy and the consequences of changes in the body on psychology, or psychology on the foetus. This is described in the section on different stages of pregnancy.
• Also, the phases of childbirth should be read carefully. Make sure to know what basically happens in every stage and what might go wrong.
• What are the psychological consequences on the sex-life that could be caused by pregnancy?

Chapter 7 - How do Contraception and Abortion work?

Contraception is not as controversial as it used to be. Nowadays effective anticonception methods are available for a variety of reasons. For example, people who are not in a relationship typically want to prevent pregnancy. The fact that anticonception is becoming more ordinary has a positive impact on the number of teen pregnancies, especially in the United States. Another good reason is the reduction of healthcare costs by avoiding unnecessary abortions.

What hormonal methods for anticonception are available?

Hormonal methods are very effective. The methods include the pill, the patch, the vaginal ring and injections.

Combination pill

The combination birth control pill contains progestin, oestrogen and a synthetic progesterone in slightly higher levels than normal. The pill needs to be taken for twenty-one days with a placebo or no-pill seven days in between. There are variations on this number of placebos versus active pills. The pill prevents ovulation by heightening levels of oestrogen and progesterone, and thus inhibiting FSH and LH production. Progestin makes the tissue very thick so implantation if the eggs were fertilized is almost impossible. In the placebo days, when progestin and oestrogen are not taken, a withdrawal bleeding takes place.

The failure rate or pregnancy rate is the number of women who become pregnant during a year of contraception. There is the failure rate for perfect users and the failure rate for typical users. The failure rate for perfect users is about 0.3% and 9% for typical users. One side effect of the pill is disease in the circular system. Women on the pill have a higher risk on the development of blood clots and high blood pressure. Other side effects are nausea, weight gain, the increasement of vaginal discharge and heightened change of getting chlamydia.

Advantages of the pill are its effectiveness and it does not intervene with sex. It also reduces cramps and lowers the amount of menstrual flow. Besides the side effects, the correct intake of the pill can be a burden on women with a busy lifestyle. Also, when people do not engage in sex often, the pill can be a contraceptive overkill. Getting pregnant can take about three months after stopping the pill, but the rates are the same as women who never took the pill. Combinations with other drugs can decrease the effectiveness.

Other kinds of pills

There are pills available with lower levels of oestrogen and pills with high levels of progestin can lead to depression. Triphasic pills contain a steady level of oestrogen but differentiate in the level of progesterone. Progestin-only pills of minipills only have low levels of oestrogen and progestin to avoid side-effects. These inhibit ovulation and implantation. The failure rate is higher. They are effective for women who breastfeed as combination pills reduce milk production. 

The patch

The patch or ortho evra contains the same hormones as the combination pill but is transdermally administered (through the skin). The patch lasts for seven days, so women do not have to remember to take the pill every day. Also, the pill does not have to be digested. Expectations are similar effectiveness of the combination pill, but extensive data is not yet available.

The vaginal ring

The NuvaRing is filled with the same hormones as the combination pill in lower dosage. She must insert the ring every twenty-one days with one stopping week. Also, this technique is quite recent, so there is no extensive research data available yet. Even though the expectation was that the typical user failure rate would be lower, this is about the same as the combination pill.

Depo-Provera injections

Depo-Provera (DMPA) is an injection of progestin, they must be repeated every three months. It inhibits ovulation and thickens the cervical mucus to prevent implantation. It is highly effective and has a low typical user failure rate. The advantage is that is does not interfere with sex and has no reliance on memory as taking pills does. Many people experience amenorrhea (no menstrual periods) which relieves endometriosis.

Emergency contraception

When a condom breaks, a woman can choose emergency contraception. The treatment should be started within twenty-four hours after intercourse and cannot be delayed any longer than five days. The pill may stop ovulation, inhibit the function of sperm and inhibit the development of a nourishing endometrium. It is used to prevent pregnancy, not to cause abortion. The failure rate is about one percent, when taken within five days of unprotected sex. 

Drugs used to treat epilepsy, tuberculosis, HIV and vertain fungal infection interact with emergency contraception drugs; making EC's less effective.

What are long-acting, reversible contraceptives (LARC)?

LARC methods, unlike sterilization can be reversed. One example is an implant, which are inserted under the skin of the arm. They only release progestin and suppress ovulation, thickening and inhibit the growth of the endometrium. The effectiveness is very high, and the typical and perfect user rates are the same. There are no lethal side effects. It requires no reliance on memory for a period of three years and there is no oestrogen causing the oestrogen-related side effects. One disadvantage is that unpredictable (or no) bleeding patterns can occur. After removal the menstrual cycle returns to normal within three months.

An intrauterine device (IUD) is inserted into the uterus. It has two plastic strings that hang from the cervix, this enables a woman to check whether the device is still in place. The IUD creates an environment that is toxic to eggs and sperm cells. Also, when fertilization would take place, it prevents implantation. The Mirena and Skyla IUD’s release progesterone into the endometrium which disrupts ovulation. The third IUD made of copper has an extra functionality. It alters the enzyme functioning to prevent implantation. The method is highly effective and lasts a long time. Side effects are irregular bleeding and for some women using the variant of copper it can increase menstrual cramps. The initial costs are high, but it pays off over the years of use. A woman can get pregnant immediately after removal.

What are condoms?

The male condom can be described as a contraceptive cover that is placed over the penis. These are typically made of latex, but other condoms, such as the polyurethane condom are available for people with allergies. The popularity increased due to the protection against STDs, including HIV. The condom must be unrolled prior to intercourse, not to ejaculation. The condom catches the semen and prevents it from entering the vagina. The condom is very effective and there is no side effect. However, the spontaneity of intercourse is disrupted, and some men complain about the reduction in sensation. The female condom exists from a ring that is placed over the cervix while another goes outside the body and covers the vulva.

What is the Diaphragm, the Sponge and the FemCap?

The diaphragm consists of thin rubber and is inserted into the vagina. It fits over the cervix and is used with a contraceptive cream. The diaphragm must be inserted six hours before intercourse and stay until six hours after. It should not be worn longer than twenty-four hours. This was the mainstream contraception until the 1960s. The FemCap is like the diaphragm but is made of silicone. The sponge is another vaginal barrier method and is a pillow-shaped sponge containing spermicide. It is effective for twenty-four hours. However, the sponge is not very effective.

What is the withdrawal -and rhythm method of birth control?

Withdrawal is a contraceptive method where the penis is withdrawn from the vagina before ejaculation. It is not a very effective method and the failure rate lies around twenty-two percent. However, it remains the only last-minute method and can be used when nothing else is available. The fertility awareness (rhythm) method is based on abstaining from intercourse around the time of ovulation. The calendar method is similar, but the woman keeps a calendar to record when she is ovulating. The basal body temperature method (BBT) is another rhythm method where a woman keeps track of her temperature to determine when she is ovulating. The cervical mucus method includes a woman checking her cervical mucus and the symptom-thermal method means that both the body temperature and cervical mucus are combined to see whether a woman is ovulating.

What is the process of sterilization?

Sterilization or voluntary surgical contraception (VSC) is the sterilization by surgical methods. Currently the word sterilization has emotional overtones because it threatens our manhood or femininity. A physician is very careful in performing this surgery and the principle of informed consent must be followed. They are gaining in popularity though.

• Male sterilization or vasectomy is the cutting of the vas deferens. Another option is a no-scalpel vasectomy where only a small incision in the scrotum is made. The vasectomy prevents the sperm from being in the ejaculate. Even though there are methods of reversing a vasectomy (vasovasostomy), the man should assume it cannot be undone.

• Female sterilization or laparoscopy includes the blocking of the fallopian tubes. Another procedure is called inilaparotomy which is done immediately after giving birth. The transcervical approach is a procedure that does not require an incision, devices block the fallopian tubes and scar tissue forms around it. It does not interfere with the ovaries and does not bring on menopause. They are also performed as a treatment of cancer.

What are the attitudes towards contraception?

Even though there are many ways of anticonception, teen pregnancies still happen every year. This can be because teenagers think they do not have access to birth control, they have a weak self-effectiveness and therefore are not motivated to avoid pregnancy. Another issue is the embarrassing and humiliating presentation of anti-conception methods in the mass-media. Solutions include better sex education and legitimizing the purchase of anti-conception methods.

What is the procedure of abortion?

Abortion is the termination of a pregnancy and is a highly controversial subject. Advocates speak of women’s rights over their own bodies and the opposition argues for the right of the foetus. Therefore, policies of abortions vary widely. There are several procedures available for abortion.

• Surgical abortion or vacuum aspiration method can be done in the first trimester and is the suctioning out of the contents of the uterus. It is also referred to as suction curettage. 

• Medication abortions or mifepristone is the abortion pill and can be used for a very early abortion. The endometrium of the uterus is then sloughed off. The use of mifepristone was only approved in 2000 in the US. 

Abortian rates in the US

The abortian rate in the United States is down 25 percent from 2008. This decline in the number of abortions may be due to the increased use of LARC methods, which are highly effective. Also, there has been an increase in state laws restricting access to abortion.

What are the psychological aspects of abortion?

The decision-making process for abortion is very difficult, many people experience anxiety and anger. The foetus has a right to live, but also to be born in a stable family. It is argued that women can be psychologically traumatized after abortion. After a few years they show good adjustment though. Men are often supportive of abortion if they are included in the decision.

What are the new developments in contraception?

According to some, the perfect method of anticonception is not yet found. Besides the condom, there is no protection from sexually transmitted diseases. Therefore, research to contraception continues.

• New male methods are new condoms to provide more sensation and are not made of latex. Other new methods are male hormonal methods to suppress production of LH and FSH so that sperm won’t be produced. RISUG or reversible inhibition of sperm under guidance makes the sperm unviable. Another option is to target pituitary FSH to block sperm production without stopping testosterone. Nestorone-Testosterone gel is a very promising new method. The gel, that is applied to the arms and shoulders everyday, contains nestorone and testosterone, inhibiting sperm production. Sperm-binding beads is a potentially new method as well: Beads are placed in the uterus that bind with sperm; so that the sperm can't go after the egg no more.

• New female methods include microbicides to kill sperm and protect against STD’s are now researched. Also, a better pill could lower a woman’s testosterone levels so she feels more sexual desire while she uses it. One way to add androgens to the combination pill. Vaginal rings are also being further developed and there has been research on reversible and nonsurgical sterilization.

Study notes:

• Make sure to know how the combination pill works. What is failure rate and why the typical user failure rate is lower than the perfect user failure rate? How is this difference resolved by other forms of anticonception?
• Could you name a few advantages and disadvantages of the use of sterilization? Think about health costs for society and other societal issues that could be resolved with this way of contraception.
• Make sure you know that available forms of anticonception, abortion and sterilization and the advantages and disadvantages of these methods.

Chapter 8 - What is Sexual Arousal?

Sexual expression contributes to an overall good mental health. Understanding sexual arousal is also important in understanding sexual dysfunctions.

What is the sexual response cycle?

Sexual response commonly happens in three stages: excitement, orgasm and resolution. The physiological mechanisms are myotonia and vasocongestion. Vasocongestion takes place when a major deal of blood flows in regional blood vessels, such as the genitals. It is a result of dilation of these blood vessels. Myotonia is the contraction of the muscles throughout the body, so not only in the genitals.

Excitement

The excitement phase is the start of sexual arousal. Vasocongestion causes the erection in males, it happens when the corpora cavernosa and corpus spongiosum fill with blood. Factors such as alcohol, fatigue and age can slow down this process. Several neurotransmitters are involved in this process, for instance, Viagra works on the nitric oxide neurotransmitter. To reverse the erection, the neurotransmitters epinephrine and norepinephrine are involved. In women, a critical sexual response is lubrication of the vagina. This is also a result of vasocongestion. The blood flow through the walls of the vagina causes the capillaries to dilate. Fluid can then seep trough the membranes of the vaginal walls. It does not happen as fast after presentation of arousing sexual stimulation as it does with men. Female response to these stimuli is also affected by age, alcohol intake and fatigue.

When the woman gets closer to an orgasm, the orgasmic platform forms. This is the narrowing of the muscle around the entrance of the vagina. When a woman is excited, the tip of the clitoris is swollen and is harder than normally. Relaxation of the muscle that surrounds the arteries allows for a great blood flow to the genitals. Nitric oxide is also the main neurotransmitter involved. One effect from myotonia is that the nipples erect, this is both present for males and females. During arousal the inner lips of the vaginal walls swell and open. The opening of the vagina is also called the ballooning response. This helps the entrance of the penis. Later in the phase of excitement, the two processes of myotonia and vasocongestion built up to the orgasm.

Orgasm

The orgasm in males exists from contractions of the pelvic organs. In the preliminary stage of the orgasm the prostate, seminal vesicles contract and the vas contract. This drives the ejaculate into a bulb at the base of the urethra. The sensation is called ejaculatory inevitability (Masters & Johnson, 1966). It resembles a feeling that ejaculation is about to happen and cannot be stopped. In the second stage, the urethral bulb that was formed in the first stage contract rhythmically and forces the semen to go trough the tip of the penis. Blood, pulse and heart rate increase during the orgasm. Muscles contract throughout the body, contractions of hand and feet are called carpopedal spasms.

In females the uterus contracts rhythmically and muscles around the anus may also contract. The sensation begins around the clitoris and spreads to the rest of the pelvis. The sensation for men and women is very alike. Faking an orgasm follows a sexual script in which the woman should orgasm first. There are other reasons to fake an orgasm as well: it can feel good to do it, it can please the sexual partner, it can birng an end to the sexual encounter, it can give a powerful feeling, and it can help to feel close to the partner. Women often fake due to the sake of their men’s feelings, which is not a good thing because it prevents a partner from getting a valid sexual response. There is one way to tell if a woman is experiencing an orgasm, which is by measuring the sudden increase in pulse rate.

Resolution

The orgasm is typically followed by the resolution phase. The body then returns to an unaroused state and processes that build up during excitement are reversed. Resolution is characterised in the shrinking of swelled organs and a decrease in blood pressure, heart rate and breathing rate. The resolution phase in men is followed by a refractory period where the men cannot be sexually aroused. This can last from a couple of minutes to twenty-four hours.

How does the female orgasm work?

Many people believe the woman can experience two types of orgasms, the clitoral and the vaginal orgasm. These types refer to the area of stimulation. However, according to Masters and Johnson (1966) there is no difference. The area of stimulation does not cause any different response, some women are even able to get an orgasm through stimulation of the breasts. However, the experience of an orgasm differs based upon the area of stimulation. The stimulation of the clitoris is almost always involved in the orgasm and is also stimulated during vaginal sex. A shorter distance between the clitoris and the vaginal opening results in a higher change of orgasm during vaginal sex. Females do not have a refractory period that men have. Women can this have multiple orgasms, having separate orgasms occurring in a short period of time. It is more likely to happen with mouth or hand stimulation than from vaginal intercourse.

What are other models of sexual response?

One criticism of the stated model above is that it neglects the cognitive -and subjective influences on sexual response. Therefore, other models were proposed. These include the Kaplan triphasic model and the sexual excitation-inhibition model.

Kaplan’s triphasic model exists of the elements of sexual desire, vasocongestion and contractions of the muscles during the orgasm. Both the contractions and vasocongestion are physiological, however sexual desire is psychological. It can happen prior to sexual arousal or spontaneously. There is empirical evidence for the approach: whereas the parasympathetic system is responsible for vasocongestion, the sympathetic system is responsible for ejaculation. Another empirical support was found in the decrease of orgasm frequency with age. Lastly, the sexual disturbance caused by impairment of vasocongestion is an erection deficit, whereas problems with (premature) ejaculation are caused by disturbance in orgasm response.

The sexual excitation-inhibition model or dual control model of sexual response states that there are two processes responsible for sexual response:

1. Excitation, the response of arousal to sexual stimuli

2. Inhibition, inhibiting sexual arousal

The leading criticism on the physiological model of Masters and Johnson (1966) is that the explanation of sexual arousal is ignoring the emotional component. Positive emotions have a positive effect on sexual arousal. Also, negative emotions have a positive effect on sexual arousal. The experience of negative emotions caused an increase in sexual arousing thoughts. According to researchers generalised arousal is caused by negative emotions which results in a higher susceptibility to sexual stimuli.

What are the neural and hormonal bases of arousal?

Besides physiological and emotional influences of arousal, hormones can influence the sexual response cycle.

The brain, the spinal cord, and sex

• Spinal reflexes control erection and ejaculation. The receptors are sensory neurons that transmit and detect sexual stimuli to the brain. Then, transmitters receive the stimuli and the effectors respond.

• Erection works trough the erection centre which is the lowest part of the spinal cord. This causes a reflex trough the spinal cord to permit blood flow into the genitals.

• Ejaculation is alike erection, but there are two centres. The ejaculation reflex sends a message to the ejaculation centre which is situated in the lumbar portion of the spinal cord. Retrograde ejaculation is when the ejaculate ends up in the bladder. A dry orgasm is the result.

• Reflexes in women are less researched, information transfers trough the dorsal nerve of the clitoris to the sacral portion of the spinal cord. The G-spot or Grӓfenberg spot or female prostate/skene’s glands is situated on the top side of the vagina. It produces a uterine orgasm which are deeper uterine contractions than with a vulvar orgasm.

• People who engage in riskier sexual behavior show more activity in the right insula than people who do not engage in risky sexual behaviors.

Brain control of sexual response

Sexual response is highly psychological and environmental factors may affect one’s sexuality. This happens trough brain -and spinal cord interactions. According to one scientist, the brain is the most important organ in sex.

• The anticipatory phase is when the sexual interest network is stimulated by arousing content. The role is probably to recognise sexual opportunity. The sexual arousal network is situated in different regions of the brain.

• The consummatory phase happens during sexual activity. Stimulation of the genitals corresponds to activity in the motor cortex.

• The orgasm causes a decrease in activity of the prefrontal cortex and increased activity in the orbitofrontal cortex.

• The resolution and post-orgasmic refractory period correspond to the de-arousal neural network and is observed in the septal area, amygdala and temporal lobe.

• Neurochemical influences on sexual response are experienced throughout the sexual response cycle. Dopamine, norepinephrine and oxytocin are released and related to sexual arousal.

What is the influence of hormones on sex?

Hormones interact with the nervous system in generating sexual responses.

• Organising effects are the consequences of sex hormones that cause permanent changes in the reproductive system and the brain.

• Activating effects of hormones are aggressive and sexual behaviours, especially in adulthood.

• Testosterone positively affects libido and desire. In women, androgens are related to sexual desire.

Could castration be used to reduce sexually violent crimes?

Physical castration is the process of removing the testes surgically. This is also known as bilateral orchiectomy. Chemical castration is the administration of a drug that reduces the testosterone level to reduce sexual desire and libido. The effects of castration are not completely predictable. Rapist cannot always be restrained by lowering their testosterone levels, there is more than sexual behaviour involved. It is an aggressive crime that is expressed trough sex. Castration might reduce the chance of rape, but psychotherapy should always be included in the treatment.

What are pheromones?

Hormones and pheromones are alike, pheromones are secreted outside of the human body. Pheromones can be described as sex attractants. They play an important role in human sexuality.

What are the existing sexual techniques?

Erogenous zones are parts of the body that are sexually sensitive. People differ in their erogenous zones. One-person sex or autoeroticism is when a person produces his own sexual stimulation. There are may examples of one-person sex:

• Masturbation is self-stimulation either with the hand or an object. It is very common sexual behaviour and s used in both males and females.

• Sexual fantasy is the mental imagery that includes sexual arousal. It is experienced by both men and women. People can fantasize about very different things, such as sex in unusual or romantic places. Men are more likely to fantasize about being masturbated by an unknown person. Images in sexual fantasies can come from the media, dreams or stories. They represent a fusion of body, emotion and mind.

• Vibrators and other sex toys can be used for masturbation or by couples. A dildo is a plastic or rubber cylinder in the shape of a penis. A vibrator can be shaped like a penis, but many of them are not. They use some form of an electric outlet. Body oils are also popular for sexual pleasure, they heighten erotic feelings.

For two-person sex there are a lot of behaviours and actions imaginable. It is important to note that the image of two-person sex often reflects heteronormativity. This -and other assumptions can put restraints on human sexuality. The techniques described below attempt to avoid assumptions about two-person sex.

• Kissing is done in almost all cultures and the variation that is used depends on personal preference.

• Touching is essential to sexual pleasure, the regions that are sensitive vary from one person to another.

• Other senses, such as smell, and hearing can also contribute to sexual pleasure.

• Fantasy can heighten the experience without violating the agreement to be faithful to another person.

• There are many positions of intercourse, the most common one is coitus, which is the insertion of the penis into the vagina. There are a few basic positions that can have infinite alterations and extensions. The missionary or man-on-top position is the most frequent. This is the best position for ensuring conception. The woman-on-top position provides a lot of clitoral stimulation which the woman can control. The rear-entry position is where the man is facing the woman’s back. It can also happen in side-to-side position which is good for the pregnant and obese.

• Mouth-genital stimulation increased in popularity over the last few years. There are two variations. Cunnilingus is mouth-stimulation of the woman’s genitals. Fellatio is the stimulation of a men’s penis. The equal occurrence of cunnilingus and fellatio is called sixty-nining.

• Anal intercourse is when the penis is inserted into the rectum of the partner. Sometimes referred to as sodomy or Greek-style. A variation is anilingus in which the tongue and the mouth stimulate the anus.

• Techniques of lesbians and gays are like heterosexual intercourse techniques, except for coitus. Gay men can engage in interfemoral intercourse in which the penis of the man moves between the thighs of his partner. Lesbians can engage in tribadism where one partner is lying on top of the other making movements to stimulate the genitals. Another option is the use of a dildo.

• Cybersex is considered a new sexual space for intimacy, fantasy and action.

What are aphrodisiacs and anaphrodisiacs?

An aphrodisiac is a substance used to increase sexual desire. An anaphrodisiac is a substance that diminishes sexual desire.

What are forms of exceptional sex?

There are characteristics that have been described that make the difference between good and great sex. These are the following:

1. Both persons should be equally present and focused.

2. A deep connection between the partners engaging in sex should be present.

3. There should be deep -or emotional intimacy.

4. Extraordinary communication contributes to a total sharing between partners.

5. Both persons should feel free of inhibitions and unselfconscious.

6. Interpersonal risk-taking, fun and exploration are central subjects of great sex adventures.

Sexual satisfaction

What most of us eventually want form engaging in sexual behaviors is to feel sexually satisfied. For some people, this can be achieved through orgasm, for others it is achieved through pleasing the partner: It is very different from one person to another.

Study notes:

• It is important to know the sexual response cycle by Masters & Johnson (1966), which explains the physiological process of sexual arousal.
• What criticisms on the theory by Masters & Johnson resulted in two other theories on sexual arousal?
• How do these theories translate to sexual arousal nowadays?

Chapter 9 - How does Sexuality develop along the Life Cycle: Childhood and Adolescence?

Lifespan development refers to the study on sexuality across the lifespan.

What kind of scientific data sources are available to study sexual behaviour?

The Kinsey reports and the NHSLS (Laumann et al., 1994) are the main sources of studying sex. Surveys are often being used, but they are subject to errors with recall and memory. Another option is studying sexual behaviour and arousal. Especially research of sexuality in children is very problematic in this sense and brings ethical concerns.

What do we know about sexuality during infancy and preschool years?

Freud was one of the first to acknowledge sexuality in children. The capacity to show sexual responses are present from birth. Reflex erections even happen before birth in the uterus. The first intimate relation that is experiences is with a parent, especially with the mother. This relationship involves a lot of physical contact can produces a sensuous response. There are several concepts that are important in studying infant and preschool sexuality.

• Attachment refers to the bond between infant and mother, father or caregiver. The bond starts to form right after birth and continues until the end of infancy. Attachment is the first encounter with emotional intimacy and love. The capacity of romantic attachment is based on the attachment style that an infant had with its parents.

• Self-stimulation occurs in infants, around the age of sex to twelve children start to touch their own genitals. This behaviour is quite normal and even orgasms are possible.

• Child-child encounters occur from the age of four to five, when children become more social. Children may hug each other or hold hands. Some children learn about heterosexual behaviour by seeing their parents have sex, or witnessing the primal scene. According to Freud this could inhibit one’s sexual development.

• Sexual knowledge and interests start in the preschool years. Children become interested in different forms of urinating and children enjoy hugging and kissing their parents. They also learn about marriage.

• Knowledge about gender starts around the age of two or three. Children start to develop a gender identity. Some children start to exhibit cross-gender behaviour. Others might experience gender dysphoria.

• A study at Danish preschools indicated that children have tolerant attitudes towards nudity in nudity and doctor games.

What is known about childhood sexuality?

The term latency is used by Freud to refer to a period in childhood where the Oedipus complex is resolved. During latency, sexual urges are not expressed. Therefore, sexual awakening for most people happens during adolescence. Adrenarche is explained as the maturation of the adrenal glands and occurs around eight to ten years of age. It indicates that sex hormone action happens way before adolescence. Many people recall sexual attraction to another person by the age of ten.

• Masturbation often happens before puberty. Orgasms are recalled by many people before the age of twelve.

• Heterosexual behaviour is learned through gender and learning about intercourse. The response to children learning about intercourse is often a combination between shock and disbelief.

• Same-gender sexual behaviour is a normal part in the sexual development of children. Children often have a gender-segregated social organisation where boys play separately from girls and spend most of their time among other children of the same gender. Therefore, they will exhibit sexual behaviours such as kissing or masturbating with each other.

• Sex knowledge and interests are often shaped by heteronormativity, the belief that heterosexuality is the only pattern of acceptable sexual behaviour.

• The sexualization of children is something many parents are worried about. It includes the value of sexual appeal -or behaviour, standard attractiveness, sexual objectification of a person and unappropriated imposed sexuality on a child. One example is when little girls play with sexualized dolls or when little boys are exposed to television shows stating boys should have “buff” bodies and be aggressive.

What is known about sexuality in adolescence?

The term adolescence is describing the period from age eleven/twelve to age twenty-one/twenty-two. Sexuality plays an important and positive role in adolescence and psychological development. However, not all adolescence sex is good. Most research found the negative aspects and consequences of adolescent sex for the family and society. Both social and biological factors are important in the adolescent development of sexuality. For example, testosterone levels in boys play a significant role in sexual activity such as masturbation and intercourse.

• The amount of masturbation increases from the age thirteen to fifteen. They used to believe it led to insanity, but attitudes are more positive now. This results in a change of attitude and affect behaviour and feelings about masturbation.

• Same-gender sexual behaviour is mostly recognised between the age of fourteen and twenty-one.

• Heterosexual behaviour is the major sexual outlet and often starts with kissing and progresses towards oral sex and vaginal intercourse. In many countries, the age where people start with sexual intercourse has risen as people become less influenced by family and community and more by mass media.

• Too early sex has several risks including teen pregnancy or sexually transmitted disease. There is a sharp decline in teen pregnancy rates. Teen pregnancy and poverty are closely linked.

• Romantic relationships during adolescence often include sexual behaviour. Low-quality relationships with conflict, controlling behaviour and dating violence can be negative outcomes of these relationships. Also, these relationships are important for learning skills and scripts for future relationships.

• New technologies have a major effect on sexual identity and learning about the body. Sexting is defined as sending of sexually charges messages or images. Consequences of sexting can be serious, when someone receives a sexting message from someone under-aged, this suffices as possession of child pornography. Sexting is quite common nowadays; as 23 percent of adolescents has been exposed unwantedly to pornography and 9 percent has received an unwanted sexual soliciation via the Internet. 

• The media have been found to have an important impact on adolescents' sexual knowledge, attitudes, and behavior. The media are an important source of knowledge for adolescents; which comes with risks as well because the media don't always report a representative image. 

• Adolescents engage in risky sexual behaviors; such as sex without a condom. This is caused by the 'delayed' maturation of the prefrontal cortex; responsible for impulse control, and the already matured brain regions that have to do with emotion (the amygdala) and seeking feel-good rewards (the ventral striatum). Teenagers tend to pursue immediate rewards and do not control (sexual) impulses.

What is known about sexual behaviour during college years?

College years are known for experimenting with sexual behaviour with little or no responsibility. There is less information available of people in the same age group that did not follow a college education.

• Masturbating during the college years is very normal. Around eighty percent of women and ninety-eight percent of men masturbate during the college years. It is a source of great pleasure, but also seen as a taboo. Especially women struggle with this kind of contradiction.

• Patterns of heterosexual behaviour can be very different between individuals during these years. There are different clusters: active unprotected, satisfied, pressured and inactive.

• Casual sex or hooking up refers to a sexual encounter between strangers of brief acquaintances. Much of this sex is bad, because it is either coercive or unpleasant. Friends with benefits refers to two people without a romantic connection engaging in occasional sex. A fuck buddy is someone to have sexual intercourse with but is not a friend or romantic partner. A booty call is the urgent request for sexual activity to a person who is not a romantic partner. The difference with hooking up is that these people are not in the same room with each other (yet).

• Same-gender sexual behaviour occurs more between women than men in the college years. People in college start to form a sexual orientation, such as lesbian, bi, gay or straight.

How does sexuality aid develop?

Erikson (1950, 1968) proposed a model of psychosocial behaviour that explained eight life cycles with crises of development. Social influences are particularly important in the outcomes of these crises. Some of the outcomes of the crises are linked to sexuality. For example, the crisis between autonomy and shame. When a young child masturbates this shows initiative an autonomy but will often be punished leading to shame and might lead to a loss of self-esteem. Furthermore, the crisis on intimacy and isolation explains the role of sexuality in the development of the capacity for intimacy.

Study notes:

• You should know the sexual development characteristics of each age period described in this chapter. Every age, from childhood to adolescence has different manifestations of sexual development.
• What stages of sexual development in for example, adolescence is a negative development? What can the influence be on the formation and duration of future relationships?

Chapter 10 - How does Sexuality develop along the Life Cycle: Adulthood

In the United States, the decline of marriage and the rise of new families caused a big change in sexuality in adulthood. This is true for sexual orientation, monogamy, marital sexuality and cohabitation.

What is sexual behaviour of a single person?

The sexual development starts from childhood and by the time people are in their adulthood they are aware of their sexual orientation -and identity. The identification of our sexual preferences is a form of maturity in sexual unfolding. Learning to communicate with sexual partners is difficult for a lot of people, because of the lack of role models in our society. Other problems are responsibility about sex and the development of the capacity for intimacy. The never married group of adults are individuals that intended to marry but did not and people who intended to stay single. Many persons are involved in serial monogamy, which is the occurrence of two or more intimate relationships prior to marriage. Why unmarried people have this status can have both voluntary and involuntary reasons. A virgin is described as someone who never had intercourse, rarely dated and has not engaged in sexual intimacy. Many singles that often report unsatisfying sexual encounters have a harder time in sustaining romantic relationships. Singleism is the stereotyping and stigmatization of people that are not in a couple relationship that is socially recognised.

The singles scene is the institutionalised opportunity for singles after the age of twenty-five to meet a partner. The nightclub is such a place and many people engage in sporting rituals and game-oriented cultural scripts to participate. Apps, such as grinder and tinder can also enable people to find each other. Cell phones play a significant role in the meeting of potential (romantic) partners. Black men and women are more likely to remain single.

A living apart together relationship or LAT is a relationship between unmarried people who live in separate houses but consider themselves a couple. Cohabitation is a way for trying out a committed residential relationship. Cohabitation is becoming a popular alternative to marriage.

What is typical sexual behaviour in marital relationships?

The decision of marriage has changed over the years. The question whether to get married was not present, the question was who to marry. This has changed due to the psychological pressures of marriage. When marrying someone leaves the family of origin to start a family of procreation. Also, the pressure of sexual performance may increase when married. Married couples report they have intercourse about eight to eleven times a month.

Nowadays, cohabitation is a way of trying out a committed residential relationship. Among heterosexuals, it has become an increasingly common alternative to marriage. However, marriages preceded by cohabitation are more likely to end in divorce than are marriages that are not preceded by cohabitation. Cohabitation after engagement does not seem to have these risks. A newly emerging trend in Western society is serial cohabitation; which is cohabitation with a sequence of people and not marrying any of them.

Marital sexuality

Sexual expression is most common within marriage. The frequency of marital sex decreases when the partners get older. There are two explanations for the decrease of sex with age, one is biological aging and the second is habituation of sex with the partner. However, learning about the partner’s sexual desires can lead to an increase in quality and possibly frequency.

• Techniques in marital sex exist within four clusters of activity: vaginal intercourse, basic (including kissing, cuddling, stroking and intercourse), basic and oral sex and basic plus oral plus masturbation.
• Negotiating sex is the mating dance prior to intercourse. Some of this is verbal, using indirect or euphemistic language. In most marriages, men and women are equal in initiating sex.
• Masturbation in marriage continues for most men and even though it is completely normal, it is done secretive. It can even be a pleasurable adjunct to marital sex.
• Satisfaction with marital sex exists from emotional satisfaction and satisfaction with the sexual activity itself. Sexual satisfaction is an important contributor to marriage.

Sexual patterns in marriage are influenced by the desire of both persons in the relationship. There are several patterns of desire and these can fluctuate. There are four patterns: stable and low, slight fluctuations and low, fluctuations and average and fluctuating and average. Lust is high when the positive affect towards the partner is high. There seems to be a link between closeness to spouse and positive affect and lust. Sexual patterns change in the course of the relationship, for some people it becomes routine, but for others this is not the case. This can be changed by communication about sexual desire.

There is a trend to have sex less frequently nowadays in America, which is driven by two factors: firstly, there is an increase in the number of individuals who have no steady partner. Secondly, there is a decline in frequency of sex even among those with a partner. Working more hours and the increased sexualization of society may be factors involved.

Sex and the two-career family

Some people argue that a double career can interfere with sexuality in married couples. However, there is little cause for concern. There were no differences in sexual intercourse, satisfaction or desire found between couples who both had their working hours. When the man and woman both had satisfying jobs, they reported a better sex life than couples with fatigue or unemployed persons.

Keeping your mate

People with high scores on narcissism and impulsiveness are more likely to engage in infidelity. Also, dissatisfaction with marriage can result in infidelity. Mate retention tactics refer to behaviours related to preserve a relationship. They might be initiated by a fear of the partner losing interest or being dissatisfied. Men use other resources for mate retention than women. Men are more likely to give resources of display, such as money. Women are more likely to appear attractive or make positive verbal statements.

What are non-monogamous relationships?

Many people make the vow to be sexually faithful to a partner, to be monogamous. When a partner is not able to be monogamous, he might engage in adultery, secret sex with someone else than his partner. Another example is internet infidelity, which is also kept secret. However, now different kinds of relationships that are not always monogamous are becoming more common, these relationships are called non-monogamous relationships. The distinction between secret non-monogamy and open monogamy is made to describe different types of non-monogamous relationships.

What are reasons for and attitudes towards extramarital sex?

The sexual activity involving a person in a long-term committed relationship with someone other than his partner. If the couple is married, it is called an affair or adultery. When the couple is not married, it is called cheating. Power is found to be associated with extra-relationship sex. Another predictor is the relationship bond, violence, separation and time spend together. The attitude of many people toward extramarital sex is negative. Even though people often have a bad attitude, this does not mean they will not engage in extramarital sex. People that approve of extramarital sex do not necessarily engage in it more. Factors that determine the attitude towards extramarital sex are gender, social class and education.

What is internet infidelity?

The rise of websites designed to connect people looking for a partner created a new phenomenon. A cyberaffair is a sexual or romantic relationship with an online contact. Erotic dialogue can be combined with masturbation. People that search for relationships online, might be dissatisfied with their partner. Lost of trust in the partner over an online relationship can be overcome by sex counselling.

What is the relationship between equity and extramarital sex?

The equity theory is a theory of social psychology, designed to explain human relations. It has been applied to explain extramarital sex. The idea is that peoples input in a relationship determine what they would like as benefits or rewards. Then people calculate if the relationship is equitable. Individuals feel that the relationship is inequitable when they feel they are not getting what they deserve, this causes great distress in some. They make attempts to restore the equity in a relationship. extramarital sex can be explained to restore equity in a relationship. The interpersonal exchange model is concerned with costs and rewards of a sexual relationship. Relationship satisfaction is related to sexual satisfaction and greater relationship satisfaction is related to higher frequency of affectionate and sexual behaviour.

What are examples of open non-monogamous relationships?

There are some examples of open non-monogamous relationships that are consensually between partners.

• Swinging is when couples exchange partners with other couples or have sex with a third person. It may be closed or open. In closed swinging couples meet their partners in a private place. Open swinging is when they the couples exchange partners and have sex in the same room. People become swingers because they feel the desire variety in sexual partners or for the pleasure of excitement.

• Polyamory is the non-possessive, responsible and honest ethical philosophy of the capability of loving two people simultaneously. It can be in a group relationship or group marriage where people express polyamory.

• There is little evidence that cases of open nonmonogamy have negative psychological consequences for the people in the primary relationship. 

What are the consequences of non-monogamous relationships?

It was found that consensual non-monogamists and monogamists do not differ significantly. There is also little evidence that consensual non-monogamy leads to more divorces. Secret non-monogamy is often related to the termination of a relationship. Persons that report extramarital sex are more likely to get a divorce. The partner that was having the affair often wanted the divorce more.

What does post-relationship sex look like?

In post-relationship sex, after divorce or death of the partner, the main sexual outlet is no longer available. Also, society places some boundaries on what is accepted after the termination of a relationship. After cohabitation, the number of sexual partners that follows the termination of the relationship is higher than for married couples. Researchers note that this could be caused by the lower commitment of cohabitation compared to marriage. Widows or divorced people start post-marital sex often about one year after the end of the relationship with a frequency of twice a month.

What are the sexual developments in later life?

Physical changes in women

The climacteric is the transition of a woman’s body from being able to reproduce to not being able to reproduce. It is marked by a decline in functioning of the ovaries. Menopause is a specific event in the climacteric where a woman’s menstruation stops. The ovaries age and are not able to respond to the normal output of LH and FSH anymore and the egg -and oestrogen production declines. There are vasomotor symptoms, including sweats and hot flashes, psychosomatic symptoms, feelings of tension, stress and depression. Two other effects caused by the decline of oestrogen are osteoporosis, porous and brittle bones and vaginal dryness. There are four ways of treatment: hormone therapy, medication, seeking advice from friends and family and alternative treatment.

Because of the biological changes, the vagina has less acidity and is more prone to infections. There is also a decline of vaginal lubrication during sex because of the decline in oestrogen. Despite these changes, some women report that sex after menopause is better. This is because they do not longer fear pregnancy. Researchers have come to the following conclusions about sex in women after menopause:

1. Most women continue to engage in sex and enjoys it.

2. There is some decline in sexual functioning after -and during menopause.

3. Oestrogen is associated with this decline in sexual functioning.

4. Another important hormone is testosterone, sexual desire might decline when the levels of testosterone decline in the ovaries.

Physical changes in men

Over the years, testosterone levels gradually decrease. Also, men develop more vascular diseases including hardening of the arteries. This can cause problems with erection as this is dependent on the blood flow in the body. It results in erections occurring more slowly. Also, the refractory period and the volume of ejaculation lengthens with age. The testes become smaller, but they still produce viable sperm. It seems that middle-aged -and older men have a better control over their orgasm than young men. This can prolong coitus and lead to more satisfaction with the partner. Satisfaction of sex in men during later life was association with whether they had erectile dysfunctions.

What are the attitudes on sex and the elderly?

In our society the leading attitude on elderly sex is negative. Sexual behaviour of the elderly is related to cultural background. In seventy percent of societies the elderly remains sexually active. The negative attitude in our society is due to our youth-oriented culture. This makes it hard to believe that unattractive elderly with a wrinkled skin could still have sex. This attitude might be an evolutionary one from the time that sex was only meant for reproduction. Another misunderstanding is about health and elderly sex. When a man believes that sexual arousal could lead to a heart-attack, he might not initiate sex. There are two factors that are critical in maintaining sexual capacity:

1. Good mental -and physical health.

2. Regularity of sexual expression.

Study notes:

• Make sure that you know the differences of marital and extramarital sex. What attitudes influence the occurrence of both types of sex and how does this influence the relationship?

• What physical changes lead to a different period of sexuality when people get older? What does this mean for sex between elderly?

Chapter 11 - What are theories about Attraction, Love and Communication?

The sexual standard for many people is that there should be a close connection between two people before engaging in sex. Therefore, the social -and emotional component of love should be discussed.

How does attraction work?

There has been extensive research on attraction and there are many forms of interpersonal attraction that will be discussed.

• The girl next door refers to the geographical -and time restrictions on attraction. People in the same class or workplace tend to be more attracted to the other due to the mere-exposure effect, repeated exposure to a stimulus causes someone to like the stimulus more. Thus, the chance of falling in love with the girl next door is bigger than a random person you never meet.
• Birds of a feather refers to the fact that we find people attractive that have the same age, gender, social -and economical status. This similarity in characteristics is called homophily. The reason for this is that we receive positive reinforcement by agreement, anticipate on positive interaction and relationship success. It turns out that agreement of attitudes does not predict a quality relationship, but similarity in attachment does.
• Physical attractiveness refers to the choice of physically attractive partners. It is one of the most important factors in sexual appeal. However, attractiveness is dependent of the perception and evaluation of one’s intelligence and the own feelings of personal worth.
• Interpersonal marketplace refers to the fact people choose partners with a similar “social worth”, this is called the matching phenomenon. Men base their social worth on success whereas women base it on beauty.
• Real life attraction refers to the real-life outcomes on researched phenomena of attraction. It is very difficult to manipulate similarity and draw reliable conclusions from obtained data. Important is perceived similaritywhich is the extent in which someone believes his partner is alike on important characteristics. Similarity and the matching principle seem to apply in everyday life. 
• Online attraction is an efficient way to look for a partner. Impatience or career or time constraints might lead a person to the online market. The downside is that the actual person can differ from the person he claims to be online. Every website uses a different matching strategy, some use biological indicators such as testosterone, dopamine and oxytocin. Others use traits and attributes and match according to proximity or similarity: For example, online, many people have racial homophily. Online dating has been found to be at least moderately effective in finding long-term relationships.

How can people’s preferences be explained?

People select their partners based on similarity in characteristics, race and education. Also, both men and women prefer physically attractive people. There are two theories on where these preferences come from. One is the reinforcement theory, the other is sociobiology.

• Reinforcement theory means that we tend to like people who give us rewards and dislike people who give us punishment. Byrne’s law of attraction means that our attraction to another person depends on the number of reinforcements relative to the reinforcements plus punishments. People that are like us provide the base for smooth and rewarding interaction. This theory is derived from the implicit egotism perspective: we are attracted to similar persons because they active a positive view about the self.
• Sociobiology looks at attraction from an evolutionary perspective. The success in producing offspring determines the attributes people look for in a partner. Someone who is more attractive is likely to be healthier. This is especially important in societies with a high prevalence of pathogens. Fluctuating asymmetry is the asymmetry of bilateral features that are similar in the population. It is said to reflect developmental instability and therefore health. People with these asymmetries are considered less attractive.

What is intimacy?

Intimate relationships are important for two reasons: one is the desire to have children and two is mutual trust and recognition by the other person. People have a need for interpersonal support to cope with stress successfully. There are several descriptions of intimacy:

1. Some features of intimacy are honesty, self-disclosure, warmth, caring, openness, mutual commitment, dropping defences and surrendering control.
2. The description of emotional intimacy is the verbal sharing and mutual self-disclosure, but also declarations of loving, liking and affection.

The first describes intimacy in terms of characteristics, the second in terms of a relationship. The definition of intimacy in a relationship is: the level of positive, cognitive, affective closeness and commitment that is experienced between two partners. Telling things about yourself to a partner is important in any relationship and is called self-disclosure. It leads to reciprocity in the partner. It generates trust end equity and there is a positive correlation between the amount of self-disclosure and the satisfaction with the relationship. Furthermore, self-disclosure of experiences, attitudes increases vulnerability, and this could be a reason for reducing self-disclosure. However, a decrease in self-disclosure is associated with sexual dissatisfaction.

What are theories of love?

In our society, there is a connection between love and sex, which is a continuum. There are several theories of love and passionate love. The triangular theory, the attachment theory, the love story theory, the passionate love theory and the biology of love are explained.

The triangular theory of love

The triangular theory of love includes three categories: intimacy, the emotional component of love and describes the feelings of closeness  to another person. The second is passion which is the motivational aspect of love. The third category is decision for commitment, which is the cognitive component. There is a short-term aspect which is the decision to love the other person and a long-term component, which is the commitment that makes the relationship endure.  This triangle theory is used to show how people can feel matched or mismatched to each other. If their levels of intimacy, passion, decision/commitment align, it is a perfect match. The Sternberg Triangular Love Scale (STLS) can be used to measure the components, and evidence has been found to support his theory.

The attachment theory of love

The attachment theory of love states that early attachment during childhood shapes future relationships. There are three attachment styles in relationships among adults:

• Secure lovers are comfortable with intimacy and do not fear abandonment.
• Anxious or avoidant lovers are uncomfortable with intimacy and it is difficult for them to trust a partner.
• Preoccupied or anxious-ambivalent lovers desperately want to be close to a partner, but often think the partner does not reciprocate the feelings. They are insecure in the relationship.

Securely attached partners have fewer relationship problems and those relationships also last longer than those of people which an anxious or preoccupied attachment style. In real relationships, the combination of two avoidant partners, nor the combination of two preoccupied lovers tends to occur. People with anxious and avoidant styles have less trust in their partner, leading to less intimacy, which is associated with less relationship satisfaction.

The quality of the relationship with parents or caregivers determines the relationship style. Conflict in a relationship can be caused by attachment style and own personal history. It affects the way people interact.

Love styles

This theory distinguishes three types of love: eros; a powerful attraction to the physical appearance of the loved person, ludus; playful love, and storge; stable love. Erotic lovers are primarily invested in sex and physical pleasure. People in ludus relationships refuse to become too involved or too dependent on the other person. Storge relationships grow gradually and are rather stable. However, sex sometimes does not occur for some time in these relationships. 

Manic lovers have passion for eros but play the games of ludus: Love in an obsession and the person is consumed with jealousy. Pragma is practical love; combining storge with the game of playing ludus: The person looks for a good match and once this is found, it tends to last. Agape is altruistic love; that is never jealous, undemanding and always kind an patients: It is a combination of storge and eros. Eros and agape love styles are associated with greater relationship satisfaction; and ludus is associated with lower relationship satisfaction.

Passionate and companionate love

Passionate love is the state of intense longing for connection with another person and the severe psychological arousal. It exists from three components:

1. Emotional, sexual attraction and psychological arousal.
2. Cognitive, idealization and preoccupation with the other person.
3. Behavioural, maintaining physical closeness and taking care of the other person.

Companionate love is the feeling of deep commitment and attachment to the other person in an intimate relationship. Passionate love is often the first stage in the relationship, followed by companionate love.

The biology of love

The complex phenomena of love are caused by the neural system and chemical bodily reactions. For example, dopamine is related to mating and increases the likelihood of bonding as a pair. Also, prolactin and oxytocin are produced when a passionate lover is present. Furthermore, oxytocin contributes to a long-term relationship as it is stimulated by touch, sexual touching and orgasm. Levels with interpersonal trust correlate to levels of oxytocin.

What types of love-research are known?

• Measuring of passionate love was done by Hatfield and Sprecher (1986) with their questionnaire. They found that scores on the passionate love scale (PLS) were positively correlated with commitment and satisfaction of the relationship.
• The two-component theory of love states that passionate love can happen when two conditions exist simultaneously: first there should be psychological arousal and second the label of “love” should be attached to the sensations that are experienced (Berscheid & Walster, 1974). The researchers describe the emotion of love, an emotion also consists of a psychological state and the label the person assigns to it. In some cases, the labelling of arousal can be mistaken, the misattribution of arousal is the misattribution of arousal as sexual arousal.
• Cross-cultural research has been studied with three important subjects. First the cultural values and meaning of love is researched and differs in individualistic and collectivist cultures. Another cultural dimension where love differs is independence-interdependence and the third is communicating-sharing. This influences mate selection. Love and marriage.

How does interpersonal communication work?

Interpersonal communication is an important aspect of relationships. There is a connection between sex, communication and the relationship. Effective communication is key in sustaining a good relationship and sex life.

Communication in relationships

Distressed couples often experience communication deficits. Marriage counsellors are trying to teach couples to communicate more effectively. There are negative and positive messages, criticism refers to the attach on the other person’s personal values and character. Contempt is insulting or abusing another person intentionally. Defensiveness is when someone denies responsibility and responds in a self-protective way. Finally, withdrawal is when a partner’s response is to walk away, turn on the tv or is just silent.

Effective communication

An effective communicator is concerned with the intent of a message, which is what you mean. Impact is also important and is what the other person thinks you mean. Lastly, an effective communicator is one who matches impact and intent. There are several skills that can be applied to ensure effective communication:

• Good messages use I-language and therefore focus on the self, and not on the partner. It is less likely the partner will respond defensive. Mind reading should be avoided, it is when someone is making assumptions about the other’s thoughts. Also important is documenting where one gives specific examples of the issue.
• Levelling and editing. Levelling is stating thoughts in a clear and simple manner to the partner. Communication should be clear and should state what is expected of the other. Editing is not saying things that are deliberately hurtful to the partner. Communication should be considerate and polite.
• Listening is actively trying to understand what the other wants to convey. Also, giving feedback is helpful in letting someone that he or she is being listened to. Paraphrasing is rephrasing what the partner said in your own words.
• Nonverbal communication is the tone of voice, facial expression and touching of the other person. This is especially important in discussions about sex.
• Validating is telling your partner that you can understand why he or she thinks a certain way.
• Drawing your partner out means testing an assumption by asking your partner it in a direct question.
• Accentuate the positive is important to recognise the strengths in the relationship, even when arguing. There is a magic ratio of positive and negative communication in sex. There should be five times as much positive communication compared to negative communication.

How do people fight in a fair way with their partner?

Rules can be set between partners in order to fight fair. Brenton (1972) and Creighton (1992) proposed some rules that can help couples fight fair:

1. Avoid sarcastic or insulting remarks about sexual performance.
2. Stick to the issue and avoid brining up previous relationship partners.
3. Do not make psychologising statements.
4. To not threaten with childish threats, this evokes similar communication in a partner.
5. Never bring children into the argument.
6. Do not dump events of six months ago on a partner.
7. Do not bring up negative issues, when there is no opportunity to discuss them.
8. Focus on solutions instead of blaming.

How can people successfully check out sexual signals?

Sexual communication, especially nonverbal sexual communication is often very ambiguous. Direct verbal assessment of sex is not common in our society. Ambiguous messages can lead to hurt, rejection and even anger. An effort should be done to clear up effective sexual communication. Ambiguous sexual signals should be drawn out with a question, not by making assumptions.

Is relationship education helpful?

There are many marital programs developed, especially in the United States to promote effective communication between married couples. Most of these programs are psycho-educational and not therapeutic. They focus on increasing communication -and problem-solving skills. According to a meta-analysis, the programs seem somewhat effective. Especially for couples with one partner in the military, this relationship education can be very helpful.

Study notes:

• Can you explain why someone is more likely to fall in love with the girl next door than someone he seldom meets? What is the role of the mere-exposure effect in this?
• In the final part of the chapter, the authors speak briefly about relationship education. What statements from communication in couples about the relationship or sex could be helpful in designing such an educational program?
• Make sure you know the different theories about matching between partners. One example is the triangular theory. Make sure you can explain the theory and how they explain a “perfect match”.

Chapter 12 - How does Gender influence Sexuality?

Gender is one of the most basic status characteristics. People feel uncomfortable with uncertainty about another person’s gender. This is rooted in the gender binary, the classification of people into either the category male of female.

What are gender roles and stereotypes?

The emphasis on gender in societies is codified with gender roles, this is a set of norms or culturally defined expectations to define how people of one gender should behave. A stereotype is a generalization about a group of people that differs those people from others. Heterosexuality is an important part of gender roles and stereotypes.

Gender roles are a product of culture. Intersectionality is the approach where the meaning and consequences of the use of multiple categories for difference, identity and disadvantage. Effects of gender should not be considered in isolation, but the category woman should be accompanied by the categories that also apply in this woman, such as ethnicity, social class, religion and sexual orientation. People then may be part of both a privileged and disadvantaged group.

• African Americans: there are two factors that are significant in the cultural heritage of African Americans, one is their past of slavery and second is the racial suppression that followed. This leaves African Americans with mixed stereotypes. There is the Jezebel, who is immoral and promiscuous. Then, there is the “fat mammy” who is fat and asexual. Numerous stereotypes have been added by the hip-hop culture. Gold-diggers who use sex to get rewards for men, and gangster bitches who survive on sex in hostile environments to feel good. Black men have been stereotyped as highly sexual and dangerous. The discrimination based this stereotype causes stress.
• Latinos are the largest minority in the US. The concept of acculturation refers to the process of incorporation of beliefs and customs of a new culture. This is what happened to people in the Latino culture in the United States who still have their Hispanic heritage, mixed with Anglo components. The roles are characterised by machismo and marianismo. Young Latino women believe they must choose between being a good girl or a flirt girl.
• Asian Americans were once recruited as workers and are now faced with racism. They share the emphasis on the importance of education with the white American middle class but place more value on family. The stereotype for men is that they lack sexuality, and for women as an erotic sex toy.
• American Indians have egalitarian gender roles compared to those of white cultures during the same period. The native Americans already had a term besides the traditional genders and called it two-spirit. They also recognised the manly hearted woman, who was aggressive and exceptionally independent. They often got the role of warrior woman. They could participate in male-activities while living and dressing as a woman.

People often behave according to their (gender)role. This is caused by the phenomenon of socialization, which is the way in which society conveys norms and expectations of behaviour. One example is that children are awarded with behaviour that fits their gender. However, many explicit gender-rewarding messages from parents have disappeared in society nowadays. Gendered parenting occurs in implicit ways: such as through gender-bound expectations.

Socialization continues in adulthood, where the norms of socialization extend from finding an appropriate job to sexuality. There are multiple sources responsible for socialization: parents, the media and peers.

What are psychological gender differences?

One major psychological difference between men and women is aggressiveness. Males are more aggressive than females. Also, males and females differ in their way of communication. Self-disclosure in friendships happens more often in girls than boys. The norms about self-disclosure are changing, whereas traditional roles favoured emotional expression, but emotional avoidance in boys there is now a change that good communication and equal self-disclosure should come from both genders. The understanding of nonverbal behaviour of others is called decoding nonverbal cues. This has implication for sexuality when men and women both have different communication styles. Meta-analyses have found that males are higher on impulsivity than females: They engage in more risk-taking and sensation-seeking; which also influences their sexual behavior.

What are gender differences in sexuality?

There are some differences between men and women regarding sexuality. However, the differences do not outweigh the similarities. Also, gender differences may be altered by culture.

• Masturbation is the largest difference in sexuality between men and women. Fewer women masturbate and begin at a later age.
• Attitudes about casual sex also differ between genders. Especially about the one-night stand where there is no emotional connection between partners. Women tend to be disapproving, while men ten to approve those interactions.
• Use of pornography is considerably more among men than women.
• Arousal to erotica also happens more often in men than women. In research, measurements are taken using the penile strain gauge, which is a physiological measure of arousal in men. The photoplethysmography is the female equivalent. Both instruments measure vasocongestion in the genitals. In the study by Suschinksy, participants were shown a variety of video clips; of which some portrayed sexual interactions and others portrayed neutral content. The researchers obtained self-report ratings of sexual arousal from the participants, as well as physiological measurements of their arousal: The penile strain gauage and the vaginal photoplethysmograph were used. Both women and men showed near zero subjective ratings of arousal to the neutral content and significantly higher ratings of arousal to the sexual interaction clips. Interestingly, for men, the correlation between subjective ratings of arousal and their physiologicla arousal is much higher than this correlation in women: This showed that women sometimes have difficulty being aware of their own physical sexual arousal.
• Orgasm consistency is better for men than women, even during masturbation.
• Sex drive is stronger in men, men think more often about sex and have more variations in their sexual fantasies.

Why do these differences in sexuality exist?

Women masturbate less than men, they disapprove casual sex and have a lesser orgasm consistency. Men use more porn and have a greater sex drive. There are several explanations for these differences.

• There is the chance that some of the reported gender-differences are not true, but that people report what is expected, based on gender norms. The bogus pipeline method was used to investigate this possibility. The researchers used the bogus pipeline condition, where students were hooked to a fake polygraph, the anonymous condition and the exposure threat condition. People in the bogus pipeline condition gave the most honest answers and it turned out the number of sexual partners for women was slightly higher than for men.
• Biological factors are separated into differences in anatomy and hormones. Differences in anatomy arise from the biological fact that the man has a penis. He can look at his sexual organs and see whether he is aroused. This is not possible for women as her sexual organs are hidden. This could be the cause for women exploring their sexuality less. Hormonal differences are also related to sexual behaviour. Women have lower testosterone levels than men, which could partially explain their lower sex drive.
• Cultural factors are the restrictions placed on female sexuality. The double standard is the best example and means that the same sexual behaviour is evaluated differently in men and women. Also, gender roles and marital -and family roles are cultural forces that contribute to differences in sexuality between men and women. Finally, body image issues influence the females sexual functioning. Women who are dissatisfied with their bodies report lower levels of sexual desire.
• Other factors include pregnancy, which can be a highly undesirable consequence of sex. Another factor could be the ineffective techniques of stimulating a woman, the most common technique (coitus) is not the best way for stimulation. The inexperience of a woman with masturbation can cause an erotic dependence on a man. This could possibly be solved with giving girls more information about masturbation.

What are gender differences in adults?

Most research about sexuality is done with young-adults and college students. However, this gives a very narrow view on gender differences between partners. This is because the sexual awakening of a woman is later then for men so for instance, they might start masturbation at a later age. The expression of sex is also different, with men it starts with body-centred sex and later it becomes person-centred sex. For women, this is the other way around.

What is transgender?

The term transgender refers more to a gender identity than a sexual deviation. Transgender is a name for people whose gender does not match their assigned gender at birth. Some people do not have any gender that appears in their genitals. This is called genderqueer, or non-binary. Another group is the transsexuals, their gender identification does not match the gender they are assigned to. For example, a person born with a female body, but a male personality. A male-to-female transsexual (MTF) is the name for a transwoman. A female-to-male transsexual (FTM) is a transman. The term trans however, is broader and includes people who identify as transsexual, cross-dressing, gender nonconforming, gender fluid, gender queer, transgender and other gender-variant persons. Individuals that are not transgender are categorised as cisgender. Gender dysphoria is the psychological distress that is caused by a mismatch between identity and gender. It can exist during childhood but does not always persist until adulthood, only about twenty percent does. When gender dysphoria exists in adolescence the change of persistence into adulthood is much higher.

What are experiences of trans people?

There is a homophobia and gay prejudice about transsexuals. The terms transphobia and anti-trans prejudice describe the attitudes and behaviours towards trans people. Transphobia is the irrational and strong fear for trans people. Anti-trans prejudice is a combination of the negative attitudes and behaviours on trans individuals. Discrimination against trans people is high, they experience injustice at every turn because they are called by gender-binary pronouns even though they do not feel these fit their gender identity. Trans people who are gynephilic are sexually attracted to women, if someone is androphilic the sexual attraction is to men.

What are medical and surgical transition processes for trans people?

There are several procedures available for people to change their binary gender identity. One of them is therapy so their body matches their identity, this is gender-conforming therapy. Other options are often medical, but a referral and assessment by a mental health professional is needed. The treatments can be accumulated with voice -and communication therapy, supportive therapy for peers to reduce stress and facial hair removal for males. The following medical treatments exist:

• Hormone therapy to accomplish pubertal suppression is used to give a person time to make a well-informed decision about the transformation. They are reversible if the choice not to make the transition is made. Also, if the transition is made, the process is simpler.

• Hormone therapy to feminize or masculinize the body is only partially reversible and applied on adolescents and adults that are already capable of deciding. It can lead to the growth of facial hair, the clitoris and breasts.

• Chest surgery is the removal or augmentation of breasts.

• Genital surgery for MTF are:

  • Penectomy: removal of the penis

  • Orchiectomy: the removal of the testes

  • Vaginoplasty: the creation of a vagina from the skin of the penis

  • Clitoroplasty: the creation of a clitoris.

• Genital surgery for FTM can include:

  • The removal of the uterus: hysterectomy

  • The removal of the fallopian tubes and ovaries

  • Metoidioplasty or phalloplasty: creating a small penis. Metoidioplasty entails releasing the clitoris, which enlarges into a small penis through hormone therapy.

  • Insertion of artificial testes

• Affirmative Psychotherapy for TGNC people has shifted from an old model of diagnosing people to a new trans-affirmative practice. This entails that psychologists are informed with the basic knowledge about the transgender experience and transgender research. They should understand the prejudice, discrimination and violence that affect the health and psychological well-being of these people. They should understand the development of a transgender across the lifespan. Also, in therapy, psychologists should understand that TGNC people have better outcomes if they receive social support and affirmative care. Lastly, psychologists are often part of interdiciplinary treatment; next to the endocrinologists, surgeons, speech therapists, and social workers.

What are the causes of gender variance?

Gender variance has often been researched using transsexuals. Some argue that the process starts before birth. There are genes associated with transsexualism that are different for MTFs and FTMs. They are more likely to have a mutation in the androgen receptor gene. Not all MTFs carry this mutation. The exact causes are still unknown.

Study notes:

• You should be able to explain what a stereotype and gender role entails and how these are expressed in the different cultural ethnicities in the United States.
• You should be able to explain the sexual differences between men and women. What possible explanations are explained in this chapter?
• What are the different solutions for transgenders and why should there always be advice from a mental health specialist before undergoing these procedures?  

Chapter 13 - What are different Sexual Orientations: Gay, Straight, or Bi?

Sexual orientation depends on the person someone is sexually attracted to with a potential for loving. A homosexual is sexually attracted to people from the same gender. A heterosexual has a sexual orientation towards the other gender and bisexual is sexually oriented towards both genders. The term homosexual comes from the word homo, which means same. The term lesbian also comes from the ancient Greeks and is used to refer to female homosexuals. Gay activists prefer gay over homosexual because there are many bad connotations to homosexuality. A heterosexual is called straight. The definition of queer is a term that embraces gay, lesbian and transgender people. The abbreviation LGB can also be used to describe lesbian, gay -and transgender, another term is sexual minority.

What are attitudes towards gays and lesbians?

People’s attitudes on one another are influenced by sexual orientation. Especially heteronormativity, which is the belief that heterosexuality is the norm, influences stereotyping about sexual minority groups. Negative stereotypes and attitudes lead to discrimination and crime against gays and lesbians. In America, many people disapprove homosexuality and some experts even believe their attitudes can be described as homophobia. This is the irrational fear in combination with fixed negative attitudes towards homosexuals. When these feelings are not strong enough to be named phobia, these negative attitudes are called anti-gay prejudice. These people also express heterosexism, the belief that everyone is heterosexual. The most severe expression of heterosexism are hate crimes against LGBs. These incidents have a high psychological toll on the people belonging to sexual minorities that are being harassed. The media plays a role in the anti-gay attitudes. Currently there are more representations of sexual minorities and they are more visible in the media, however they are often still stereotyped, whether this is a positive or a negative one.

Gays and lesbians belong to a minority group and suffer from discrimination. In America, an experiment was conducted to research job discrimination for gay men. They found that job interviews for gays were shorter and rated more negatively. Homosexuals have the advantage of being able to hide that they are part of a minority and get along with heterosexuals. This is also a disadvantage because lying about a sexual orientation is not only dishonest, but also psychologically stressful. Changes must occur on individual level, in corporations, educational institutions, he law and society to accept these sexual minorities and eliminate the negative stereotypes.

What are life experiences of LGBs?

It is important to understand the lifestyles and experiences of LGBs. A covert homosexual is someone who may be married to a heterosexual, has children and is respected in the community. They spend a few hours each month in secretive homosexual behaviour. An overt homosexual is someone who lives in he LGB community. There is more discrimination against gay men than women due to gender roles, however more lesbians do not express that they are homosexual. Coming out is the acknowledgement of being gay or lesbian to oneself and others. Peer harassment of homosexuals can be intense and even result in dropout of school and suicidal thoughts. Therefore, the climate for sexual minorities in schools must be enhanced. Some people do not have a set sexual orientation and it can change over time, this is called sexual fluidity.

What are lesbian, gay, and bisexual communities?

There are LGB communities all over the world. They use symbols and rituals to define their community. The pink triangle is their symbol of pride. Gay bars are a big part of the community to meet other people. Recently the internet also became a place to meet a potential partner. The LGB community encouraged them to be less covert, more open and liberate their sexual orientation. 

Research has shown that taking a positive psychology approach to understanding same-gender couple relationships is effective: Doing this, one does not focus on the pathologies but on the strengths of the individuals in these relationships or the relationship in general. 

What do gay and lesbian relationships -and families look like?

According to several surveys, between eight and twenty-one percent of lesbian couples was together for ten or more years, this was about eighteen and twenty-eight percent of gay couples. Like heterosexual couples, homosexual couples struggle with the difficulty of finding a balance between money, sex and housework. There is no difference between the couple’s interaction compared to heterosexual couples in positive and negative behaviours by each partner. Creating children is a controversial subject for homosexuals. It is suggested they are unfit partners. However, according to research the adjustment of mental health of children growing up in homosexual families is no different, children often have a heterosexual orientation and their social skills do not deviate from children from heterosexual families.

What is the prevalence of gay, straight or bi?

The prevalence depends on the used definition of homosexual. To do this, sexual identity should be explained. Sexual identity is someone’s self-identification or self-label as homosexual, heterosexual, queer, bisexual or something else. Also, there might be a contradiction between one’s sexual identity and their actual partner. The definition of homosexual is difficult, because what are the restrictions. Should someone mainly -or only have same-gender sexual experiences? About five percent of men and fourteen percent of women have had at least one homosexual experience. It is believed that about ninety percent of women and ninety percent of women are exclusively heterosexual.

What is the association between sexual orientation and mental health?

Some people still believe that homosexuality is a mental illness. In the twentieth century the sin model was replaced with the medical model. The sin model viewed mental illness as a sin which deserved punishment. The medical model treats mental illness as a result of biological factors and are viewed as sickness.

• Clinical studies in early ages (1920; 1974) found that homosexuals were poorly adjusted and neurotic. Therefore, they were labelled mentally ill. However, current evidence does not support this view.
• Studies with control groups improved research about homosexuality, however they used faulty measures. By comparing homosexuals in therapy to a random group of normal individuals they obviously found differences between groups.
• Nonpatient research used people recruited by LGB organisations and researchers found that these people are as adjusted as heterosexuals. In 1973, homosexuality as removed from the listing of psychiatric disorders.
• Population studies found some higher rates of depression and anxiety among gays. Also suicide and PTSD are more common. This does not indicate mental illness, but rather the result of dealing with stress about concealing their identity.
• Resilience in sexual minority individuals states that people should focus on the resilience LGB people show to stigmatization. Support for sexual orientation should help LGBs maintain their psychological health.

Is it possible to change sexual orientation by therapy?

There are forms of therapy designed to change LGBs into heterosexuals. There is conversion therapy or reparative therapy that are mostly created by religious groups. These treatments were quite inhumane and still believe that homosexuality is an illness. The consequences can be bad, it can make people feel guilty about their behaviour. These therapies make no sense, as homosexuality is not a mental illness and therefore their sexual orientation should not be changed against their will.

How do people become gay or heterosexual?

Older theories use the heteronormative approach to describe homosexuality, more recent theories not that heterosexuality should be equally explained and are likely to explain sexual orientation.

Biological theories

• Genetic factors can account for sexual orientation, there are three possible influences found on chromosomes: 7, 8 and 10. There are probably multiple genes that contribute to one’s sexual orientation.
• Prenatal factors or variation in prenatal development could account for homosexuality. The epigenetic phase of pregnancy could shape sexual orientation by the receptivity of androgen receptors. However, none of the research can be completely accepted yet.
• Brain factors to determine sexuality have not been identified. However, the response of the brain to stimuli is different for gays and lesbians. Both heterosexual men and lesbians are turned on by women’s pheromones.
• Hormonal imbalance was researched by looking at testosterone. There were no differences found between gay men and heterosexual men. Androgens are related to sexual desire but won’t make a homosexual heterosexual.

Learning theory

Learning is important in the development of sexual orientation. Punishment and rewards could influence the development of predominant hetero -or homosexual behaviour. Behaviourists argue that people are born sexual, not gay or straight. Another possibility proposed by learning theory is that early sexual experiences with same-gender persons are pleasant; this behaviour becomes more likely. The evidence is mixed, rape in young women does not seem to turn them into lesbians. Early life experiences are important though in the development of sexuality.

Sociological theory

According to sociologists, there are effects of the label “homosexual” and the impact of society on the development of homosexual behaviour. When a young boy that is behaving in a feminine way is repeatedly called “fag” he might turn gay because of a self-fulfilling prophecy. The theory of Reiss (1986) describes the negative pathway to homosexuality. He describes that in societies with a rigid gender role for males, the males that reject these roles become homosexual. He also describes a positive pathway where in a free society people experience with homosexuality and find is satisfying.

What are the differences between gays and lesbians?

Women are more likely to be bisexual instead of solely homosexual. Also, women show more flexibility over time in their sexual orientation. Women show sexual arousal for both male and female stimuli. Men are more specific in their sexual arousal; heterosexual men are aroused by female and not male stimuli whereas homosexual man show the reverse pattern.

What are multicultural perspectives on sexual orientation?

In every society homosexuality is treated differently. Therefore, the process of sexual identity is different. However, the percentage of occurrence of homosexuality is the same across cultures. Black and Latino men are more likely to engage in same-gender sexual behaviour while calling themselves a heterosexual. In Mexico, there is a way of dichotomizing same-gender sexual behaviour. The man that is the receptive partner in same-gender anal intercourse is seen as homosexual, unmanly and feminine while the inserting role is seen as masculine and not homosexual. For the Asian Americans, there is a very small percentage that is “out” because sexuality must be kept private.

What is bisexuality?

Someone who is bisexual has a sexual orientation towards both men and women. It is more common than exclusive homosexuality. The gay community might view bisexuals with suspicion and refer to bisexual women as “fence-sitters”. Heterosexuals are also quite biased against bisexuals and label them as non-monogamous. In research, a pattern for bisexuals was found in rating attractiveness that was distinct from heterosexuals. Some people argue that bisexuality is just a phase to discover one’s true sexuality. However, it seems that no-one’s sexuality is fixed and can, unlike gender identity, change over time. The group mostly heterosexuals are people that are not quite bisexual, but not exclusively heterosexual. They have a small amount of occasionally same-gender sexual behaviour but are mostly heterosexual. It supports the idea that sexual orientation spreads along a continuum.

Pansexuality refers to people who are sexually or romantically attracted to people regardless of their gender. As a sexual identity, it seeks to overcome gender binary assumptions which are present in the term bisexual.

Study notes:

• What are the different ways in which someone can become a homosexual according to old -and new theories? One of the theories is that hormonal changes can cause someone to become a homosexual, what are the other theories?
• What influence did old research methods on homosexuality have on the stigmatization and stereotyping of homosexuals?

Chapter 14 - What are the Variations in Sexual Behavior?

Scientists have the tendency to describe behaviour in terms of normal or abnormal. Abnormal sexual behaviour is described with the following terms: sexual deviance, sexual variance, paraphilias and perversion.

When can sexual behaviour be classified as abnormal?

One approach in describing abnormal behaviour is the statistical definition, it classifies rare and uncommon sexual behaviour as abnormal. In the sociological approach the dependence on culture is acknowledged. Abnormal sexual behaviour is described as deviant in the society. The psychological approach (Buss, 1966) describes abnormal sexual behaviour as inefficient, bizarre and discomforting. The medical approach is classified by the DSM. It recognises eight forms of abnormalities: sexual masochism, frotteurism, sexual sadism, fetishism, voyeurism, transvestism, pedophilia and exhibitionism.

The definition of paraphilia is the intense sexual interest in sexual stimulation other than with normal human partners. Paraphilia is not necessarily a mental disorder but might require intervention. When the person feels great distress either caused by societal pressure or unwilling sexual partners the paraphilia can be classified a disorder. The general diagnostic criteria described in the DSM are:

1. The urges or fantasies must last over a period of at least six months
2. The urges or fantasies cause clinical impairment or distress that affects occupational or social functioning.

It can be difficult to distinguish normal from abnormal sexual behaviour. Many people hold mild fetishes, such as the fetish for exciting lingerie. Also, forty-two percent of people reported they engaged in voyeurism and thirty-five percent engaged in frottage, this is sexual rubbing against a woman while in a crowd (Templeman & Stinnett, 1991). The fetish becomes abnormal when it gets more extreme or when it becomes a necessity.

What is fetishism?

Fetishism means having a sexual fixation on an object other than a human. Also, a great erotic significance is attached to this object. A fetishistic disorder is when urges, behaviour or fantasies for a non-living object enhances or produces sexual desire without or with the partner. It should last for at least six months and cause significant distress. In some cases, people are unable to get an orgasm unless the object is present. There are two types of fetishes: media fetishes and form fetishes. There are three theoretical explanations of why people develop fetishes: learning theory, the sexual addiction model and cognitive theory.

• According to learning theory a fetish is the learned association between an object and sexual arousal or an orgasm. They are formed as a result of classical conditioning.
• The cognitive psychology explanation stresses the importance of cognitive distortion where people perceive a non-human object as erotic. Not only the perception of the object, but also the perception of arousal is distorted. The unconventional behaviour is mistaken for arousal.
• The third theory: the sexual addiction model states that fetishism comes from a compulsive behavioural disorder.

What is cross-dressing?

When someone dresses as the opposite gender this is referred to as cross dressing. Many transsexuals have a phase of cross-dressing in the process of becoming their preferred gender. Drag queens are people who dress up as women. Drag kings are women who dress up as men. Female impersonators are men and women who dress like a specific woman for the purpose of entertainment. A transvestic disorder is when the cross-dressing causes sexual arousal -and excitement and the behaviour is maintained for at least six months. It happens almost exclusively with males, this is because female’s clothing is designed for sensual purposes, men’s clothing is mostly designed for comfort.

What is sadism and masochism?

A person who experiences intense and persistent sexual arousal from physiological or physical suffering is called a sexual sadist. A person who gets sexually aroused by humiliation, beatings or bondage is called a sexual masochist. It can be expressed in behaviour, but also in urges and fantasies. When it causes significant distress and lasts for more than six months it is classified as paraphilic disorder. The difference between sadism and masochism is the sexual nature, thus giving or receiving pain. There are two techniques important for sadism-masochism (S-M). The techniques are bondage and discipline (B-D). Sexual interaction is done with physically restraining devices or constraints. These devices or constraints may also enforce obedience without physical pain. Dominance and submission (D-S) refers to the interaction to exchange power to control sex. These behaviours of both B-D and D-S can be atypical or paraphilic.

What is sadomasochistic behaviour?

There are both nonparaphilic and paraphilic forms of sadomasochistic behaviour. There is a spectrum of activities that constitute S-M. Before people enact in S-M they often tried a range of activities of which a few are satisfying. Santtila et al. (2002) found four clusters of S-M behaviour: hypermasculinity, receiving and administering pain, physical restriction and humiliation. The sexual activities within each cluster seem to be scripted, less intense behaviours are more common. Social interaction and play are important in S-M, especially the enactment and creation of scenes.

Causes of sadomasochism are not yet known. There are several theories, which are learning theory, the sexual addiction model and cognitive theory, the same as for fetishes. Baumeister (1988) proposed a theory to explain masochism, not sadism. The theory states that masochism is the motivation to escape self-awareness. This might be because self-awareness can lead to anxiety or pressure. Masochism provides an opportunity to be autonomous and powerful.

What are theories on sexual addictions?

According to the analysis of Carnes in his book “sexual addiction”, sexually addictive behaviour proceeds in a four-step cycle:

1. The first is preoccupation where someone is unable to think about something else than the sexual act of the addiction.
2. Rituals refer to the repetitive motions that become prelude to the addictive act.
3. Compulsive sexual behaviour is the behaviour the person does not have control about.
4. Despair is the feeling of hopelessness that results from the addiction.

The Compulsive sexual behaviour approach to sexual addiction is when a person has no impulse of controlling the behaviour rather than being driven to perform the sexual action.

What is bondage and discipline?

The sexual behaviour of using restraining devices for sexual purposes is called sexual bondage. It is difficult to gather data about this type of sexual expression. People engage in B-D because it is playful, some do it because of the exchange of power. The key to S-M is not pain, it is dominance and submission (D-S). It is often practised according to a strict script where people take roles as master or naughty child. The outcomes of serious risks are rare because social arrangements are made in advance.

What is voyeurism and exhibitionism?

Exhibitionism and voyeurism are quite different. A voyeurist would not be aroused by watching an exhibitionist. A voyeur is defined as someone who experiences sexual arousal from watching a person in the process of engaging in sexual activity. This person is often not suspecting being watched. It becomes a paraphilia, when the behaviour is classified as “peeping”. It is normal for a person to enjoy watching someone get undressed in a strip club. The behaviour becomes problematic when people start watching strangers engage in sexual activity that do not want another person to know what they are doing. Exhibitionism is receiving pleasure from exposing his or her genitals to another person. Generally, when a woman shows her breasts this is seen as arousing, however when a man shows his penis, this is considered offensive. Whether it is a paraphilic depends on the person engaging in exhibitionism. Most people that have an exhibitionistic disorder characterise their youth with inconsistent discipline, but the exact cause is unknown. It might be a bad relationship or marriage with little positive sexual reinforcement. Sexual offenders in general seem to have fewer social skills than others.

What is hypersexuality and asexuality?

Hypersexuality and asexuality are not listed in the DSM, but they might still be paraphilic due to the consequences. The conditions nymphomania (women) and satyriasis (men) are forms of hypersexuality where someone has an extraordinarily high sex drive. The meaning of these terms differs from person to person. One might think sex every day is completely normal whereas in other cultures this might be considered abnormal. Clinical researchers therefore use the term hypersexuality. It leads to compulsive behaviour where negative and inefficient behaviour can intervene with everyday life. This might result in not having orgasms or never being satisfied with sexual activity. The criteria for paraphilia are that there should be about seven or eight orgasms in each weak for at least six months. Additionally, the man should engage in sexual activity for about two hours per day. Unconventional behaviours are masturbation, exhibitionism, voyeurism, pedophilia and promiscuity. There is an ongoing discussion about whether hypersexuality should be considered a disorder or not. Carvalho (2015) described two clusters of hypersexuality. First, when a person experiences a lack of control and various negative outcomes hypersexuality seems problematic. Second, if someone has high desire and frequent activity this behaviour does not have to cause any problems.

Asexuality is the absence of sexual attraction to any sex. Asexuals are more likely to be women and have poorer health and a low socioeconomic status. It does not seem to be a sexual orientation, which is a strong preference for intimate relationships with people of one gender, because asexual people often cohabit, marry and even have children. According to Bogaert (2015) most asexual behaviour can be classified as hypoactive sexual disorder. This is a dysfunction rather than a paraphilia. Most asexual people tend to masturbate, they however are not interested in having sex with another person. This is why some scientist claim that asexuality counts as a sexual orientation.

What is the use -and abuse of cybersex?

Recently, a new type of sexual -and possibly problematic behaviour is concerning clinicians and therapists. Cybersex can be divided into three categories: It can be non-arousal OSA (online sexual activities) (such as joining a dating site), solitary-arousal OSA (individual; such as watching webcam sex), or partnered-arousal OSA (such as participating in an online sexual chat). 

Cybersex can become compulsive, paraphilic and addictive, especially because of the variety and availability of online content. The compulsive and persistent use of cybersex can be classified as hypersexuality if it causes distress and lasts for at least six months. Whether the extensive use of pornography can be classified as compulsive behaviour depends on the problems caused by the behaviour. A pornographic addiction is like another type of addiction and is characterised by the craving for a substance and the inability to control the craving. Also, neurological changes have been reported for people with a pornographic addiction that are similar to other addictions. There seems to be a high prevalence of co-occurrence with depression, alcohol -and drug abuse and sleep disturbances.

What are other sexual variations?

Other sexual variations are uncommon and have not been thoroughly studied. These variations include asphyxiophilia, zoophilia and frotteurism.

• Asphyxiophilia is the wish or desire to get into a state of oxygen deficiency to create sexual arousal, excitement and an orgasm. People with asphyxiophilia believe the lack of oxygen intensifies the orgasm.
• Zoophilia is the pleasure of sexual contact with an animal. Other names are bestiality or sodomy. Zoophiles describe themselves as having consensual sexual intercourse with animals with a concern for the animal welfare. The pleasure can be described by learning theory where sexual rewards from animals are easy, intense and extremely reinforcing.
• Frotteurism is the sexual fantasy, urge or behaviour to rub genitals against the body of someone else in a public space. Frotteurism can result in a frotteuristic disorder when the symptoms cause significant distress.
• Troilism is the sexual encounter by three people. It is also be referred to as voyeurism if there is one person just watching the sexual encounter between the other two. If the third person in troilism is a heterosexual encounter is male, it places the male in a cuckold.
• Saliromania is the desire to soil or damage a woman’s image or clothing for sexual arousal.
• Coprophilia is the sexual desire to use feces for sexual satisfaction and urophilia is the use of urine.
• Necrophhilia is described as having sexual contact with a dead person.
• Sexsomnia or sleep sex is when someone exhibits sexual behaviour during sleep. The person is often unaware of this behaviour. The sexual behaviours range from masturbation to sexual assault.

How can sexual variations be prevented?

The distress or harm caused by sexual disorders calls for prevention methods. The best way would be to prevent the sexual variation from happening in the first place. It is problematic due to the difficulty to diagnose sexual variations. Another option is to analyse components of sexual development. Disturbances in these components might give clues on prevention of sexual variations. The components are the following (Bancroft, 1978):

1. Gender identity
2. Sexual responsiveness
3. Formation of relationships with others

The different components can cause different variations. Childhood sexual abuse is seen as a great risk for paraphilic behaviour. This is done by adults, so they also should be educated and treated.

How can sexual variations be treated?

Treatment options range with the variety of the sexual disorder. Only sexual behaviour in the abnormal part of the continuum need to be treated. Especially for paraphilic disorder classified by the DSM, treatment is necessary. There are four categories of treatment:

• Medical treatments view paraphilia as disorder with a biological cause. Surgical castration used to be common for men with uncontrollable sexual urges. Currently hormonal treatment can be used to reduce sexual desire. The drug MPA binds to androgen receptors to reduce sexual desire but has serious side effects and did not reduce the chance of reoffending. Now CPA is replacing MPA and blocks testosterone uptake. LA is also used and suppresses androgen production and reduces sexual fantasies.
• Psychopharmalogical treatment such as the use of antidepressants seems to work as well. They change the obsessive or compulsive disorder rather than the sexual desire.
• Cognitive behavioural therapy (CBT) can be used to reduce inappropriate sexual behaviour, modify distorted thinking, train social skills and prevent a relapse.
• Skills training is training in forming and maintaining relationships. People with paraphilia often lack the social skills to even maintain a conversation. Some programs use sex surrogates where the surrogate interacts sexually with the client. Some people think of this method as unethical
• AA-type 12-step programs are based upon sex addiction and aims to help control the uncontrollable and inappropriate sexual behaviours.

Do these interventions work?

Some programs are more effective than others, medical treatment is quite successful a reduced sexual recidivism by thirty-seven percent. Also, classic behavioural programs are the least effective and CBT-methods have proven to be the most effective. The chance of re-offending after CBT is only twenty-seven percent, however this depends on the type of paraphilia. The AA-type 12 step programs have not been proven to treat sexual disorders.

Study notes:

• You should be able to explain the continuum between normal and abnormal sexual behaviour. When is certain sexual behaviour abnormal and when can it be classified as a disorder (DSM)?
• You should know the most common forms of abnormal sexual behaviour described in the middle part of the chapter.
• What kind of treatments are available for paraphilia and what do these treatments tell you about the causes of these abnormalities in sexual behaviour?

Chapter 15 - What is Sexual Coercion?

In this chapter sexual coercing is discussed. Rape, child sexual abuse and sexual harassment are studied.

What is rape?

The definition of rape is the non-consensual vaginal, oral or anal penetration obtained by force. The most important point is that the victim did not consent to it. The impact is high, psychological distress such as depression, suicide ideation and attempt, anxiety and posttraumatic stress are often reported after rape. The long-term psychological distress suffered by someone who experiences an uncontrollable and terrifying event is called posttraumatic stress disorder. Symptoms are depression, nightmares, lack of feeling safe and depression. People with PTSD form a schema with information about the traumatic event and their responses. This schema is involved in triggering cues and feelings of terror after the event took place. There are several factors that are associated with the severity of psychological outcomes:

1. The number of experienced violent traumatic experiences.
2. The severity of the experienced violence.
3. The responses of persons that the violence is disclosed to.

Self-blame is experienced sometimes by women after they were being raped. This is linked to worsen the psychological outcomes. Besides psychological, there are also physiological effects of rape. People can experience bleedings, get pregnant or get a sexually transmitted disease. Posttraumatic growth is the positive life change after trauma.

Most rape is conducted by people in the inner circle of the victim. Date rape is the most common, especially on college campuses. It can be the result of miscommunication where a man misperceives the intentions of a woman. A big problem today is the existence of Rohypnol, a date-rape drug that causes drowsiness or sleep. Marital rape or intimate partner rape is also quite common, and the consequences are no less severe. Motives include power, domination, sadism, anger and sexual desire.

How can friends and family help a rape survivor?

Friends and family should respect the victim's decisions, try to listen and be available. It is very important that they believe the victim and offer him or her a safe place to stay. Friends anf family should recognize that recovery may take a long time, and be sensitive and respectful of the victim's wishes for closeness and affection: Some want closeness, and others want distance. Friends and family should not forget to deal with their own feelings as well, and not project those on the victim. In the case of a partner, he or she should understand the impact that sexual assault may have on sexual interactions.

What are causes of rape?

There are several views of the theoretical causes of rape:

1. Victim-precipitated rape is a view stating the woman is responsible for rape, it resembles the tendency to blame the victim.
2. The psychopathology of rapists’ states that rape is always committed by someone who is psychologically disturbed. His deviance is responsible for the crime.
3. Feminist theories say that rapists are the result of the gender-roles in our culture. Sex is used by a man to demonstrate power. Feminists also argue that the erotisation of violence is a cause of rape.
4. Social disorganization means that in a disorganized society the rape (and crime) rates increase. The community is unable to prevent crimes by enforcing strict norms.

Sexual scripts also play a significant role in rape. Sex is learned trough society and people might get the idea that a man should be oversexed and aggressive. Another influence is early life, people who were sexually abused at a young age are more likely to become rapists themselves. Peer influence is another cause, one example is fraternity gang rapes where fraternity members are encouraged to take part in rape. The situation can trigger rape, for example with large amounts of alcohol or drugs. Lastly, power motives are an important consideration. Men might want to express their power through rape. This could be due to the attitudes of masculinity in men.

What is the role of alcohol in rape?

Alcohol plays a significant role in the motive for rape. Intoxicated men are more likely to commit a crime of sexual assault then men who are not. The correlation between alcohol and rape is unclear. Does someone drink to create a motive for sexual assault or is the disappearance of boundaries after drinking alcohol the trigger? There are two types of effect of alcohol:

1. Pharmalogical effects are the bodily effects of alcohol and include impairment of higher cognitive functions. This can a predisposed man to rape set him to commit the actual crime.
2. Psychological effects are the glamorous effects that are assigned to drinking alcohol. It is widely believed that alcohol enhances a man’s sex performance which creates expectancy effects.

In one study they researched the effects of alcohol consumption on the justification of sex. Men that were intoxicated showed a higher willingness to force sex than men that were sober (Abbey et al., 2009). The effects of alcohol on victims are the same. It causes a woman to miss cues about a dangerous situation or be less effective in their defence.

What is the profile of a typical rapist?

There is no typical rapist. They vary on all characteristics. One thing there is consensus about is that they often repeat their offences. In comparison with normal men, rapist tend to have the following characteristics:

1. They hold implicit theories supporting rape and believe women are sexual objects. They believe a man should have superiority and control.
2. Rapists often have poor self-regulation and inhibition.
3. They have a lack of empathy. They do not understand the victim can suffer.
4. They have been exposed to an environmental trigger such as being in a war.
5. They are often victims of sexual abuse themselves.

Who are other victims of rape?

Women are almost exclusively victims of rape, however there is a small percentage of men being raped. The perpetrators of these male rapes are predominantly black men (Black et al., 2011). Men suffer the same consequences of rape as women do. It is important to recognise the possibility of male rape victims. 

Prison rape happens among males. These men are coerced in having repetitive anal sex with other inmates. It is a new example of the coercion of power and dominance among men. Cultural context also influences rape. 

Ethnicity plays an important role in the reporting of rape, for example the report statistics among African American women is very low due to their violent history. They do not believe they are credible victims.

How can rape be prevented?

There are three categories of strategies to prevent rape, the first is avoiding the situation, second is knowing self-defence techniques and third is changing attitudes that contribute to rape. The strategies proposed by the Association of American colleges are the following:

1. Set sexual limits
2. Decide early if you want to have intercourse
3. Do not give mixed messages
4. Be forceful and firm
5. Do not do anything you do not want to do to avoid unpleasantness
6. Be aware that drugs and alcohol are related to rape
7. Try to avoid rape situations or use self-defence

Self-defence classes are organised to teach necessary skills to thwart a rape. However, it is better to prevent rape in an earlier stage. There is a variety of rape-prevention programs available to help people.

1. Awareness based programs to create awareness on the prevalence of rape.
2. Empathy based programs to seek support for the victims.
3. Social norms-based programs can make people question existing gender-roles.
4. Skills based programs teach people the skills to avoid being a victim of sexual violence.
5. Bystander intervention programs encourage bystanders to intervene when they see it happening.

What is child sexual abuse?

Many cases of child abuse are not reported, the perpetrators are mostly men, about ninety-four percent. Factors that account for the imbalance are male socialization towards sexuality and existing sexual scripts where the partner is often smaller. A new form of sexual abuse is sexual solicitation on the Internet, where a perpetrator meets his victim online, gives confidence and then sets a meeting. The latest form of online exploitation is sextortion; which refers to threats to expose sexual images with the goal of coercing victims to provide additional pictures or engage in sex.

Incest covers a large percentage of child sexual abuse. Not only parents or adult family are causes, but also sibling incest occurs. The effects of child sexual abuse are considerable. The child may be traumatized and testifying repeatedly after reporting the crime is association with even worse outcomes. CSA affects both mental and physical health and can cause anxiety, depression, eating disorders, alcohol and drug dependence and negative feelings about sex.

Who are offenders of child sexual abuse?

Pedophilia is the sexual activity with a child that is prepubescent, generally age thirteen or below. To get diagnosed with pedophilia the person must have intense fantasies, urges and behaviours over a period for at least six months. There are people that have pedophilic urges, but never act on them. Child molesters often score low on measures of social competence and lack the interpersonal skills to function in relationships. Researchers measured the associations of pedophiles and found that they have an association between children and sex whereas normal people have the association between adults and sex. There are a few treatments available including chemical castration, SSRIs, androgen drugs and cognitive-behavioural therapy. This form of therapy is trying to learn pedophiles to control their sexual urges, attitudes and beliefs towards children. Some experts question if there are successful treatments for pedophiles.

What is sexual harassment?

Sexual harassment is the unwelcome request for a sexual favour, sexual advance or any other conduct of sexual nature. The submission to this request is a condition for the person’s further employment or academic advancement. The decision to not comply can have serious repercussions for the person’s work or academic life. This is made clear by the harassing person. It may occur at work, education, but also in medical settings.

• Sexual harassment at work is more common than people realise. Between twenty-five and fifty people are being harassed in the workplace. This is reported by both males and females. There are four types of harassment, first is earnest harassment where the man is truly motivated for sex, but does not take no for an answer. The second is hostile harassment where the motive is domination, third is paternalistic-ambivalent harassment where the man wants sexual intimacy, but at the same time feels like a father figure for the woman. Finally, there is competitive ambivalent harassment where the hostile desire of a man is mixed with the real sexual attraction. The #MeToo movement came up as a raction to sexual harassment at work. 
• Sexual harassment in education is also quite common. Results can be dropping out courses, changing majors and dropping out of higher education in general. The psychological consequences of harassment by a teacher are more severe than by a peer. A National Academy of Sciences report concluded that several institutional factors contributed to sexual harassment occuring in educational settings.
• Doctor patient sex is another category of dangerous sexual encounter. The client can be seriously damaged because there is a situation of unequal power that applies. Especially in psychotherapy sexual harassment has extremely serious consequences. This is because the client expressed emotions and is very vulnerable.

Study notes:

• There is no clear profile on rapists or people that become rapists which makes prevention difficult. However, there are some characteristics that rapists seem to have in common. Make sure to know and explain these characteristics.
• What are the different types of child sexual abuse and what consequences does it have on mental health? What are the overlapping consequences with victims of rape?
• Make sure to know what types of sexual harassment exist and what the correlation is with other forms of sexual abuse.

Chapter 16 - What is Sex for Sale?

In many societies the exchange of money and sex is a prominent feature. A lot of money is made in the porn industry and prostitution. These subjects involve controversial -and legal issues, but also attract a lot of customers.

What is prostitution?

People that engage in partnered sex and are rewarded with material gifts, money or other payment are considered commercial sex workers or prostitutes. The venue where this sex word takes place depends on the client and type of sex worker.

• A call girl works via cell phone or online and makes appointments outside of her own residence. This type of sex worker often has a middle-class background and may be a graduate from college. She might have regular customers and has control over who visits her. The call girl often provides her clients with an illusion of intimacy.
• A brothel comes in many forms. Some are fancy mansions where guests are well-treated, some are clip joints where the man’s money was stolen while he was sexually occupied. The workers are often Latina, and the Latinos are the preferred clientele (Dank et al., 2014).
• There are also in-call services where a woman services a client regularly for sexual gratification. The autonomy of the sex worker in this scenario is less than the call girl, because there usually is a manager or madam to set up the appointments.
• The massage parlour can offer legitimate massage therapy. In some venues, it is also a place for commercial sex. They are usually operated by Asian women. Sometimes they offer commercial sex on the price list, but sometimes the masseuse will perform sexual acts for a tip. Some have a very high-end setting, but some do not. Especially in Vietnam, there are low-class prostitutes that work in barber shops. They are poor migrant workers that service sex to middle-class men. The middle-class works in bars and services tourists and the high-end sector are up-scale bars where prostitutes meet high-status Vietnamese men.
• An escort service has a standard menu, but extras may be added by the escort. This scenario is referred to as out-call service, because the escort visits the client. This is risky for the escort because he or she cannot decide where they meet their clients. However, the client should share the location with the escort company for safety and time management.
• Nowadays, the Internet is a place on which camgirls sell erotic services using webcam technology.
• A common sex worker is the streetwalker selling sex on the city streets. She charges a lot less than a call girl or escort and is less attractive. It is likely a streetwalker gets arrested. They are often also addicted to drugs. The prevalence of ethnicities of street walkers reflects their employment in the country.
• The strip club sells sexual interactions, but not always intimate contact. They follow the same continuum from elegant to low-class. There are also strip clubs for same-sex desiring women (SSDW).

What is the role of third parties in sex work?

Prostitutes are often associated with a pimp, who is her companion-master. He provides food, shelter and may bail her out of jail. She provides him with money and sex. A madam is a woman who manages the out-call and in-call services at a hotel, escort service or brothel. This woman is often an experienced and skilled person in managing prostitutes. Other third parties might include the manager of the massage salon. These third parties determine the autonomy of the sex worker.

What is sex trafficking?

Sex trafficking is described by Hynes and Raymond (2002) as the recruitment of sex workers for sexual exploitation. Some sex workers are recruited from third world countries with the promise of a good job as dancer, nanny or secretary. When these women arrive in the county their travel documents are taken away and they are forced to work in a brothel or massage parlour. A different type is the child sex slave, where a child is forced into sexual labour and is harmed with physical violence.

What is the career of a sex worker?

There is a big stigmatization of sex workers. There are two general explanations for getting into the sex-worker profession, the first is based on negative childhood -and adolescence experiences, such as abuse, poverty and contact with exploitative men or pimps. The second explanation is that there is a great economical need while someone has little education and no other job opportunities are available. People from the service industries of food and beverages and barbering and hairstyling are most likely to start working in the sex industry. Some are coerced into sex working by their husband or boyfriend, the coercion is also an important factor in sex trafficking. Leaving the life can be difficult due to a lack of job skills. Others might be able to leave because of a long jail sentence.

How is the well-being of a sex worker?

The “happy hooker” refers to the healthy, autonomous and attractive prostitute. Other stereotypes are the “though chick” or the (young) emotionally bruised victim. All of these stereotypes are true, and the well-being of a prostitute depends on the venue she is working in. According to a study of (Venicz & Vanwesenbeeck, 2000) women in the sex industry scored higher on depersonalization as a result of their work than people that worked in health care. This is probably because they lack autonomy, experience violence and work under coercion. Victimization is often related to the lack of control of the sex worker. Bernstein (2007) argued that the high levels of violence in prostitution do not result from the sex work itself, but from the stigmas attached to it. For example, prostitutes have a higher risk of being raped because the attitude exists that raping a prostitute does no harm to you. Some prostitutes use alcohol and drugs to cope with this, others a strategy to shut down their feelings or depersonalization. Sex education could help these women improving their strategies to cope with this kind of stereotypes and risks at work.

What is the role of early abuse on prostitution?

Prostitutes that experienced abuse in their childhood have poorer outcomes in well-being. Coercive sexual activity in childhood is correlated to a variety of adverse social -and health outcomes, such as unintended pregnancy or low self-esteem.

Who are typical customers of prostitutes?

In the past seventy years the use of prostitution declined dramatically. This is due to the increased frequency of non-marital and casual sex. Most customers of prostitutes come occasionally, but there are also impulsive and compulsive customers. Thus, one-time clients are clients that the worker does not expect to see again, regular clients/friends are clients the worker knows for some time. Long-term financial providers are clients that provide constant financial support for the prostitute by paying for her major expenses. Men use prostitutes for a variety of reasons, but mainly for the satisfaction of their sexual needs.

What types of male sex workers are there?

Male sex workers that provide services to women work in three settings. These are escort services, massage parlours and as gigolo. A gigolo is a man that provides companionship and sexual gratification in exchange for money. Men working in the prostitution for women rarely work on the streets and therefore have a much safer profession. However, a hustler is a male sex worker, working for other males. They work on the streets and face stigmatization and assault. Bar workers in gay bars that provide sex services face less stigmatization and assault than hustlers working on the streets. There is a minority of men working in brothels, the largest group of male sex workers works in escort services or are call boys.

What is sex tourism?

Sex tourism is a way of travelling with the purpose of purchasing sex. It is made possible by the migration to third world countries, migration from urban to rural areas and the commodification of sexual intimacy. All types of sex are now for sale. Another cause is globalization and the movement of information across the world.

What is pornography?

Material intended to produce sexual arousal is called pornography. There is a lot of discussion going on about what type of pornography is tolerable. In legal terms the word obscenity is used to describe offensive materials. There is a distinction between hard-core pornography and erotica or soft-core pornography. Internet porn ranges from access to arousing videos to live performances of cam models. Pornhub has published a data report showing that porn is very popular nowadays. There are several subcategories of pornography that can be found online:

• Adult web sites
• Chat rooms
• News groups
• Commercial bulletin boards
• Virtual reality porn is a new development; it is a technology in which someone has a VR experience of porn.

DVDs, videos and films are making big profits, many of them are hard-core pornography films. Besides professional pornography movies, people started to make amateur movies in their own bedroom. Also, there is a lot of sexual content in music videos shown on television. Pornography in magazines ranges from soft-core to hard-core and is now in decline. Currently magazine porn is being replaced with online pornography. Live entertainment refers to sexualized entertainment, such as burlesque shows. Burlesque features women who seductively undress and are now transformed into the well-known strip club. Besides female strippers, there are also male strippers who perform acts.

Telephone sex is another example of technology to provide sexual entertainment. It is a sexually explicit conversation over the telephone. Many times, the participant(s) engage in masturbation. It can be between people that know each other, but also through a company providing sex calls. Kiddie porn is photo, video or film content involving imagery of the genitals or nudity of an underaged person. It has an obvious victim, the featured child and is made illegal to distribute, produce and possess. The ability to consent is a major concern in kiddie porn. Producers might be motivated by pathology or profit. Finally, sex in advertising is both subtle and obvious. It is used to sell a wide variety of products. In men’s magazines, seventy-eight percent of women wear sexually suggestive clothing. Besides magazines, television advertisement is also highly sexual. There is the concern that the exposure to these materials might lead dissatisfaction with the body of both males and females.

Who produces and consumes sexually explicit materials?

There is a variety of stereotypes about actresses in pornographic movies. According to Griffith et al. (2013) these actresses identify more often as bisexual and report an earlier age of first intercourse. Besides that, there are many different types of people that work in the producing of sexually explicit materials and this shows that the stigma associated with is drastically declined over the years. Pornography is used primarily by males, women are less attracted to porn because it emphasises impersonal sex. Currently there has been some femme productions of female-empowered adult entertainment.

What are the effects of exposure to sexually explicit material?

Sexual script theory explains how the exposure to sexual material shapes our sexuality. There are four questions that are asked about the effects of pornography:

1. Does it produce sexual arousal?
2. Does it affect the attitudes of the viewer?
3. Does it affect sexual behaviour?
4. Does it affect criminal or aggressive behaviour?

Media portrayals influence the way we define appropriate sexual behaviour. It also affects sexual arousal, especially if the material presented is considered acceptable by the viewer. Sexual behaviour is influenced by pornographic images, especially thoughts and fantasies. It also leads to an increase in masturbation and sexual partners. However, greater viewing numbers of pornography is related to enjoying sex with the current partner. It is unclear if exposure to sexual aggression leads to an increase in rape, some studies report a connection between exposure to sexual aggressive behaviour and attitudes towards sexual aggression, others do not find this connection.

The differential susceptibility to media effects model states that several factors predict who chooses to view porn: namely individual predispositions, developmental factors (such as age), and social factors. This theory also states that porn has cognitive, emotional and ecxitative effects on the person. This theory assumes that different people show different responses to viewing pornography: Certain people are more susceptible than others to experience negative effects from watching pornography.

What are issues related to pornography?

There are three reasons that feminists, opposing to pornography have; one is that pornography debases women. Second is that pornography associate’s violence with sex towards women. Third is that unequal power between male and female is glamorised. Another concern is pornography addiction where people spend hours watching pornography and masturbating. This can cause problems in romantic relationships. Legal restrictions can help set boundaries for the pornography industry.

Study notes:

• Make sure you know the differences between types of sex workers, the risks and the amount of autonomy. What are the risks of sex work and how can these risks be avoided?
• What psychological issues contribute to someone working in the sex industry? You can find this in the part on sex careers.
• What is pornography and what forms of sexually explicit materials shapes our beliefs and attitudes on sex?

Chapter 17 - What are Sexual Disorders?

Sexual disorders cause a big deal of psychological distress. A sexual disorder is described as a problem with responses in sexuality that cause mental distress. Another term is sexual dysfunction. Defining a sexual disorder is not straightforward because the disorders are spread over a continuum. There is a distinction between a lifelong sexual disorder; one that is present from the moment sexual development began, and an acquired sexual disorder; one which developed after some time of normal sexual functioning.

What are sexual desire disorders?

There are two types of disorders concerning sexual desire: hypoactive -and discrepancy of sexual desire.

• Hypoactive sexual desire (HSD) is when an individual is not interested in sexual activity. It is a deficiency in sexual desire or libido, which refers to the interest in sexual activity. It is found in both men and women. The responsive desire is the pattern of the start of feeling sexual desire.
• Discrepancy of sexual desire is when hypoactive sexual desire is caused by the discrepancy between partners levels of sexual desire.

In the DSM the distinction between male hypoactive sexual desire disorder and female sexual interest/arousal disorder is now made to split the disorder. There might be a third category needed to represent other genders.

What are arousal disorders?

There are two types of disorders with sexual arousal, they include the female sexual arousal disorder and the male erectile disorder.

• Female sexual arousal disorder is the lack of response to sexual stimulation. It has several components including a psychological, a subjective and a physiological one. It can be expressed by the lack of feeling sexually aroused despite of adequate stimulation or the absence of enough lubrication in the vagina. These problems occur more during menopause.
• Erectile disorder is described as the inability to maintain or get an erection. Another term for the disorder is impotence or erectile dysfunction. The result is that a man has trouble to have intercourse. A lifelong erectile disorder is when a man has never been able to have an erection hard enough for intercourse, whereas an acquired erectile disorder occurred after some successful erections. Responses to this disorder are severe and it can cause depression.

What are orgasmic disorders?

Orgasmic disorders include male orgasmic disorder, premature ejaculation and female orgasmic disorder.

• Premature ejaculation (PE) is when a man ejaculates too soon, which may even be before the intercourse has started. The man might be unable to delay the orgasm long enough for the partner’s preference. The precise criteria for early ejaculation are unclear, but experts defined it as the occurrence of an orgasm when the intercourse lasted less than one minute. Kaplan (1974) believes that it is the lack of control over the orgasm that defines the disorder. The best definition might be self-definition when a man thinks he ejaculates too early and is worried about it.
• Delayed ejaculation or male orgasmic disorder is when a man is unable to have an orgasm despite of erection and stimulation. It is a frustrating experience to have a long-lasting erection without an orgasm. Some women might experience the inability of the man as a personal rejection.
• Female orgasmic disorder is the inability for a woman to have an orgasm. The term frigidity is a name for disorders ranging from total lack or sexual arousal to arousal without an orgasm. Therapists reject this term because it is an incorrect description of the disorder. A common pattern for women is the situational orgasmic disorder where a woman sometimes has an orgasm and sometimes, she does not. There should be room for the self-definition of these disorders. The request for therapy should come with the own dissatisfaction of the woman.

What are sexual pain disorders?

Examples of disorders causing pain during sex are vaginismus and painful intercourse.

• Painful intercourse or dyspareunia is a disorder where genital pain is experienced during intercourse. It can be experienced by males and females. Occasional dyspareunia is common among women, but persistent dyspareunia is not. It decreases the enjoyment of sex and may lead to abstinence of sexual activity.
• Vaginismus is a spastic contraction in the vagina. It can be so severe that the vagina is closed, and intercourse becomes impossible. If intercourse is possible, this is often painful. In the DSM, dyspareunia and vaginismus are merged into genito-pelvic pain or penetration disorder.

What are the physical causes of sexual disorders?

The physical factors causing a sexual disorder are also referred to as organic factors and include disease, drugs or injuries.

• Erectile disorder can be caused by any heart, vascular and circulatory problem because erection depends on this system. Damage to the arteries and veins stops the blood flow to the penis. It is associated with diabetes. Another cause of ED is hypogonadism, low testosterone levels in the testes. Erectile disorder can also be caused by fatigue, stress or psychological issues. The distinction between psychological and organic causes is very important for treatment.
• Premature ejaculation is more often caused by psychological, than physiological problems. Often it is an acquired disorder for which the organic cause could be an infection in the prostate.
• Delayed ejaculation is associated with medical surgical conditions such as a spinal cord injury. However, more often psychological factors are causing this dysfunction.
• Female orgasmic disorder can be caused by injury, illness or extreme fatigue.
• Painful intercourse and vaginismus can be caused by disorders of the vaginal entrance, disorders of the vagina or pelvic disorders. In a man, the cause could be poor hygiene when he is uncircumcised.

What are the effects of drugs on the development of sexual disorders?

The side affects of many drugs can cause sexual disorders. It was found that medicine for high blood pressure caused a decrease in sexual desire and an increase in erectile problems.

• The effects of alcohol fall into three categories. The first is short-term pharmacological effects, second are expectancy effects and third are long-term effects of alcohol abuse. Alcohol abuse often causes a variety of sexual disorders such as loss of desire and erectile disorder. This might be caused by reduced hormones in the testes or the dysfunctional relationships people with chronic alcohol abuse have.
• Illicit or recreational drugs have different effects, depending on the drug and dosage. Marijuana is an aphrodisiac according to users but can lead to risky sexual behaviour. Chronic users report a decrease in sexual desire. Cocaine is said to increase sexual desire and prolong the orgasm; however, it is also associated with a loss of desire and orgasmic and erectile disorders. Amphetamines can cause an increased sexual arousal and desire. Crystal methamphetamine users have the tendency to engage in highly risky sexual behaviour, such as unprotected sex with multiple partners. Opiates have a suppressing effect on sexual response and desire.
• The psychiatric prescription drugs affect sexual activity and functioning because they influence neurotransmitters. For instance, medication for schizophrenia may cause delayed or dry ejaculation in men.

What are the psychological causes of sexual disorders?

There are different types of psychological causes including emotional factors, prior learning, problems with sexual inhibition/excitation or immediate causes.

• Immediate psychological causes are the things that happen during lovemaking that can inhibit the sexual response. Immediate psychological causes are anxiety, fear of failure, failure of communication, failure to engage in effective -and stimulating behaviour and cognitive interference.
• Prior learning refers to the learned experiences in earlier sexual encounters, it might be a traumatic experience that can lead to a sexual disorder, for example a history of sexual abuse.
• Emotional factors can contribute to the development of sexual disorders. Depression or emotions such as sadness and anger can interfere with pleasantness of sexual activity.
• Behavioural or lifestyle factors are the consumption of drugs, alcohol or obesity. These behaviours lead to organic causes of sexual disorders but can be modified trough psychological interference.
• Sexual excitation/inhibition means that people who score low on sexual excitation and high on sexual inhibition are more likely to develop a sexual disorder.

What are combined physiological and cognitive causes for sexual disorders?

The two-component theory of love describes that love depends on the fulfilment of two conditions: the physical arousal itself and the cognitive label: “love” attached to it. Palace (1995) argues that sexual functioning is good when people are sexually aroused and have the label of “sexual arousal” attached to it. People with sexual disorders tend to misinterpret arousal as anxiety. Research proved that the combination of cognitive and physiological factors can help treatment for sexual disorders.

What is the role of interpersonal factors in sexual disorders?

Another main cause of developing a sexual disorder is the status of the relationship. Anger resentment towards the partner is a far less than optimal environment for pleasurable sexual behaviour. The big problems with relationships and sex are intimacy or conflict over power. Problems with intimacy often reflect psychological and relationship problems. Some people fear intimacy which might be the result of disappointing previous intimate relationships.

What are newly discovered causes of women’s sexual problems?

In 2001, a new view of the nature of sexual problems in women was formulated (Tiefer, 2001). It is argued that the current listings in the DSM have three flaws in the definition of their categories:

1. Male sexuality and female sexuality are considered equivalent even though they differ in many ways.
2. The relational aspect of sexuality and desire is ignored.
3. The naturally occurring variation between women and women’s sexuality are ignored.

Based on these criticisms, the experts described new categories to describe sexual disorders for women.

1. Sexual problems because of sociocultural, economic or political factors is a category that describes ignorance and anxiety as a result of bad sexual education, no access to health services or social inhibitions. It also includes distress or avoidance of sex because someone thinks he is not able to meet the cultural requirements. Lastly, this category includes people who have a lack of interest in sex due to stressful work -and family conditions.
2. Sexual problems caused by the relationship and the partner include fear of abuse, discrepancy in desire, bad sexual communication, loss of sexual interest and loss of arousal due to health.
3. Psychological factors as causes for sexual problems exist from three subproblems, one is the sexual aversion due to prior experiences with emotional -and sexual abuse. Second is problems with rejection or attachment and third is sexual inhibition caused by the possible consequences of sexual acts.
4. Medical factors as causes for sexual problems is when sexual disorders are caused by medical issues.

What therapies can be used for sexual disorders?

Dependent on the nature and expression of the sexual disorder, a fitting type of therapy should be applied. There are four major therapies available to treat sexual disorders, these are cognitive therapy, behavioural therapy, biomedical therapy and couple therapy.

• Behaviour therapy works with the notion that sex problems are caused by prior experiences. These problems can be unlearned by conditioning using reinforcement and punishment. One goal in this therapy is to eliminate goal-oriented sexual performance. One technique to use is sensate focus exercises where one partner, the giving role touches the other, who plays the receiving role.
• Cognitive-behavioural therapy uses cognitive restructuring to help the client restructure thoughts or patterns of behaviour that lead to the sexual disorder.
• Mindfulness therapy uses the technique of focusing one’s attention on experiences in the present moment in a calm, nonjudgmental way. Mindfulness therapy trains people in these practices; helping to regulate negative emotions. It can be used as treatment for sexual arousal and desire disorders in women.
• Couple therapy is based on the notion of conflict in a relationship. Couples-therapists use a combination of cognitive behavioural -and couple therapy. Spector (1994) proposed a five-part model that is being used for treatment of a men with erectile disorder. First the sexual -and performance anxiety must be reduced, then there should be education and cognitive intervention followed by scrips assessment and modification. The fourth step is conflict resolution and relationship management and finally there is relapse and prevention training.
• Online sex therapy is quite new. It has the advantage of anonymity, also people can seek help without their partner knowing. Also, online sex therapy can provide accurate educational information and communication with an online sex therapist can break the isolation walls down for a patient with a sexual disorder. However, there not yet a system for licencing online sex therapists and many of them are unqualified.

What are more specific treatments that can be used?

Besides these forms of therapy, there have also been more specific treatments developed.

• The stop-start technique is helpful for men with premature ejaculation. The woman stimulates the men until he gets an erection and stops until he loses his erection. She then stops again and so on. This learns a man to get an erection and be aroused without getting an orgasm.
• Masturbation is effective for women and men with orgasmic disorder.
• Kegel exercise is a form of sex therapy for women where the woman exercises the muscles around the vagina. It helps with an orgasmic disorder. The pubococcygeal muscle is trained that runs along the sides of the vagina. It can help with enhancing awareness of the genitals and with involuntary urination during the orgasm.
• Bibliotherapy is the use of a self-help book to treat a sexual disorder.

What kinds of biomedical therapies are used to treat sexual disorders?

For some people, drug or even surgical operations can be used to help the sexual disorder cure.

• Drug treatments can be used together with cognitive-behavioural therapy to increase positive outcomes. Viagra is widely used for treating erectile disorder. Viagra does not cause an erection, but erotic stimulation after taking the pill causes an erection more easily. Viagra is easily accessible but does not solve the psychological -or relationship causes of the erectile disorder.
• Drug treatment for females is another story: There is now a promising approach to treat female sexual desire problems by prescribing a combination of drugs that act on two biological systems at once: The combination is either testosterone with sildenafil (for too low sexual excitation), or testosterone and buspirone; an anti-anxiety drug (for high sexual inhibition).
• Testosterone supplements can be taken by men who suffer from hypogonadism (a testosterone deficiency). 
• Intracavernosal injection (ICI) is another treatment for erectile disorders where a drug is injected into the corpora cavernosa of the penis. They dilate blood vessels so that an erection is produced. It is only used when the erection problem is organic, and a man does not respond to Viagra. It helps the man with performance anxiety and has positive psychological effects.
• Suction devices are placed over the penis and produce suction. This way a man gets an erection which is then maintained using a rubber band. This is used on men with diabetes.
• Surgical therapy can be used to implant a penile prosthesis. The men can pump up his penis to a full erection. It is a radical treatment that eliminates natural erections from ever happening again.

Which types of sex therapy are effective?

After the sexual therapy approach posed by Masters and Johnson, many more therapies have been developed. For certain therapies research evidence showed the effectiveness. There are several conclusions that can be drawn on research to therapies to treat sexual disorders:

1. When women experience primary orgasmic dysfunction, this is treated successfully with directed masturbation. This treatment can be enhanced with specific sensate focus exercises.
2. The treatment for acquired orgasmic dysfunctions are less straightforward. The combination of sexual skills training, education, body image therapy and communication skills training seem to work best. This is probably because there exists a wide range of different types of anorgasmia that have not been discovered by research.
3. The best treatment for vaginismus is relaxation and physical therapy. Kegel exercises might also help.
4. Drugs, such as antidepressants are effective for premature ejaculation. Especially when combined with CBT.
5. Women with hypoactive sexual disorder can be treated with cognitive behavioural therapy.

An important disadvantage or critic on this approach is the medicalisation of sexual disorders. Financial and political issues are involved when the prescription of drugs for these disorders becomes more common than psychological therapy. There is not only a cost to society, but also to the patient. The patient might be relieved quickly from the disorder, but underlying anxiety might not be resolved. The new view of women’s sexual problems is one alternative for the medicalisation of sexual disorders.

How can sexual disorders be avoided?

People could use some principles posed by sex therapists to avoid getting a sexual disorder. There are some principles that can be applied to achieve a good sexual health:

1. It is important to keep communicating with your partner¸ it should be clear what is pleasurable and what is not. Verbal communication works well, but non-verbal communication can be used in this context as well.
2. Try not to be a spectator, there is no constant evaluation needed of your sexual performance. It is better to focus on the pleasures.
3. Do not create goals for sexual performance, setting of goals cause failure. It is better to just relax and enjoy.
4. Be specific about the situations in which you have sex. Avoid having sex in a hurry or when you are disturbed. Trust in the partner is essential for good sexual functioning.
5. There will be failures, it is important how these are dealt with. Do not let them ruin a relationship but use them to make it better.

It can be difficult to find a good sex therapist, but the medical psychological association can provide a list with qualified sex therapists that have a special training in sex therapy. It is best to choose a therapist that uses an integrated approach because of the recognition of all factors that can contribute (cognitive, biological etc.).

Study notes:

• You should know the physical and psychological causes of the most common sexual disorders.
• What kind of considerations about the nature of the sexual disorder should be considered when choosing an appropriate treatment technique?
• Looking at the different causes and types of sexual disorders, what are the key ingredients of avoiding sexual disorders?

Chapter 18 - What are Sexually Transmitted Infections?

It is important to know, how to prevent and treat sexually transmitted diseases (STD) or sexually transmitted infections (STI). Sexually transmitted infections are more common among youth, age fifteen to twenty-four and the infections human papillomavirus (HPV), trichomoniasis and chlamydia are the most common. Prevention efforts are not working as well as they should as this age group accounts for half of the STIs in the United States.

What is Chlamydia?

An example of a STI caused by a bacterium is Chlamydia, the chlamydia trachomatis is a bacterium that can be transmitted trough sexual contact. It can infect the genital organs of both men and women. Adolescent girls have a particularly high infection rate of chlamydia compared to Gonorrhea. This is important, because the symptoms can be similar, but the treatment for Gonorrhea does not work for Chlamydia. The symptoms are discomforting urination and it can be detected using a urine sample (or sample of cells in the vagina). The problem with Chlamydia is that about seventy-five percent of the women, and fifty percent of men do not have any symptoms, they are asymptomatic. Therefore, many people go untreated. This can cause urethral damage, infection of the epididymis and proctitis (in men that performed anal intercourse). The most extreme complication is pelvic inflammatory disease (PID) and infertility. Also, a baby born from a mother with Chlamydia can develop eye infections or pneumonia. Chlamydia can be treated with azithromycin or doxycycline. There is no vaccine available for Chlamydia yet, but it is being developed. The best prevention method is the consistent use of a condom.

What is HPV?

Human papillomavirus or HPV is a virus that increases the risk of specific cancers, such as cervical cancer. It also causes genital warts, there are warts appearing around the urethral opening, the scrotum or the shaft of the penis. For women the warts appear on the walls of the vagina or the cervix. Most people with HPV are asymptomatic. Not all infections with HPV cause cancer but it is the most important risk factor for developing cervical cancer. Oral sex can transmit HPV and people who get HPV trough oral sex have a higher risk for mouth and throat cancer. However, in most cases HPV infections go away within two years. A test of DNA cells from the cervix can detect HPV cells that can cause genital cancer. The diagnosis can also be made by studying warts, note that high-risk variants of HPV do not cause warts and warts can be out of sight, inside the vagina. Warts can be treated with chemicals or be frozen off. Drugs like Podofilox are used additionally. A vaccination is available for HPV, for both males and females to protect against most cases of cervical cancer and genital warts.

What is Genital Herpes?

Genital Herpes is caused by the herpes simplex virus (HSV) and is a disease in the genital organs. There are two types of the virus: HSV-1 and HSV-2. Both types can cause genital herpes and sores around the mouth. Many people with the virus are asymptomatic and can transmit the disease unknowingly. Symptoms consist of blisters and painful sores on the vagina lips or penis. They can also be found around the anus. HSV-2 infections are more severe, and the person can undergo seven to fourteen-day periods of sores. People are most infectious when the sores are present but can transmit the disease when there are no symptoms present.

There is no known drug to kill the virus, infected people can be treated with acyclovir to reduce symptoms. It does not cure the disease but reduces the rate of transmission to an uninfected person. The process of creating a vaccine for immunization is still ongoing. Long-term consequences are problems with urination and infection with HIV. The blisters that are open make the genitals more susceptible to get the virus. Another serious risk is the transmission from mother to child during childbirth. This can lead to illness or death in the baby. Besides medical, there are psychological consequences of herpes. The stigmatization of people with herpes is big and some people believe that infected people should abstain from sexual intercourse in general.

What is HIV and AIDS?

Acquired immune deficiency syndrome (AIDS) is caused by the human immune deficiency virus (HIV). HIV destroys the natural system of disease immunity of the body. The terms global epidemic and pandemic have been used for a reason: worldwide there are about seventy-five million people infected with HIV and it causes about one point six million deaths worldwide each year. HIV can be transmitted trough semen, blood and secretions of the vagina and cervix. There are four ways to transmit HIV:

1. Sexual intercourse, this can be both coitus or anal intercourse.
2. By contaminated blood, for example by receiving a blood donation.
3. By contaminated needles, people who use drugs or health care workers are at risk.
4. An infected woman can give it to her baby during childbirth.

The people that are mostly hit by the HIV infection are men who have sex with men, secondly heterosexual contact, injection drug use and other sources. Among women, the highest chance is heterosexual contact and contaminated needles. The greater the number of sexual partners, the bigger the chance of getting HIV. Condoms give around eighty to ninety-five percent of protection against getting infected with the HIV virus during intercourse.

HIV is a retrovirus, it reproduces in the living cells of the host species. Each time a cell divides, there are viruses produced because the cell contains the genetic code of the virus. The virus infects T-cells that are critical to the immune system. While reproducing the HIV virus destroys the T-cells. When someone does not have enough T-cells, an infection cannot be fought off anymore. There are several stages of HIV infection before it leads to the AIDS disease.

1. Stage 0 is the initial infection and development of antibodies to protect the body from the virus. In this stage someone can be tested positive for HIV-1 or HIV-2 antibodies. The T-cell count is normal, and people do not have any symptoms.
2. Stage 1 is when the count of T-cells drops to about five hundred. One thousand per μL of blood is a normal count. The immune system is declining, and people develop symptoms such as fever, night sweats, swollen lymph nodes or fatigue.
3. Stage 2 is when the T-cell amount drops to between two hundred and five hundred cells.
4. Stage 3 is called AIDS; the number of T-cells drops to below two hundred and people are vulnerable to all kinds of life-threatening infections. Opportunistic infections can only happen in people with severely compromised immune systems, such as people with AIDS. These infections include invasive cervical cancer and pneumocustis jirovecii, a rare type of pneumonia.

The disease can be diagnosed with the detection of antibodies. This can be used to screen blood prior to blood transfusions and determine which people are asymptomatic carriers to avoid further transmission of the HIV virus. The test is called ELISA and is very precise in the detection of antibodies. One drawback is that there are some false positives, so when a positive result is obtained another test should be performed. Also, the waiting period for the ELISA is long. There are new, faster methods for (home) testing of HIV available on the market that give the results in about twenty minutes.

There is no cure for AIDS available, but there is treatment to control the disease. One is AZT, azidothymidine that can stop the virus from multiplying. Another option is protease inhibitors that attack the viral enzyme so it cannot copy and multiply. Patients often take a drug cocktail consisting of a combination of the existing drugs. Besides the control of the virus, there is also medication to prevent or cure the opportunistic diseases.

What are the psychological considerations in AIDS?

People exhibit a few typical reactions when they are diagnosed with incurable diseases. It starts with denial, followed by anger and depression. Patients diagnosed with AIDS can have an even more severe response, because AIDS victims are highly stigmatized. They are often labelled as either gay or drug addicts. Psychological treatment can be helpful and can improve the effectiveness of medication.

What recent progress is made in research on AIDS?

There is not yet a cure available for AIDS and better treatments are sought. For example, researchers are trying to create a vaccine, but this turned out to be very complicated. The problem is the rapid mutation of the HIV virus, the virus changes before a vaccine can take effect. There are strategies to develop a vaccine to form resistance to the HIV virus to create T-cells that are toxic to the HIV virus. Another development is a vaccine so the virus cannot be transmitted trough breast milk or sexual activity. ART treatment is highly effective in preventing transmission. Preexposure prophylaxis (PrEP) is when antiretrovirals are given to a healthy person so they do not become infected. This is used for people in high-risk situations. There has also been research on nonprogressors, people with an unexceptional good immune system and killer T-cells and chemokines, these can avoid the HIV-virus to enter the cells. Genetic resistance refers to gene mutations to avoid the HIV virus to enter healthy cells. Lastly, behavioural prevention is about changing people’s behaviour to avoid infection.

What is Gonorrhea?

Gonorrhea is transmitted trough penis-in-vagina intercourse and invades the urethra. It produces inflammation of the urethra and a thin discharge seeps out, this is called purulent. It also causes pain with urination. If Gonorrhea is untreated it can cause prostatitis, epidymitis and cystitis. After that it can spread to the testes and cause impotence. There is also asymptomatic Gonorrhea, but the prevalence is low. Women can be unaware with the infection, unless they are told by their partner. When Gonorrhea is untreated in females, it can infect the fallopian tubes, and someone can get pelvic inflammatory disease. There is also non-genital infection possible in the mouth, eyes or throat.

What is Syphilis?

Syphilis is a bacterial infection and after the pandemic 1500s the prevalence is low. The effects when remain untreated are very severe though. It can damage the nervous system and can cause death. It makes people more susceptible to HIV and vice versa. The most common symptom is the chancre on the genitals, a lesion that resembles a crater. The bacteria can also infect the person trough any other cut or wound on the body. The progress of the disease is divided into four stages:

1. The primary-stage syphilis where the chancre goes away, but the infection is not cured.
2. The secondary-stage syphilis is characterized by a rash over the body, but it does not hurt or itch. There might also be a loss of hair. The symptoms are bad enough for someone to seek help. These symptoms disappear after a few weeks.
3. The latent syphilis stage does not have any symptoms, but the bacteria spreads trough the body. The person is no longer infectious, a woman can only pass it on to her child. Half of the people remain in this stage without further complications, others enter the next stage.
4. The late syphilis stage or cardiovascular late syphilis is when the major blood vessels and the heart is attacked. Also, the brain and spinal cord are attacked. This can lead to insanity and paralysis.

A child can get congenital syphilis, meaning it is present from birth. It can cause spontaneous abortion or severe illness after birth. Syphilis is difficult to diagnose from the symptoms, but it can be diagnosed using a blood sample. Treatment is penicillin.

What is Hepatitis B?

One symptom of hepatitis B is the enlargement of the liver. The symptoms range from asymptomatic to severe symptoms such as yellowish skin and vomiting. It can be transmitted via blood, semen, saliva and vaginal secretions. Some people develop a short-term illness but recover from that. Others develop long-term illness or serious liver disease. The HBV virus stays in the body forever. There are antiviral treatments and a vaccine available.

What is Trichomoniasis?

Trichomoniasis can be transferred no sexually trough toilet seats or other objects. It is an organism called trichomonas vaginalis. For women, the symptoms are vaginal discharge and an unpleasant small. For men, these are discharge from the penis. If untreated trichomoniasis can lead to pelvic inflammatory disease and problems with childbirth.

What are Pubic Lice?

Pubic lice are tiny lice that live in the pubic hairs. They feed on blood from their host and lay eggs. They can be transferred trough intercourse, but also towels and toilet seats. Medication to kill the lice are available and clothing should be washed roguishly.

How can STIs be prevented?

The most obvious way to prevent an STI is to abstain from sex or have a monogamous relationship with an uninfected person. Otherwise, the condom or diaphragm can be used. Also washing of the genitals and inspecting the genitalia of the partner are important to avoid lovemaking with someone with an STI.

What is Candida?

Candida or yeast infection is caused by fungus that is normally present in the vagina. Long-term birth control pills, menstruation and diabetes can increase the chances of candida getting out of hand. There is over the counter treatment available. It can be passed on to a child during birth and the child will develop thrush, yeast in the digestive system.

What is Prostatitis?

An inflammation of the prostate gland is called prostatitis. This is caused by the E coli bacteria. It can be caused by gonorrhea or chlamydia. Frequent urination, sexual dysfunction, pain around rectum and anus are symptoms. Antibiotics are the most common treatment option.

Study notes:

• Make sure to know what STIs exist, what the broad symptoms and implications are and how they can be prevented and treated.
• What are the psychological consequences for people with an STI? Why would some people restrain from getting help? Think about the part on stigmatization of AIDS patients.
• What are ways in which STIs can be prevented? What prevention method works best for each type of STI?

Chapter 19 - How do Ethics and Religion influence Sexuality?

The reasons for evaluating ethics in sexuality is for two reasons: the first is ethical and religious considerations must be taken into account when scientists describe sexuality. The second is the personal importance of ethics and the influence of ethics on personal decision making.

What are the basic concepts of ethics?

Fundamentally, ethics refers to right or wrong. It also refers to a set of principles put together by a specific group of people. When there are two things that are desired, ethics are used to choose among them. Sexual decisions are integrated in our pattern of decision making. Religion provides an ethical code and provides rules, rewards and sanctions. It helps create culture and thus is an important influence on individuals and shapes a society’s orientation towards sexuality. There are some basic terms that are important in the discussion about ethics:

• Hedonism is the belief that the goal of human life to pursuit pleasure, including eating drinking and sexual activity.
• Asceticism is the belief there is more to life than material components. They view sexuality as evil, bad or neutral because spiritual values and the avoidance of physical gratification are more important.
• Legalism is a method of ethical decision making and is concerned with moral principles and law. These principles come from outside of the individual, such as religion. The focus is the distinction between right and wrong.
• Situationism or contextual ethics is the belief there are broad guidelines for behaviour. Each decision is dependent on the context and individual itself. In sexuality, it focuses on relationships instead of rules.

Old religious and ethical systems are called old morality and the situationist approach is part of new morality.

What was the view of sexuality in ethical traditions?

Ethical traditions deal with norms on sexual behaviour, here are some examples of (mostly) Western sexual ethics in the past.

• Classical Greek philosophy believes that virtue results from wisdom and ascetism played an important role. Violent passions such as sex must be avoided. Pederasty is a sexual relationship between an older man and younger woman. The older man was the younger woman’s teacher. Later the Greeks life goal was ataraxia, which is the tranquil state between pain and pleasure. Such stoic thinking was the primary source of negativism towards sex in the Western tradition.
• Judaism has a positive view and sexual differentiation is an integral part of life. It is a deep and intimate part of a relationship, not only for reproduction. However, sexuality should never be separated from the social consequence and it needed to be regulated to avoid jealousy. The Hebrew scriptures see sexuality as an aspect of national and religious loyalty.
• Christianity is based on dualism, the separation between body and soul. The Christians insist on monogamy and oppose divorce. In the new testament, there were no regulations about marriage as an institution and there were no rules against homosexuality, the negativism about sex is not rooted in the bible, but in the philosophy of that time. The early Christian church value of celibacy is primarily about being a virgin, marriage was good and honourable. In the middle ages, the attitude towards sex for pleasure was highly negative. Sex was basically evil and only meant for reproduction. The protestants highly overestimated the disgust of sexual expression causing revolution in that age. Current trends view sex as a part of the divine creation, but also as a source of temptation. This causes serious conflict between religious groups.
• Humanism is non-religious thinking and values can be found in human experience. According to humanism there is a realistic approach needed, intimacy should be sought between individuals, but attentive to the human living, humanists are tolerant towards claims on right and wrong.
• Islam has a double standard on sexuality. Extramarital affairs are tolerated for men but can lead to honor killing for women. It recognises some rights for women, but this depends on the interpretation of the Koran. In Iran however, about seventy-three percent of women use birth control.
• Hinduism’s approach to sexuality includes virtually every approach there is. There are four different approaches that are acceptable: Kama, the pursuit of pleasure, Artha, the pursuit of marital wealth and success, Moksha, the pursuit of liberation and Dharma, the pursuit of moral life.
• Buddhism has an approach between hedonism and asceticism. However, males tend to live an ordinary and married life whereas monks cultivate ascetic wisdom by being celibate. Tantric Buddhism has a special interest in sex and perceives sex as the unity of all things. Sexual expression according to them can lead to enlightenment.

What are the contemporary issues in sexual ethics?

The concept of sexuality can cause conflicts in society because there is no consensus on the norms of sexual behaviour. The debate over the limits of sexuality resembles the clash between old and new morality. The view of old morality is also described as moralism, that there are objectified standards which need to be followed. The new morality is based on pluralism which is a more complex view of morality. They deny the objectivity and unchanging nature of morality and propose that the truth lies in the clash between different opinions and convictions. They are less likely to refer to religion or law and more likely to embrace freedom. Besides moralism, the pro-family position, rooted in religion and in favour of a ban on abortion, discrimination against gays and cohabitation before marriage.

1. Sex outside marriage is always seen as a sin in Western society. Fornication, sex before marriage and adultery, sex between persons who are married to others are condemned. This position has become less strict and there are four general rules for judging the morality of such decision. First is genuine respect for humanity, second is genuine affection between partners, third is avoidance of unwanted pregnancy and finally there should be openness and honesty between partners.
2. Contraception is opposed by most religions when it is artificial. However, Jews and Protestants promote family planning by married couples and most ethicists would say unmarried persons who are sexually active should use birth control.
3. Abortion is probably the most persistent issue where the conflict is between religious belief and political conviction. Is abortion better or more desirable than an unwanted pregnancy? Some Christians argue that an abortion can take place within three months of conception because the foetus does not have a soul yet. Then it is not a person and can thus not be murdered. Most liberal protestants and Jews hold this modified pro-choice position. The pro-life position is an absolute and strict position such as moralism, opposing to abortion.
4. Attitudes on homosexuality are starting to change. There are broadly three views on homosexuality, the first is the rejectionist position states that sexual acts between persons of the same gender are sins and the people are dreadful sinners. The second position is love the sinner but hate the sin, which is a modification on the rejectionist approach. They believe being homosexual is not sinful, but homosexual acts are. Full acceptance is the third position and deny or disbelieve the condemnation in the scriptures. They argue pro same-gender marriage and acceptance of LGB with members of the church.
5. HIV and AIDS are another ethical concern. Religious groups suffer to deal with the ambivalence of ministering persons with HIV or AIDS. Some argue AIDS is a punishment of god to sinful sexual behaviour. Other people try to educate members of the church on how to show compassion towards AIDS patients. The conflict is about the dignity and autonomy of the person and has both personal and public aspects. According to the middle-position, people in high risk groups should practice safe sex and get tested regularly. Another consideration is the high cost of HIV/AIDS patients for health insurance companies.

What is the connection between technology and sexual ethics?

The fast development of technology raises new moral issues without the time to resolve the older ones. The moral climate is changed by the wide availability of anticonception and abortion. Another issue is conceiving children without intercourse. Technologies such as in vitro fertilization or artificial insemination are approved by most to let infertile people have children. Some people argue that these techniques are “playing god” and should be forbidden. The exploitation of others is a concern, especially in surrogacy. The question is whether it is ethical to use procedures that can put an unborn baby at risk?

1. Orthodox Judaism may permit the techniques of AIH and IVF, but when a third party is present, this is seen as adultery.
2. The Roman Catholic position is open about child-conceiving methods on the conditions that the woman body and the men’s sperm should be used. He cannot collect the sperm by masturbation though.
3. A centrist position on these new reproductive theories is that in a marriage fertilization can be accomplished artificially between men and wife because the wife’s fallopian tubes may be blocked. It forbids the use of a stranger for the egg and only the men’s sperm. In that case, there might be issues with the age of the women.

Another issue of technologies on sexuality is human cloning or somatic cell nuclear transfer. A child born from cloning is genetically identical to the mother and might not have a sense of autonomy. Currently it is considered morally unacceptable to create a child using cloning methods. The newest development, therapeutic cloning is used in the treatment of diseases, such as Alzheimer. The development of technology cannot be stopped, but the moral implications must be adequately addressed in order to sustain the human values.

What is the way towards ethics of human sexuality?

Traditional sexual ethics are considered narrow and repressive by the new morality. However, the new morality has not proven to be everyone’s satisfaction. Opponents of the old morality say they fail to incorporate the joy of sexuality, human physicality and the undermining of human freedom by applying universal rules. The new morality tends to lean towards hedonism which affirms both the positive and negative side of sexuality. It may have pushed to far leaving people irresponsible and undisciplined about sexuality. Situational ethics includes the broad principles of respect, love and interpersonal responsibility but does not evaluate the actual effects of our actions. The middle ground is to incorporate the need for principles as guidelines and affirm the goodness and vital part of experience of human sexuality.

Study notes:

• You need to know the four basic concepts of ethics and how to apply them in the discussion on human sexuality.
• There are two main views about morality: the old and the new morality. You should be able to explain these three views on morality. Why is none of these views satisfactory for everyone.
• You should be able to explain the contemporary issues with sexuality. How do you look at them from your own culture and what are the standpoints of another culture?

Chapter 20 - How is Sex included in the Law?

Many sexual behaviours, such as adultery or sex with someone younger than eighteen are crimes in the United States. There are several laws that tell people about their sexual behaviour.

Why are there laws about sex?

Laws about sex are ancient and has its roots in the Hebrew Bible. These rules were used to regulate the religious morals. Even though sex has become a much more private subject, most societies have laws for sexual behaviour. These rules should free people from sexual assault and coercion and that children should not be sexually exploited. Fornication is illegal because this often results in extramarital births. It is compelling that the Judeo-Christian religion still determines some sexual laws since constitution forbids imposing others with religious beliefs. However, these sexual laws resemble rather moral than religious belief. The Victorian compromise refers to the conflict in attitudes about sexuality and results in the law not criminalizing the behaviour per se, but the conduct that is visible to the outside world. The study of sex and the law reflects inequality, sexuality, sexual identities and individuality of a society.

What kinds of sex laws exist?

The categorization of sexual laws is difficult because no-one knows how many there are. Civil law, in addition to criminal law might penalize certain sexual behaviours with regards to government employees and immigration regulations. Also, the laws (on sex) are constantly changing, therefore the authors attempt to give a broad overview of the different kinds of sex laws.

• For crimes of exploitation and force there are laws against rape, incest and sexual activity with children.
• Criminal consensual acts have laws to protect young people from exploitation. These laws promote public health, morality and illegitimacy. Laws are against fornication, cohabitation, adultery and sodomy.
• Crimes against good taste are sex offences such as voyeurism and exhibitionism. These acts are likely to be offensive, especially when it includes public nudity. When nudity is used with the intention to shock someone this is prohibited.
• Crimes against reproduction are rooted in the Judeo-Christian heritage and include reproduction sins. Some laws criminalize such behaviours. The behaviours are homosexuality, sodomy and birth control. It made conception impossible.
• Criminal commercial sex, such as prostitution are illegal in most states in the US. Other activities, such as pimping or procuring are also forbidden because they can encourage minors into prostitution. Obscenity is also subject to law enforcement, but it remains a challenge to determine what is obscene and what is not.

Which laws exist for sexual discrimination?

• Sexual orientation and gender identity are subject to discrimination in society. There are laws that prohibit discrimination based on sexual orientation and gender identity in employment. There are also laws to protect transgenders from discrimination, but they vary in prohibitions. Regarding military service, lesbians and gays had an ambiguous status; it was possible to refuse them from entry. There are also ambiguities in formal rights, in some cases same-gender couples do not have the rights to the same insurance benefits or inheritance rights. This is because their bonds are not recognized by the law system.
• Same-sex marriage is a contentious issue for many people, most people in the United States would vote against it. It has gained greater acceptance in the last few years and it is already legal in some states. Proponents argue that providing both (homosexual) parents with parental rights will give them greater security.

How does sex-law enforcement work?

The privacy of sexuality is intruded by the law and sex laws are enforced with great inconsistency. The number of severe sexual crimes and the fluctuation in enforcement and punishment reflects on the ambivalence of society against the subject. This calls for a reform in the sex-law system. However, the consequences of sex offences are enormous, someone can lose friendships, family and reputation. It is debatable if such consequences should apply for such private acts. The public good is more often violated by the enforcement of sex laws, rather than the prevention of the sexual crime.

What are trends in Sex-Law reforms?

The laws on sex are very difficult to change because the topic of sex is a controversial. The precise directions of changes in sex-laws are impossible to predict. There are some important principles that brought changes in sex-laws before.

• Decriminalization and legalization. One is the decriminalization of many kinds of sexual behaviour. For example, the American Law Institute now acts on the principle that private sexual behaviour, if consensual, is no business of the law. Important to notice is that decriminalization is morally neutral, whereas legalization causes conflict.
• The right to privacy is an important matter in sex-law but is often invoked. It has com into play by criticisms on sex-laws through the courts. The right to privacy is used in matters on sexuality that are unconstitutional.
• Equal protection means that sex-laws should not give a disadvantage to one group while the other group can seek relief.
• Victimless crime is a concept that is not only applied in sex-law. When the act does not harm the victim, it is not defined as a crime.
• Obscenity and pornography are hard to define. Some people consider certain materials offensive, while others do not. The distinction between pornography and obscenity is made to determine what is legal and illegal. Pornography is arousing imagery, video, literature or speech in which an explicit description of sexual activity and the genitalia is present. Obscenity is what is offensive to society and authorities. Obscenity causes harm to the general population; one example is child pornography.

How is the controversy weighted over reproductive freedom?

Abortion is one of the most difficult and controversial topics of law enforcement. The pro-life movement is well financed, organized and has a lot of lobbying influence. The pro-choice movement is also organized and is starting to be effective. The pro-life movement used five strategies to reduce and eliminate abortions:

1. Restrictions on funding;
2. Procedural requirements and clinical restrictions;
3. The human life amendment;
4. Banning partial life abortions;
5. Actions against providers of abortions;

How is ethnicity considered in sex laws?

The constitution promises equal protection to people of all races, some still experience disadvantages. For example, there is not much known about the abortion rates and reproduction needs of coloured women in the US. The information about abortion and birth control for this group of coloured women should be sensitive to their cultural heritage and available to them. Even though their abortion rates tend to be higher, they do not receive this proper information and data about abortion practices is not available. Abortion is just one example of disadvantages for ethnic groups under the present sex-law system.

What are reforms in sex-law?

There has been a trend of more permissive laws on sexuality. This was caused by the civil rights movement, feminism and the sexual revolution. The new right has replaced most conservativeness with less restrictive laws. The government has two important priorities considering AIDS and the law:

1. Protection of individual rights;
2. Defend against discrimination and injustice;

People can lose their job, health insurance, custody rights over their children face all kinds of discrimination after being diagnosed with AIDS. These people seek protection from federal laws. One of these laws is the Vocational Rehabilitation Acts that prohibits discrimination against disabled people in jobs. Some scholars even argue that the medical records of HIV positives should be private to protect people with AIDS.

What is the legal challenge of assisted reproductive technologies?

Embryo fertilization -and transfer, IVF and surrogate motherhood technologies raise legal questions for the government. There are some laws that try to regulate these practices. One is the prohibition of child trafficking or baby buying. In the US, twenty-seven of the states have laws to manage IVF pregnancy. However, there is no comprehensible overview of the biotechnologies of enabling infertile mothers to have children, therefore the creation of laws is extremely complex. The most important question is whether it is a human right to be able to reproduce. Other issues are whether the embryo is a person or a property or what are parental rights when a child is born from a donor?

Perhaps the most complex issue is surrogacy, it might lead to the exploitation of poor women that lease their uterus for conception. The government can either regulate the surrogacy issue by providing binding contracts or fine, but the second option is to stay out of it and leave it to the people involved. Yet, it is probably better to maintain legislation on this issue, because most surrogacy cases already go to court and the government is almost always involved.

Finally, there is the issue of confidentiality. What will those standards be and who needs to be responsible for a child that is conceived by artificial techniques? Is reproduction a private, or a public issue? A group of medical -and social scientists argue that there should be a minimum number of regulations and laws about artificial reproduction. These are the following:

1. Artificial reproduction should be a non-commercial service.
2. There should be a licencing system for the offered clinical services.
3. Directives should be collected in advance from donors for the use of ova, embryos and sperm.
4. There should be a time restriction on the preservation of embryos and gametes.
5. These services should be available to all married or cohabiting couples.
6. Cloning technologies should be illegal.

The scientists reached consensus on these issues, but there remained discussion on the following topics:

1. The access to the services for single or lesbian women.
2. The preservation of human embryos.
3. Whether children should have access to information about their parentage and conception.
4. The allowance of experiments with human embryos.

The considerations above should be applied by lawmakers to define their minimum threshold of rules for artificial procreation. Goodwin (2010) proposed another approach: that people harmed by reproductive technologies (premature birth, disabilities or low birth weight) should be able to sue the physician or fertility clinic. It might promote the reduction of harmful incidents. Nonetheless the responsibility for seeking redress is then placed in the hands of the individual.

Study notes:

• You should know what the different sexual crimes are and what laws are made to protect people from them. This is described in the section on laws about sex and what kind of laws exist.
• There are several ways of discrimination by sex laws. What laws exist to protect sexual minorities from discrimination?
• What are the considerations that should be considered by sex-law creators?