College Level Human Sexuality by AudioLearn

COLLEGE LEVEL human sexuali ty

Introduction to Human Sexuality www.AudioLearn.com

TABLE OF CONTENTS Preface........................................................................................................ 1 Chapter One: Human Sexuality Anatomy and Physiology ............................ 5 Male Reproductive System .............................................................................................. 5 Female Reproductive System ........................................................................................ 15 The Female Breast ......................................................................................................... 24 Reproductive System Development .............................................................................. 26 The Brain and Sexuality ................................................................................................. 27 Male Circumcision ......................................................................................................... 29 Female Genital Mutilation ............................................................................................. 31 Key Takeaways ............................................................................................................... 33 Quiz ................................................................................................................................ 34 Chapter Two: The Human Sexual Response Cycle ..................................... 36 Sex Drive ........................................................................................................................ 36 Differences in Libido with Gender ................................................................................ 38 Sexual Arousal................................................................................................................ 39 Erogenous Zones ............................................................................................................ 40 Sexual Stimulation ......................................................................................................... 41 Theories on Sexual Responsiveness .............................................................................. 43 More on Orgasm ............................................................................................................ 44 Studying Aphrodisiacs ................................................................................................... 47 Key Takeaways ............................................................................................................... 50 Quiz ................................................................................................................................ 51

Chapter Three: The Psychology of Intimate Relationships ........................ 54 Early Attachment and Intimacy .................................................................................... 54 Attachment Styles in Adults .......................................................................................... 57 The Biology of Attachment ............................................................................................ 58 Attachment in Relationships ......................................................................................... 59 Physical Attraction ......................................................................................................... 60 Male Attractiveness........................................................................................................ 60 Female Attractiveness .................................................................................................... 62 Theories on Love ............................................................................................................ 64 Intimate Relationships .................................................................................................. 66 Non-Monogamous Intimacy.......................................................................................... 69 Key Takeaways ................................................................................................................71 Quiz ................................................................................................................................ 72 Chapter Four: Sexual Behaviors ................................................................ 74 Masturbation.................................................................................................................. 74 History of Masturbation ................................................................................................ 78 Sexual Fantasies ............................................................................................................. 78 Oral Sex .......................................................................................................................... 81 Coitus ............................................................................................................................. 81 Anal Sex .......................................................................................................................... 84 Key Takeaways ............................................................................................................... 87 Quiz ................................................................................................................................88 Chapter Five: Sexual Dysfunction in Men and Women .............................. 90 Hypoactive Sexual Desire Disorder or HSDD ............................................................... 90

Sexual Arousal Disorder ................................................................................................ 92 Anorgasmia .................................................................................................................... 93 Vaginismus ..................................................................................................................... 94 Erectile Dysfunction ...................................................................................................... 95 Premature Ejaculation ................................................................................................... 97 Delayed Ejaculation ....................................................................................................... 98 Key Takeaways ............................................................................................................. 100 Quiz ...............................................................................................................................101 Chapter Six: Sexually Transmitted Diseases and their Transmission ...... 103 Risk Factors for STIs .................................................................................................... 103 Chlamydia .................................................................................................................... 104 Gonorrhea .................................................................................................................... 107 Genital Herpes ............................................................................................................. 108 Hepatitis B ....................................................................................................................110 Syphilis .......................................................................................................................... 112 HIV Disease................................................................................................................... 114 Trichomoniasis ............................................................................................................. 115 Pubic Lice ...................................................................................................................... 116 Human Papillomavirus Infection ................................................................................. 118 Key Takeaways ............................................................................................................. 120 Quiz ............................................................................................................................... 121 Chapter Seven: Contraception, Conception, Pregnancy, and Birth .......... 123 Types of Contraception ................................................................................................ 123 The Process of Conception ........................................................................................... 129

Sexuality in Pregnancy ................................................................................................. 132 Pregnancy ..................................................................................................................... 134 The Birth Process ......................................................................................................... 136 Abortion ....................................................................................................................... 139 Key Takeaways ............................................................................................................. 142 Quiz .............................................................................................................................. 143 Chapter Eight: Gender Expectations and Roles ....................................... 145 Development of Gender ............................................................................................... 145 Development of Gender Identity ................................................................................. 147 Gender Concepts in Children....................................................................................... 148 Gender Roles and Stereotypes ..................................................................................... 150 Transgender Issues ...................................................................................................... 154 Key Takeaways ..............................................................................................................157 Quiz .............................................................................................................................. 158 Chapter Nine: Sexual Orientation ........................................................... 160 Sexual Orientation Explained ...................................................................................... 160 Types of Orientation .................................................................................................... 165 Same-Sex Sexual Behaviors ......................................................................................... 168 Key Takeaways ..............................................................................................................172 Quiz ...............................................................................................................................173 Chapter Ten: Sexuality at Different Ages .................................................. 176 Childhood Sexuality ..................................................................................................... 176 Sexuality in Adolescents .............................................................................................. 179 Aging and Sexuality ..................................................................................................... 183

Aims: ......................................................................................................................... 184 Materials and Methods: ........................................................................................... 184 Results: ..................................................................................................................... 185 Conclusion: ............................................................................................................... 185 Sex and Disabilities ...................................................................................................... 185 Key Takeaways ............................................................................................................. 187 Quiz .............................................................................................................................. 188 Chapter Eleven: Sexual Aggression, Sexual Harassment, Rape, and Child Sexual Abuse .................................................................................. 191 Defining Sexual Aggression .......................................................................................... 191 Sexual Harassment ...................................................................................................... 192 Sexual Assault .............................................................................................................. 194 Rape.............................................................................................................................. 197 Childhood Sexual Abuse ............................................................................................. 200 Key Takeaways .............................................................................................................204 Quiz .............................................................................................................................. 205 Chapter Twelve: Sexual Fetishism and Paraphilic Disorders ................... 207 Sexual Fetishism .......................................................................................................... 207 What is a Paraphilia .....................................................................................................209 Development of Paraphilias......................................................................................... 210 Types of Paraphilias ..................................................................................................... 210 Some Specific Paraphilias ............................................................................................ 213 Key Takeaways ............................................................................................................. 215 Quiz .............................................................................................................................. 216 Chapter Thirteen: Sex Addiction, Prostitution, and Pornography ........... 218

Sex Addiction ............................................................................................................... 218 Prostitution ..................................................................................................................220 Pornography Addiction ................................................................................................ 223 Internet Pornography .................................................................................................. 223 Key Takeaways ............................................................................................................. 225 Quiz .............................................................................................................................. 226 Summary ................................................................................................ 229 Chapter Question Answers ...................................................................... 233 Chapter One ................................................................................................................. 233 Chapter Two ................................................................................................................. 235 Chapter Three .............................................................................................................. 236 Chapter Four ................................................................................................................ 237 Chapter Five ................................................................................................................. 238 Chapter Six ................................................................................................................... 239 Chapter Seven ..............................................................................................................240 Chapter Eight ............................................................................................................... 241 Chapter Nine ................................................................................................................ 242 Chapter Ten .................................................................................................................. 244 Chapter Eleven ............................................................................................................. 246 Chapter Twelve ............................................................................................................ 247 Chapter Thirteen .......................................................................................................... 248 Course Questions and Answers ............................................................... 250 Answers to Course Quiz ...............................................................................................290

PREFACE The purpose of this course is to introduce the student to matters related to human sexuality. The research and understanding of human sexuality are rather recent events compared to the study of other sciences and research is still ongoing. The course touches on the anatomy and physiology of the human reproductive system as well as what is known about the human sexual response, sexual arousal, and intimate relationships in humans. How sexuality figures into contraception, conception, pregnancy, and childbirth are also important issues covered in the course. There are complex issues involving sexual and gender orientation, sexual dysfunction, and behaviors considered to be sexually deviant in today’s society that are part of what is discussed in this course. Chapter one in the course opens up the discussion of human sexuality by talking about the anatomy and physiology of the male and female reproductive system. While not all of sexual behavior and sexuality is focused on the reproductive system, a knowledge of these systems is important to understanding human sex. The study of the brain in human sexuality is not well understood but it is important to recognize its role in sexuality. Some of the cultural issues about the sexual organs is covered in this chapter, including male circumcision and female genital mutilation, sometimes referred to as female circumcision. The topics of chapter two are the human sex drive or libido, sexual responsiveness, and the study of aphrodisiacs. As you will hear, there are differences between men and women when it comes to the sex drive. The sexual response cycle is a relatively predictable pattern of physiological variables that change during sexual activity. There are drugs and supplements considered to be aphrodisiacs. What these substances are and how they are studied are discussed in this chapter. Chapter three in the course looks into the psychology of intimate relationships. Intimacy starts with attachment, and attachment, as you will learn, begins in infancy. The type of attachment a person develops in childhood determines how they will

respond to intimate relationships in adulthood. Many times, intimacy involves some type of physical attraction, which is discussed in the chapter. There are several theories on what love really is, some of which is neurobiological. The chapter ends with a look at intimate relationships and the different types of intimate relationships that can be part of this or other societies. Chapter four looks into different types of sexual behavior performed in human sexual experience. Sexual behavior can be a singular activity as is seen in masturbation. Some people practice oral sex, which is one of the sections in this chapter. The most common sexual activity in heterosexuals is sexual intercourse, while both homosexual and heterosexual couples can practice anal sex, which is covered in the chapter. The focus of chapter five in the course is sexual dysfunction or sexual disorders in men and women. There are problems associated with low libido or low sexual arousal as well as problems with attaining an orgasm, which are discussed in the chapter. Men can have erectile dysfunction as a sexual problem, while women can have vaginismus that affects sexual satisfaction. Sexual problems in men discussed in the chapter include premature ejaculation and delayed ejaculation. Sexually transmitted diseases and the risks of getting them are the topics of chapter six. As you will learn, certain sexual behaviors predispose a person to getting a sexually transmitted disease and there are ways to decrease their transmission. The different sexually transmitted diseases, which can be viral, bacterial, protozoal, or parasitic, are discussed in the chapter. For a couple of sexually transmitted diseases, there are vaccines that can be used in the prevention of these infections, which are covered in the chapter. Chapter seven in the course encompasses several issues related to conception, pregnancy, birth, and contraception. Many sexually-active couples and single people practice contraception in order to avoid an unintended pregnancy. The process of conception, when it does occur, is discussed in the chapter. The changes seen in pregnancy, including changes in sexuality with pregnancy, are covered. The process of childbirth is explained in this chapter along with the practice of terminating a pregnancy, which is referred to as having an abortion.

Chapter eight talks about the development of sex differences and gender in humans as well as the different issues that come out of gender identification, such as gender roles and stereotypes. There are individuals who are born with a specific sex assignment who feel as though they do not belong to that gender. These transgender people and their issues are discussed in this chapter. The topic of chapter nine in the course is sexual orientation. This refers to the longlasting sexual or romantic attraction to a person of a certain gender. There is a wide range of choices for sexual orientation, which are described in this chapter. The specific issues related to what it means to be heterosexual, homosexual, bisexual, gay, or lesbian are covered in this chapter as are the different sexual practices involved in sexual relationships between same-sex couples. Chapter ten includes the topics of childhood sexuality, adolescent sexuality, sexuality and aging, and sex among people with disabilities. Sexuality develops first in childhood, usually with sexual curiosity and simple sexual behaviors that develop into adolescent sexual behaviors that increasingly approach adult sexual activity. These are discussed in the chapter as well as the changes in sexuality that occur with aging. Also covered in the chapter is sex in individuals with disabilities. As you will see, sexual behavior persists throughout life and in different life circumstances. The focus of chapter eleven in the course is sexual aggression, which can involve sexual harassment, sexual abuse, rape, and child sexual abuse. In no culture are these things considered to be normal sexual behavior, although it certainly does exist in all societies of the world. Sexual harassment usually involves unwanted sexual attention or behaviors directed at one person by another, often in the workplace. Sexual assault involves many different types of sexual aggression, including rape, which is discussed in the chapter. Child sexual assault is also covered, which involves sexual aggression directed at children. The subjects discussed in chapter twelve include sexual fetishism and paraphilic disorders. The vast majority of sexual fetishes are completely benign and do not necessarily represent a sexual disorder. Paraphilic disorders are intense sexual feelings and behaviors not experienced by most people because of their extreme nature. These

disorders are usually considered problematic if they cause the individual to have distress about their sexual feelings or behaviors, or if there is a victim involved with the paraphilia. The different fetishes and paraphilias are covered as part of this chapter. Chapter thirteen in the course talks about the interplay between sex addiction, prostitution, and pornography. People with sexual addictions often have impulses and compulsiveness related to engaging in sexual activity. They often turn to soliciting prostitution to handle their need for frequent sexual behaviors, as you will see in the chapter. A related addiction is pornography addiction, some of which is related to internet sex or pornography addictions, which are relatively recent phenomena.

CHAPTER ONE: HUMAN SEXUALITY ANATOMY AND PHYSIOLOGY This chapter opens up the discussion of human sexuality by talking about the anatomy and physiology of the male and female reproductive system. While not all of sexual behavior and sexuality is focused on the reproductive system, a knowledge of these systems is important to understanding human sex. The study of the brain in human sexuality is not well understood but it is important to recognize its role in sexuality. Some of the cultural issues about the sexual organs is covered in this chapter, including male circumcision and female genital mutilation, sometimes referred to as female circumcision.

MALE REPRODUCTIVE SYSTEM Both the male and female reproductive system have, as their evolutionary function, to produce gametes which, in males, is the male sperm cell or spermatozoon. It takes a single male gamete and a single female gamete to create a zygote, which represents the beginning of human life. The male reproductive tract produces sperm and allows for its transfer to the female, where human life begins. As you will learn, the major hormone responsible for all of male reproductive physiology is testosterone. There are actually several male structures responsible for making, maturing, and transporting spermatozoa. Figure 1 shows the major structures of the male reproductive system:

Figure 1.

The structures of the male reproductive system include those that can be seen, or what are called the external genitalia, and those that cannot be seen, or what are called the internal structures of the reproductive system. The scrotum can be seen from the outside of the body. It is a pigmented muscular sac that houses the male testes, which are the male gonads. The scrotum is behind and slightly below the penis. It is believed to be located specifically outside the body so that it can keep the testes cooler than the core body temperature by 2 to 4 degrees. This is

necessary because spermatogenesis or the production of male sperm does not effectively happen at core body temperatures but below this level. Just beneath the subcutaneous muscular layer of the scrotum is the dartos muscle. It is the muscle that helps to create the scrotal septum, which separates the testes into two compartments. There are also two cremasteric muscles that descend from the abdominal muscles to create a net over the testes. Both the dartos and cremaster muscles contract at the same time in order to bring the testes closer to the body when the outside temperature is too cold. These help to regulate testicular temperature. They will relax as well to increase the scrotal surface area in order to increase heat loss in the testes. The median raphe is the visible line that can be seen running up the scrotum centrally. The testes or testicles are the male gonadal structures or the main reproductive structures of the male reproductive system. Testosterone and sperm cells are made in the testes throughout the male lifespan. Men do not stop making sperm as they age, which is different than what you’ll see in women. Each testis is an oval structure about 4 to 5 centimeters in total length. There are two layers of connective tissue around the testes. The outer layer is the tunica vaginalis. It has a thicker parietal layer and a thinner visceral layer. Figure 2 shows these layers around the testes:

Figure 2.

The inner layer beneath the tunica vaginalis is the tunica albuginea. It is tough and white in color; it directly surrounds the testes and invaginates to divide the testis into about three to four hundred lobules. Inside the lobules are the seminiferous tubules that make the sperm. As you will see, the testes originate inside the abdomen and descend into the scrotal cavity during the seventh month of intrauterine life. If this does not happen, the condition is called cryptorchidism. Most of the testes is made up of seminiferous tubules, which are highly coiled tubes that are involved in sperm cell production. Cells that make sperm gradually mature from the outside of the seminiferous tubules into the lumen or center of the tubules, where they are released. Ultimately, the tubules straighten out to become tubuli recti or straight tubules that together form a meshwork called the rete testes. There are about 20

efferent ductules that cross over the tunica albuginea, which are the small ducts that the sperm leave from the testes themselves. There are actually six different cell types making up the seminiferous tubules. There are supportive cells called sustentacular cells and different types of germ cells. As mentioned, the germ cells start out least mature in the periphery of the seminiferous tubules and become increasingly mature as they approach the lumen of each tubule. The Sertoli cells are sustentacular cells or supporting cells, found throughout the tubules. They are long and branching so they can come in contact with each germ cell and produce certain signaling molecules that result in sperm production. There is a tight blood-testes barrier formed by tight junctions between adjacent Sertoli cells so that germs, toxins, and antibodies from the bloodstream cannot get to the germ cells. If they do not do their job, autoantibodies to sperm cells can be made, which can greatly affect male fertility. As mentioned, there are different levels of maturation with regard to the sperm cells. The cells closest to the basement membrane on the periphery of the seminiferous tubules are called spermatogonia. These are essentially sperm stem cells that ultimately divide into primary and secondary spermatocytes, then into spermatids, and then into sperm cells themselves. The process that does this is called spermatogenesis. Spermatogenesis does not happen until puberty but will continue throughout the male lifetime. It takes 64 days for the entire process to occur and a new cycle begins every sixteen days. This means that insults to the male reproductive system take about two months to take effect. Advancing age will reduce the sperm count, with reductions after thirty-five years of age. Things like smoking can also lower sperm counts as well. Meiosis is a special type of cell division that only happens to reproductive cells. They start out as diploid, which means they have 46 human chromosomes representing the man’s genetic material. Through the process of meiosis, which includes genetic rearrangement of genes on the chromosomes, a total of 4 haploid sperm cells or male gametes are formed. Haploid means they have just 23 chromosomes, which potentially combine with female chromosomes in the egg cell to make a diploid human cell unique from all others. Figure 3 shows the process of meiosis:

Figure 3.

When spermatogenesis occurs, the spermatogonium divides into two identical cells. One cell remains a stem cell, while the other becomes a primary spermatocyte, continuing on to mature further into sperm cells. The process of spermiogenesis is not the same thing as spermatogenesis. Spermiogenesis is the creation of what is seen as a sperm cell, with reduced amounts of cytoplasm and the start of what becomes a sperm cell with a tail. Sperm cells are small—so small that they are more than 85,000 times smaller than the female egg cell. Every man makes up to 300 million sperm per day. They are distinct in their structure because they have a head, a cap called an acrosome, and a tail. The

acrosome contains special enzymes that will help the sperm to penetrate the egg cell. There are a lot of energy-producing mitochondria in the midportion of the sperm. These will make ATP energy that drives the tail or flagellum. The flagellum allows the sperm cell to move. There is an axial filament that drives the flagellum. Figure 4 shows the structure of the sperm cell:

Figure 4.

The sperm cells need to get from the seminiferous tubules to the outside of the body. The process of this is called ejaculation. The sperm are completely immobile when they leave the testes. They travel for maturation in the epididymis. The epididymis is a coiled tube behind the testis where sperm cells mature. There are twenty feet of total epididymis distance, even though it is tightly coiled and appears small. It takes about 12 days for the sperm to travel through this structure, where it develops a tail and the ability to mobilize itself.

The sperm exit the epididymis through the vas deferens, which is a muscular tube that is sometimes cut to ensure male sterility in a procedure called a vasectomy. The vas deferens—one for each testis—enters the abdomen through the inguinal canal and comes toward the middle, where semen is made. Semen is 95 percent something other than sperm cells. It is the milky substance that men ejaculate out of the penis. There are several things that happen to make semen. First, the sperm are mixed with fluid in the seminal vesicles, which are paired glands that contain fructose—a type of sugar that nourishes the sperm cells as they progress through the reproductive system. The two ducts become ejaculatory ducts that send the semen to the prostate gland. There is just one prostate gland, which surrounds the urethra at the base of the bladder. The prostate gland secretes an alkaline fluid so that another component of semen is created. The alkaline fluid helps to coagulate and uncoagulate semen after ejaculation. The semen is first coagulated in the female vagina so it doesn’t fall out and then it uncoagulates to allow sperm to travel into the female reproductive system. The semen is considered in its final state after it passes through the Cowper’s glands or bulbourethral glands. They make a salty fluid that acts as a lubricant for the semen. It is only when the male is sexually aroused that the Cowper’s glands add their component. Prior to this point, the semen is called pre-ejaculate. A woman can get pregnant from pre-ejaculate fluid, even if the man does not actually ejaculate. The penis is the copulatory organ of the male reproductive system. Most of the time, it is flaccid but becomes turgid and rod-shaped during sexual arousal. The stiffness is caused by an increase in blood flow in the penis in order to allow it to penetrate the vagina and deposit semen into the vagina. Figure 5 shows the internal structure of the penis:

Figure 5.

The penile shaft surrounds the male urethra. In the shaft, there are three columns of erectile tissue. The lateral chambers are called the corpora cavernosa, which make up most of the penis. The corpus spongiosum is a single shaft that surrounds the urethra itself. The end of the penis is called the glans penis. This is the part of the penis that contains the most nerve cells and is the most sexually sensitive. The prepuce or foreskin covers the glans like a collar. It is removed during a circumcision but also contains nerve endings and a means of lubrication of the glans. The foreskin retracts during sexual arousal. Figure 6 shows what a circumcised and uncircumcised penis looks like:

Figure 6.

The penis becomes erect and engorged because of a release of nitric acid from the nerve endings in the area of the corpora cavernosa and the corpus spongiosum. This causes dilation of the arteries leading to the penis and an increase in blood volume that causes blood to fill the erectile chambers of the penis. The veins exiting the penis are compressed so that there is an excess of blood inside the penis itself. As mentioned, the main androgen hormone in the male reproductive system is testosterone. This is made by the Leydig cells between the seminiferous tubules. This production of testosterone in the male embryo at about seven weeks’ gestation is what triggers the development of the male genitalia. Testosterone increases during puberty in order to cause spermatogenesis and the development of the male sex characteristics. Males produce between six and seven milligrams of testosterone per day. It is the hormone responsible for libido or sex drive in both men and women. It is the hormone necessary for muscular development, bone growth, and the development in puberty of 14

secondary sex characteristics. You should know that, in women, testosterone is also secreted by the female ovaries but in a smaller amount than is seen in males. The endocrine system controls the production of testosterone. It all starts with the release of gonadotropin releasing hormone or GnRH from the hypothalamus. This happens steadily in males but is cyclical in females. The GnRH causes the pituitary gland to make follicle stimulating hormone or FSH and luteinizing hormone or LH. The FSH is responsible for Sertoli cell function and spermatogenesis. Sertoli cells make inhibin, which is a peptide hormone that feeds back to block FSH release. The LH triggers the Leydig cells to make testosterone. The entire process is a type of negative feedback system. Low testosterone concentrations will increase GnRH production by the hypothalamus, which sets the process in motion. When testosterone levels are considered high enough, the testosterone will block both the GnRH release and the LH release. The same thing happens to the feedback loop involved in FSH secretion.

FEMALE REPRODUCTIVE SYSTEM The female reproductive system is responsible for making the female gamete, which is called an oocyte. There are internal and external structures in the female reproductive system. Figure 7 shows the external genitalia in the female:

Figure 7.

The vulva is the female external genitalia. There is the mons pubis, which is the fat pad that covers the pubic bone in front. This will be covered with pubic air after puberty. The labia minora or larger lips are hair-covered folds on either side of the vagina. Just inside these are the labia minor or minor lips. Each of these protect the urethra and vagina. Coming together in the front or anterior of the labia minora is the clitoris. This is embryologically the same tissue as the glans penis in men and is extremely sensitive with nerve endings. The clitoris is erectile and will swell with stimulation. It has a tissue

fold covering, called the prepuce. The clitoris is the most important structure in aiding female orgasm. There are corpora cavernosa, which are also erectile, extending on either side of the vulva. The hymen is a membrane that covers, at least in part, the vaginal opening until it is disrupted, usually when the woman first has intercourse. The urethra is where urine exits. It is located in the anterior part of the vaginal introitus or vaginal opening. On either side of the vaginal opening are lubricating glands called Bartholin glands, which are not visible under normal circumstances. There are lesser mucus-secreting glands near the clitoris. The perineum is the tissue space between the vulva and the anus. This is the part that is cut when a woman has an episiotomy at the time of birth. The vagina opens at the vaginal introitus. It is a ten-centimeter muscular tube that becomes the entrance to the reproductive tract. It is where the fetus and menstrual blood exit the body. There are rugae or transverse folds that make the surface rough in texture. The fornix is the very top of the vagina. This is where the cervix protrudes into the vagina. The cervix is smooth rather than rough, making it easier to identify. The muscles and rugae allow the vagina to expand during sexual excitement and childbirth. The vagina is not a sterile environment but has a collection of normal bacteria and other organisms that prevent other, more serious organisms from gaining traction in the vagina. Most of these bacteria are called Lactobacillus, which secrete lactic acid as part of their metabolism. This has the effect of lowering the pH of the vagina. This acidity prevents the alternative growth of pathogenic bacteria. Douching will disrupt this milieu and can lead to an increase in infections. The female gonads are called the ovaries. These are oval and located on either side of the uterus, being about two to three centimeters in length. There is part of the abdominal peritoneum called the mesovarium; this will help to support the position of the ovaries. There is also a suspensory ligament that helps to connect the ovary to its blood and lymph vessels. Third, there is an ovarian ligament that attaches the ovary to the uterus.

There is an outer epithelial layer on the ovarian surface, underneath which is the tunica albuginea, which is a tough layer of connective tissue around the ovary. Beneath this is the cortex, which is the framework for the germ cells and supportive cells. A combination of the oocyte plus its supportive cells is referred to as a follicle. Figure 8 is what an ovarian follicle looks like:

Figure 8.

The ovary goes through a natural ovarian cycle, which leads to a mature egg. The cycle happens only during the reproductive years and completes itself every twenty-eight days. This is not exactly the same thing as the menstrual cycle. The two parts of this cycle are related to oogenesis or egg-making and folliculogenesis or follicle-making. As in the male testes, there are stem cells or germ cells called oogonia, which are formed in fetal life. They divide normally in the process of mitosis but become primary oocytes before birth. This is where they stop developing and remain until the process of meiosis resumes after puberty. Most of the egg cells are present at birth but decline to be about 400,000 in total at the time of puberty. This number becomes zero at the time of menopause. 18

Ovulation is the release of an oocyte from the ovary. This happens for the first time at puberty and again happens about every 28 days until menopause is reached. Luteinizing hormone triggers meiosis to continue in the primary oocyte to make the secondary oocyte. The main difference between men and women is that, while men create four equal sperm cells, the process of oogenesis gives rise to just one mature egg cell and three polar bodies, which are inactive cells that disintegrate. Interestingly, the secondary oocyte does not complete meiosis until the sperm cell has penetrated the egg cell. These leads to a haploid ovum plus a polar body. The haploid ovum combines with the haploid sperm cell to become a zygote. As you can imagine, this haploid ovum state is very brief. The female gamete or ovum is very large. It contains all the mitochondria and organelles not found in the sperm cell. Mitochondria have their own DNA, which is passed on to the offspring. In fact, mitochondrial DNA analysis can look specifically at the ancestry of a child along the maternal lines. Folliculogenesis is the development and maturation of the oocytes and the supportive cells. One follicle matures every 28 days in women of reproductive age. There are other follicles developing at the same time but most of these undergo atresia, which is regression and disintegration. There are primordial follicles, primary follicles, secondary follicles, and tertiary follicles. The oocyte stays inside the follicle until the time of ovulation. Primordial follicles are found in newborn babies and in adults. There is a single layer of supportive cells called granulosa cells around the oocyte. Primordial follicles often remain this way for years. After the time of puberty, some of the primordial follicles will be recruited to make primary follicles. The granulosa cells thicken and proliferate. These follicles become secondary follicles and a new layer of estrogen-producing cells called theca cells begin to do their job. There is a thin membrane around the primary oocyte called the zona pellucida. This is the layer that gets broken down by the enzymes in the acrosome of the head of the sperm cell. Follicular fluid is made to create a space called the antrum, which enlarges the follicle. This tertiary follicle is called an antral follicle. There are several antral

follicles made per cycle but must will undergo atresia, leading to a dominant follicle. Only one percent of follicles will completely mature. Atresia can happen at any time in folliculogenesis. There is a great deal of hormonal control over this ovarian cycle. It takes about two months from the time of the primordial follicle to the time of the tertiary follicle. It is the secondary oocyte that gets ovulated every month. There is GnRH, exactly as in men but it is released in a cyclical fashion by the hypothalamus. This leads to FSH and LH to be released by the anterior pituitary gland. FSH contributes to folliculogenesis, while LH stimulates the release of female sex hormones. There is a similar feedback loop regarding these hormones in females as there is in males. The feedback mechanism contributes to the survival of just one follicle per cycle. The surviving follicle is called the dominant follicle, which continues to secrete estrogen. It creates a great deal of estrogen that overrides the feedback loop and actually becomes a positive feedback loop, leading to a surge in luteinizing hormone, called the LH surge. It is the LH surge that triggers ovulation. It also triggers protein-degrading enzymes to break down the follicle wall so the oocyte can be released in the process of ovulation. After the oocyte has been released, there is a change in the granulosa cells and theca cells, which undergo luteinization, causing them to secrete progesterone as a dominant hormone. Then the follicle remnants are called the corpus luteum. Progesterone increases the woman’s body temperature slightly and will support the beginnings of a pregnancy. If no pregnancy happens, the corpus luteum stops making progesterone and the menstrual flow begins. Progesterone also suppresses the development of more dominant follicles. The corpus luteum ultimately degrades into a nonfunctional corpus albicans. Figure 9 shows the internal structure of the female reproductive system:

Figure 9.

The uterine tubes are also called the oviducts or fallopian tubes. These are passageways for the egg from the ovary to the uterus and is where fertilization takes place. There are several parts to the fallopian tubes. The fimbriae are on the far outer side. They are fingerlike projections that embrace the ovary to sweep in the oocyte as it is being released. The oocyte enters the wider infundibulum and then the ampulla in the middle, where fertilization occurs. The isthmus is the connecting piece to the uterus. There are cilia and contractions of the fallopian tubes that coordinate to push the otherwise immotile oocyte down the tube. You should know that the oocyte is actually ovulated into the peritoneal cavity. It is only because of the fimbriae activity that the egg is swept into the fallopian tube itself. The sperm travel up into the tube to fertilize the moving egg. Once the oocyte is fertilized, the zygote successively divides into twos, fours, eights, etcetera. It will ultimately implant in the uterus. The egg that does not get fertilized degrades within one to two days after ovulation. Sperm cells survive longer than egg cells before disintegrating. The uterus is where the embryo and fetus develop. It is about the size of a fist in the nonpregnant state and is highly muscular. There are three sections to it. The fundus is the top part above where the tubes enter the uterus. The body is the main, central part of

the uterus. The cervix is narrow and protrudes into the vagina. It produces secretions that change in character, depending on the stage of the woman’s menstrual cycle. When it becomes clear and stretchy, the woman can get pregnant as this fluid best supports the passage of sperm cells. There are three layers in the uterus. The perimetrium is the outermost layer, which is basically a thin, serous membrane. The middle layer is the myometrium, which contains all the muscles of the uterus. These muscles stretch greatly in pregnancy and contract forcefully in labor and during the menstrual period. The endometrium or inner lining has two layers itself. The stratum basalis is near the myometrium and doesn’t shed each menstrual period but the stratum functionalis will shed each time the woman has her period. This inner layer changes greatly in character in different parts of the menstrual cycle. The stratum functionalis thickens in the follicular or beginning part of the menstrual cycle. Once progesterone is made by the corpus luteum, the stratum functionalis changes in character to become secretory and more mature for implantation. If the corpus luteum degrades, the endometrium thins out and the spiral arteries feeding it constrict and break open. Prostaglandins, which are what cause menstrual cramping, contribute to this process. The stratum functionalis dies off and gets shed during menses. The first period a girl has is called menarche. The menstrual cycle is considered different from the ovarian cycle but, of course, these are related. It refers to the changes in the endometrial lining and pelvic structures over the course of a month. The first day of bleeding is called day 1 of the menstrual cycle. A typical menstrual cycle is 28 days but this can be longer or shorter than that, depending on the women and specific circumstances. These difference in cycle length are generally due to shortening or lengthening of the first half of the cycle and not the second half, which is almost always 12 to 14 days in total length. The menses phase is when a woman bleeds. This often lasts between 2 and 7 days, with an average of five days. The uterine lining is shed and the LH, FSH, and progesterone levels are very low. In fact, it is the sharp decline in progesterone secretion that triggers menses. Figure 10 shows the different phases of the menstrual cycle:

Figure 10.

The proliferative phase starts next. The granulosa cells and theca cells make more estrogen, which thickens the uterine lining. This continues to grow until the LH surge, when the ovulation phase takes place. When ovulation happens, the proliferative phase is over. After ovulation is the secretory phase of the menstrual cycle. The vagina becomes more hospitable to sperm about the time of ovulation and then the corpus luteum begins to make progesterone. The secretory phase is what prepares the uterine lining for implantation. Glycogen is secreted by the uterine glands that will ultimately nourish the zygote after implantation. The spiral arteries develop to supply blood to this tissue.

THE FEMALE BREAST The breasts are accessory organs of the reproductive system in females but they can be important sexually. The areola is the pigmented area surrounding the nipple; it is sexually sensitive. There are raised areolar glands that secrete a lubricating fluid that protects the areola during suckling. The entire areola is taken up by the baby’s mouth during breastfeeding. Breast milk is made by the female mammary glands, which are in effect sweat glands that have been modified to produce milk. There are about twenty lactiferous ducts that open out into the nipple. Inside the breast itself, the lactiferous ducts open into lactiferous sinuses that lead to lobes containing clusters of cells that make milk. The cells are arranged in alveoli, which are the actual cell clusters. There are myoepithelial cells around the alveoli that contract to eject milk into the lactiferous sinuses, where it is further drawn out by the action of suckling. The rest of the breast is made by fat, which is what determines the actual size of the breasts. This means that larger breasts do not put forth more milk than smaller breasts. There are suspensory ligaments that hold the breasts in place. Figure 11 shows the anatomy of the breasts:

Figure 11.

REPRODUCTIVE SYSTEM DEVELOPMENT The reproductive system develops in the first few weeks of gestation. After one month in utero, primordial gonads develop. While this changes during gestation, very little change happens between infancy and puberty. All embryos start out life as phenotypic females so that, if there is no chemical intervention, the infant would appear female at birth. The male Y chromosome has a special gene called the SRY gene. Both male and female gonads have early cells that have the potential to be either gender but the SRY gene recruits other genes, leading to a gene cascade. This gene cascade causes spermatogonia to form. If this doesn’t happen, then oogonia and an ovary develops instead. Leydig cells develop in the testes, which make testosterone. This helps to cause the male sexual structures to form. Without testosterone, the glans penis would otherwise be the glans clitoris. There are two separate ducts for the male and female reproductive system. Female organs are derived from the Mullerian duct, while male organs are derived from the Wolffian duct. The two ducts cannot grow simultaneously. The Mullerian duct will degenerate when the Wolffian duct develops and vice versa. It is testosterone that triggers the Wolffian duct to develop. If testosterone does not get made, the Wolffian duct will degenerate. Puberty is the time of further sexual maturation. The hormonal control of the boy and girl are similar but the outcome is different. The release of GnRH by the hypothalamus stimulates the onset of puberty. This triggers the events that happen to develop the secondary sex characteristics in adolescence. At the age of eight or nine, LH first becomes detectable, even before there are physical changes. The sensitivity of the feedback system during this time is quite high so it doesn’t take much testosterone or estrogen to feed back onto the hypothalamus and pituitary to shut off LH, FSH, and GnRH production. This sensitivity decreases near puberty and the gonads are more sensitive to LH and FSH. This leads to enlargement of the gonads.

Genetics, psychological stress, and nutrition contribute to the age at onset of puberty. The average age at menarche is 12.75 years but it was much higher 150 years ago, when nutrition was poorer. The amount of fat stored in the body will help to determine whether puberty occurs in girls. It is believed that leptin, a hormone made by fat cells, helps to determine the age of menarche. Girls who are thin and active will have delayed menarche. The secondary sex characteristics develop at the time of puberty. In males, these characteristics include increased laryngeal size, which deepens the voice, greater muscle development, and the growth of pubic hair, facial hair, and overall body hair. In females, it is increased fat deposition in the hip and breast area, increased breast size, and broadening of the female hips. Pubic and axillary hair develop. The growth spurt in girls happens prior to the onset of menarche with breast development being the first sign. In males, the first sign is the growth of the testes. The first fertile ejaculate happens at around 15 years of age.

THE BRAIN AND SEXUALITY The brain is involved in all aspects of sexual behavior, from the onset of desire to orgasms and the need to cuddle. Researchers have done neuroimaging studies on human sexual behavior, which looks for the changes in the brain during sex in men and women. There is a four-component model that has been developed to try to understand the role the brain plays in sexual responsiveness. The first stage is cognitive or the thinking phase. It involves the perception of the visual sexual stimulus, deciding if it causes sexual feeling. The ventromedial prefrontal cortex in the front of the brain is connected to the limbic system, which is the emotion system of the brain, as well as certain parts of the brain associated with the senses. The end result is the focusing of the attention toward the sexual stimulus, which activates both the occipital lobe, involved in vision, and the temporal lobe, involved with hearing. There is a specific extrastriate body in the brain that is connected to perceiving the human body.

The next stage is the emotional component, which involves mainly the limbic system. The amygdala is part of this system. It interacts with the ventromedial prefrontal cortex to control the processing of senses. The amygdala is highly connected to motivation so it helps to guide sexual behavior. Interestingly, if the amygdala is deactivated, this is what’s seen in patients who have indiscriminate sexual behavior and hypersexuality. Two of these syndromes are called Kluver syndrome and Bucy syndrome. The emotional part of this phase isn’t strictly so because it is also tight to the genitalia and the physical feelings of sexual pleasure. The next stage is motivational, which is also highly dependent on the limbic system. Parts of the hypothalamus, thalamus, and anterior cingulate cortex get activated in this stage. This leads to the motivation toward reaching a sexual goal. Sexual urges, the need for reward, and sexual desires come at this time. Lastly, there is the physical or physiological component. This involves hormonal changes, high blood pressure, racing heart, and genital responsiveness. Sexual arousal occurs to prepare the body for sex. This is all activated in the brain to generate the hormonal and autonomic responses to arousal. The hypothalamus is particularly important because it controls the parasympathetic and sympathetic nervous systems— two parts of the involuntary autonomic nervous system—which get activated during sex. There are also inhibitory processes that help us control our sexual behavior so that not all urges are satisfied. If these processes are too activated, there may not be a gratifying sexual experience. If the anterior cingulate cortex and ventromedial prefrontal cortex are damaged, there can be the onset of excessive pleasure-seeking behavior that might be socially inappropriate. In general, women have weaker brain responsiveness to visually erotic stimuli. While most researchers believe there are real differences in sexual brain activity and activation between men and women, these types of studies have not yet been done. Most studies have been done on heterosexual males and haven’t compared the two genders. It appears that women are more complex when it comes to sex than men. Men more easily respond to visual sexual stimuli, when women have a stronger response to the sense of smell of their sexual partner. Women also respond more to erotic videos that

have an emotional component or a story, while this just isn’t the case with men. Interestingly, women are less sexually aroused during the follicular phase of their cycle, which may play a role in being selective about one’s mate. Men have a strong neural reaction when exposed to a specific sex but not to the other sex, while women respond similarly to erotic stimuli that involve either sex. This appears to be true of both homosexual and heterosexual individuals of both genders. Patterns of orgasm, on the other hand, are the same between men and women. During orgasm, the amygdala and ventromedial prefrontal cortical areas shut down immediately—similar to taking heroin. This accounts for the disinhibition that transiently occurs during orgasm. After orgasm, there is the experience of an endorphin rush and releases of oxytocin and prolactin. This differs between men and women and isn’t completely understood. It is believed that these hormones contribute to increased bonding and to post-coital cuddling behavior seen in some individuals.

MALE CIRCUMCISION As mentioned, male circumcision is the removal of the foreskin from the glans penis. There are specialized devices used in the newborn period to crimp off the foreskin. No actual stitching is involved. The blood flow to the foreskin is cut off and the remaining devitalized foreskin is removed. This is an elective procedure done for medical, social, or religious reasons. It can be done as an emergent or relatively urgent procedure if the foreskin gets trapped in the retracted position, called paraphimosis, or if there are chronic bladder infections. The elective circumcision done at birth is done for the parent’s personal preference or for religious reasons. Societal norms drive the desire to have a child circumcised. It is considered to have a modest health benefit. It will decrease the incidence of HIV disease so it is done more often in Africa, where the prevalence of HIV is higher. There are no medical organizations that have either supported or banned circumcision in modern time. It cannot be done if there are birth defects involving the penis or in known bleeding disorders.

There is a decreased risk, not only of HIV disease, but of certain types of human papillomavirus infections, syphilis, genital herpes, and chancroid in men who get circumcised. There is mixed evidence that it protects against other sexually transmitted diseases and it does not decrease the risk of getting gonorrhea. If the penis cannot be retracted, this is called phimosis, for which circumcision is recommended. Forced retraction of the foreskin and infections of the foreskin are other reasons to have a circumcision. While circumcision will decrease the risk of penile cancer, it will not completely protect against it. About 38 percent of males in the world are circumcised, with half being done for cultural or religious reasons. The rate is highest among Muslims, in Africa, in Israel, in South Korea, and in parts of the United States. It is rare in Europe, Latin America, Oceania, and Asia. Circumcision is believed to have happened in prehistoric times. It spread from geographical area to geographical area. It was practiced by Ancient Egyptians and was picked up by Muslims and Jewish people. It was practiced by Australian Aborigines and by the Polynesians. It is believed to have been practiced by the Mayans and Aztecs. Some Native American peoples practiced circumcision. In more modern times, circumcision became popular by Westerners in the late 19th Century, when doctors believed it would deter masturbation. At the time, masturbation was felt to cause a variety of mental and physical conditions. It was later felt to be healthier for the penis to be circumcised because the smegma, which is the whitish substance beneath the foreskin, was believed to cause disease. Circumcision is a part of culture and religion. It is practiced specifically in today’s society by people in the Islamic and Jewish faith. In the Jewish faith, it is done on the eight day of a child’s life and must expose the glans penis entirely. In the Islamic faith circumcision is universal and is believed to lead to cleanliness and purity. It is done up to 15 years of age and is thought to be related to being able to recite the Quran. It is not practiced by most Christians as part of their religion. Certain cultural groups in Africa have circumcision as a custom. It does not always have religious significance but is primarily cultural in origin. In some cultures in Africa, many

boys of different ages are circumcised at one time. It is still practiced by Australian Aborigines as a test of self-control and bravery. It is part of a wider tradition that includes scarification of the body. Most Filipino men are circumcised during the springtime months. The circumcised boy is treated as an adult after the procedure is done.

FEMALE GENITAL MUTILATION This practice is also sometimes referred to as female circumcision. It removes some or a portion of the external female genitalia. It is mainly done in parts of Asia, Africa, and the Middle East, where it is believed to have affected 200 million living women. It can be done at birth or even beyond puberty but is primarily done before five years of age. The procedure involves removal of the clitoris, clitoral hood, inner labia and outer labia, with closure of the vulva, although there are different degrees of severity. It leaves behind a small hole that will allow for urination and menstrual blood. The vagina is later opened for intercourse and childbirth. Much of the practice is related to certain cultural ideas about modesty, beauty, and purity as well as an attempt to control female sexuality. The practice is actually done by women who fear that failing to do the procedure would alienate the child culturally. Side effects include problems urinating, infections, chronic pain, and incomplete passage of menstrual flow. The most common type of this procedure performed involves complete or partial excision of the glans clitoris. This is called type I. In type II excisions, the inner labia and sometimes the removal of the clitoris and external labia are performed. Type III is referred to as infibulation, where the remaining portions of the external genitalia are sewn together. The remaining hole is about 2 to 3 millimeters in diameter. This is primarily done in Africa. The genitals are opened up by a midwife or by the woman’s husband. Some women have it repeated after childhood, widowhood, or divorce. In cultures where infibulation is more common, both men and women tend not to like the sight of a natural women’s vulva and there is a preference for dry sex as well as a dry vaginal area without any odor. Some women will insert things, such as tree bark, Vicks

menthol rub, and toothpaste in order to reduce the vaginal lubrication. It is believed by both men and women that infibulation allows for better hygiene. Women also cite things like cultural acceptance, religion, marriageability, and preservation of virginity as reasons for the procedure. In some cultures, such as Egypt, it is seen as a religious obligation.

KEY TAKEAWAYS •

The male gonads are the testes, which produce spermatozoa and testosterone.

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The mature sperm cell swims with a flagellum; it is mixed with several fluids to make semen.

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The male copulatory organ is the penis, which has most of the nerve endings. It must become turgid in order to penetrate the vagina.

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The female gonads are the ovaries, which produce ova, estrogen, progesterone, and a small amount of testosterone.

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Testosterone is necessary for both male and female libido.

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The female menstrual cycle sets the uterus and ovaries up for fertilization; menses occurs when fertilization does not occur.

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Much of sexuality and sexual feelings originates in areas of the brain linked to attention, motivation, and emotions.

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Male circumcision removes the male foreskin. It is primarily done for cultural and religious reasons, although there are a few health benefits.

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Female genital mutilation is practiced in upper and middle Africa and in parts of the Middle East, where it is believed to be a hygienic and culturally-positive thing to do.

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There are many long-term and short-term complications of female genital mutilation so that it is discouraged by all world organizations and is not practiced in most societies of the world.

QUIZ 1. Which hormone is considered the major male androgen or male hormone? a. Progesterone b. Testosterone c. Androstenedione d. Luteinizing hormone 2. Why are the testes located in an exterior sac called the scrotum? a. The scrotum contains muscles that propel male sperm cells. b. The male scrotum is considered sexually arousing to females. c. The sperm cells do not mature at core body temperatures. d. The scrotum decreases the distance sperm must travel in ejaculation. 3. Where does the sperm cell get its characteristic tail? a. Seminiferous tubules b. Prostate gland c. Epididymis d. Vas deferens 4. Where does the semen become in its final state? a. Vas deferens b. Seminal vesicles c. Prostate gland d. Cowper’s gland 5. How many gametes arise from spermatogenesis and how many gametes arise from oogenesis? a. Four gametes from each process per stem cell. b. Two gametes in males and two gametes in females. c. Four gametes in males and one gamete in females. d. One gamete in males and four gametes in females.

6. How often does ovulation occur in females? a. Every week b. Every four weeks c. Every two months d. Every three months 7. During which phase of the menstrual cycle are the progesterone levels the highest? a. Menses phase b. Proliferative phase c. Secretory phase d. Ovulatory phase 8. What hormone is most responsible for thickening of the uterine lining in the proliferative phase of the menstrual cycle? a. Estrogen b. Human chorionic gonadotropin c. Progesterone d. Luteinizing hormone 9. What group of people is least likely to participate in circumcision? a. Muslims b. Jews c. Europeans d. Australian aborigines 10. Where in the world is infibulation or sewing together of the female genitalia usually performed? a. Asia b. Australia c. Middle East d. Africa

CHAPTER TWO: THE HUMAN SEXUAL RESPONSE CYCLE The topics of this chapter are the human sex drive or libido, sexual responsiveness, and the study of aphrodisiacs. As you will hear, there are differences between men and women when it comes to the sex drive. The sexual response cycle is a relatively predictable pattern of physiological variables that change during sexual activity. There are drugs and supplements considered to be aphrodisiacs. What these substances are and how they are studied are discussed in this chapter.

SEX DRIVE The human sex drive or sexual libido involves a person’s desire to have sexual activity. There are social, biological, and psychological factors associated with libido. In humans, the hormone testosterone as well as dopamine in the nucleus accumbens regulate a person’s libido. Many other things besides biology can affect libido, including interference by family and work, age, personality, stress, relationship issues, and medical conditions can affect sex drive. Having a sudden increase in sex drive is referred to as hypersexuality, while having a decrease in sex drive is called hyposexuality. Sex drive itself may have nothing to do with actual sexual activity. For situational, moral, or religious reasons, a person might have a normal libido but will choose not to act on their feelings. In general, research indicates that sex drive is higher in men than it is in women. Sex drive is part of what leads to the formation of intimate connections with others. Differences in libido can affect couples in a relationship. Sigmund Freud’s work was largely about human libido, which he regarded as a form of quantifiable energy. The libido is said to come from the energy of the id, which is largely unconscious. Freud believed that libido was as important and instinctual as hunger and thirst. He defined different erogenous zones, which start as the oral stage and progress through the anal stage, phallic stage, latency stage, and genital stage. His work in 36

psychoanalysis was to uncover these hidden drives of the id and to allow them to be met rather directly rather than through defense mechanisms. Carl Jung believed that libido was a form of energy not altogether related to sexual desire. Libido was defined as any impulse or desire that has been left unchecked. Like Freud, he believed that libido was not unlike the need for sleep, food, or water. It is defined as any type of psychic longing. As mentioned, libido is related to the dopamine pathways in the limbic system, particularly the nucleus accumbens and ventral tegmental area. Phenethylamine, which is a trace amine, is also said to affect this neurotransmitter system. There are hormones and other neurotransmitters believed to affect libido. Both estrogen and testosterone are important to augmenting libido. Oxytocin augments libido as well, while progesterone and serotonin suppress libido. In women, the sex drive is related to the menstrual cycle. There is an increase in sex drive during the peak time of fertility, which is about two days before ovulation. It normalizes at about two days after ovulation. This is when testosterone levels are highest. About a week after ovulation, progesterone levels increase, which suppresses orgasms, and testosterone levels drop, which suppresses libido. There can be a slight increase in libido right before menses because of stimulation of the nerve endings by a thickened endometrial lining. There are mixed opinions about the effect of menopause on libido. Most researchers believe that the loss of estrogen at the time of menopause will decrease a woman’s libido and will increase vaginal dryness. On the other hand, there is an increase in testosterone after menopause, which will increase libido during this time. There are many psychological factors that can decrease a person’s sex drive. Things like lack of privacy, fatigue, stress, depression, environmental stress, and distraction can decrease sex drive. Psychological factors, such as a history of sexual abuse, prior rape, childhood neglect, anxiety, and body image issues can lead to decreased libido. The major physical factors that affect libido include hypothyroidism, which will decrease libido. Men who ejaculate frequently will have a decreased testosterone level and decreased libido. Alcohol abuse, anemia, and smoking can lower libido. We will talk 37

soon about aphrodisiacs, which tend to increase libido. Opioids, antipsychotics, antidepressants, selective serotonin reuptake inhibitors, and beta blockers all decrease libido. Contraceptive hormones increase sex hormone binding globulin, a hormone that binds testosterone, which will decrease libido. Dopaminergic agonist drugs, which increase dopamine, increase libido. It is speculated that males have their highest libido during adolescence and that females have their highest libido in their thirties. The peak testosterone level in males is between fifteen and sixteen years of age, dropping gradually after that. Females have a gradual increase in testosterone, which peaks in the mid-thirties. There are wide differences in the levels of estrogen and testosterone between different people.

DIFFERENCES IN LIBIDO WITH GENDER Multiple research studies have shown differences in libido among men and women. Men are more straightforward with their libido and have stronger sex drives overall. Women are more sensitive to things like context and the environment. Emotional connection is more important in women and cultural factors figure in to a greater degree. While there are wide differences among people, research has shown that men think about sex much more often than women, with the majority thinking about sex at least once a day. The incidence of sexual fantasy decreases with age but is still twice as frequent in men compared to women. Men have more varied fantasies as well. Men will want sex more often, even during the start of a relationship. This is true of both gay men and heterosexual men. Lesbians have less desire for sex at all stages of a relationship. More than half of men masturbate, even if they feel guilty about it. Less than half of women masturbate and the overall frequency is less. Almost all prostitution is related to men seeking sex with a woman, rather than women seeking sex with men. Men in the clergy fail their vows of chastity about 60 percent of the time. As mentioned in the last chapter, heterosexual men are aroused by men and women having sex or by two women having sex. Gay men are aroused by two men having sex. Women are equally aroused by all types of sexual interactions, regardless of gender, even if they don’t admit their arousal. It appears that women are more open to 38

attraction with the same gender compared to men. Gay women report more sex with men, yet this isn’t true of gay men and their interactions with women. Women’s attitudes toward certain sexual practices are more likely to change over time and are more likely to be influenced by peer group activities and religion. Women who have higher levels of education have generally more experience with a wide variety of sexual activities. Women are more inconsistent with regard to their value system and actual sexual behaviors. There are differences in the paths men and women take to getting at sexual desire. Women are more attracted to a novel that has romance and a plot, which isn’t the case with men. Women like the anticipation associated with sex, while men do not need to enlist their imagination. Men use sex as the language of their connection, while women need connection first. There is a difference in the time taken to arrive at orgasm for men. It takes about four minutes in men and about ten minutes in women, if women have an orgasm at all. Men usually have an orgasm, while only 25 percent of women actually do have one. Because male libido is more tied to biology, they are more likely to be responsive to medications that treat low libido. While testosterone is more likely to work quickly to restore libido in men, it doesn’t work as quickly or as effectively in women. There is a testosterone patch use for women in Europe; however, because libido is less biologically driven in women, it may not be safe or effective for long-term use.

SEXUAL AROUSAL Sexual arousal or sexual excitement is the feeling one gets when anticipating sexual activity. There are different responses seen in men and women. Men will get an erection, while women will have engorgement of the vulva, clitoris, vaginal walls, and nipples. There will be increased vaginal lubrication. Given enough sexual stimulation, sexual arousal leads to orgasm in both men and women. Sexual arousal usually begins with one or more erotic stimuli. There are mental and physical stimuli possible, depending on the situation. Arousal can be visual and related

to a person, a part of a person, or something inanimate. Foreplay or touching of the erogenous zones can lead to arousal, particularly in the right setting. There are touch-related stimuli, visual stimuli, and olfactory stimuli that affect arousal. Auditory stimuli are less effective. Thoughts and memories can lead to sexual arousal as can petting, cuddling, and kissing an erogenous zone. This can lead to the desire for more direct sexual stimulation and furthering of sexual activity.

EROGENOUS ZONES So, what can be considered an erogenous zone? This can be any area of the body that has a heightened degree of sexual sensitivity. It mostly depends on the number of nerve endings in a specific area; touching one of these areas is a sign of physical intimacy. Not all erogenous touching is considered pleasurable, depending on the person’s history and things like culture and circumstances. There are certain zones that are nearly universally erogenous. These include the lips, the nipples, the glans penis, the vulva, and the perianal skin. These areas naturally have more nerve endings and are considered to be naturally erogenous. Areas that are more nonspecific include the neck on the sides and back, the inner arm, the sides of the chest, and the axillae or armpits. Notice how these areas tend to be more ticklish. Men are aroused by any stimulation of the penis or foreskin, the front of the scrotum, the perineum, the anus, and the prostate gland, which is only accessible through the rectum. In women, the clitoris and vulva are erogenous, while the vagina is less so. The vaginal front wall and parts near the opening or introitus tend to be more innervated and more sensitive. Some women will have an area sometimes referred to as the G spot on the anterior vaginal wall but this is not universal. Other areas that might be erogenous include the lips and tongue. The back of the neck can be bitten, licked or kissed, which is felt to be erogenous to some people. The area on and behind the earlobe can be erogenous. There are sensitive nerve endings in the nipple and areolar area, with hair on the areola increasing its sensitivity. The breast itself is erogenous but there is a decreased density

of nerve endings in large breasts so they may need more stimulation. Nipple stimulation alone can lead to orgasm in some people; there is a release of both prolactin and oxytocin when these are stimulated, which can impact genital feelings. The abdomen just above the pubic region can be intensely erogenous. The navel itself is very erogenous, particularly when touched by a finger or the tip of the tongue. The sacrum at the base of the spine can be erogenous as can the skin of the inner arms. The inner crease of the elbow is especially sensitive to touch. The armpits are erogenous to some people. The smell of sweat can be erotic. Other erogenous zones are the fingertips, the back of the thighs, and the toes.

SEXUAL STIMULATION Sexual stimulation can, of course, be unrelated or related to touch. Most of the time, however, achieving an orgasm necessitates some type of physical sexual stimulation. Physical stimulation that leads to orgasm usually has to be related to the erogenous zones or to direct genital stimulation. Endorphins are chemical rewards that act to encourage the pursuit of further stimulation. Sex toys have been used for millennia for sexual stimulation. Dildoes have been found dating to prehistoric times. They were also used in Ancient China, by the Greeks, and by the Romans. In some cases, a dildo was used to break the hymen of a woman on her wedding night—both to confirm virginity but also because hymeneal blood was considered unclean. Visual stimulation has been extensively studied. This is heightened in people who exhibit voyeurism. Pornography involves visual stimulation, which is more prominently used by men but can be used in women. Visual stimuli can be very powerful in causing sexual arousal. Olfactory stimulation is extremely important. Men are particularly aroused by the smell of some women’s perfume. It is believed that olfactory cues in evolution helped to avoid incest. Women in particular rate olfactory experiences as possibly negatively affecting physical desire.

As mentioned, auditory stimulation is less likely to play a role in arousal but it certainly does play a role in sexual activity. Moans and increased breath rate all will reinforce sexual arousal, leading to positive feedback. There is commercially produced erotic material mainly marked toward men. Music itself can be sexually arousing. Phone sex is based exclusively on auditory stimulation. Mental stimulation includes erotic literature, dreams, imagination, fantasy, and roleplaying. Sexual fantasy is a type of mental stimulation that is extremely important. Men are more likely to see themselves in a dominant role in fantasy, while women are more likely to see themselves passively in a sexual fantasy. Women’s fantasies are more connected to commitment and affection than is true of men. The downside of fantasy is that it can be connected to sexual criminal behavior. Dreams can cause sexual arousal in both men and women. Orgasms can be achieved during sleep. Things like BDSM, which involves bondage, sadism, and masochism, are linked to sexual role-playing. Sexual fetishism and paraphilias involve sexual arousal because of an association with a non-human object. The physiological response to sexual arousal differs between the genders. The sex organs are the most affected. Men will have the corpora cavernosa fill with blood, leading to an erection. Women will have increased blood flow to the vulva and clitoris; there will be increased vaginal secretions. The most reliable measure of male physiological response to sex is an erection. The testes are pulled into the body and the scrotal skin is drawn in more tightly. The glans of the penis swells and the testicles will increase in size. There can be increased flushing of the scrotum. The muscles of the pelvic floor contract to force semen into the urethra in order to have ejaculation. If the orgasm cannot happen for any reason, it can feel uncomfortable in the testes. This is what is referred to in slang terminology as having “blue balls”. Women first notice vaginal lubrication and wetness. Then there will be engorgement of the external genitalia and internal enlargement of the female vagina. The clitoris will swell and redden. The heart rate and blood pressure increase. After an orgasm, some

women don’t want any further stimulation, with dissipation of sexual arousal. Multiple orgasms in women are more possible than in men. There are several hormones that are involved in sexual arousal. These include estradiol, cortisol, and testosterone. Testosterone has been most studied and it has been studied primarily in men. There does appear to be some relationship, however, between testosterone and measures of sexual arousal in women as well.

THEORIES ON SEXUAL RESPONSIVENESS While there are several theories on sexual responsiveness, none of them have been flushed out to the degree that has been done by the work of William Masters and Virginia Johnson, who wrote a book on the subject in 1966. They list several phases of physiological responses to different kinds of sexual stimulation that was referred to as the human sexual response cycle. These are the different stages or phases of the sexual response cycle: It starts with the excitement phase, also called the arousal phase. Things like erotic stimuli which, as you know, can be of several different types. The body prepares itself for sexual activity. Foreplay happens in this phase, which varies among individuals and in different social and cultural contexts. In both men and women, the excitement phase involves an increased breath rate, an increased heart rate, and a rise in the blood pressure. More than 80 percent of women and more than fifty percent of men say that nipple stimulation enhances this response. There can be a sex flush because of increased blood flow to the skin. The flush happens in the upper torso, the face, the hands, and the feet but it can affect the whole body. This flush generally goes away after an orgasm. There will be an increase in muscle tone in the excitement phase, which may be voluntary or involuntary. The anal sphincter contracts when touched. Males will experience some degree of erection and the testes are drawn toward the body. The scrotum tenses up and gets thicker. In women, there is congestion of the vagina, labia

minora, and clitoris. The uterus is lifted up, increases in size, and vaginal secretions increase. The nipples harden and become erect. The next phase is the plateau phase. This happens just before an orgasm with increasing stimulation of the genitals. Muscle tension further increases and involuntary vocalizations occur. Being in this phase too long will lead to some people feeling uncomfortable and sexually frustrated. Males in the plateau phase have contraction of the urethral sphincter to prevent semen from mixing with urine. Rhythmic contraction of the pelvic muscles begins and preejaculate can be released. In women, the clitoris is increasingly sensitive and there is increased lubrication. This is the peak of sexual excitation if an orgasm isn’t reached. The orgasm phase involves cyclical contraction of the anal and perineal muscles, uterine contractions, and vaginal contractions. Muscle spasms happen throughout the body, the heart rate increases further and a sensation of euphoria is experienced. Males will ejaculate during orgasm. Women also experience the same sexual pleasure as men, even though most do not ejaculate.

MORE ON ORGASM Orgasm is also referred to as sexual climax. It discharges the sexual excitement built up in the excitement and plateau phases of the sexual response cycle. Its physiological activity is under the control of the autonomic nervous system. There is a natural euphoric response that releases oxytocin, prolactin, and endorphins, which contribute to a relaxing experience. The muscular contractions, particularly of the pelvic muscles, are a key feature of an orgasm, which help to dissipate sexual tension. The exact definition of what an orgasm is cannot, however, be agreed upon by doctors and researchers. There are physical, neurological, endocrine, and psychological definitions included under the umbrella of the word “orgasm”. An orgasm can be achieved with anal, vaginal, oral sex. It can also be achieved without penetration and can involve both masturbation and sex toys. While orgasms usually

mean genital stimulation is required, some can achieve orgasm through stimulation of other erogenous zones. Multiple orgasms are more common in females but are not universal. Dreaming can lead to orgasms and psychological orgasms can be gotten among people with spinal cord injuries. Sexual assault and rape can lead to involuntary orgasms. Males generally require penile stimulation to have an orgasm and ejaculation usually occurs. With dry orgasms in men, retrograde ejaculation, which is the passage of semen into the bladder rather than to the outside, is usually the underlying cause. Men can also have an orgasm by stimulating the prostate and can have ejaculation without an orgasm. There are two stages of male orgasm. The first is emission and the second is called the refractory period. In the refractory period, it is impossible to have an orgasm. Males can feel ejaculation coming on and will not be able to delay or stop this. This knowing that an ejaculation is coming happens about three seconds before it happens. Young men have a shorter refractory period than older men. Multiple orgasms in men are rare. The hormone oxytocin is responsible for the refractory period. Women usually require clitoral stimulation to achieve an orgasm. There are differences in how much stimulation is required to achieve one. The vagina is much less sensitive but the anterior wall and the area between the labia minor and the urethra will be sensitive. The G-spot is believed to be a spot called the urethral sponge along the anterior of the vagina. Some women have increased sensitivity of the clitoris after an orgasm that can be painful. Women can have a refractory period but are also capable of multiple orgasms. Most women cannot have a vaginal orgasm. Remember that the corpora cavernosa of the female clitoris extends downward on either side of the vaginal introitus. Because of this, some women will experience clitoral arousal from vaginal penetration but, rather than being a true vaginal orgasm, it is actually the clitoris that is being stimulated. The root of the clitoris extends to the anterior vaginal wall, which may explain arousal in this area. Anorgasmia is the inability to attain an orgasm after sexual stimulation. Some of this is due to an increased amount of time it takes for some women to attain an orgasm. Women experience orgasm about 25 percent of the time with vaginal penetration alone

but 81 percent will achieve an orgasm through cunnilingus, which is oral stimulation of the female clitoris. It was also once suggested that exercise alone could bring about an orgasm but this is hotly debated. There are nerve endings in and around the anus so sexual pleasure can be gotten through this type of sexual activity. We will talk more about anal sex in the next chapter. The prostate gland is also very sensitive in men so it can be stimulated with a perineal vibrator, perineal massage, or anal sex. Many men feel longer and more satisfying orgasms through stimulation of the prostate gland. In women, the shared sensory nerves among the clitoris and anus will lead to some clitoral stimulation with anal penetration. It is, however, rare to have an orgasm in females with anal sex alone. Nipple stimulation can happen as part of foreplay but can sometimes lead to breast or nipple orgasms. This is not a common phenomenon. What is known, however, is that nipple stimulation is received by the same parts of the brain that get sensations from the cervix, clitoris, and vagina. Oxytocin is released in nipple stimulation, which increases excitement and sexual arousal. The length of the male orgasm is between ten and fifteen seconds but it can be longer. The contractions of the pelvic muscles and anal sphincter happens along with contraction of the prostate. The euphoria rapidly dissipates after ejaculation and the amount of ejaculate decreases as the orgasm progresses. The duration of orgasms and the amount of semen released will decrease over time. In older males, the refractory period can last several days. Women have longer orgasms, lasting an average of twenty seconds. There will be muscle contractions of the anus, vagina, and uterus. Shuddering can also occur and pelvic contractions can be absent. The clitoral glans will retract under the clitoral hood and the inner labia darken. The outer vagina tightens while the total length of the vagina increases. The vagina will become congested with blood. The tipples will be erect and the feeling of contractions are felt to be pleasurable. Muscle contractions are the most reliable measure of an orgasm in women. Brain activity and orgasms have not been well studied. PET scanning or positron emission tomography has been used of the brain to assess orgasms in women. The

research shoes that letting go of anxiety and fear is necessary to have an orgasm. These parts of the brain diminish when clitoral stimulation happens. When these areas are shut down, an orgasm can more easily happen. Similar brain activity with orgasms is seen in males as well. The pleasure centers of the brain are turned on to a greater degree in men and the emotional centers are deactivated to a lesser degree in men compared to women. Orgasms as a whole are considered healthy. A study in middle-aged men showed that having more orgasms was associated with a decreased rate of all-cause death. There is a reduction in heart disease in men who have sex more than three times a week. Some men, on the other hand, will have post-orgasmic illness syndrome, which is muscle pain lasting up to a week after ejaculation. The resolution phase follows an orgasm as the body returns to having normal vital signs. The refractory period is part of this phase. Men, as mentioned, cannot generally be sexually aroused in the refractory period. Women probably do have a refractory period but it is generally shorter than in men. Because of differences between men and women, Masters and Johnson’s model better applies to men than it does to women.

STUDYING APHRODISIACS An aphrodisiac is a drug or substance that increases the sex drive. These are different from drugs that treat erectile dysfunction. The opposite of an aphrodisiac is an anaphrodisiac. It is difficult to study an aphrodisiac drug because of a high incidence of the placebo effect. Common substances that have been believed to be an aphrodisiac that do not have proof of this property is Spanish fly, yohimbine, bufo toad, and mad honey. Certain foods, like raw oysters, strawberries, honey, chocolate, and coffee, do not really have an effect. Of the known drugs felt to be aphrodisiacs, only testosterone and phenethylamines, such as methamphetamine and amphetamine, have been found to be successful. Testosterone seems to work only in those who have known low testosterone levels and amphetamines or methamphetamine will also have an effect but only in some people and only if the drug is given in high doses.

There are considered to be three types of aphrodisiacs. There are those that enhance sexual pleasure, those that increase potency, and those that improve libido. There are both animal and plant substances used throughout the world as aphrodisiacs. Most have not been well-studied. There are drugs and natural substances used to treat erectile dysfunction or ED, which will be covered more in a later chapter. It can be due to vascular causes, nerve damage, or psychological factors. Vascular causes are believed to play the greatest role in having ED. The drugs available do not work all the time, cannot be used in certain circumstances, and have side effects. There are many types of herbal supplements that are sometimes used instead. Chlorophytum borivilianum is the scientific name of the roots of a plant known as safed musli. It is believed to enhance male potency. It has been studied on animals, with an increase in sexual behavior seen in laboratory rats who took the supplement. It was believed that the drug has testosterone-like effects. It was also found to enhance libido and sexual arousal in rats in a dose-dependent fashion. From these studies, it has been suggested that the same thing might be true for men and women who use it. Mondia whitei is another herbal substance for libido and low sperm count. It was studied on sperm samples, showing improved sperm motility so it is suggested to be used for men who have sluggish sperm. It is also believed to enhance libido and sexual desire but it has not been adequately studied in humans for this purpose. Tribulus terrestris is a plant substance found in warm and tropical areas. It has been studied in animals and humans; it has been found to enhance libido and improve spermatogenesis. A recent study, however, showed it was not an androgen substance but that it does increase the testosterone and other androgen levels in test subjects. Research studies on rats show an increase in sexual behavior and potency. Crocus sativus is known as saffron and is made in Greece, India, and Iran. It is recommended in alternative medical circles as an aphrodisiac and increases sexual behavior in male rats. A randomized study, however, was done on the herb and compared it to traditional ED drugs. It was not shown to be beneficial.

Nutmeg has been studied in rats, showing increased mating performance. Date palm is used in the Middle East to treat male infertility and has been studied in rats. Maca is a Peruvian plant that has shown increased sexual activity in male rats. It does enhance sexual desire in human males but does not directly affect testosterone levels. Eurycoma longifolia is a Southeast Asian plant that is felt to have an aphrodisiac effect on male rats. Panax ginseng is believed to increase nitric oxide release in rabbits, potentially making it effective against erectile dysfunction. The takeaway from aphrodisiac studies of herbal supplements as aphrodisiacs is that most of the research has been done on laboratory animals and not on humans. There are no long-term studies looking at the safety and effectiveness of these substances in humans. There is a high chance of a placebo effect so any study done on humans requires a placebo-controlled study with clear endpoints in order to see if they work in humans at all.

KEY TAKEAWAYS •

Sex drive is also referred to as libido. It reflects an interest or desire for sex.

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There can be many types of external and internal stimuli that trigger libido.

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Sexual responsiveness can be due to the touching or stimulation of erogenous zones.

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Most orgasmic responses come directly from genital stimulation.

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Men and women differ in terms of their sexual arousability.

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The sexual response cycle refers to the different phases of excitation, plateau, orgasm, and resolution.

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Orgasm involves the discharge of sexual energy.

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Aphrodisiacs can address potency, libido, or sexual arousal.

QUIZ 1. Which neurotransmitter in the brain is most associated with libido? a. Serotonin b. Dopamine c. Acetylcholine d. GABA 2. According to Freud, where does libido come from? a. Subconscious desires of the id b. Lack of sexual satisfaction c. Adequate parenting in childhood d. The action of defense mechanisms in everyday life 3. What is true of sexual fantasies between men and women? a. Men and women fantasize about sex equally as often. b. Men fantasize ten times more frequently about sex than women. c. Women have more varied sexual fantasies. d. Men have twice as many fantasies and more varied fantasies. 4. What is true of arousal to erotic images between men and women? a. All women are more attracted to men, regardless of their orientation. b. Men are less likely to be aroused by the gender opposite to their orientation. c. Men tend to be more fluid with regard to what they are aroused by. d. Men are equally aroused by men having sex with men and men having sex with women.

5. What area in women is the least erogenous because it has the least number of nerve endings? a. Clitoris b. Vagina c. Anus d. Vulva 6. What area of the body is least likely to be erogenous? a. Back of the neck b. Navel c. Midback d. Inner elbow 7. What phase of the sexual response cycle involves the discharge of built-up sexual energy? a. Excitement b. Plateau c. Orgasm d. Resolution 8. What hormone is least likely to be released into the body as a result of having an orgasm? a. Testosterone b. Endorphins c. Oxytocin d. Prolactin 9. What is true of orgasms between males and females? a. Different areas of the brain are stimulated in males and females. b. Muscle contractions occur in women but not as often in men. c. Orgasms last longer in women. d. Men have a refractory period but women do not.

10. What is true of studying aphrodisiacs for their usefulness in humans? a. There are several herbal substances that have been found to help libido in men. b. Long-term safety studies show herbal treatments to be safe. c. Most herbal supplements are found to increase testosterone. d. Studies in humans need to take the placebo effect into account.

CHAPTER THREE: THE PSYCHOLOGY OF INTIMATE RELATIONSHIPS This chapter looks into the psychology of intimate relationships. Intimacy starts with attachment, and attachment, as you will learn, begins in infancy. The type of attachment a person develops in childhood determines how they will respond to intimate relationships in adulthood. Many times, intimacy involves some type of physical attraction, which is discussed in the chapter. There are several theories on what love really is, some of which is neurobiological. The chapter ends with a look at intimate relationships and the different types of intimate relationships that can be part of this or other societies.

EARLY ATTACHMENT AND INTIMACY Attachment is the need or tendency to develop a long-term interpersonal relationship with another person. Most people associate attachment with childhood but attachment affects how adults perceive themselves in a relationship and now they interact with their loved ones. Attachment itself does not encompass the entirety of a relationship but addresses specifically how a person responds in a relationship when they are separated from a loved one, hurt, or perceive some type of threat. All infants become attached as long as there is a caregiver but there are differences in the quality of that attachment. Infants have a natural tendency to seek proximity with their parent with the expectation that they will receive emotional support and some type of protection. Evolutionarily-speaking, attachment has advantages to the survival of the infant in the face of injury by predators or the threat of adverse environmental circumstances. Adequate social and emotional development depends on the ability of the infant attach to at least one of their parents. If the parent is responsive and sensitive, the baby will use the parent as a safe port from which to begin exploring the world.

Not all problems with attachment is the fault of the parent. There can simply be a mismatch or situation in the environment that can adversely affect the parent-child relationship. The difference between a sensitive parent and one that is not sensitive is the ability of the parent to manage disruptions and to repair the relationship. The infant has the disadvantage of not being able to get out of the caregiving relationship, even if it is a poor one. Instead, the infant learns to adapt to the situation and survive within the relationship that exists between themselves and their caregiver. They type of attachment a child develops determines their expectations in relationships they have as adults. There are four different attachment styles that will be discussed. In secure attachment, the child learns she can rely on the parent to attend to their needs. This is the healthiest attachment style. In anxious-ambivalent attachment, the child feels extreme separation anxiety and does not feel better when the caregiver returns. In anxious-avoidant attachment, the infant often avoids their parent, even though they are attached to them. In disorganized attachment, the child does not show any attachment behavior. The goal of attachment in a child is to maintain the availability of the attachment figure. This attachment behavior is activated by alarm or the fear of danger. Anxiety can occur when the child anticipates or fears being cut off from the parent. The first response is anger and anxiety. This is followed by feelings of grief and despair. By the age of three, the child is no longer feeling as much separation anxiety but certain threats to the child can reactivate the attachment system, such as parental absence, emotional unavailability, and evidence of abandonment or rejection by the parent. So how do babies learn to attach? It starts in the newborn period with smiles and crying that brings them to the attention of the parent. By two months of age, the child is more responsive to a familiar caregiver than one who is unfamiliar. The child may cling to the parent by six months of age. By one year, the child has more attachment behaviors and may follow their caregiver. After locomotion starts, the parent is seen as a safe port from which the world is examined. Any type of illness, fear, or anxiety will increase the child’s attachment behaviors. By two years of age, the child recognizes the caregiver as separate from themselves.

The overall strength of the child’s attachment behaviors is unrelated to the actual strength of the attachment bond. In other words, insecure children might have extreme attachment behaviors, while secure children might not put much effort into seeking attachment that they know is already there. Attachment affects the adult’s approach to romantic love, trust toward love partners, and readiness to have loving relationships. The securely attached child will engage with strangers and will be upset if the parent leaves. She will, however, be happy when the parent returns. All children attach according to the parent’s sensitivity to their needs. Parents who are relatively consistent will usually have securely attached children. The child learns to trust in a predictable parental responsiveness toward them. The anxious-ambivalent attachment involves little exploration of the environment and a wariness of strangers, even when the parent is present. This is a child who is very distressed by the loss of the parent but does not seem happy or satisfied when the parent returns. There can be anger or helplessness with regard to their parent when they return to the child’s environment. Children of abusive parents will have these types of ambivalent attachments. There will be difficulties maintaining an intimate relationship as an adult. The anxious avoidant or dismissive-avoidant attachment style will happen when the child shows little emotion when the parent leaves or the parent returns. He or she will not learn how to explore their environment with or without the parent present. This avoidant behavior actually masks the real distress the child is experiencing. As an infant, they likely did not have their needs met and learned that their behavior did not change the outcome of the attachment. The child is attached to the caregiver but is distant enough to avoid being rejected by them. The disorganized or disoriented attachment style describes a child who is trying to control crying as part of their distress over being unattached. There is a flooding of the attachment system and the appearance of a child that is not seeking attachment at all. Their behavior is neither avoidant or ambivalent. The parent may have been suffering from severe depression and often has trauma in their own life. Severe neglect can also lead to this type of attachment.

ATTACHMENT STYLES IN ADULTS Attachment styles have been extended to include certain attachment styles in adulthood that strongly affect their intimate relationships throughout life. The four different attachment styles seen in adults roughly correspond to those of infant attachment styles. The securely attached adult has a positive view of himself and of his partner. Intimacy is comfortable and balances with independence. There is a feeling of competence and the perception of the ability to control one’s environment. This is a person who feels that they can meet relationship challenges in the future. Communication with the partner is diverse in the different topics that are talked about and the relationship provides a secure base the adult can depend upon. The anxious-preoccupied adult needs a high level of intimacy along with a need for approval and responsiveness from their romantic partner. Becoming overly dependent can be an issue. The views the person has of themselves and their partner is less positive and there is more impulsiveness and worrying about the relationship. This would be an adult who had anxious-ambivalent attachment in childhood. Self-sabotage can happen in the relationship and the relationship can be anxiety-provoking. The person with this attachment style often looks for a dismissive-avoidant partner. The dismissive-avoidant adult is highly focused on independence and appears to avoid attachment. They feel self-sufficient and don’t think they need close relationships. Feelings are often suppressed and conflict is dealt with by distancing themselves from their partner. They often have a poor opinion of their partner and have a distinct lack of interest in having intimacy with others. They do not believe that another person can support them emotionally and invest greatly on their accomplishments. Their selfesteem depends on their level of competence rather than on social acceptance. Relationships that are getting too close are often avoided; they are dismissive of positive feedback from their peers. The ultimate goal is to avoid potential rejection. Fearful=avoidant adults are mixed in their feelings about clos relationships. They see themselves as unworthy of close and intimate relationships, even though they desire

them. They do not have a great deal of trust regarding their partners and suppress their feelings about intimacy. The secure adult is less likely to seek sexual experiences outside of their primary relationship. The dismissive-avoidant person is more likely to engage in activities of sex without love, such as one-night sex. Insecure people will tend to partner with insecure people but they don’t necessarily have shorter relationships—just those that are less emotionally satisfying. Secure relationships will have better conflict resolution and will process stresses together better.

THE BIOLOGY OF ATTACHMENT The study of attachment now includes concepts related to temperament, behavioral genetics, and neural development. It appears that some childhood temperaments make the child more susceptible to the stressors involved with abusive, neglectful, or unpredictable caregiver relationships. Certain children are simply more vulnerable to having an attachment disorder. The quality of parenting received during infancy and childhood affect the individual’s adaptive systems related to the regulation of stress. It is believed that the autonomic nervous system and the relationship between the hypothalamus, the pituitary gland, and the adrenal gland are most related to stress adaptation. Each of these, along with increased stress in childhood, relates later in life to the activity of the immune system and can affect things like the development of cancer and autoimmune diseases. There has been some research into the brain and how attachment works. There are distinct and interconnected brain regions that are shaped by attachment. Some neurotransmitter systems are connected to anxious attachment, while other neurotransmitter systems are attached to avoidant attachment. Markers in the immune system have been found to be different in adults with different attachment styles.

ATTACHMENT IN RELATIONSHIPS It turns out that our attachment styles affect who we select for our partner and how the relationship progresses. Knowing your attachment style can help you know what your strengths and weaknesses are in any relationship we are in. As mentioned, attachment styles are formed in childhood but provide a model for how we attach as adults. Your attachment style determines how we see our needs to be and how we go about getting those needs met. The anxious-preoccupied attachment style reflects a person who feels they need to be close to their partner at all times and to constantly get reassurance. They often select a partner who is dismissive or avoidant. The dismissive-avoidant person acts as though they don’t have any needs so they attach to someone who is more anxious and preoccupied. Basically, we look for a partner that confirms the model we have set up for ourselves. The anxious-preoccupied person often sets up some type of fantasy bond experience in which there is just an illusion of a connection. They feel an emotional hunger toward another person rather than true love. They look for someone to rescue them but often do things to push their partner away. This tends to reinforce clinging or possessive behavior. They see independence on the part of their partner as an attempt to leave the relationship. The dismissive or avoidant person often has a sense of pseudo-independence and feel they must parent themselves. They tend to be more self-focused and often focus on attending to their own needs. This, too, is an illusion because every human really needs some type of connection. The dismissive person will detach easily and will often shut down from an emotional perspective. They will say they don’t care if their partner leaves them. The fearful avoidant person is ambivalent because they are afraid of being close to others and are afraid they are too distant from others. This leads to unpredictable moods and behaviors because there is both a fear and a need for attachment. They do not really know how to get their needs met by another person and have rocky

relationships with fears of both intimacy and abandonment. This type of person is most likely to be in an abusive relationship.

PHYSICAL ATTRACTION Another part of intimacy and intimate relationships is physical attractiveness. This is the degree to which one person sees another as beautiful or aesthetically pleasing. This may or may not be related to sexual attraction. There are features of physical attraction that are the same in all cultures, such as a desire for facial symmetry. Certainly, there are personal preferences from on person to another person. Things like honesty and intelligence are rated higher by those who see the person as also being physically attractive. This may once have had evolutionary significance. Physical attractiveness and the perception of physical attractiveness can play a major role in a person’s social advantages, employability, sexual behavior, ability to have friends, and marriageability. The one thing that both genders appreciate is facial symmetry. Body symmetry is also important. Other things judged to be important by both genders are vivid eye and hair color, skin smoothness, skin clarity, and youthful appearance. The brain senses attractiveness in the orbitofrontal cortex, where the brain is most activated when exposed to what they perceive as an attractive face. Studies of the brains of heterosexual and gay people indicate that this area of the brain is most activated when exposed to the gender the person feels most physically attracted to. On the other hand, the nucleus accumbens and the anterior cingulate cortex are most activated when appreciating the physical features of an attractive body.

MALE ATTRACTIVENESS When it comes to women rating the attractiveness of a male, they are most attracted to a narrower waist and broad shoulders. A V-shaped torso is more appreciated as attractive as are the man’s height and facial symmetry. In general, women of any sexual orientation are less concerned with the physical attractiveness of their sexual partner.

The degree of differences between a man and woman’s physical traits is referred to as sexual dimorphism. Because of sexual dimorphism, male features include prominent cheekbones, high forehead, prominent nose, strong chin, and large jaw. Women who are in the follicular phase of their cycle and are ovulatory tend to prefer these things. This is less likely to be a factor during menses, during the luteal phase of the cycle, and if a woman is on birth control pills. This is believed to have an evolutionary advantage to the woman. Women who see themselves as being attractive are more likely to choose a man as being attractive if they have masculine facial dimorphism. This isn’t the case with women who don’t see themselves as being attractive. A similar study of gay men showed that tops preferred a man who appeared feminine, while bottoms preferred men who appeared more masculine. Men with no preference sexually also had no preference with regard to another man’s femininity or masculinity. Women of childbearing age like symmetrical faces in a man. These are believed to belong to healthier men in general. Facial symmetry in a man will predict the ability of a woman to have an orgasm with him. Men and women who are facially symmetric have a greater chance of having sex early in life and will have more sexual partners. They are also more likely to cheat on their partner. Some studies have shown higher salaries in men who are facially symmetric. Women are more interested in scent as being something that is associated with physical attractiveness. Women who like the scent of a man are also more likely to be attracted to a man who has facial symmetry. In men, body odor is linked to diet. An attractive male body odor is linked to a diet high in protein, fruits, and vegetables, and low in carbs. Women are also attracted to the scent of a man who has dissimilar genetics to her. This is believed to be the avoidance of inbreeding from an evolutionary perspective. Age and youthfulness may play a role in female attraction to men. In ancient times, being beardless and having a smooth body were considered attractive, although body hair in today’s time is believed to be more attractive than it once was. Gay men tend to prefer a man who is about their same age, although feminine men prefer older men and masculine men prefer younger men, in general.

Both men and women see the male with broad shoulders, a slim waist, and a muscular chest as being more attractive. Gay men especially see a low waist to chest ratio as being attractive. There is some evidence that a normal body mass index versus being overweight is considered more attractive to both genders. Women also prefer a flat abdomen but are less likely to prefer muscular men than is true of men appreciating another man’s musculature or their own musculature. Men who have a large penis see themselves as more satisfied with their appearance. Women, on the other hand, prefer a medium-sized penis for their long-term partner and a larger penis for a one-time sexual encounter. Skin tone preferences vary from culture to culture. Men who work outdoors in the sun tend to be darker so that light skin was considered to be associated with greater wealth. Men with red or yellow skin tones are believed to have better oxygenation and to eat more fruits and vegetables. These are believed by some to be men who are more attractive.

FEMALE ATTRACTIVENESS Heterosexual men are more attractive to body symmetry and younger women. Men play more attention to female attractiveness than women do of male attractiveness. Men prefer a woman’s face that has a high forehead, broad face, small nose, small chin, high cheekbones, smooth skin, wide-set eyes, and full lips. The overall face shape is also considered important. A thick ring around the iris is a sign of youth so this is also considered attractive. A face that is more feminine is considered to be more attractive than a face that is less feminine. Because fertility and youthfulness are considered to be related, younger women are considered to be more attractive and desirable than older women. Older women have higher ratios of testosterone to estrogen, which changes their facial appearances and makes them appear less attractive. All of this makes the desire for a youthful appearance be more prevalent in women of younger and younger ages. There is contradictory evidence as to the desirability of the female breast in terms of its size. While men like the appearance of the female breast, there are differences in 62

whether large breasts are preferred or small breasts are preferred. In general, men like breasts that are symmetric. Sagging breasts, on the other hand, are considered less attractive and associated with older age. Some cultures prefer women who are plumper, while others like thinner women. Certainly, the Western ideal is for a woman to be thin. What is just as important is having a proportionate body, regardless of actual size. Societies that have food shortages prefer women who are plumper. In general, women perceive men as liking other women who are thinner than is actually the truth. In other words, women are more judgmental about thinness than men. A waist to hip ratio of 0.7 is linked to better health and better fertility in women. High waist-to-hip ratios tend to be associated with decreased fertility rate. A smaller waist to hip ratio is judged to be more attractive by both genders. This is considered to be one of the most important aspects of the male choice for a mate. There are slight differences according to ethnicity with a preference for overweight women being seen in cultures who do not have obesity as a problem. The opposite of what happens in men is true in women when it comes to physical height. In general, men in today’s Western societies like short women and height itself is less important in selecting a female mate than selecting a male mate. The view of a tall woman with a shorter man is less likely to be an appealing one. This is less true in certain ethnic groups. On the other hand, long legs are valued in women but not in men. Small feet are valued in a woman but not in a man. Long hair is considered more attractive in women. Walking with a hip sway is attractive in women as well. Women are perceived as more attractive when they are the most fertile, although it is not clear if she changes her appearance or behavior during that time. Faces are subtly different during ovulation by both men and women. On the other hand, women prefer men with a more symmetrical face during their most fertile time. Women with a lot of estrogen are seen to be more attractive than women with low estrogen levels.

THEORIES ON LOVE Love involves a wide range of positive, strong emotions and thoughts toward another person. Love is different depending on the context. Parental love, for example, is different from romantic love. Love implies some type of attraction and emotional attachment. Love helps to facilitate many types of interpersonal relationships and is a big part of the creative arts. It is considered an evolutionary advantage to be able to love. Love can mean many different things and, in fact, since ancient times, there are several different types of love that have been named. An example is romantic love, called the eros in Ancient Greece. The opposite of love can be the presence of hate or neutral apathy. Love and lust are two different things and, while love and friendship are related, they are also not the same thing. One can have impersonal love toward a goal, principle, or object they are highly committed to and value a great deal. Material objects can be loved, such as the love for an animal, material object, or certain activity. Romantic love and passion for an object is called having a paraphilia. Most of what we consider to be love is interpersonal love. If it is unrequited, it means the love is not reciprocated. Interpersonal love can be between couples, close friends, or family members. The different theories on love relate to a variety of things, from biology, neuroscience, psychology, and anthropology. Love in biology is seen as a typical mammalian drive, related to thirst and hunger. There are three stages of love in some theories, which include lust, attraction, and attachment. There are different neural circuits associated with these three stages. Lust promotes mating and involves sexual desire. There is an increase in estrogen and progesterone in this phase. Attraction requires some type of mate selection, involving the neurotransmitters norepinephrine, dopamine, and serotonin. These are the same hormones seen when amphetamines are used. Both lust and attraction are temporary and lead sometimes to attachment. This involves long-term bonding and lasting relationships. Oxytocin and vasopressin are released in attachment.

Love also has a psychological component. This leads to Sternberg’s triangular theory of love, which indicates that love is a combination of commitment, intimacy, and passion. Intimacy can be seen in romantic relationships and friendships. Commitment is the expectation of permanency. Passion refers to a sexual connection with the person. Different types of relationships have different components of each of these. Complete or consummate love includes all three components of the triangle. People tend to love those people who are similar to them. There doesn’t appear to be any truth to the idea that opposites attract. Many psychologists have proposed that love is not just a feeling but also involves actions and activities. Evolution favors love as being advantageous. Human love often leads to monogamy rather than polygamy. When in a monogamous relationship, there is a decreased risk of sexually transmitted diseases, which can later diminish fertility. This creates an evolutionary advantage to being able to love. There are different forms of love in Ancient Greek teachings. There are four types of love as defined by the Ancient Greeks. These include Agape, which generally means love or pure, ideal love, and eros, which involve passionate love and sexual desire. Philia is virtuous love toward the community, family, and friends. Storge is love and affection that is natural, such as between parents and children. Xenia is also called “guest love”, which is more ritualized. There are different ways that love is seen in different religions. In the Hebrew religion, there is no difference between love between God and God’s creations is the same as interpersonal love. There is also loving-kindness between different individuals. Christians believe in love that comes from God. Agape is also recognized as selfless and unconditional love. Phileo is called brotherly love. Love in Islam is available to all who hold faith. Divine love is a feature of Sufism in the Islamic faith. Buddhists, on the other hand, believe that sexual love can block the pathway to enlightenment because it can be selfish. Compassion and mercy are forms of love that are necessary for enlightenment because they reduce the suffering of other people. In Hinduism, sexual love is pleasurable, although there is a term used to describe elevated

love and one that describes both compassion and mercy. There is also love to one supreme God. There are psychological theories of love by different psychologists and psychiatrists. Sigmund Freud had an early theory on love, where he believed that engagement of the ego was related to the ability of love. According to Maslow’s hierarchy, self-actualization at the top of the hierarchy indicates someone who is capable of love. Rubin identified the difference between liking and love, with love having the components of caring, attachment, and intimacy. According to Sternberg, intimacy is the most important factor in attaining love. Sternberg identified several forms of love that involved different combinations of intimacy, passion, and commitment. Currently Sternberg’s triangular theory of love is most accepted.

INTIMATE RELATIONSHIPS Intimate relationships involve, of course, some level of intimacy. There are certain neuroanatomical theories on why humans are intimate. Components of love are romantic love, attachment, lust, and rejection as part of love. As mentioned, attachment is a big part of intimacy. It helps to initiate preferences in a partner. Most monogamous relationships are exclusive and involve a desire to share responsibilities of parenting. Studies on animals show that dopamine in the ventromedial area, nucleus accumbens, and prefrontal cortex gets activated, which leads to activation of reward systems in the brain. Oxytocin is more important in female intimacy and less important in males, whereas arginine vasopressin is a major component of mate selection and pair bonding in males. Both males and females will activate the dopamine system. There are also oxytocin receptors in the prefrontal cortex and arginine vasopressin receptors in the ventral pallidum. Romantic love involves attention to a specific person. Studies have shown that the right ventral tegmental area of the brain is activated when a person sees a picture of someone they love. Dopamine is released by other parts of the brain as part of a reward system.

The limbic system involves the hippocampus, amygdala, hypothalamus, and temporal lobes. These areas are involved in processing emotions, motivation, and the development of memory. Both oxytocin and vasopressin are released by the hypothalamus as part of bonding and romantic love. Figure 12 shows the limbic system, which is deep within the brain:

Figure 12.

Lust is also part of libido, which is the pursuit of sexual gratification. The endocrine system, which includes the hypothalamus-pituitary-gonadal axis and the hypothalamicpituitary-adrenal access are partly responsible for sexual priming and the stress response. Activation of steroid hormones helps to drive social attachment and partner preference when it comes to sex. Dopamine, as mentioned, is part of the reward system. Different parts of the brain are activated when it comes to romantic love and lust.

Separation from a loved one or rejection by a love interest can lead to depression. There will be hypothalamic dysfunction with loss of eating and sleeping. Anhedonia or lack of interest in things is related to the amygdala and the ventral striatum. In actuality, many areas of the brain shut down after rejection by a loved one. There is ongoing involvement of the reward system, which can lead to stalking behaviors and obsession. Love tends to activate the same neural pathways as addictive drugs like cocaine. The dopamine reward system gets activated suggesting that love is addictive. Brain activity has been studied, showing activation of the same pathways as those people addicted to cocaine The emotional processing center, the amygdala, is more activated in the left hemisphere in women and the right hemisphere in men. Emotional processing then is considered generally gender specific. Different areas of the brain are activated when emotions are part of an intimate relationship. Jealousy stems from insecurity in a relationship. It can lead to abuse and violence in extreme situations. Sexual infidelity activates different parts of the brain in men and women. Men have more amygdala stimulation, while women have more stimulation of the thalamus and visual cortex. This may explain why aggression is part of sexual infidelity and jealousy in males. In cases of emotional infidelity in women, there is an increased connection to trust and deception related to the other partner. An intimate relationship involves both some type of emotional and physical intimacy. It is generally a sexual relationship but does not always have to be. There is emotional intimacy, involving liking or loving, and physical intimacy, which involves sexual activity or passionate attachment. The desire for intimacy is innate in humans and gets satisfied through having intimate relationships. Intimacy is a feeling. It involves having a close and personal connection to others as well as a sense of belonging. It is gathered through the knowledge and overall experience with another person or people. There needs to be some type of vulnerability, reciprocity, dialogue, and transparency with another. What intimacy means depends on the person and their relationship. Successful intimacy involves being both separate and attached to another. In other words, there must be self-differentiation.

The failure of developing intimacy can involve difficulty attaining and maintaining intimate relationships, along with a fear of disruptions in these types of relationships. A fear of intimacy is related to discomfort with emotional closeness and lack of satisfaction relationships. There is increased anxiety and loneliness with a fear of intimacy. Researchers divide intimacy into four different forms. There is physical intimacy, which can involve being inside another’s personal space and sexual activity. Emotional intimacy involves trust and “falling in love”. Cognitive intimacy is the interpersonal exchange of thoughts, while spiritual intimacy involves bonding over one’s spiritual beliefs.

NON-MONOGAMOUS INTIMACY While most people have physical intimacy with a single person, the phenomenon of polyamory involves the desire for or practice of having intimate relationships with more than one person, with the total consent of all partners. It is also referred to as responsible non-monogamy. These are open relationships that together manage things like rivalry and jealousy. It is a particular life philosophy similar to gender identity and sexual orientation. People who practice polyamory believe in loyalty and fidelity in the group settings rather than with a single person. Communication and negotiation are important with the acceptance that there will be issues in these types of relationship. Members of a polyamorous group have mutual respect for one another, dignity, trust, and honesty. There is an emphasis placed on not being possessive of any one person. One phenomenon is called compersion, which is being empathetic when another member feels joy and happiness. It is considered the opposite of jealousy. The prevalence of polyamory is unknown but European research indicates that 9 percent of people agree that they could have several sexual relationships at a time. Many people in these relationships keep their behavior private in settings where it is not considered socially acceptable. This type of relationship is not accepted by most Christian religions nor is it accepted by mainstream Judaism. People who practice

satanism are somewhat more forgiving of these types of relationships. Unitarian Universalists involve a greater tolerance for polyamory. Polyamory is just one aspect of an open intimate relationship. Open relationships largely involve sexual non-monogamy but not necessarily emotional non-monogamy. There are different types of open relationships besides polyamory, including multipartner relationships, hybrid relationships, and swinging. Swinging involves couples in committed relationships who engage in recreational sex with other couples. Usually the sexual relationship is casual and can involve group sex. Open marriages involve an intimate couple who both believe the other can have another sexual relationship. In a hybrid relationship, one person is monogamous, while the other is non-monogamous. Polygamy is being married to more than one person at a time.

KEY TAKEAWAYS •

Attachment is part of intimate relationships. It tends to form a pattern in childhood that persists into adult relationships.

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Sexual attractiveness is another part of an intimate relationship. Attractiveness is different with men and women and is generally more important to men.

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There are many theories on love, which involves intimacy but can mean other things as well.

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Intimate relationships and the desire for intimacy is said to be a part of innate human needs.

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There are variations on monogamy that some couples practice.

QUIZ 11. Which type of attachment involves a lack of attachment behavior? a. Secure attachment b. Anxious-ambivalent attachment c. Anxious-avoidant attachment d. Disorganized attachment 12. Which type of attachment most involves having marked separation anxiety? a. Secure attachment b. Anxious-ambivalent attachment c. Anxious-avoidant attachment d. Disorganized attachment 13. What adult attachment style is most associated with a person who needs regular reassurance about their relationship? a. Secure attachment b. Anxious-preoccupied c. Dismissive-avoidant d. Fearful-avoidant 14. Which attachment style would lead a person to possibly being in an abusive relationship and have rockier relationships than most? a. Secure attachment b. Anxious-preoccupied c. Dismissive-avoidant d. Fearful-avoidant 15. What is not true of men with facial symmetry? a. They are more likely to cheat on their partners. b. They are more attractive to women. c. They have more sexual partners. d. The are more honest.

16. What is not true of a woman’s perception of the male scent? a. It is not a factor in selecting a mate. b. Certain body odors are considered related to attractiveness. c. Body odor attraction is related to the man’s genetic makeup. d. Body odor is related to having a better diet. 17. Love directed toward what in particular is a paraphilia? a. Sexual partner b. Close friend c. Inanimate object d. Family member 18. What aspect of love is most long-lasting? a. Sexual attraction b. Lust c. Attraction d. Attachment 19. Which neurotransmitter is most associated with the phenomenon of intimacy? a. Serotonin b. Glutamate c. GABA d. Dopamine 20. What is not a part of intimate relationships and intimacy? a. Intimacy is an innate human need. b. Intimacy means some type of sexual contact. c. Intimacy may be emotional and can occur with non-sexual people. d. Intimacy can happen with more than one person at a time.

CHAPTER FOUR: SEXUAL BEHAVIORS This chapter looks into different types of sexual behavior performed in human sexual experience. Sexual behavior can be a singular activity as is seen in masturbation. Some people practice oral sex, which is one of the sections in this chapter. The most common sexual activity in heterosexuals is sexual intercourse, while both homosexual and heterosexual couples can practice anal sex, which is covered in the chapter.

MASTURBATION Masturbation involves becoming sexually aroused by the stimulation of one’s own genitalia for the purposes of achieving an orgasm. This type of stimulation can involve using one’s own hands, fingers, sex toys, or everyday sexual objects to become sexually aroused. There is also the phenomenon of manually stimulating one’s sexual partner through things like a “hand job” or fingering, which can be done mutually or all at the same time. This type of activity is generally a substitute for penetration. People of both genders engage in masturbation, which is currently felt to be related to a healthy attitude toward sex in general. Figure 13 shows several vibrators used in masturbation:

Figure 13.

The word “masturbation” was first used in the 1700s, although the actual Latin meaning of the term. An earlier term for masturbation was onanism. There are numerous slang terms for masturbation, including jerking off, wanking, and flicking the bean. There are numerous techniques, such as rubbing, massaging, pressing, or inserting one’s fingers or some type of object into the anus or vagina. An electric vibrator can be used along with stimulating other erogenous zones in the body. Lubricants are sometimes applied in both genders and many people will use sexual fantasies or pornography in order to masturbate. Some will do “sounding” of the urethra, which involves inserting some type of tube or small, thin object into the urethra—a practice that can be associated with infection or injury. The process of edging involves masturbating until one is close to an orgasm and then stopping for a bit before resuming in a multi-cyclical fashion that leads to the buildup of sexual tension and an even stronger orgasm at some point in the process. Men who masturbate will lie down, sit, kneel, stand, or squat. The penis is held in the fist and stroked in an up and down fashion. Some will do this quickly while others will 75

do it slowly. This is usually all that is necessary to ejaculate and have an orgasm. Men who are uncircumcised will pump the foreskin over the glans, resulting in darkening of the glans penis. The foreskin is lubricated to reduce friction. It can be done in circumcised men who have enough of the excess skin left over. Men who have been circumcised will make contact with the glans and their hand. Often, a lubricant or saliva is used in order to reduce friction. Sometimes the shaft is slid back and forth or the man will use the friction from a mattress while lying face down. An artificial vagina or simulacrum is sometimes used. Still another technique is to do prostatic massage by inserting a dildo or finger into the rectum. The prostate is on the anterior wall of the rectum and is sometimes called the male G-spot. Pressure on the perineum will sometimes stimulate the prostate gland from the outside of the body. Men can engage in anal masturbation without stimulating the prostate gland. A finger or dildo can be used. An object placed in the anal sphincter will stretch the perianal muscles, which will often intensify the orgasm because these muscles contract during an orgasm. The anal area is highly sensitive and the practice is preferred by using a lubricant. The outer ring of the anus alone is very sensitive. Fondling of the scrotum, testes, nipples, or other erogenous zones can help. Pelvic thrusting can be done with still hands in order to simulate the activity of sexual intercourse. A handheld showerhead can be used to direct water at any of the male genitalia. Men will also sometimes use dildoes. Female masturbation involves the stroking or manipulation of the clitoris and vulva, usually with two fingers. A finger or a dildo can be inserted to stimulate the anterior vaginal wall. The caressing or stimulation of the breasts or anal stimulation can be used. Some women prefer a lubricant, while others do not need this. Typical positions can be kneeling, standing, lying supine or prone, and sitting. A handheld shower head can be used to stimulate the clitoris or vulva. Rubbing against a pillow while lying prone can be used as well as the corner of a chair or other piece of furniture. Pressure or direct contact with the clitoris may be alternately preferred.

Crossing the legs and clenching the leg muscles can be done in public and some women can have an orgasm just with fantasy. Mutual masturbation involves two people stimulating each other, which can be done with any sexual orientation. It can be a part of foreplay or can replace penetration. There are different ways of doing this. Non-contact masturbation involves two people masturbating together but without touching. Contact mutual masturbation involves one person touching another at the same or different times. Non-contact group masturbation involves a group of people who do not touch each other, while contact group masturbation involves masturbating each other in a group. There are several things that determine the frequency of masturbation. It depends on one’s hormone levels, resistance to sexual tension, peer influences, sexual habits, and societal attitudes about the practice. About 95 percent of males masturbate and 70 percent of women masturbate at some point in their lives. In all studies, males masturbate more frequently. Infants and children are known to masturbate. Masturbation happens just as often in a relationship as when a person is single. Having an orgasm between a minute before or forty-five minutes after insemination will increase the chances of conceiving a child. For this reason, masturbation and orgasm are said to be evolutionarily advantageous. In men, masturbation flushes out old and poorly motile sperm so that better and more active sperm cells can be ejaculated in intercourse to increase the chances of conception. As you will soon hear, masturbation was not always considered to be healthy Now it is considered universally to be a healthy behavior unless it is compulsive and results in distress. It was only considered to be a normal behavior by the AMA in 1972. In fact, it is sometimes used in sex therapy. Among the health benefits of masturbation are that it increases sexual satisfaction, relieves depression, improves self-esteem, improves interpersonal relationships, decreases prostate cancer, and decreases all-cause mortality, including those from coronary artery disease. In addition, it cannot cause a sexually transmitted disease and promotes relaxation and sleep.

Compulsive masturbation is like any other compulsive behavior can be problematic. Be aware that babies and young children will play with their genitals and this does not usually represent a problem unless it is all-consuming. Excessive masturbation can be a sign of prior sexual abuse in a child.

HISTORY OF MASTURBATION Masturbation has existence since prehistoric times. It was considered healthy by the Sumerians, the Ancient Egyptians, and the Ancient Greeks. Each of these cultures had a relative relaxed attitude toward sex and to masturbation. In some Asian cultures, it was believed to lower energy levels. African countries and ethnic groups do not always have words for masturbation in their languages. In Western societies, masturbation wasn’t always considered healthy. It was once believed that it was criminal behavior and that it decreased male virility. In the early 1700s, it was called onanism and was believed to be both injurious and sinful. In the 1800s, it was believed to cause insanity. This was when circumcision was recommended in English-speaking cultures. Sigmund Freud believed that masturbation was addictive. In the same era, medicallyinduced masturbation was recommended for women with hysteria. It was also felt to induce feelings of guilt in those who practiced it. Kinsey in the 1940s said that masturbation was instinctive and should be practiced. It was a diagnosable psychiatric condition prior to 1968. In recent years, it has been promoted as a healthy physical and sexual activity.

SEXUAL FANTASIES An erotic or sexual fantasy is some type of thought or imagery that enhances sexual feelings and sexual arousal. It can be directed through the use of pornography, literature, memories, the presence of an object, or attraction to another person. Sexual arousal itself can give rise to a sexual fantasy. Sexual fantasies are found throughout the world but do not always get acted upon. If acted upon, it could lead to sexual role playing. 78

Sexual fantasies may be a positive or negative image or both. It can be entirely imaginary or related to a past experience. Fantasies do not have to be practical or socially acceptable but can be an interesting look into a person’s psychological processes regarding sexual behavior. There is an entire genre of fantasies displayed in literature, movies, and other media, although some are not completely comfortable for everyone. It is not always easy to objectify or to measure sexual fantasies. Research is done with things like checklists, asking people to write down their fantasies, or having people record their sexual fantasies. Some research has been done looking at the subjective experience of fantasies along with objective measures of sexual responses, which can be done experimentally. Women are more difficult to judge than men with regard to sexual fantasies. They are harder to measure when it comes to physiological responses and do not always know when they are aroused. In addition, they can become aroused by romantic imagery rather than just sexually explicit imagery. Gay people are difficult to study because they can be afraid of being outed for being gay. Children are also much more difficult to study so there is little research done on young people. Sexual fantasies can be extremely ordinary or so bizarre that they can be seen as taboo. Many fantasies involve dangerous things or things that are illegal, such as kidnapping and rape. Nevertheless, it allows people to escape the restraints of their actual sex life. Fantasies can be so powerful that they can be the only way a person gets an orgasm. Sexual fantasies can be used to help couples have better sexual pleasure and communication. Arousal and orgasms are enhanced by sexual fantasies, which are increasingly being seen as a part of healthy sexual behavior. Some simply cannot be done in real life and, even if they represent abnormal sexual thinking, they tend to strengthen everyday sexual relationships. They can be used to resolve difficult emotions. Fantasies often relate to attachment issues. People with anxious attachment have more fantasies than people with secure attachment. It allows people with attachment issues to work through their sexual feelings in a safe manner. While women fantasize about people they already have an attachment to, men will fantasize about sex with someone

young and seemingly perfect as a reproductive partner. There may or may not be the desire to actually carry out a fantasy Couples can use shared fantasies to enhance intimacy and improve trust between them or to increase sexual arousal as a part of foreplay. Sexual fantasy can be used in sex therapy to improve the sexual experiences of a couple. Common fantasies include reliving a past exciting sexual experience or having sex with a different partner. Other fantasies involve oral sex, sexual power, sexual irresistibility, sex in a romantic place, and even rape. Of all fantasies, those of having oral sex are of the greatest frequency, although others involve sex with multiple partners, sex in risky locations, and some type of infidelity. Men are more likely to fantasize about an experience they’ve already had, while women are more likely to invent an imaginary lover or an encounter they haven’t experienced. Men will fantasize with explicit visual detail, while women fantasize about certain types of emotional or mental images. Women often incorporate aspects of the relationship with another into their sexual fantasies than is true of men. Both sexes fantasize about sex with a same-sex partner. Men are more likely to fantasize about group sex or threesomes; they have more variation in partners in their fantasies. Men fantasize more equally on submission and dominance, while women fantasize more frequently about submission. Some of the disparity has decreased with changing gender roles in society. Men fantasize first between 11 and 13 years of age, while women first fantasize at a somewhat older age. There are some people who have what could be termed paraphilic fantasies. This can include voyeurism, fetishism, incest, pedophilia, and zoophilia (which is sex with animals). More than half of men fantasize about sex with someone who is underage, while a third fantasize about rape. The onset of these types of fantasies is prior to 18 years of age. More men have unusual sexual fantasies than women.

ORAL SEX Oral sex involves the stimulation of another person’s genitals by using some part of the mouth. The proper terms are cunnilingus, which is oral sex on a woman’s genitals, fellatio, which is oral sex on a penis, and anilingus, which is oral sex on the anus. Oral stimulation of other body areas is not considered oral sex. Oral sex can replace penetration altogether or can be used as part of foreplay. It generally increases sexual arousal. There is a risk of getting an STD but it is less than with penetrative intercourse. Oral sex is a matter of preference but it isn’t considered taboo in most societies of the world. Variants of oral sex include face-sitting, which means the receiver sits on the other person’s face in order to have oral sex. It can be done on both partners at the same time, depending on their position, which is often called the sixty-nine position. Autocunnilingus involves a woman stimulating her own genitals with her mouth. Oral sex can be done in order to preserve virginity as can be true of other nonpenetrative sexual acts. This may not be the case with lesbian females, who consider fingering as a loss of virginity, although this can vary with the couple. It is also a way to practice safe sex and to reduce the incidence of STDs. Unless sperm get on the hands or fingers, a woman cannot get pregnant with oral sex. Condoms and dental dams are used in fellatio and cunnilingus, respectively, to decrease the risk of passing on an STD. Oral sex can transmit human papillomavirus, gonorrhea, herpes, and certain types of hepatitis. There is a risk of HIV but this is lower than with penetrative sex. There are different cultural views on oral sex. Fellatio, in particular, is considered taboo in many cultures and was taboo in Ancient Rome. Cunnilingus, however, has been more accepted through the ages. Lesbian couples have differing opinions about whether or not to engage in this sexual activity.

COITUS Coitus or sexual intercourse involves the thrusting of the penis into the vagina, also referred to as vaginal sex. There are other forms of penetrative sexual intercourse, such 81

as anal sex, which will be discussed next, fingering, which involves sexual penetration by the fingers, and penetration with a dildo. Each of these is used for physical and emotional pleasure, while vaginal sex with the penis can also be used for human reproduction. Some people use the term sex to mean sexual intercourse only but, of course, there are other kinds of sex in human sexuality. Sexual intercourse for the purposes of reproduction in non-humans is often called copulation. In most mammals, copulation occurs around the time of estrus, which is the female’s most reproductive time. Chimpanzees, dolphins, and bonobos all engage in sex outside of estrus and can engage in sex with a partner of the same gender. While it isn’t known for sure, the behavior may be related more to the experience of pleasure than for reproduction. Penetration of the vagina by a penis that is erect is called intromission. The age of first sexual intercourse is called sexarche. Legally, in some countries, the term “carnal knowledge” is used to mean some type of sexual intercourse. When a woman has sexual intercourse, it is said she “loses her virginity” but the term could also mean having any other kind of sex and is also used for men who’ve had their first sexual intercourse experience. Sexual intercourse involves both physiological and psychological stimulation. The most common position for intercourse is the missionary position. Foreplay may precede sexual intercourse, which allows for penile erection and vaginal lubrication. Nonprimate female animals only copulate in estrus, even though it is possible at all points in the menstrual cycle. There are sex hormones or pheromones used to stimulate copulation in animals but in humans, there is not believed to be an effect of pheromones in humans. One of the goals of intercourse is to position the two individuals so that there is friction between the penis and the vaginal walls. Most women require direct clitoral stimulation to have an orgasm but vaginal intercourse may be enough to cause an orgasm in the woman. The woman on top position most increases clitoral stimulation. The act of vaginal intercourse is the best way to have human reproduction. Semen contains spermatozoa that get expelled through ejaculation, where the sperm cells then

travel through the vagina, cervix and uterus to get to the fallopian tubes. There are millions of sperm in each male ejaculation. As mentioned, there are only a few days in the cycle that a woman can conceive a child. We will talk more about birth control in a later chapter. Non-penetrative sex can be used or anal sex to avoid a pregnancy. If the penis is anywhere near the vagina during ejaculation, however, pregnancy can occur. Condoms are used for reduction in pregnancies and to reduce STDs. About 85 to 99 percent of HIV transmission is avoided when condoms are used. Some cultures practice fertility awareness or the rhythm method for birth control. Couples can practice coitus interruptus or the exiting of the penis before ejaculation but this does not always work because pre-ejaculate can contain motile sperm. Couples who use condoms have been studied and have the same amount of sexual satisfaction as can happen without a condom so this is a common practice to avoid a pregnancy. Most heterosexual couples engage in sexual intercourse every time they have sex, with intercourse being the most prevalent sexual behavior among men and women of all ages. Oral sex is the next most common and anal sex is less commonly practiced. The age at first intercourse varies among the different cultures. The age is higher in Catholic countries. In the US, the average age is about 17 years at the time of sexarche. Most girls lose their virginity to boys who are older than they are by one to three years. There are health benefits to sexual intercourse. It increases the immune system, decreases the risk of prostate cancer, and decreases blood pressure. It releases oxytocin, which enhances bonding and trust. The biggest risk of sexual intercourse is the passage of sexually transmitted diseases of all types. Another risk is unintentional pregnancy. Sex can lead to sexual addiction or hypersexuality as a type of obsessive-compulsive disorder. There is a gene that gets turned on with sexual activity that can lead to hypersexuality or sex addiction. There is also a risk of a heart attack during sex but this is rare. Women often do not have an orgasm in the time it takes for the man to have an orgasm so they are more likely to fake an orgasm. Some women experience anorgasmia or the inability to have an orgasm despite adequate stimulation. Another possible problem

with sexual intercourse is vaginismus, which is tensing of the pelvic floor muscles so that penetration cannot occur. Men can have erectile dysfunction. We will talk more about the different sexual problems in a later chapter. Sexual intercourse plays a big role in bonding between a man and a woman. As we have discussed, intercourse can be for relational, reproductive, or recreational purposes. In humans, it isn’t known when a woman is ovulating so protection against pregnancy has to occur if this is not desired. Couples who do not have a good experience with intercourse have a greater chance of becoming divorced or separated. Infidelity also plays a role in relationship dissolution. While intercourse is primarily for reproduction from a physiological standpoint, there are a great many moral and ethical issues associated with the legal system and religion in a given culture. There are different practices that are considered acceptable or taboo in the various cultures. We will talk about rape and sexual assault in another chapter but this is defined as sexual intercourse without the person’s consent. Most countries have an age of consent when sex can be consented to but this varies in different cultures. In most societies, incest is criminalized behavior. In most cultures, intercourse is necessary for the consummation of a marriage. Failure to do this is grounds for annulment in some places. Other cultures consider intercourse to be a marital right, mainly referring to the husband’s marital right to have intercourse. Until recently, it was considered impossible for a husband to rape his wife because of marital exemption. Adultery or engaging in intercourse with someone other than the spouse is considered a criminal offense in some parts of the world, while sex between unmarried persons is also considered illegal in some places.

ANAL SEX Anal intercourse involves the insertion of the erect penis into the anus and rectum. Fingering and sex toys can be used for this practice and one can also do anilingus or pegging, which involves a strap-on dildo. Sometimes, anal intercourse is used to define penile to anal penetration and anal sex to include any other type of anal sex behavior in a couple situation.

Anal sex is often associated with homosexual male sex but men and women do this too and not all gay men engage in anal sex. Lesbians an also engage in anal sex because the anus is highly innervated and sex involving the anus can lead to an orgasm in men because of prostate stimulation. Some people, on the other hand, find anal sex extremely painful. STDs can be passed through anal sex, particularly because the anus is not lubricated as is the case with the vagina. Anal sex can be pleasurable for both men and women because of the sensitivity of this area and the high concentration of nerve endings. The outer anus is more sensitive than the inner anus. Both the anus and rectum can expand when necessary. Anal sex is less frequent than other sexual behaviors. There are people who engage in anal sex using anal beads, dildoes, butt plugs, or fingering of the anus. Fisting involves inserting the entire hand into the anus but this is the least practiced of all anal activities. The male receptive partner has the added stimulation of the prostate gland, which can lead to an orgasm. Men sometimes say the orgasm is deeper and more intense with prostatic stimulation. In women, the deeper structures of the clitoris can be stimulated, leading to sexual pleasure and sometimes an orgasm but this would be rare. A major goal of painless anal intercourse is to use a personal lubricant so as not to tear the tissues. Men receive greater pleasure inserting the penis into the anus of a female rather than the vagina because the muscles of the anus are tighter. It is also felt to enhance the male dominant role in sex, which makes it more sexually pleasurable for the man. Women differ in their desirability over having anal versus vaginal sex; there is a great deal of personal preference. It is sometimes used by a male-female couple to prevent pregnancy or during menstruation. It is also said to lead to technical virginity so the woman doesn’t tear her hymen. Most anal intercourse is associated with male to male sex, even though many gay couples do not have anal sexual intercourse. The insertive male member is called a top, while the recipient male member is called a bottom. Some men are versatile and do either practice. It is a natural expression of intimacy between two men in a homosexual

relationship. About 46 percent of gay men prefer to be tops and 43 percent of gay men prefer to be bottoms. About 75 percent of gay men have had anal sex at some point. Female to male anal sex is done through fingering the man’s anus, prostatic massage, anilingus, sex toys, or a strap-on dildo, which is referred to as pegging. This practice is not well-accepted by the male member who see it as a feminine act. Nevertheless, the actual incidence of this behavior is not completely known but is believed to be about 7 percent of men. Lesbians can also engage in anal sex of all forms. There is less information on this type of behavior mostly because lesbian sexual practices are not well studied. It is believed to be more common among younger lesbians. Anal sex is somewhat more risky than vaginal sex. There is an increased risk of generalized bacterial infections, sexually transmitted diseases, and anal trauma. Condoms and lubricant can decrease the risk of all of these problems. Condom breakage or coming off is more likely with anal sex than with vaginal sex. Receptive anal sex carries a high risk of HIV disease and is the highest risk of sexually contracting the disease. Pain experienced during receptive anal sex is called ano-dyspareunia. It affects about 60 percent of gay and bisexual men, affecting about 25 percent of gay men all of the time. Some men cannot engage in receptive anal sex at all because of this. Most of the time, the pain is psychological, particularly if measures are taken to reduce the incidence of pain. Anal sex will increase the risk of a man who receives it of developing antisperm antibodies, which might affect fertility. Other problems with anal sex is the exacerbation or formation of hemorrhoids, or an anal fissure. Perforation of the colon can occur. Fisting, in particular, can be linked to tearing of the anus and rectal trauma. Anal cancer can be gotten from an HPV infection of the anus during anal sex.

KEY TAKEAWAYS •

Masturbation involves self-stimulation of one’s genitals for the purposes of attaining an orgasm.

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Sexual fantasies are universal with some differences between men and women in their choices of sexual fantasy.

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Oral sex involves the stimulation of the genitals or the anus with some part of the mouth.

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Fellatio is oral sex related to the male genitals, while cunnilingus is oral sex related to the female genitals.

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Sexual intercourse generally means penile to vaginal penetrative sex.

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Anal intercourse involves any type of penetrative act with regard to the anus itself.

QUIZ 1. The practice of sounding in masturbation involves what? a. Inserting one’s fingers into the vagina. b. Inserting an object into the anus. c. Using a vibrator instead of one’s hands. d. Inserting an object into the urethra. 2. What is another term for onanism? a. Sexual intercourse b. Masturbation c. Anal intercourse d. Sexual fantasies 3. What is prone masturbation? a. The practice of mutual masturbation b. Lying face down and masturbating with a mattress or pillow c. Masturbating with an object rather than the fingers d. Masturbating with a handheld showerhead 4. At what age is masturbation first possible? a. Infancy b. School-age c. Adolescence d. Early adulthood 5. What is the most common sexual fantasy? a. Oral sex b. Group sex c. Sex with strangers d. Sex in risky places

6. What is not true about sexual fantasies among men and women? a. Men fantasize more about group sex. b. Women fantasize more about sex with a famous person. c. Men have more submissive fantasies than women. d. Men and women equally fantasize about oral sex. 7. What is it called when there is penetrative sex in non-human species? a. Copulation b. Coitus c. Vaginal intercourse d. Coition 8. What is a non-penetrative form of sex? a. Fingering b. Sex with a dildo c. Coitus d. Anilingus 9. What is the greatest risk for sexual intercourse in humans? a. STDs b. Unintended pregnancy c. Sex addiction d. Coronary heart disease 10. What is the least common anal sex activity? a. Dildo insertion b. Fingering c. Anilingus d. Fisting

CHAPTER FIVE: SEXUAL DYSFUNCTION IN MEN AND WOMEN The focus of this chapter is sexual dysfunction or sexual disorders in men and women. There are problems associated with low libido or low sexual arousal as well as problems with attaining an orgasm, which are discussed in the chapter. Men can have erectile dysfunction as a sexual problem, while women can have vaginismus that affects sexual satisfaction. Sexual problems in men discussed in the chapter include premature ejaculation and delayed ejaculation.

HYPOACTIVE SEXUAL DESIRE DISORDER OR HSDD This is a disorder of libido that is represented by a lack of sexual fantasies and a decreased desire for sex. This, like most of these types of disorders, must include the presence of interpersonal difficulties or distress in order to be considered as a disorder. Essentially, the person will not initiate sex and cannot respond to their partners request for sex. There are different types, depending on severity and when it occurred in the person’s life. It is split in the Diagnostic and Statistical Manual for Mental Diseases into male or female disorders. It used to be referred to as frigidity in women. As mentioned, it takes more than just low sexual desire to have HSDD. One must have distress or some type of difficulty because of it and must not have it because of another disorder. In men, there are three subtypes of the problem. In lifelong or generalized disease, the man has never had a desire for sex. In acquired and generalized disease, the person used to have sexual desire but now does not in a generalized way. In acquired/situational disease, the focus of the lack of sexual desire is most related to their current sexual partner. These are not necessarily related to the same cause. No one knows the cause of lifelong disease but it may be medical or psychiatric in origin, due to high prolactin levels, or due to testosterone deficiency. Basically, the person has more inhibitory factors than excitatory factors related to sexual desire and some of this is purely biological. The 90

excitatory neurotransmitters are dopamine and norepinephrine, while serotonin has inhibitory activity in the desire for sex. Certain medications can cause acquired HSDD and other causes include chronic illness in the partner, relationship problems, difficulty with intimacy, and sexual addiction in the partner. You should know that this is not a well-researched disorder so that the actual causes of this problem are not completely flushed out yet. In women, HSDD is probably caused by mood disorders or other psychiatric problem, medical issues, or increased prolactin levels, although other hormones may contribute to this. Stress and relationship problems can contribute to hypoactive sexual desire disorder. Most do not have a negative association with sex but instead have a weaker level of responsiveness to sex. In order for a man or woman to have the disorder, it must be present in a minimum of 75 percent of sexual situations for at least six months. In the treatment of HSDD, most people are treated along with the help of their romantic partner but this does not have to be the case. The sex therapist will try to uncover the cause of the disorder and treat any underlying cause. Communication is addressed with the couple as well as improvement in sexual intimacy. Some of the treatment is educational because there may be unrealistic expectations about what is normal and what is not normal. Stress reduction is addressed. Men with generalized and lifelong HSDD are unlikely to be treatable except with emotional support and adaptation to the situation. Drugs have been tried, although testosterone is considered the best shortterm treatment. As mentioned, HSDD was once called frigidity and was believed to be mainly a woman’s problem. The advances in sexual research in the last fifty years have increased the understanding of the disorder but it was only recently that both male and female HSDD were included in the DSM-5. In some cultures, having a low sexual desire is considered a positive attribute instead of a negative one. There are many criticisms related to having HSDD included as a sexual disorder with some people feeling like it medicalizes sexuality. There are also big differences between male and female sexual desire with some women having little spontaneous interest in sex who have retained the ability to respond to sexual stimulation. In addition, the

disorder has a great many more factors than just biological ones. Relationship difficulties and social factors have taken a back seat to the physiological bases for the disorder.

SEXUAL AROUSAL DISORDER Sexual arousal disorder is different from hypoactive sexual desire disorder and is basically the female equivalent of male erectile dysfunction. It involves having a lack of sexual fantasies and a low desire for sex even when in a situation that should cause sexual arousal. The symptoms include a lack of vaginal dilation or lengthening, decreased vaginal lubrication, decreased nipple or genital sensation, and decreased genital swelling. While the problem seems to have physiological implications, these women may actually have relatively normal responses to erotic stimuli. The problem has many underlying causes. The taking of SSRI drugs can cause the disorder when taken for depression and there can be hormonal problems, decreased blood flow to the genitals, nerve damage, or concurrent drug use. Psychological problems include anger, depression, relationship issues, stress, poor past experiences with sex, or some other type of psychological conflict. The disorder must be present for six months with both psychological problems and lack of physiological responsiveness to erotic stimuli also being factors necessary to diagnose the disease. The problem is likely physiological in 30 to 80 percent of cases and includes blood vessel and nerve-related issues. This is similar to the issues related to erectile dysfunction in men. In addition, lack of education about sexuality, anxiety or guilt around sex, communication failures, and performance anxiety can play a role in a woman having this problem. Like HSDD, the problem can be lifelong, generalized or situational in nature. The treatments involve hormonal therapy to enhance blood flow, such as Viagra, which can be used in women as well as men, bremelanotide, which is being developed for women to increase their sexual desire, and treating other underlying causes. Testosterone has been used as an off-label treatment for this problem.

ANORGASMIA Anorgasmia is the inability to reach an orgasm even with adequate stimulation. It is extremely rare in younger males and much more common in females, who have it with an incidence of about 5 percent. In men, it can be linked to delayed ejaculation. The problem can easily lead to sexual frustration and interpersonal difficulties. The problem can be physiological or psychological. It can be linked to diabetic neuropathy or nerve disease, genital mutilation, multiple sclerosis, trauma to the pelvis, hormone problems, spinal cord injury, or surgical complications after childbirth or hysterectomy. Vulvodynia or pain in the vulva as well as heart disease can be physical causes as well. Drugs that contribute to the problem include SSRIs and other antidepressants, and opioids such as heroin. Primary anorgasmia is when a person has never had an orgasm. It mainly affects women but can occur with men who have a lack of what’s called the bulbocavernosus reflex, which is congenital from birth. It can lead to vascular engorgement in the pelvic area of a woman or low levels of sexual arousal. The problem can be idiopathic and without an obvious cause. Secondary anorgasmia is a problem that happens after there have been normal orgasms in the past. It can be psychological or due to alcoholism, or it can be related to having had pelvic surgery, estrogen deprivation in menopause, illness, rape, or certain medications. Among men with secondary anorgasmia, a radical prostatectomy can lead to anorgasmia due to nerve damage. Situational anorgasmia is a selective problem with attaining an orgasm so that certain conditions lead to the problem rather than all situations. In some cases, there is simply a lack of sufficient foreplay or stimulation that would lead to a lack of an orgasm. It sometimes takes some thinking to try and determine which factors most contribute to anorgasmia in certain situations. In making a diagnosis of the problem, it is a good idea to determine if the problem is psychological or physical. If it doesn’t appear to be psychological, one should look for diabetes, thyroid dysfunction, lipid profile, and hormone levels, such as estrogen,

testosterone, and both FSH and LH. In less common situations, genital sensation and blood flow are determined quantitatively to see if this is a problem. Remember that diabetes is a big factor in having anorgasmia in both sexes. The treatment of anorgasmia related to physical causes includes the correction of hormonal imbalances, clitoral vacuum pumps to help engorge the clitoris, sildenafil or Viagra, and vardenafil, which is another drug related to Viagra. As mentioned, this can be used for both men and women with anorgasmia. Cabergoline, which decreases prolactin production, can be used to restore orgasms in a woman with secondary anorgasmia. Other drugs are being studied for anorgasmia from SSRI use.

VAGINISMUS Vaginismus is a sexual problem leading to involuntary muscle spasms that prevent adequate penetration. The woman often has extreme pain with any attempt at having sexual intercourse. The most common underlying factors include vaginitis, previous episiotomy, endometriosis, and sexual assault in the past. In order to qualify for the disorder, there should not be an anatomical cause of the problem. Primary vaginismus is usually discovered in young women or teens, when tampons cannot be used or a Pap smear is impossible. The woman has never been able to have vaginal penetration. The problem can be due to inflammation of the vulva and vaginal introitus, urinary tract infections, history of sexual assault, yeast infections of the vagina, fear of penetration, history of nonsexual trauma, stress, anxiety, or living in a sexually repressive environment. The problem can be idiopathic. The disorder has different degrees, with first degree vaginismus involving being able to accept penetration with reassurance and fourth degree vaginismus involving being unable to open the thighs at all. Some women will have a sympathetic fight or flight response with sweating, palpitations, trembling, and hyperventilation. The main muscle involved in vaginismus is the pubococcygeus muscle, although the bulbocavernosus or the entry muscle the levator ani muscle, and the puborectalis muscles in the mid vaginal area can be a factor. The spasm usually happens with an attempt at vaginal penetration so that intercourse cannot happen easily or at all. 94

Secondary vaginismus is when the woman once was able to achieve penetration but now cannot. Trauma from childbirth or a yeast infection can be causative. Menopause and vaginal dryness can play a role in vaginismus. There are many psychological factors involved, including a fear of losing control, sexual assault, denial of sexuality, or lack of trust in one’s partner. The treatment is more successful with secondary vaginismus than it is with primary vaginismus. Desensitization may or may not help. Because of the high risk of childhood sexual trauma in the disorder, psychological treatment related to that can be helpful. Vaginal dilators and Kegel exercises along with lubricants can sometimes help. Botox is being investigated and has been shown to be successful in some cases. Antidepressants and anti-anxiety drugs can help the anxiety.

ERECTILE DYSFUNCTION Erectile dysfunction or ED was once known as impotence. It is seen when a man cannot attain an erection or cannot maintain an erection during sex. Men who have it can develop low self-esteem and relationship problems. About 80 percent of the time, the disorder is found to be physical, with the rest being purely psychological or a combination of physical and psychological causes. The problem must be present for three months to be called erectile dysfunction. There are numerous physical causes of erectile dysfunction, including many types of prescription drugs, such as beta blockers, SSRIs, diuretics, and certain hormonal treatments. Neurological causes include diabetes, Parkinson’s disease, multiple sclerosis, temporal lobe epilepsy, and multiple system atrophy. There can be anatomic problems with the penis, high prolactin levels, surgery to the pelvis, cardiovascular disease, kidney failure, smoking, and general aging that can contribute to the problem. Nerve damage from cycling can cause erectile dysfunction. Purely psychological causes of erectile dysfunction happen in 10 percent of cases. Any type of psychological or psychiatric problem can contribute to the problem, and both stress and performance anxiety can be causative.

It is helpful to understand the mechanisms that need to be in place in order to have an erection. There must be a reflex erection that happens when touching the penis and a psychogenic factor, which involves reacting to erotic stimuli. There needs to be intact peripheral nerves, an intact lower spinal cord, and normal activity of the limbic system. As mentioned in the first chapter, nitric oxide is released after penile stimulation that relax the muscles of the erectile tissues of the penis to get an erection. The pituitary gland and testosterone levels need to be normal. A lack of blood flow to the penis can impact the attainment of an erection, which is seen in coronary artery disease. The diagnosis of erectile dysfunction can usually be made by listening to the patient’s symptoms. If this is not helpful, an exam should be done to look for hypogonadism or immature genitalia in the male. Labs for diabetes, testosterone level, and prolactin level can be done. Less commonly, nocturnal penile tumescence can be done, which assesses the presence of erections during the man’s sleep. This can tell if there might be a psychological cause for the erectile dysfunction. An ultrasound of the penis is done with a Doppler ultrasound of the erect penis in order to evaluate the blood flow in the corpora cavernosa. Prostaglandin E1 is injected to create an erection and then blood flow is checked every five minutes for a half an hour. Sildenafil or stimulation can be used to induce an erection. The test checks to see what happens to the penile blood flow after an erection. It can tell the difference between erectile dysfunction from atherosclerosis versus other causes of erectile dysfunction. Less common tests for erectile dysfunction include assessing the bulbocavernosus reflex, which involves stimulating the glans of the penis and checking for tightening of the anal sphincter, penile biothesiometry, which checks for penile sensation, and corpus cavernosometry, which measures pressures in the penis. An angiogram can be done using magnetic resonance imaging or MRI scanning to look at the blood vessels to the penis. The treatment of ED depends on the cause. Aerobic exercise and counseling can treat mild disease or psychogenic erectile dysfunction. The mainstays of more severe ED include medications and penile vacuum devices. Penile implants and medications injected into the penis are less commonly used.

The three main medications for erectile dysfunction include sildenafil or Viagra, vardenafil or Cialis, and tadalafil or Cialis. These are taken orally and are called phosphodiesterase-5 inhibitors. There is a cream called alprostadil used in Canada, while alprostadil, phentolamine, and papaverine are used as injections into the penis to get an erection. Alprostadil is a urethral suppository that works within ten minutes. Testosterone can be used for those with low levels of this hormone.

PREMATURE EJACULATION Premature ejaculation involves having an orgasm and ejaculation within a few seconds after initiating sex and without much stimulation. The cutoff for what constitutes “premature” ranges from 15 seconds to 1 minute. While most men say they wish they could go longer without ejaculating, the average is about 4 minutes. The opposite of premature ejaculation is delayed ejaculation. Premature ejaculation can be embarrassing and can lead to both relationship and emotional issues. No one knows the causes of premature ejaculation. There are theories about the possible psychological causes of this but there has been no consistent proof of a psychological cause. There is a nucleus in the brain responsible for the control of ejaculation, which may play a role. Genetic causes have been suggested and it is thought that there is simply a faster neurological reflex in these men. There are two actions that need to happen in ejaculation. The first phase is emission, when the fluid gets mixed and deposited into the upper part of the urethra. The second phase is expulsion, where the bladder neck gets closed off and there is contraction of urethral and pelvic muscles to expel the semen. The emission phase involves the sympathetic nervous system and the expulsion phase involves the motor nervous system. The central nervous system, as mentioned, plays a role in control over ejaculation. The diagnosis is based on the patient’s history of their problem as there are no tests for the disorder. According to the International Society of Sexual Medicine, the problem cannot be related to a mental illness, a relationship problem, or a medication. As

mentioned, the cutoff time for what constitutes premature is variable, depending on the organization defining the problem. The treatment can be medical or nonmedical. Some men will distract themselves or control their sexual behavior in order to increase the latency time. Other men will use more than one condom to decrease penile sensation. Sex therapy can help, which makes use of Kegel exercises to strengthen the pelvic floor muscles, the squeeze technique, which involves squeezing the head of the penis to stop the ejaculatory reflex, and the stop-start technique, which involves stopping for a period of time to slow the process. Medications can be used successfully to treat premature ejaculation. SSRI drugs like paroxetine and dapoxetine have been used to delay ejaculation but these are not without side effects. Desensitizing medications like topical lidocaine can block the sensation to the penis. Tramadol and clomipramine can be used as well. Surgery to disrupt the nerve supply to the penis in severe cases is common only in South Korea.

DELAYED EJACULATION Delayed ejaculation involves the inability to have an orgasm and ejaculate even if there is sexual desire and adequate sexual stimulation. In some cases, it can take in excess of 45 minutes to ejaculate if it happens at all. Some cases only involve delayed ejaculation with a sexual partner and not with masturbation. As a sexual disorder by itself, it is not very common and, if present, is generally the side effect of a medication. The problem can be minor or very severe, without the ability to ejaculate at all. Medical reasons for delayed ejaculation include drug or alcohol abuse, Cushing’s disease, thyroid dysfunction, prostate surgery, and hypogonadism or immature gonads. Trauma to the pelvic nerves that affects penile sensation can cause this problem. Many medications can be causative, such as SSRIs, opiates, benzodiazepines, blood pressure medications, and antipsychotic drugs. There are some psychological or lifestyle factors that can contribute to delayed ejaculation. Lack of sleep, stress, anxiety, distraction, and overactive masturbation can contribute to delaying of ejaculation. Different sensations found in masturbation can lead to a decrease in the ability to have ejaculation with vaginal penetration. 98

The main treatment is sex therapy, which involves learning how to ejaculate in the presence of a partner in ways that gradually approach that of vaginal penetration. There are some studies showing that meditation can help. Drugs, such as sildenafil, have not been found to help delayed ejaculation and can instead prolong the latency time.

KEY TAKEAWAYS •

Hypoactive sexual desire disorder is basically a disorder of diminished libido.

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Sexual arousal disorder is the female equivalent of erectile dysfunction in men.

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Anorgasmia is the absence of an orgasm despite sexual stimulation and desire.

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Vaginismus is an involuntary disorder of muscle contraction of the female pelvic muscles that prevent sexual penetration.

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Erectile dysfunction is generally a medical disorder involving an inability to attain or maintain an adequate erection.

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Men can have premature ejaculation or delayed ejaculation, depending on their sexual latency time.

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QUIZ 1. Which sexual problem was once referred to as frigidity? a. Anorgasmia b. Delayed orgasm c. Vaginismus d. Hypoactive sexual desire disorder 2. What is least likely to be a cause of lifelong male hypoactive sexual desire disorder? a. Previous bad experience with sex b. Low testosterone levels c. High prolactin levels d. Psychiatric disease 3. What drug is most associated with sexual arousal disorder? a. Beta blockers b. Hormonal birth control c. LSD d. Selective serotonin reuptake inhibitors 4. What medical treatment is not used to manage sexual arousal disorder in women? a. Viagra b. Bremelanotide c. Selective serotonin/norepinephrine reuptake inhibitors d. Testosterone 5. What disease is most likely to lead to secondary anorgasmia? a. Kidney disease b. Heart disease c. Diabetes d. Autoimmune disease

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6. What is not a factor contributing to vaginismus? a. Anatomical vaginal issues b. Fear of sexual penetration c. Involuntary muscle contractions of the pelvic muscles d. Inability to adequately penetrate the vagina 7. What percent of the time is erectile dysfunction related to a physical problem in the male? a. 20 percent b. 40 percent c. 80 percent d. 95 percent 8. What is least likely to be a cause of secondary erectile dysfunction? a. Psychological trauma b. Atherosclerosis c. Diabetes mellitus d. Low testosterone 9. What is the underlying cause of premature ejaculation? a. Performance anxiety b. Increased penile sensitivity c. Genetic causes d. The cause is unknown 10. Which medication is least likely to be helpful in treating premature ejaculation? a. Sildenafil b. Paroxetine c. Tramadol d. Lidocaine

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CHAPTER SIX: SEXUALLY TRANSMITTED DISEASES AND THEIR TRANSMISSION Sexually transmitted diseases and the risks of getting them are the topics of this chapter. As you will learn, certain sexual behaviors predispose a person to getting a sexually transmitted disease and there are ways to decrease their transmission. The different sexually transmitted diseases, which can be viral, bacterial, protozoal, or parasitic, are discussed in the chapter. For a couple of sexually transmitted diseases, there are vaccines that can be used in the prevention of these infections, which are covered in the chapter.

RISK FACTORS FOR STIS Sexually transmitted diseases or STDs are also called sexually transmitted infections or STIs. While some of them can be transmitted in nonsexual ways, all of them carry the potential for transmission through sexual activity, such as vaginal sex, anal intercourse, and oral sex. If the STD does not cause symptoms, there is an increased risk of passing the disease to one’s sexual partner. In some cases, an STD can cause infertility or can be transmitted from the mother to the baby in utero or at the time of birth. There are more than thirty different microorganisms that can cause some type of sexually transmitted disease. Chlamydia, gonorrhea, and syphilis are bacterial diseases. Herpes, HIV disease, and genital warts are viral diseases. Trichomonas is a protozoal disease and Pubic lice is a parasitic disease. The problem exists in all parts of the world but is generally harder to test for and treat in developing countries. While the best way to prevent STDs is not to have sex. As mentioned, HPV and hepatitis B have vaccinations for them. Other prevention techniques include limiting the number of sexual contacts, using condoms, and having purely monogamous sex. Circumcised males have a decreased risk of passing on a sexually transmitted disease. Many STDs, as you will hear, are treatable, except for HIV, HPV, hepatitis B, and herpes, which can be managed but not cured. 103

There are certain sexual behaviors that can pass on an STD. Anal sex carries the highest risk of passing on the disease. Oral sex on a man can pass on a variety of throat infections, including HPV, gonorrhea, and chlamydia. Oral sex on a woman is less likely to cause disease but it can cause herpes and HPV. Receiving oral sex in a man can cause chlamydia and gonorrhea, while receiving oral sex in a woman can cause herpes. Vaginal sex can cause all types of STIs to both men and women. The same is true of insertive anal sex and receptive anal sex. Anilingus can pass on some diseases through the fecal-oral route. Types of risky sexual behavior include the following: •

Oral sex

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Barebacking, which is sex without a condom

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Sex at a young age

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Having sex with someone who is not monogamous or uses IV drugs

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Having many sexual partners

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Anal sex

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Working in the sex industry

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Using drugs or alcohol

Things that are most linked to risky sexual behaviors are not using condoms regularly, using drugs and alcohol, mental illness, childhood sexual abuse, lack of social support, domestic violence, and recent incarceration.

CHLAMYDIA Chlamydia is a sexually transmitted infection caused by Chlamydia trachomatis. The biggest problems with transmission are that it does not always lead to symptoms and the development of symptoms can take several weeks after contracting the infection. Women will have burning on urination and vaginal discharge; men will have similar symptoms along with testicular swelling. In women, it can be very severe, leading to pelvic inflammatory disease of the uterus and tubes, which contributes to ectopic 104

pregnancy and infertility. It is a cause of blindness in developing countries when the eyes get infected. Chlamydia can get passed through anal, vaginal, or oral sex; it can also be passed to the baby during childbirth. Eye infections can be passed with general contact, infected flies, and contaminated towels or bedding. This is only a human infection. It is one of the more common STIs, affecting about 2 to 4 percent of people throughout the world. It is more commonly seen in young people. In women, chlamydia can easily infect the cervix with half ultimately getting pelvic inflammatory disease, which means it has infected the uterus, fallopian tubes, and ovaries. The scar tissue is the biggest complication so that women can have pelvic pain, infertility, and ectopic pregnancies. Up to 80 percent of women will have no symptoms. For this reason, young women are screened for the disease as part of routine care or when asking for emergency contraception. Figure 14 shows what PID looks like:

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Figure 14.

Men who have chlamydia tend to be more symptomatic than women with half experiencing burning of the urethra. There can also be testicular pain, fever, and urethral discharge, with spread of the infection to the epididymis in some cases. Male infertility is possible as is prostatitis. A few men will have some type of arthritis as a secondary problem. Chlamydia in the eye leads to conjunctivitis or what’s called trachoma. It can lead to blindness if not treated and can be spread through fomites, coughing, and sneezing. Newborns can get this type of eye infection when passing through the birth canal. Infants can also get pneumonia from chlamydia. Individuals can be tested for genital chlamydia through tests that amplify the DNA of the organism and detect this molecule rather than doing some type of bacterial culture

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or microscope examination of the genital drainage. These genetic tests for chlamydia are much better and more sensitive tests. Chlamydia can be treated with a variety of antibiotics, some of which can be given in pregnancy. Often, the sexual partner is treated as well in order to prevent another infection in the index case from occurring later. This is not a disease that a person can be permanently immune to. All patients should be followed up in three months in order to be tested again.

GONORRHEA Many people refer to gonorrhea as “the clap”. It is a sexually transmitted infection caused by Neisseria gonorrheae, which is a bacterium. The mouth, genitals, and rectum can be affected. Men will complain of testicular pain, urethral discharge, and burning on urination. Women will often have pelvic pain, pain on urination, vaginal discharge, and abnormal vaginal bleeding. Like chlamydia, gonorrhea can cause pelvic inflammatory disease in women and epididymitis in men. Not everyone will have symptoms. It is spread through sexual contact, including anal, vaginal, and oral sex. A child can get the disorder upon contact with the birth canal. It is recommended to screen all women under 25 years of age and in all men who have sex with men. It can be prevented by using a condom. The disease is less common than chlamydia, affecting less than 1 percent o all people. It takes an average of 4 to 6 days to develop symptoms after exposure to the pathogen, if they are present at all. Throat infection involves a sore throat and swollen gland in the neck. Gonorrhea of the rectum and eyes can be seen in both men and women. Infants can develop severe infections of the eyes from contact with an infected birth canal. When the disease spreads unchecked, this can lead to skin, joint, and other organ involvement Look for rashes and sores along with swollen and inflamed joints. It is possible to be allergic to gonorrhea, which makes the systemic infection worse. In rare cases, it can settle in the heart valves, leading to infective endocarditis, or can settle in the spinal column, leading to meningitis.

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Gonorrhea is caused by a bacterium, which means it can be treated with antibiotics. Having the infection does not mean that the person cannot be infected again. Asymptomatic carriers likely spread the infection through sexual behavior. There is a 20 percent chance of getting gonorrhea from an infected woman after one act of vaginal intercourse, with a higher rate seen in men who have sex with other men. Women, on the other hand, have a 60 to 80 percent chance of contracting the disease after an infected man performs vaginal sex with her. Gonorrhea used to be assessed with a gram stain and bacterial culture; however, techniques similar to those use to detect chlamydia are now used, which detect bacterial DNA in a swab or other sample. In some cases, both types of tests are done to confirm the disease. Disseminated gonorrhea is detected by swabbing several body areas, including the rectum, mouth, urethra, and cervix. If the joint is involved, this is proven by getting a swab of the joint fluid. All patients who have a positive test for gonorrhea should also be checked for HIV, syphilis, and chlamydia because the coinfection rate with chlamydia is about 50 percent. There is a lesser link between gonorrhea and other STIs. Screening should be done on all women under 25 as well as men who have sex with men and others who are high risk because of their sexual practices or because of a past infection. Treatment of gonorrhea involves antibiotic therapy, with ceftriaxone and azithromycin used. There is a high risk of antibiotic resistance, which can affect the antibiotics used. Babies are given erythromycin at birth because of the risk of severe eye infections gotten from congenital gonorrhea. Sexual partners should also be treated, even without an examination. Penicillin was once used to treat gonorrhea but there is just too much antibiotic resistance to the drug to make it helpful.

GENITAL HERPES Genital herpes is a viral infection passed through sexual contact. Most patients have no symptoms but those that do have tiny blisters that open up to lead to painful ulcerations. In some cases, systemic symptoms like swollen lymph nodes, body aches,

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and fever can be present. The lesions last four days after getting exposed and the lesions can last up to a month. Recurrences are common but less severe. The infection is spread through genital contact with an infected person, usually because of sexual behavior. It does not require actual sores in order to spread the disease. There are two types of herpes simplex, which includes HSV-2 and HSV-1. Most are caused by HIV-2 disease but HSV-1 can also cause the disease. The infection is not curable. Figure 15 shows genital herpes infection:

Figure 15.

Most of the lesions in males are on the glans penis, the penile shaft, and on parts of the genitals, including the anus. Women can get the lesions on the vulva, clitoris, mons pubis, perineum, buttocks, or around the anus. It can be burning, itching, or painful with generalized symptoms usually present with the first infection. About 80 percent will get a reinfection from HSV-2 with 50 percent getting a reinfection from HSV-1. HSV-2 infections recur at 4 to 6 times per year with HSV-1 infections recurring once a year.

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The treatment involves suppressive therapy with acyclovir or valalcyclovir. These can also be used in the treatment of recurrence. Antiviral agents can reduce the chance of spreading the disease. The longer a person has this, the less likely they are to have a recurrence. Herpes genital infections affect about 16 percent of young people so it is a commonly transmitted organism. About 80 percent of infected people have no symptoms. There is no screening done in the US. While pornography actors are tested for most other genital infections, herpes is not tested for.

HEPATITIS B Hepatis B can be transmitted through sexual contact or contact with infected blood. It is transmitted by the HBV virus and affects the liver both acutely and chronically. While many will have no symptoms, those that do will ha malaise, vomiting, yellowed skin, abdominal pain, and dark urine. The symptoms last several weeks after an incubation period of 30 to 180 days. Babies can get infected around the time of birth, with 90 percent ultimately developing chronic hepatitis B infections. The main side effects of chronic hepatitis include cirrhosis and liver cancer with some having liver failure. The disease is passed through blood and body fluid contact. IV drug abuse and sexual intercourse are the most common ways to transmit the disease although, if the infection is prevalent in a community, vertical transmission from mother to child is the most common way to contract the disease. It is not easily passed through blood transfusions, tattooing, acupuncture, or living with a victim, although these were once more common before screening and sterilization practices. Kissing and hugging cannot pass the disease. Breastfeeding cannot pass the disease. Some patients have no symptoms, while others get an acute hepatitis B infection with jaundice being common. Figure 16 shows what jaundice looks like:

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Figure 16.

While most people with hepatitis B are sick for a few weeks and recover, some will have severe and fulminant hepatitis leading to death. Others will develop a chronic hepatitis B infection that will either be asymptomatic or mild. Those with chronic disease can go on to having hepatitis or liver cancer. Hepatitis B is up to 100 times more infectious than HIV disease. The chances of vertical transmission of HBV to a fetus is about 20 percent during the pregnancy. Rarely, the disease can be transmitted to household contacts, usually through open skin. Breastfeeding cannot transmit the virus. Hepatitis B cannot be easily tested for, particularly in the beginning of the infection. Blood or serum can be tested for antigens, which are virus-related proteins, and antibodies, which are produced by the host in response to the infection. Hepatitis B surface antigen is tested to see if there are live viruses in the bloodstream. It is the first thing that can be detected in an acute infection and does not disappear in a chronic infection. There will be antibodies developing as the patient fights off the infection. There is a vaccine that can be used to prevent hepatitis B. It is currently given in three doses, starting at one day of life. Patients can be tested for antibodies to see if they have 111

had a response to the vaccine. Over the course of one’s lifetime, the antibody response diminishes but is effective in most people. The baby born to a hepatitis B positive mother will get the vaccine plus immune globulin against hepatitis B, which prevents transmission in up to 99 percent of cases. Hepatitis B cannot be cured but there are drugs that can be used in very sick patients. Most people will clear the infection by themselves. The medications that exist will prevent replication of the virus so that the damage to the liver is diminished. Patients who already have cirrhosis can improve their situation with treatment.

SYPHILIS Syphilis is strictly a sexually transmitted disease, although vertical transmission is possible. The bacterium Treponema pallidum is the causative agent of this infection. There are four stages to the disease, with a person going through all four stages if they are not treated early on. In the primary stage, the person develops a painless chancre, usually on or near the genitals. Figure 17 shows a primary chancre of the lip:

Figure 17.

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In secondary syphilis, the patient has a rash over their entire body that involves the palms and soles of the feet. Sores can exist in the vagina or mouth as well. Latent syphilis can last for several years and involves no real symptoms. Tertiary syphilis involves neurological symptoms, soft tissue growths called gummas, and heart damage. Primary syphilis can show itself between 3 and 90 days after contact with an infected person. Most women will have this on the cervix, while men will have chancres of the penis, anus, or rectum. Lymph nodes can also be swollen with this stage lasting between 3 and 6 weeks. Secondary syphilis happens between four and ten weeks after the initial infection. The rash may be flat or slightly warty in appearance with many patients feeling generally unwell. Without treatment, the problem goes away after about three to six weeks. Latent syphilis can only be determined with a blood test that proves the patient has the infection. It can last less than a year or longer than a year, depending on the person. There is still the chance of infectivity but it is less as the latency period goes on. Tertiary syphilis can take up to 15 years to develop after the initial infection. There is gummatous syphilis with soft tissue swellings throughout the body, neurosyphilis, or cardiovascular syphilis. Those with neurosyphilis have many types of neurological symptoms with things like seizures and dementia taking the longest to develop. Cardiovascular syphilis, usually means inflammation of the aorta but it can mean other heart-related symptoms. Congenital syphilis happens in babies, who don’t usually have symptoms at birth. The main findings are liver and spleen enlargement, rashes, fever, lung inflammation, and neurological symptoms. Babies can be born with birth defects, primarily involving abnormally-shaped teeth. The most infective stages of syphilis are the primary and secondary stages. More than half of all cases happen in men who have sex with men, which includes oral sex. Blood products can pass on the infection but all blood products are screened for the disease. Rarely can sharing needles lead to syphilis transmission. The organisms die outside the body so fomites like surfaces are not usually the cause of the disease.

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Early syphilis is difficult to detect because the blood tests are not positive right away. Later on, there are blood tests that can look for the presence of the organism or the antibodies to the organism. Screening tests are done on all pregnant women because of the risk of passing on the infection to the fetus. Screening is also done on men who have sex with men. The best prevention is not having sex with an infected person and using condoms. There is no vaccine for the disease. Antibiotics can be given for all stages of the disease. Penicillin treats all cases but there are other choices for people who are allergic to penicillin. Treating late infections do not treat the patient’s damage that has already occurred.

HIV DISEASE HIV stands for human immunodeficiency virus; it is a type of retrovirus that leads to acquired immunodeficiency syndrome or AIDS. In AIDS, the individual develops extremely low levels of helper T cells, which are important in fighting off infections. Macrophages and dendritic calls in the immune system are also targeted. The person with HIV disease can have an increased risk of rare opportunistic infections and unusual types of cancer. The average age of survival in the untreated patient is 10 years. HIV disease can be gotten from sexual transmission or exposure to blood products. Vaginal fluids, ejaculate, and pre-ejaculate all contain the virus. Saliva cannot transmit HIV disease. If the HIV-positive patient has an undetectable viral load because of treatment, they are not able to transmit the virus. Pregnancy can lead to vertical transmission of the virus both in utero and at the time of birth. Breast milk contains the virus as well. HIV is a retrovirus, meaning it does not contain DNA in its genome but instead contains RNA. It is an enveloped virus, meaning it has a lipid or fatty outer layer that has been targeted as a possible means of developing a vaccine for the virus. While most people associate HIV with its effect on the human helper T cell, it can also get into macrophages, microglial cells, and dendritic cells—all of which help to “eat” pathogens as part of the immune response.

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There are two types of HIV, including HIV-1 and HIV-2. HIV-1 is more dangerous than HIV-2. HIV-2 is seen in West Africa almost exclusively. It is somewhat more successful than HIV-1 because it doesn’t kill the host as aggressively so it can more easily be transmitted. HIV has a high risk of mutating to related but dissimilar forms of the virus, even in the same patient. HIV disease is much easier to catch in Africa, where fewer than one percent of the population has even been tested and HIV can more easily be passed from a woman to a man or from a woman to her child before or during birth. Because most people with the disease don’t know they have it, all blood is screened, which is also the case in other parts of the world. There are tests that look at the antibodies made to the virus, which help to detect exposure to the disease. The screening test will be correct in determining whether or not the patient has HIV disease more than 99 percent of the time. Even so, there is a two-step process in determining if the person has the disease. The person is generally tested right after exposure, six weeks after exposure, and then again at three months and at six months. If the test isn’t positive by six months after exposure, the person did not contract the disease.

TRICHOMONIASIS Trichomoniasis is a sexually transmitted infection caused by the protozoon called Trichomonas vaginalis. This leads to symptoms in just 30 percent of infected men and women. If infection occurs, it happens within a month of exposure, leading to genital itching, foul-smelling vaginal discharge, burning on urination and pain with intercourse. One of the biggest complications of trichomoniasis is an increased risk of getting an HIV infection. Trichomoniasis is usually spread through oral, vaginal, or anal sex but can also be contracted through the touching of another’s genitals. The parasite can be cultured from vaginal fluid and DNA testing for the organism. This infection can be treated with antibiotics; the sexual partner should also be treated. Having the infection once does not mean the person can’t get the infection again.

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The infection cannot be transmitted to the fetus but it can lead to prematurity in the pregnancy. It can affect men as much as women. Men can get infection of the urethra and the prostate gland. Long-standing prostatic inflammation can ultimately lead to an increase in prostate cancer. Trichomonas can be tested for by looking at the organism under a light microscope. It can also be cultured in the laboratory but it is only about 70 to 89 percent sensitive in detecting the disease. The best test is one that looks for the DNA that is found in the fluids of people infected by the organism. It can be prevented by using male or female condoms. It is not likely to be spread through water because, at least in hot water, the organism dies within thirty minutes to three hours. It is not screened for in pregnancy or in nonpregnant females but is tested for in women with vaginal discharge. It is treated with certain antibiotics, usually metronidazole. Sexual partners should be treated as well. One dose kills most of the infections.

PUBIC LICE Pubic lice are also referred to as crab lice or crabs. This is a parasitic insect that feeds only on human blood. It is found in pubic hair and is only found in humans. It can rarely be seen on human eyelashes. It is a tiny louse less than 2 millimeters in length and has a round body. Figure 18 is what the pubic louse looks like:

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Figure 18.

The pubic louse likes to lay its eggs on coarse hair so it tends to stick to genital, perianal, beard, eyelash, moustache, or armpit hairs. They are not found on scalp hair. About three eggs a day are laid, which take about a week to hatch. After hatching, it takes up to 27 days to reach adulthood. Each adult lives about thirty days. They only eat human blood about 5 times a day. The most common symptom of a louse infestation is pubic itching caused by the sensitivity of the human host to the louse saliva. About 2 percent of the population is believed to be infested with pubic lice. It is usually spread through sexual contact but nonsexual transmission can happen through the sharing of towels, bedding, and clothing. They cannot survive easily outside of human contact. Pubic lice themselves do not transmit other diseases. They can travel up to 10 inches on the human body and are almost always seen in adults. Secondary bacterial infection can

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happen because of scratching the affected area. They die within 2 days off of a human host.

HUMAN PAPILLOMAVIRUS INFECTION Human papillomavirus or HPV is a virus that, like other similar diseases, does not always cause symptoms. Some people fight off the infection and it is resolved. It is, however, a virus that is precancerous for cancers of the vulva, cervix, vagina, anus, penis, throat, and mouth. Almost all cervical cancer is because of an HPV infection, particularly with two particular strains of the virus. Other strains cause genital warts and papillomas of the throat. HPV is the most commonly spread sexually transmitted disease. It is a DNA virus that has more than 170 subtypes. More than 40 types are sexually transmitted with an increased risk incurred by having early sexual intercourse, smoking, poor immune functioning, and having multiple partners. Vaginal and anal sex most easily pass the virus. It can be spread to the baby during childbirth but can’t be spread through toilet seats. It affects only humans and a person can be infected with more than one virus type. Some HPV infections never yield symptoms and never get cleared from the body. There are numerous HPV infections that do not cause genital warts but cause plantar or common warts. HPV 6 and HPV 11 cause genital warts, while others are precursors to cancer. Genital warts are very contagious. The warts that cause genital warts are different from the warts that cause common warts. Most HPV infections are cleared without treatment and sometimes without symptoms. It is possible to pass on the disease even without symptoms. Immunity can develop over time but it does not confer immunity to other species. The same warts that cause genital warts can cause laryngeal papillomatosis or laryngeal warts. HPV vaccines are used to prevent the most common types of HPV infections. They must be given before a child is sexually active and are recommended between 9 and 13 years of life. There are different types of HPV vaccines that protect against certain strains of 118

the virus. All vaccines prevent the major cancer-causing HPV infections, while others protect against those that also cause genital warts. None of these will help a woman who is already infected with the virus. They are generally paid for in girls but are also approved for use in boys. It is more effective in younger girls. Getting the vaccine doesn’t mean a woman should stop being screened for cervical cancer. It does not mean that it is not possible to get genital warts. The vaccine is believed to last for the person’s lifetime. Male condoms will be partially protective against an HPV virus infection but not completely. Female condoms are more protective against the virus because they cover more skin.

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KEY TAKEAWAYS •

Sexually transmitted diseases can be viral, bacterial, protozoal, or parasitic in nature.

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There are several types of high-risk sexual behaviors that increase the risk of STIs.

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Diseases like syphilis, HIV disease, and hepatitis B can be transmitted vertically to the fetus.

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Herpes, HIV, hepatitis, and HPV are all viral sexually transmitted diseases.

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In those diseases that can be treated with antibiotics, the sexual partner should be also treated.

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There are vaccines for the HPV virus and hepatitis B infection.

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Things like condoms, monogamy, and abstinence can decrease the risk of an STI.

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Things like oral, anal, and vaginal sex can all transmit a sexually transmitted infection.

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QUIZ 1. Which STD is considered a protozoal infection? a. Chlamydia b. Trichomoniasis c. Gonorrhea d. Syphilis 2. Which STD is not considered a viral disease? a. Pediculosis pubis b. HIV c. Genital warts d. Hepatitis B 3. What type of infection is considered to be the most common chlamydial infection in the newborn exposed to this organism in the birth canal? a. Pneumonia b. Meningitis c. Genital infection d. Conjunctivitis 4. Which STD is referred to colloquially as the clap? a. Syphilis b. Gonorrhea c. Chlamydia d. Pubic lice 5. What is least likely to be a complication of chronic hepatitis B infections? a. Liver failure b. Cirrhosis of the liver c. Gallbladder cancer d. Liver cancer 6. What is the least likely way to transmit hepatitis B? 121

a. Anal sex b. Vaginal sex c. Sharing IVs d. Kissing 7. What is not true of HIV? a. It can be passed through breast milk. b. There are two major subtypes of HIV disease. c. HIV infects the B cells in the body that make antibodies. d. HIV-2 disease is found mainly in West Africa. 8. How long after exposure to HIV should a person be tested to make sure they didn’t get the disease? a. 2 weeks b. 2 months c. 6 months d. 1 year 9. What type of cancer is least associated with an HPV infection? a. Anal b. Throat c. Esophageal d. Penile 10. What is the least likely to cause transmission of the HPV infection? a. Toilet seats b. Childbirth c. Anal sex d. Vaginal sex

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CHAPTER SEVEN: CONTRACEPTION, CONCEPTION, PREGNANCY, AND BIRTH This chapter encompasses several issues related to conception, pregnancy, birth, and contraception. Many sexually-active couples and single people practice contraception in order to avoid an unintended pregnancy. The process of conception, when it does occur, is discussed in the chapter. The changes seen in pregnancy, including changes in sexuality with pregnancy, are covered. The process of childbirth is explained in this chapter along with the practice of terminating a pregnancy, which is referred to as having an abortion.

TYPES OF CONTRACEPTION Contraception or “birth control” involves any medication, method, or device that will decrease the chances of a pregnancy. While contraception has been practiced throughout the ages, reliable and safe methods to prevent a pregnancy were only available in the last century. Using contraception is also referred to as “family planning”. The exact methods used to prevent a pregnancy is somewhat regulated by politics, society, and religion. The different methods of birth control discussed in this chapter include those that are very effective, such as tubal ligation in women, vasectomy in men, intrauterine devices, and implantable methods of birth control. There are hormone-based methods of birth control, including patches, vaginal rings, pills, and injections. Much less effective are diaphragms, condoms, birth control sponges, and the different fertility awareness methods. The least effective birth control methods include coitus interruptus or penile withdrawal techniques and spermicides. Certain methods have the combined effect of preventing pregnancy and decreasing the chances of getting a sexually transmitted infection. Other methods, such as emergency birth control, can help prevent pregnancy if taken within 120 hours after having unprotected sex. Simply teaching abstinence to teens without discussing other birth 123

control techniques actually increases the chance of pregnancy in teens because of noncompliance. Birth control methods used in developing countries have saved thousands of deaths due to pregnancy complications. In fact, pregnancy deaths have decreased by about 40 percent. Using birth control methods to spread out the time between having children improves childhood survival and maximizes childbirth success. It also improves a country’s economic growth because it allows more women to join the workforce without having to raise so many children. The different categories of birth control include hormonal methods, barrier methods, intrauterine devices, behavioral methods, and sterilization. Emergency contraception is a hormonal method used after an episode of unprotected sex. The effectiveness of a birth control method is determined by the percent of women who get pregnant in the first year of use or as a percentage failure rate over the course of a woman’s lifetime. Methods deemed to be more effective are those with long-acting implications that also do not require ongoing health or doctor’s visits. The most effective techniques with less than a one percent failure rate include implantable hormones, surgical sterilization, and intrauterine devices. Some techniques have a high theoretical success rate but a lower practical success rate. These include estrogen-containing patches or vaginal rings, hormonal birth control pills, and lactation. Other techniques have a lower practical success rate plus a low theoretical success rate. These include diaphragms, spermicides, and condoms, which can be used perfectly but will still not adequately prevent pregnancy as well as other methods. All methods of birth control have side effects and risks but none are higher risk than pregnancy itself. Hormonal contraception involves several different medications and devices. A woman can take birth control pills, intermittent injections, hormonal implants, IUDs with hormones, hormonal patches, and vaginal rings that contain hormones. There are no available hormonal birth control methods for men. In terms of hormones for birth control, the two hormones involved are estrogen and progesterone. The Mini-pill contains just a progestin. Both types of birth control hormones prevent fertilization by

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thickening cervical mucus and blocking ovulation. The lining of the uterus is altered to decrease the chances of implantation. Any pill or other method that makes use of estrogen will increase the risk of arterial and venous blood clots. While the risk is about 10 out of 10,000-woman years, this is still less than the risks associated with pregnancy. Because of the risk of blood clots, these types of methods are not recommended for smoking women who are older than 35 years of age. Some people experience an effect on libido with hormonal birth control pills, but the effect is variable. Some women experience an increase in libido, while others will have a decrease or will experience no effect at all. The combined hormonal birth control techniques can decrease the risk of endometrial and ovarian cancer but do not change the risk of breast cancer. Menstrual cramps and the amount of menstrual bleeding are decreased. High doses of estrogen, however, will increase breast tenderness, nausea, and certain types of headaches. The advantages of using progestin-only pills are that they don’t cause blood clots and they can be used by breastfeeding women without an effect on milk production. Some women will complain of irregular vaginal bleeding or no vaginal bleeding. Injectable progestin has a very high theoretical success rate but has a six percent failure rate in the first year because of noncompliance. Barrier methods are those devices that physically prevent sperm cells from getting into the uterus. The different devices include male and female condoms, diaphragms, cervical caps, and contraceptive sponges that are used along with spermicide. The most common method of birth control in the world is the male condom. Most are made from latex but some are made from lamb’s intestine or polyurethane. The female condom is made from latex, nitrile, or polyurethane. Figure 19 shows a female condom:

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Figure 19.

Male condoms are cheaper than female condoms and are simple to use. The rate of male condom use is quite variable throughout the world, with only 18 percent of couples in the US using them and 80 percent of couples in Japan using them. They do not increase teen sexual behavior when offered to teens and can prevent some sexually transmitted diseases. Contraceptive sponges make use of a spermicide. These are placed within the vagina before intercourse in order to cover the cervix. The failure rate is twice as high among women who have had children before. It can be inserted up to a day before intercourse and must remain in place for a minimum of six hours after sex. There is a risk of allergy to the spermicide and a greater incidence of toxic shock syndrome. Intrauterine devices or IUDs are often shaped like the letter T. They contain levonorgestrel or copper and are both long-acting and reversible. These are the most effective reversible method of birth control. The failure rate is about 0.8 percent for the copper IUD and about 0.2 percent for the IUD that contains levonorgestrel. There is overall a great deal of satisfaction with the IUD so it is extremely popular. They can be

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used with breastfeeding moms and after an abortion. Their use is entirely reversible. Figure 20 shows what an IUD looks like:

Figure 20.

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Sterilization is a mostly irreversible surgical procedure called a tubal ligation in women and a vasectomy in men. Tubal ligation itself can decrease the risk of ovarian cancer. The only real risks are that of having to use general anesthesia in women and the fact that they do not decrease the risk of sexually transmitted. There is a low but significant risk of regretting the decision in women but a very low risk of regret in men. In fact, about 9 percent of those who’ve had it done and are already patients say they would probably not ever have wanted children. There are reversal procedures for both a tubal ligation and vasectomy. The success rate of a reversed tubal ligation is about 30 to 90 percent, although there is an increased risk of an ectopic pregnancy. The chances of pregnancy after reversed vasectomy are just as good but is decreased if there has been a long period of time between the vasectomy and the reversal procedure. Behavioral techniques for birth control include the fertility awareness method. Fertility beads that help a woman decide if she’s fertile can help, along with examining the cervical mucus to see if it has changed to a more fertile form. The basal body temperature technique is less successful because it shows only when ovulation has occurred after the fact. The failure rate in the first year is about 24 percent. Coitus interruptus or the withdrawal method involves the man pulling out before ejaculating. It may or may not be successful, depending on the man. The failure rate of this method with typical usage is about 22 percent. There are varying amounts of sperm in pre-ejaculatory fluid, which complicates this method of birth control. Abstinence and practicing non-penetrative sex are also forms of birth control that can be successful. Abstinence, as mentioned, is particularly difficult for young people and any type of penile to near-vaginal sex can lead to an unintended pregnancy. Lactation can prevent pregnancy to some degree. The woman needs to exclusively breastfeed and must not have periods. The failure rate is about 2 percent in the first six months after childbirth. When six months have passed, the failure rate increases to about 13 percent at two years of age. Pacifiers and using formula will decrease the success rate as will giving solid foods.

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Emergency contraception is sometimes referred to as the “morning after pill” but it can be used for up to 120 hours after unprotected sex. They prevent fertilization and ovulation but do not affect implantation. Most of them contain high doses of female hormones to prevent pregnancy. There are few side effects of these methods, which decrease the pregnancy chances by 85 percent. IUDs are also used as emergency protection and these are more effective than hormones alone.

THE PROCESS OF CONCEPTION The process of conception is referred to as human fertilization in humans. It happens in the ampulla of the fallopian tube and represents the union of the sperm and egg to created a zygote cell. It begins with vaginal sex and ejaculation before or during female ovulation. The major exception to this process is in vitro fertilization or artificial insemination, which do not involve sex but still lead to human fertilization. As you remember from chapter one, the sperm must bind to and fuse with the egg cell or oocyte. The corona radiata surrounds the secondary oocyte and is a layer of follicular cells. There is a drawing out or conical elevation of the yolk or cytoplasm of the egg when the sperm cell is about to pierce the egg. This is also referred to as the reception cone or the cone of attraction. The outside of the yolk changes into a membrane called the perivitelline membrane after the sperm cell has entered. The purpose of this membrane is to prevent more sperm from entering the oocyte. Figure 21 shows the structure of the egg and sperm cell:

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Figure 21.

Sperm cells that are freshly ejaculated do not fertilize eggs well. They must undergo capacitation in the female to increase its motility. It needs to be prepared for the acrosome reaction, which is the enzymatic process that allows the sperm to penetrate the zona pellucida, which surrounds the egg cell just inside the corona radiata. The zona pellucida is made from glycoproteins as part of an extracellular matrix. It binds to sperm cells and triggers the acrosome to burst and release lysozyme, an enzyme used to get through the zona pellucida. There is a process called kin selection, which allows some sperm cells to facilitate the pathway for other sperm cells.

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The cortical reaction happens when the zona pellucida has been breached. There are cortical granules that fuse with the cell’s plasma membrane, causing exocytosis of the enzymes in the granules. The zona pellucida glycoproteins then crosslink with one another so no further sperm cells can enter. In that sense, it is both the cortical and acrosome reaction that prevent more than one sperm entering the cell. The tail disintegrates and the second part of meiosis occurs in the egg cell, releasing a polar body and allowing for fusion of the sperm with the egg. Figure 22 shows the zygote initial growth:

Figure 22.

Fertilization marks the inital point of prenatal development. Times measured after this are referred to as the fertilization age, embryonic age, conceptional age, or fetal age. These are all different from the gestational age, which is marked from the first day of the last menstrual period.

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SEXUALITY IN PREGNANCY There are many emotional and physiological changes that happen in pregnancy, which can affect a woman’s libido, sexual responsiveness, and sexual behaviors. Sexual interest decreases in the first trimester, is variable during the second trimester, and decreases markedly during the third trimester. There are very few guidelines as to the recommendations for sex during pregnancy, which impacts the knowledge women have regarding how sex should work in pregnancy. Nearly half of all women believe that sexual intercourse is harmful to their pregnancy. The majority of women have some type of sexual dysfunction during pregnancy, which might include pain with sex, problems with libido, arousal problems, or orgasm difficulties. In theory, coitus during pregnancy can increase exposure to infections, stimulate uterine contraction, release oxytocin, and release prostaglandins in semen. Large studies, however, have not shown differences in outcome related to the frequency of intercourse among pregnant women. Despite the apparent safety, few women discuss sexuality with their doctor while they are pregnant or after the six-week postpartum visit. Studies on sexual responsiveness in pregnancy have shown an increased circulation to the pelvic structures during pregnancy, which becomes enhanced during sexual excitement. The vulva will change in color when they become engorged. Orgasms can trigger uterine contractions, which may be felt as pelvic cramping in the first trimester and as uterine contractions in the late third trimester. Pelvic congestion is not usually relieved in the resolution phase; in fact, it can take up to 45 minutes for this to occur. Women in the postpartum period often have decreased vaginal lubrication and thinner vaginal rugae. The cervix will be closed by about 4 weeks postpartum but the uterus is in the abdomen. Ovulation returns in non-nursing women by about 3 months postpartum and normalization of lubrication and the vaginal tissues. Normal sexual responses occur by the third month postpartum. Some researchers feel that intercourse can begin two weeks after delivery but most recommend waiting six weeks.

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The third trimester is when coital activity is at its least level. It declines throughout the third trimester so that only 17 percent of women have sex just prior to deliver. Interestingly, 10 percent of women will not have sex at all once they learn they are pregnant. The incidence of the man on top missionary position decreases with pregnancy advancement, with more couples using the woman on top or side-by-side positions. Some will use a rear-entry position. Most women still prefer genital-to-genital contact, while lesser numbers engage in oral sex, masturbation, or anal sex. Mutual masturbation is increasingly practiced in pregnancy. The actual sexual practices are culturally influenced. The rate of domestic violence increases in pregnancy, particularly in lesbian relationships. Some of the factors that influence a woman’s sexual activity in the first trimester include physical problems, such as fatigue and nausea. More than half fear injury to the fetus and about 28 percent report a decrease in sexual satisfaction. There is also a decrease in clitoral sensitivity and orgasmic dysfunction in the first trimester. Libido also decreases. Many women in the second trimester will have improvement in their libido and increased eroticism. There is increased vaginal lubrication and vulvar engorgement, both of which favor an orgasm. The actual coital frequency will, however, vary from person to person. The presence of fetal movements can change the quality of sexual intercourse and intercourse positioning. All of the features that increase sexuality in the second trimester will decrease in the third trimester. The patient will be more uncomfortable and will have decreased clitoral sensitivity, decreased libido, and decreased ability to have an orgasm. Some will have increased pain with genital contact. Engagement of the head can cause the cervix to contact the penis, which can lead to vaginal spotting. After delivery, up to 17 percent will reinitiate vaginal intercourse before six weeks postpartum, while most resume it at six weeks following the delivery. Even after a year, however, some women will not have resumed sexual activity. The presence of lacerations, decrease lubrication, and postpartum mood changes may affect sexual

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activity. Mood changes, in fact, often play a very big role in resuming normal sexual functioning. Body image and stress do not play a role in sexuality in the postpartum woman.

PREGNANCY Pregnancy or gestation is when a fetus or fetuses grow and develop inside the woman’s uterus, usually as a result of sexual intercourse. Any pregnancy can result in miscarriage, intrauterine fetal demise, abortion, or live birth. Childbirth is measured as 40 weeks after the first day of the last menstrual period. The term “embryo” is what the offspring is called prior to eight weeks’ gestation, while fetus is used at eight weeks to the time of birth. There are three trimesters, divided relatively equally. The first trimester is up to 12 weeks’ gestation; the second trimester is between 13 weeks and 28 weeks’ gestation, and the third trimester is from 29 weeks to 40 weeks. The term gravidity means the number of times a woman has been pregnant, while the term parity refers to the number of times a pregnancy is carried to viability. A nulligravida is a woman who has never been pregnant, while a primigravida is a woman who has had one pregnancy. Multigravida refers to having more than one pregnancy. The woman who is gravida 2, para 1, is pregnant for the second time and has one pregnancy carried to term. Abortions, miscarriages, and stillbirths are the reason why parity might be affected. The nulliparous woman may have been pregnant before but never carried a pregnancy past 20 weeks’ gestation. A term pregnancy is at least 37 weeks’ gestation in length. Prior to this, the pregnancy if delivered is preterm. A pregnancy that has lasted longer than 42 weeks’ gestation is called a post-term pregnancy. There are risks to the pregnancy if there is delivery before or after what’s considered a “term” pregnancy. Pregnancy can affect a woman’s health in many ways. Some health issues are secondary to hormonal issues, while others are related to the growth of the pregnancy. Common symptoms are morning sickness, fatigue, constipation, back pain, low blood pressure, swelling, increased urinary frequency, varicose veins, breast tenderness, heartburn, stretch marks, and hemorrhoids.

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Pregnancy starts with fertilization, which has been discussed. The zygote, or fertilized egg, divides rapidly and eventually becomes a blastocyst. This is what implants into the uterine wall about 12 days after fertilization. The cells also begin to differentiate into the placenta, which attaches the embryo to the uterine wall, the umbilical cord, and the embryo itself. At the 8th week of development, the embryo becomes a fetus. Once the fetal stage is reached, the risk of miscarriage diminishes, so that most miscarriages happen prior to 10 weeks of development, which is 12 weeks’ gestational age. The heartbeat happens at about 7 to 8 weeks’ gestation and involuntary movements are seen. Sex organs are seen as different after 12 weeks’ gestation. Brain activity is detected between five- and six-weeks’ gestation. Connections between nerve cells form at 17 weeks’ gestation and continue after birth. Figure 23 shows the different stages of fetal development:

Figure 23.

There are numerous changes in the woman’s physiology that occur with each trimester. The first change noted is the absence of menses. The minute ventilation increases by up

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to 40 percent during the first trimester. The breasts grow in size and become tender. The uterus just becomes palpable above the pubic bone at 12 weeks’ gestation. Women tend to be more energetic in the second trimester and the uterus can be seen above the pubic bone. In total, the uterus expands twenty times its normal size. Fetal movement is felt at about 20 weeks’ gestation or slightly earlier than that in subsequent pregnancies. In the third trimester, most of the weight is gained and the fetus sits in the head-down position most of the time. There will be regular fetal movement, which can be disruptive. Eventually, the head engages and there is increased pressure on the bladder. Prenatal care can begin before pregnancy with preconception counseling. Prenatal medical care is recommended throughout the pregnancy in order to monitor for pregnancy-related complications. Nutrition is important before and during pregnancy. Folic acid consumption is particularly important in order to prevent spina bifida in the fetus. Omega-3 fatty acids are also helpful in brain and eye development. Iron is important to prevent anemia. Calcium and vitamin D are important for bone development. Foods that should be avoided are those that are unwashed and might contain pathogens, and unpasteurized deli meats and dairy products. Women need to gain weight in order to have a healthy baby. Overweight women do not need to gain as much as underweight women. About 25 to 35 pounds is recommended for the woman who has a normal body mass index prior to getting pregnancy. Gaining too much weight can increase the risk of a cesarean section, hypertension in pregnancy, and large fetal size. Regular aerobic exercise is recommended unless there are pregnancy complications.

THE BIRTH PROCESS The birth process in humans is called childbirth. It is the final aspect of a pregnancy that involves expulsion of the fetus, which becomes an infant, from the vagina or through Cesarean section. Childbirth usually happens in a hospital in a developed country and in a home in developing countries.

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There are four stages of labor. The first stage of labor involves cervical dilation and lasts about 12 to 19 hours. The second stage of labor is when the fetus or infant is delivered, which lasts about 1 to 2 hours. The third stage of labor is when the placenta is delivered, which lasts 5 to 20 minutes. The fourth stage of labor is the hour or so after the placenta is delivered, when bleeding is controlled and the woman’s episiotomy, if given, is repaired. Labor starts with an increase in uterine contractions, which become strong and repetitive. The contractions also become more painful and some women receive opioid pain medications or what’s called an epidural block, which involves injecting an anesthetic into the epidural space around the lower spinal cord to anesthetize the pelvic and leg structures. As the head descends the birth canal or vagina, which stretches markedly, it is said to crown, when it is visible at the vaginal opening. The hormone, oxytocin, is increased in late pregnancy, which increases contentment, calmness, and a sense of bonding with the partner. The uterus is also sensitive to this hormone, resulting in increased uterine contractions and expulsion of the fetus. Oxytocin after birth and during breastfeeding will increase bonding and maternal behavior after childbirth. It causes the letdown reflex in breastfeeding. As many as 80 percent of mothers in the US will report sadness after delivery of their baby, often called the “baby blues”. This can last a few minutes to a few days and disappears after two weeks’ postpartum. About 10 percent of women will develop postpartum depression, which is more long-lasting and has a greater effect on infant bonding and the care of the infant. Figure 24 shows the stages of labor in a vaginal delivery:

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Figure 24.

The cervix ripens before delivery so that it is softer and easier to thin and dilate. In the first stage of labor, this will dilate to full cervical dilation status, often referred to as being 10 centimeters dilated. Most women start labor with uterine contractions, while some will have rupture of membranes, which is the breakage of the amniotic sac around the baby. The first stage of labor is sometimes divided into a latent stage and active stage, the later allowing for greater contractions and more cervical dilation. In the second stage of labor, the fetus is delivered. There is marked stretching of the perineum, which is the space between the vaginal introitus and the anus. This is the area that is cut if an episiotomy is done. This stage can be short in women who’ve given birth before but requires a longer period of stretching if the woman has never given birth. Head and shoulders are the hardest part to deliver, with the shoulders sometimes becoming stuck. The remainder of the infant’s body is relatively easy to slip out of the vagina. The third stage of labor can be just a few minutes or up to 20 or more minutes. There is a gush of blood as the placenta separates and before it can be expelled from the vagina.

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The uterus can be massaged after the placenta has delivered in order to promote contractions, which will slow the bleeding. The biggest risk of this stage is a retained placenta; this can lead to hemorrhaging or infection if part of the placenta does not leave the uterus. The umbilical cord can be clamped after it stops pulsating, which can take several minutes. The fourth stage of labor is the beginning of the postpartum period. The uterus contracts and the bleeding slows. The episiotomy is repaired to restore the perineal structure. The woman may have chills or shivering during this stage and there is a risk of postpartum hemorrhaging. Skin-to-skin contact with the infant is recommended at this stage as long as mother and baby are stable. Sometimes, labor needs to be induced for medical or practical purposes. It involves giving intravenous oxytocin, although other medications are sometimes given to ripen the cervix beforehand. Those who require an emergency delivery or who do not progress in labor will often require a cesarean section. The majority of these surgeries are done with an incision across the lower uterine segment, which allows for later being able to have a vaginal birth after cesarean or what’s called a VBAC.

ABORTION An abortion is the termination of a pregnancy by removing or allowing for the expulsion of the embryo or fetus before it can survive. A spontaneous abortion is called a miscarriage, while a deliberate abortion is called an induced abortion. When used by itself, the term abortion usually means an induced abortion. A late-term abortion is one in which the pregnancy is terminated after the fetus is technically viable. Induced abortions can be therapeutic for the health of the fetus or mother, or elective, which is an abortion done for other reasons. Most abortions are done because of an unintended pregnancy. Those abortions on an intended pregnancy are done because of genetic issues in the fetus. The manner by which the abortion is performed depends on the gestational age. Selective reduction involves terminating one or more fetuses in a multiple gestation in order to reduce the total number.

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A spontaneous abortion or miscarriage is the expulsion of the fetus before 20 weeks’ gestation. If the fetus dies after that, it is referred to as a stillbirth or intrauterine fetal demise. Less than half of all pregnancies make it past 12 weeks’ gestation. Most that fail will fail before a woman knows she’s pregnant. About 15 to 30 percent of known pregnancies will end in miscarriage, usually before the twelfth week of gestation. Chromosomal abnormalities account for the majority of these terminations. An induced abortion can happen with the use of drugs, called a medical abortion. Methotrexate and misoprostol, which induces abortions, will both kill and expel the fetus. It can only be done up to 10 weeks’ gestational age. A combination of mifepristone and methotrexate can be used later in the second trimester. Medical abortions are the most effective measure before 7 weeks’ gestation. A surgical abortion is done after a medical abortion fails or in the second and third trimesters. Up to 15 weeks’ gestation, vacuum aspiration or suction is used to dilate the cervix and suck out the products of conception. This can be done manually or with an electric pump. Curettage can be done in order to scrape out the interior of the uterus. Dilation and evacuation use suction to remove the fetus after 12 to 16 weeks. An abortion an also be done by inducing labor and then by causing fetal demise if necessary. It can be done in the second or third trimester to expel the fetus naturally. This is rarely done in the US but is done more often in Europe. Rarely, herbal treatments have been used, but this is dangerous. Also dangerous is causing trauma to the uterus in order to kill the fetus. Abortions can be very safe, except when it is done by unskilled people in situations that are unsanitary. Abortions are about fourteen times safer than childbirth in developed countries. Vacuum aspiration is the safest technique in the first trimester; it can be done as an outpatient. Infections are the greatest cause of death in abortions so antibiotics are often given before an abortion procedure. Research has shown that even illegal abortions can be safe if done by skilled practitioners, which isn’t necessarily guaranteed. There are no correlations between having an abortion and later having mental health problems, especially when compared to the mental health issues of an unwanted

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pregnancy. Some women will regret their abortion in what’s called “post-abortion syndrome”, which is not recognized as being a true psychological disorder by health professionals. The abortion rate is the number of abortions per 1000 women of childbearing age. This is about 28 out of 1000 worldwide. The abortion percent includes the number of abortions out of 100 known pregnancies, including pregnancies that end in live births or miscarriages. This rate is about 21 percent worldwide. In those countries that restrict abortions, there is an increased risk of unsafe abortions. Access to contraceptives reduces the chances of abortions and abortion complications. There is a wide variety of reasons why a woman would want an abortion. Some cite domestic violence, finances, the desire to finish education, feeling too young to have a baby, rape, and lack of social support as personal reasons to have an abortion. There might be pressure to have a child of a certain race or gender, population control in society, lack of access to contraceptives, and the stigma of having a child with a disability that play into wanting to have an abortion. Maternal or fetal health can play a role. Exposure to a teratogenic infection or chemical might lead to the decision to have an abortion.

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KEY TAKEAWAYS •

There are many different types of contraception, including hormonal, barrier, and behavior methods.

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Fertilization or conception occurs in the fallopian tubes, when the sperm cell and egg undergo reactions that contribute to the fusion of the DNA of these cells.

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Pregnancy is associated with changes in libido, sexual responsiveness, and sexual behaviors.

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Pregnancy lasts from the first day of the last menstrual cycle until 40 weeks’ gestation.

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There are many physiological changes a woman undergoes during pregnancy.

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Childbirth involves several stages, leading to the delivery of the infant from the vagina or through an abdominal incision.

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Abortions involve termination of a pregnancy; there are many reasons why a woman would want an elective abortion.

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QUIZ 1. Which of the following is the least effective method of contraception? a. Fertility awareness b. Spermicides c. Oral contraceptives d. Implantable contraceptives 2. Which teen birth control method has been found to be least effective? a. Oral birth control pills b. Implantable birth control c. Abstinence education d. Condoms 3. How long after sex should a woman keep the contraceptive sponge in place in order to prevent pregnancy? a. It can be removed within 15 minutes b. Two hours c. Six hours d. 24 hours 4. What is not a problem with using the contraceptive sponge with spermicide? a. Blood clots b. Allergic reactions c. High failure rate d. Toxic shock syndrome 5. What measurement is different from the others? a. Gestational age b. Conceptional age c. Fertilization age d. Fetal age

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6. What is not true of sex in pregnancy? a. Libido will decrease in the first trimester. b. There can be increased pain with intercourse during pregnancy. c. There is no known risk of pregnancy complications and sex. d. Sexual activity tends to increase in pregnancy. 7. In pregnancy, when does the first trimester end? a. 6 weeks’ gestation b. 8 weeks’ gestation c. 12 weeks’ gestation d. 15 weeks’ gestation 8. A woman who has been pregnant once or is pregnant is called what? a. Multigravida b. Nulligravida c. Nulliparous d. Primigravida 9. What is not something that oxytocin does as part of the birth process? a. Increases feelings of contentment b. Increases bonding to the infant c. Causes mild production d. Increases uterine contractions 10. An abortion done in multiple gestation pregnancies in order to reduce the total number is called what? a. Induced abortion b. Late-term abortion c. Therapeutic abortion d. Selective abortion

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CHAPTER EIGHT: GENDER EXPECTATIONS AND ROLES This chapter talks about the development of sex differences and gender in humans as well as the different issues that come out of gender identification, such as gender roles and stereotypes. There are individuals who are born with a specific sex assignment who feel as though they do not belong to that gender. These transgender people and their issues are discussed in this chapter.

DEVELOPMENT OF GENDER Gender is not the same as sex and it is not the same thing as sexual orientation. Sex itself refers to the different biological characteristics that are not the same between males and females. The XX chromosomes lead to the formation of female hormones, ovaries, and female sexual characteristics. The XY chromosomes lead to male hormones, the formation of testes, and make sexual characteristics. Gender, on the other hand, is related to the cultural differences expected by a culture that is according to the person’s sex. The sex of a person is defined from birth and is unchanging, while the gender will vary from person to person later in life. In years past, it was relatively clear what constituted feminine and masculine behavior. Now, gender is a much more diverse thing and occurs on a scale from feminine to masculine. The biological approach suggests that gender and sex are the same so that the individual’s biological sex creates their gender and resultant behavior. In such cases, gender is determined by chromosomes and hormones. Remember that the same sex hormones exist in both males and females, although they are found in different amounts and act on different areas of the body. The high amount of testosterone in utero determines the development of male sexual structures. This masculinizes not only the male body but the male brain, starting at 7 weeks after fertilization. The effect of testosterone on the male brain leads to

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competitiveness, increased visuospatial abilities, aggression, and a higher sex drive. The sexually dimorphic nucleus in the hypothalamus is bigger in males compared to females. Testosterone affects the lateralization of the brain. In most people, the left side of the brain is used for language, while the right side of the brain is used for spatial and nonverbal skills. Studies have shown that, when it comes to language, women often use both hemispheres, while men only use the left hemisphere. This increased lateralization of the brain appears to be because of testosterone. Female monkeys exposed to testosterone in utero will be more aggressive in their play when compared to normal females. Sexual behavior can also be changed in rats through differing exposures to testosterone and female hormones during prenatal development. Some of the sexual behaviors were reversed and did not change after the hormones were withdrawn. It was believed that the sexually dimorphic nucleus was changed in this type of exposure to hormones. Studies on women who were given male hormones in pregnancy to prevent miscarriage showed that their female offspring had more aggression later in life. We have also talked about the SRY gene, found on the Y chromosome. It becomes activated by six weeks into development, causing the male gonads to develop. Without this gene, the gonads will become ovaries. There are some women who are born as XY males but who do not have an active SRY gene. These girls grow to become women despite having a male chromosomal pattern. There are some people born with abnormalities of their sex hormones. Two of these disorders are Turner syndrome and Klinefelter syndrome. In both of these cases, the person has normal chromosomes with the exception of their sex chromosomes. Individuals with Turner syndrome have an XO genotype, which means they just have one X chromosome and no Y chromosomes. About 1 in 5000 girls will have this. They will be phenotypically girls but will not have normal ovarian development. At maturity, they will not mature. They may have lower than normal special ability, visual memory, and math skills, good verbal skills, low stature, and webbing of the neck. Social adjustment and peer relationships are not considered normal.

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Klinefelter syndrome patients have an XXY genotype. It occurs in 1 out of 750 males. They will appear to be male and will have some secondary sexual characteristics, except they will have poorly-developed genitals and less body hair. The male child with Klinefelter syndrome often has poor language skills with reading difficulties in school and slow language acquisition. The Klinefelter child tends to be cooperative, shy, and passive as children, which remains as part of their emotional and behavioral characteristics throughout life. The study of men with Klinefelter syndrome has indicated that aggressiveness is largely biological rather than environmental. Researchers in evolution attempt to explain how certain gender characteristics have developed. The argument is that the division into gender roles was particularly adaptive to the hunter-gatherers in the dawn of mankind. In this type of society, the division into separate gender roles was advantageous. Hunting of game necessitated agility, good visuospatial skills, and speed. Women required other skills to care for children, grow or gather food, and make clothing and shelter. In the biosocial approach to gender determination, there is an interaction between biology and environment, which together play a role in the development of gender. Parents and others in society treat a phenotypic boy and a phenotypic girl differently, which steers their overall development. Prenatal exposure determines sex hormones and their role in giving the child a phenotypic sex. Children continue their gender development through social labeling and different treatment of the genders. According to the biosocial role, gender identity is relatively neutral prior to the age of three and may be changed, depending on how the child is treated. The boy who is biologically male who is raised as a girl will have the gender identity more closely mirroring that of a girl. This is called the neutrality theory.

DEVELOPMENT OF GENDER IDENTITY Interestingly, while Western cultures generally think of two genders, this is not always the case in other cultures. In these cultures, there are more genders than just masculine and feminine. In this culture, gender wasn’t even studied until the 1970s. This was 147

when some of the first textbooks came out on gender identity and gender roles. Research was done on intersex children, who are born with characteristics of both sexes. It was then determined that there is just as great a role of society on gender identity as biology is. Sex-related differences in thinking and cognition are sometimes looked at through standardized testing, which has its limits in actually looking at how real-life problems are solved. In addition, there have been biases found in existing research. Even so, males seem to be better at aiming, while females are better at fine motor skill and coordination. Men can visualize geometry better, while women are better at verbal memory and object location memory. Women read body cues and facial cues better than males and have better verbal memory and spelling abilities. Men in Africa who can travel furthest from their tribe without getting lost have better spatial abilities. This too can be biased so that there is reinforcement for those individuals that have learned to do something well. This selfselects those that are good at a task. According to perspectives more related to the social and cultural sides of gender identity, there are gender schemas, which are gendered cultural ideals of boys and girls that determine their preferences. Think of pink clothing for girls and blue clothing for boys. These things begin in infancy. Gender stereotypes get reinforced even more as children get older, which can lead to sexism. It leads to the ideals of girls staying at home and boys going out to the workforce. Much of these things have changed over the years and are altered further when dealing with homosexual couples. The person in the same-sex relationship who behaves more closely like those of their opposite gender is called a congenital gender invert. This type of person has more problems feeling comfortable in society.

GENDER CONCEPTS IN CHILDREN There have been a lot of theories about how children develop the concept of gender. One question is: do infants understand gender? Children likely seek information about the meaning of gender and what it means to them. This is how they learn to socialize. 148

Infants can recognize the different genders at three months of age and by six months, understand the differences between male and female voices as well as male and female faces. By ten months of age, they can form stereotypes about gender, although they are primitive. About half of all 18-month-old girls understand the gender differences but boys of the same age tend not to be so accurate. Children of two years of age know which gender group they belong to and can pick out the correct picture that corresponds to their gender. By two years of age, children will play with toys that match their gender, although girls do this earlier than boys. Children, according to most studies, know their gender by 18 months and seek information about what it means. Stereotypes become more solidified by 2 to 3 years of age. They understand abstracts related to femininity and masculinity, and they know about roles, tools, and possessions that belong to each gender. Physical aggression stereotypes are found in early childhood. Stereotypes about other things, like sports and adult roles, get larger as the child gets older. They become more sophisticated in identifying the different stereotypes related to gender. At about 8 years, they recognize masculinity and femininity. There becomes more flexibility with regard to gender after about six or so years of age. The peak age of gender rigidity is about 5 to 6 years of age. Personal interests and knowledge will play a role in either the further development or hindrance of a child’s stereotype formation. Children ultimately begin to evaluate the two genders differently. They become aware of a membership in the male or female group, identifying with their group and developing a prejudice regarding the other group. Preschool children will feel better about their own gender than the opposite sex. Children who feel closer to their own gender have more prejudices regarding the other gender. Children also start at an early age to anticipate their upcoming adult roles. Girls can feel like a princess who are looking forward to their prince and boys can anticipate their future role as a husband with a wife. When do children see a difference in status between boys and girls? Greater power is seen in males, while more helplessness is seen in females at a young age, although this 149

has not been well studied. Children of six years or so see the traditional male jobs to be held at a higher status than the typical female jobs. It takes an older child to know that, for example, only men have been presidents and that males are held in higher esteem than females. Children around 8 to 10 years of age are also aware of gender discrimination. Because of gender role rigidity, children around five years of age are more punitive toward a peer who, for example, plays with a toy associated with the opposite sex. This did not get worse with age but, in fact, got better with age. In groups of children, there tends to be a “gender enforcer” who most limits what boys and girls can play with. This person is suggested to be more sexist than other children, even in preschool. Children also make negative judgments about peers that engage in gender-atypical behavior, particularly boys who do so. Most studies do not see an association with this phenomenon before the middle elementary school with increasing negativity as a child gets older. Children at age three years will be selective toward having same-sex peers. There is favoritism and exclusion of peers from gender stereotypic activities, such as baseball and ballet, even though the same children recognize that excluding an opposite-sex child is wrong. There is more rigidity in preschoolers than there is in older children about exclusivity in certain gender-related groups.

GENDER ROLES AND STEREOTYPES So far, we have looked at how children develop gender identity and gender roles. Now we will talk about gender roles in adults, within different cultures, and with regard to religion. A person’s gender role is the social role they play that determines what is appropriate and acceptable for their sex. Usually, gender roles are based on preconceptions about what is masculine and what is feminine. This varies significantly from culture to culture. No one knows what role biology and sociology play in determining gender roles. Gender socialization refers to the way in which a person acquires their gender role. Some cultures recognize androgyny as a third gender. This is a person who has features of 150

both genders. Interestingly, many transgender people do not see themselves as a separate gender but simply as being men or women. One’s gender role is different from one’s gender identity. As we have talked about, there are social construction theorists, who believe that social conventions determine gender behaviors. There are also evolutionary theorists who believe that evolution determines gender behaviors. The term patriarchy is based on male dominance and is seen out of many agricultural societies. There are several theories on gender roles. A researcher, Talcott Parsons, created the model of the nuclear family, which was prominent in the 1950s when the model was created. There were two models of gender roles, one of which involved complete segregation of social roles, while another involved total integration of social roles. Most couples in today’s society have a relationship that is somewhere between the two extremes. A Dutch researcher, Geert Hofstede, studied the effects of gender on culture. He said that the terms, masculinity and femininity, are related to the differences in sexual behaviors between men and women. Masculine cultures expect men to be competitive, ambitious, and assertive—attracted to fast, big, and strong things. Feminine cultures see an overlapping role between men and women so that men do not have to be competitive and may strive for other things besides material success. Feminine cultures are more collaborative and collective, while masculine cultures are more individualistic. In feminine cultures, the goal is quality of life and care for others; in masculine cultures, the goal is success and achievement. John Money studied intersex children in the 1950s to see how these children grew up. The conclusion of the research was that a child’s chromosomes, gonads, and hormones did not automatically determine the child’s later gender role. Much of this research has since been criticized, mostly because he was involved in some false reporting. The concept that gender is unrelated to sex was promoted during the 1980s. These views indicated that a person can have the sex of one type but the gender of another. This reinforces the idea that gender roles and gender identity are two different things.

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There are influences of biology on gender traits, however. Studies of children born with adrenal hyperplasia, who have excess male hormones, show that female children with this issue are more likely to have masculine traits. Children who have an XY chromosome pattern but were intersex because of a 5-alpha reductase deficiency, were considerably more likely to be male at the time of adulthood. The culture and the era both determine gender behaviors. There have been some cultures, for example, where homosexual relationships were accepted. There are also cultures where men are not expected to hold back their emotions. In the Middle Ages, women were assigned to the roles of healing and medicine but this was quelled after the witch hunts in Europe and by the institutionalization of medicine. Gender norms are important in religion as well. The Bible states the appropriateness of male and female hair lengths. In some religions, such as Roman Catholicism and Eastern Orthodox churches, only men can be priests or deacons. Protestant and Pentecostal religions see females in leadership roles as largely acceptable. Gender roles in Islam center mainly on the family unit and are largely traditional and conservative. Muslim women are expected to dress modestly and the laws of these countries reflect a masculine perspective. Nevertheless, the mother is revered in this culture. In Hinduism, the deities are often androgynous compared to other religions. Even so, the culture is contradictory regarding women. They value a woman’s fertility but female sexuality per se is felt to be more destructive and dangerous than men. Marriage also influences gender roles and equality. The media and culture depict the acceptable roles for those in a married relationship, although for practical reasons, most couples learn to work out their roles among themselves. Men rank youth and beauty more highly than women, while women value social status and finances more highly than men. Certainly, society has changed and is changing rapidly. About a third of wives now make more money than their husbands and there is increasing access for women to get an education, such as internet-based college, which has resulted in women getting better educated. More men are involved in raising their children than ever before. 152

There are differences in communication styles between men and women, with women being more expressive in their language. Women understand nonverbal cues better than men and laugh or smile more than men. Men are taught to suppress their emotions and to be less expressive. Men show more dominant body language, such as eye contact and interpersonal distancing, more than is true of women. There are distinct communication cultures for men and women, just as there are for gays, older people, African Americans, and disabled individuals. Men are more likely to express their sexual interests than women and are better at communicating their sexual desires. In general, men are less inhibited by various social norms regarding the expression of their sexual desire. Women are more indirect in showing their sexual desires than men. Women, however, are more direct in offering refusals for sex, even when men are not compliant with their refusals. Gender issues are important in politics. While there have been marked increases in women running for political offices, only about 20 percent of major offices are held by women. The aggressiveness of a female candidate is seen as a masculine trait, which favors their likelihood of political success. Women are seen as better on poverty and women’s rights, while men are seen as better at handling foreign affairs and crime. There has, of course, been big changes with regard to women’s rights. Women were given the right to vote with the Nineteenth Amendment and began working in industry from the beginning of the Twentieth Century. This drifted back to involve the nuclear family of the 1950s and 1960s. Now, women make up half of the workforce and are often the major breadwinners in the family. There is also a men’s rights movement that has been advanced since the early 1970s. There are men who feel that men are discriminated against, disadvantaged, and oppressed, particularly when it comes to issues like domestic violence, reproductive rights, and family law. Men are also discriminated against in areas related to compulsory military service and health policies. There are distinct differences between men and women with regard to sentencing for certain crimes. Men and women are equally involved in criminal behavior involving minor property issues and substance abuse offenses but men are more likely to be

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charged and convicted for robbery and murder. Only in prostitution are women more heavily involved. In addition, intimate partner violence is the same in same-sex couples compared to heterosexual couples.

TRANSGENDER ISSUES A transgender person is one whose gender identity is different from their assigned sex. Those who get medical assistance to make a physical transformation are said to be transsexual. The term transgender is sometimes used to refer to people who consider themselves bigender, gender fluid, or gender queer and is sometimes called the third gender, although we have already discussed that most transgender people do not feel that this is the case. Transgender issues are completely different from sexual orientation. The transgender person may be asexual or may be heterosexual, homosexual, or even bisexual. Some do not like to label their orientation at all. Transgender is different from being intersex, which is a medical term used to describe someone who has ambiguous genitalia. A person who is cisgender believes they have a gender identity that is the same as their assigned sex. Transvestitism is not the same thing as transgender and refers specifically to how one prefers to dress. The terms “trans man” and “trans woman” refers to the assignment the person desires. So, for a person who is a male transitioned to female, this would be called “trans woman” and for a person who is female transitioned to male, this would be called “trans male”. The words trans-masculine and trans-feminine are also increasingly used. As mentioned, a transsexual is a subset of being transgender. These are people who desire to have hormones and sex reassignment surgery. The word transsexual has more to do with one’s physical sex than transgender, which has more to do with one’s psychological sex. Some transgender people do not like the term “transsexual” because gender involves more than just sexuality. Each transgender person is different with regard to how they would like to be labeled so one should always ask about this when dealing with the individual person.

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There are other categories that need to be considered. The non-binary or genderqueer person does not desire to be categorized as being specifically male or female. There are some people who see themselves as genderless or gender fluid. These too are different from sexual orientation. The transvestite or cross-dresser prefers to dress in clothing of the opposite gender to what they were assigned at birth. Most people in this category prefer to be called crossdressers. There are people who do this as part of their livelihood, such as “female impersonators”. Most cross-dressers are heterosexual and do not want to change their physical bodies. Cross-dressing is different from transvestic fetishism, where the person dresses in the opposite gender because of a sexual fetish. A person who dresses in drag does so for purposes of entertainment or performance. It can be something comedic or theatrical. Drag queens are men who dress in female drag, while drag kings are women who dress in male drag. A faux queen is a woman who does female drag. Because of some of the confusion between orientation and gender, the terms androphilic and gynophilic are used to describe the attraction to a man or woman, respectively, while bisexual means an attraction to both genders and asexual means an attraction to neither gender. This avoids the confusion of what a person would be if they were biologically one sex, transitioned to the opposite sex, and attracted to the gender they have chosen as their preferred sex. There is a mental health classification for gender dysphoria or gender identity disorder, despite the confusing roles of sex and gender in society. A person who is transgender, however, does not have to have gender dysphoria if they are happy with the gender they have chosen. The problem is that mental health and medical insurance does not pay for a person who is otherwise happy with themselves so many of these people are labeled as having gender dysphoria in order to get the care they need. Some prefer to call it “gender transition” to define a person needing medical assistance to achieve the gender they desire but do not have true dysphoria. It can also refer to people who want to undo their previous transition.

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There are therapies available for transgender people who desire medical help to change their physical appearance. Trans men can take hormone replacement therapy, which will alter their voice, skin, hair, and fat distribution. Trans women can take hormones to feminize their fat distribution but it will not change their voice or hair growth. These people need voice lessons and laser hair removal to alter these features. There is surgery also to alter the Adam’s apple, breasts, and genitals. Trans men can have their female reproductive structures removed. Those men who do not do this run an increased risk of endometrial cancer because of the hormonal changes to the endometrium. Transgender people are discriminated against in the workforce and are more likely to be unemployed. In many places, their status is not legally protected and it takes a diagnosis of gender identity disorder in order to get funding for sex reassignment and hormone therapy. In Europe, sterilization is required to receive treatment. There are few good research studies on the biological basis for transgender phenomena. There is an increased risk of being transgender if an identical twin is transgender but it is only about 33 percent of identical twins who choose this route. Hormone levels have not been found to be statistically different in transgender people. There some studies suggesting brain chemistry may play a role but this has not been proven.

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KEY TAKEAWAYS •

There are certain things that determine gender in utero but this does not mean the person will remain that gender until adulthood.

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There is a difference between gender roles and gender identity.

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There are both biological and cultural or social factors determining gender identity and gender roles.

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Children are aware of their gender from the preschool years and have stereotypes about gender that exist from infancy, even if they are rudimentary at that time.

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Gender roles have changed greatly over cultures and in different time periods.

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There is a difference between gender identity and gender orientation.

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Transgender people wish to be of a gender different from their sexual assignment at birth.

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Intersex means a person who has ambiguous genitalia from birth.

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QUIZ 1. What is not an effect of the brain after being exposed to testosterone in utero? a. Increased visuospatial skills b. Decreased lateralization of the brain c. Increased competitiveness d. Increased aggression 2. What does the SRY gene do in humans? a. It activates estrogen to be made in females. b. It turns off estrogen production in males. c. It regulates secondary sexual characteristics in females. d. It allows for testosterone production in male embryos. 3. What cognitive/behavioral issue is most noticeable in boys who have Klinefelter syndrome? a. Dyslexia b. Decreased IQ c. Poor mathematical skills d. Poor language skills 4. What is the genotype of the person with Klinefelter syndrome? a. XXY b. XY c. XYY d. XXYY 5. When are children considered the most rigid about their own stereotypes in gender and gender roles? a. 2 years b. 5 years c. 9 years d. 13 years

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6. At what age does sexism in a child begin? e. Prior to 5 years a. Between 5 and 9 years b. Between 10 and 13 years c. Adolescence 7. Which religion or religious faith is most tolerant of women in leadership roles? a. Pentecostal b. Catholic c. Islam d. Hinduism 8. What is true of sexual communication between men and women? a. Women express their sexual desires more directly than men. b. Men are more inhibited socially in saying what they want sexually. c. Men tend to express their sexual intentions indirectly. d. Women are clearer about sexual refusal than they are of sexual desires. 9. A person who has ambiguous genitalia at birth is referred to in what way? a. Transgender b. Transsexual c. Cisgender d. Intersex 10. What best defines a transvestite or cross-dresser? a. Someone who has a fetish about dressing in the opposite gender. b. Someone who chooses to dress in clothing of the opposite gender. c. Someone who is transgender but does not wish sexual reassignment surgery. d. Someone who is homosexual and dresses for entertainment purposes.

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CHAPTER NINE: SEXUAL ORIENTATION The topic of this chapter is sexual orientation. This refers to the long-lasting sexual or romantic attraction to a person of a certain gender. There is a wide range of choices for sexual orientation, which are described in this chapter. The specific issues related to what it means to be heterosexual, homosexual, bisexual, gay, or lesbian are covered in this chapter as are the different sexual practices involved in sexual relationships between same-sex couples.

SEXUAL ORIENTATION EXPLAINED Sexual orientation is specifically about who a person is attracted to, if anyone. A person can be considered heterosexual, homosexual, bisexual, or even asexual. The asexual person does not have sexual attraction to any person. Some people can be pansexual or polysexual. These are the definitions you should know about: •

Heterosexual—this is a person, also called “straight”, who is sexually attracted to the opposite sex.

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Homosexual—this is a person, called “lesbian” if a woman and “gay” if a man, who is sexually attracted to a person of the same sex. The term “gay’ can be used to describe a lesbian woman as well.

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Bisexual—this is a person who has sexual attraction toward males and females, although it does not have to be an equal attraction.

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Asexual—this describes a person who does not have sexual attraction to any person. This is different from celibacy, which involves not partaking in sex.

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Pansexual—this describes an attraction towards people regardless of their gender identity or sex. This person does not use gender to decide their sexual attraction.

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Polysexual—this describes a person who has attraction to many genders but not necessarily all genders.

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Sapiosexual—this describes a person who is attracted to the intelligence of another person. It is not specifically a sexual orientation because it does not represent sexual attraction.

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Androphilia—this describes a person who is attracted to masculinity.

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Gynephilia—this describe a person who is attracted to femininity.

Sometimes the term “sexual preference” to describe sexual orientation, although most scientists believe that sexual orientation isn’t a choice. There are likely hormonal, genetic, and environmental influences on sexual orientation, although biology appears to play the largest role. Childhood experiences and upbringing have little to do with sexual orientation, and people are believed to exist on a continuum rather than being exclusively one orientation or another. Most of the time, a person’s sexual orientation includes some type of psychological aspect, including to what or to whom one’s erotic desires are attached. There is also a behavioral aspect, which involves the person’s sexual behaviors. The sexual orientation is first established between middle childhood or early adolescence. All cultures and people of the world have individuals attracted to more than just the opposite sex. Sexual orientation is completely different and separate from biological sex, gender identity (which is psychological), and gender roles (which are more cultural and refer to behavior). Sexual behavior refers to the acts the person engages in sexually. Orientation, rather, focuses on one’s fantasies and longings. A person may elect to express or not express their sexual orientation. A person who has a non-heterosexual orientation that differs from their sexual behaviors and sexual identity is called “closeted”. There are terms called “concordance” and “discordance”. A person is said to be concordant if their sexual orientation matches with their sexual behaviors, while a discordant person does not have a match between their sexual orientation, identity, and sexual behaviors. The terms “sexual identity” and “gender identity” are sometimes confusing. Gender identity strictly means one’s psychological attachment to their own genitals, while sexual identity can be more all-encompassing and can also mean sexual preference, even though the term “preference” indicates a voluntary choice, which is not usually the case. 161

As mentioned before, perhaps the terms androphilia and gynephilia are better used to describe sexual orientation than heterosexual and homosexual. This is because they refer strictly to what one is attracted to without making assumptions about the gender identity of the person who has the attraction. In addition, the terms “pansexual” and “polysexual” also do not assign a gender to the person having the attraction. Another term used in sexual orientation is “same gender loving” or SGL. This is a term that introduces the idea of love into sexual orientation. It makes the acknowledgment that orientation also refers to the fact that these are people who have a loving relationship with a person of the same sex. Terms that most focus on the object of one’s sexual attraction rather than on the person are less confusing and more applicable to a wider variety of people. In the beginning of the study on sexual orientation, it was believed that sexual orientation was linked to one’s gender identity. For example, a person in a female body attracted to other females was thought to have masculine attributes. The same would be true of a homosexual male. This concept has changed in the past fifty years so these are considered to be different. Individual people might be masculine, feminine or even androgynous, despite their sexual orientation. Certainly, gender nonconformity exists as early as childhood but it doesn’t necessarily relate to later sexual orientation. A person who is gay or lesbian can have an intimate or sexual relationship with another person of the opposite sex. This can be secondary to a variety of reasons, including religious reasons and the desire for a traditional family life. Much of the time, the person hides their orientation from their spouse and family. This person can later “come out” to themselves and their family, which can be challenging to everyone in the family. A person may also have a change in their sexual orientation identity throughout their life. This can be referred to as having sexual fluidity. This sexual fluidity is more likely to occur in women as opposed to men but, as we’ve already talked about, women tend to be naturally more sexually fluid than men. So, what are the biological influences on sexual orientation? Some possible factors include prenatal hormone exposure, genetic makeup, and brain structure. None of

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these have come out on top as being causative of differences in sexual orientation. Male sexual orientation is more tightly linked to biology than female sexual orientation. There are some who believe that orientation is determined at conception. Genetics may relate to sexual orientation. A 2014 study in males showed a specific gene linked to homosexuality, located on chromosome 8. Fetal exposure to hormones may also contribute to orientation, but it is not believed to be the major factor. Exposure of the brain to male hormones may or may not affect the orientation of the fetal brain. Some studies fraternal birth order to sexual orientation in males so that a woman who’s had several male children in the past has an increased likelihood of conceiving a homosexual male child. This is thought to be related to the mother’s immune responses to male fetuses. Conversion therapy involves psychological interventions that try to change one’s sexual orientation. Not only does this type of therapy not work, it is viewed as possibly being harmful to the individual undergoing this type of treatment. Much of this type of therapy involves conservative religious views rather than any true altruistic attempt to change the person’s sexual orientation. The global scientific view on same-sex orientation is that it is basically normal behavior and not representative of pathology. The Kinsey scale is also referred to as the heterosexual-homosexual rating scale, first published in 1948. It was designed to change the assumption that a person is either homosexual or heterosexual. It gives a rating that describes the degree of heterosexuality or homosexuality a person has. The rating scale goes from 0 to 6, where zero represents a person who is exclusively heterosexual and six represents a person who is exclusively homosexual. The downside of the scale is that it correlates sexual orientation with sexual behaviors and, as we’ve talked about, these two things are not altogether related. One could also evaluate a person’s sexual behaviors separately from one’s sexual reactivity, which are two different things. The Klein Sexual Orientation Grid looks at things besides a person’s behaviors and sexual reactivity, looking instead at attraction and how it relates to sexual identification and lifestyle factors involved in one’s sexual orientation. The Kinsey Scale, in addition to not making a distinction between behaviors

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and psychological attraction, implies that there is some kind of tradeoff between homosexuality and heterosexuality, which may not be the case. The Klein Sexual Orientation Grid looks at past orientation, present orientation, and ideal orientation. There is also the Sell Assessment of Sexual Orientation, which considers the different dimensions of sexual orientation and does not have a tradeoff between homosexuality and heterosexuality. It consists of questions addressing sexual attraction, sexual behavior, and sexual orientation identity so that it doesn’t give a clear-cut answer on one’s sexuality but allows discussion of how sexual orientation is determined. Sexual attraction is a better measure of a person’s actual sexual orientation, according to the Sell Scale. Sexual behavior plays the least role in orientation, on the other hand. The prevalence of certain sexual orientations varies according to which of the three factors is being looked at. If sexual attraction is looked at alone, the prevalence of homosexuality is two to three times greater as that which is assessed through sexual behavior or sexual identification. Women, in particular, are apt to change their sexual identity over the course of time. Remember also that a woman’s sexual arousal patterns are not always consistent with their stated sexual orientation—a fact that is less likely to be true for men. While sexual orientation is independent of social factors and culture, the open identification of a person’s sexual orientation may be linked to the social or cultural setting. Not everyone places a focus on their orientation when considering their sexual identity and are felt to have different degrees of sexual fluidity. Certain cultures, too, are more accepting of sexual fluidity than other cultures. Interestingly, there is such a thing as “gaydar”, which is how some people predict a person’s sexual orientation based upon their appearance, voice, clothing, and behavior. Guesses on sexuality based on a person’s face photo alone are better than average. Others believe that this is based on LGBT stereotypes, rather than on an actual ability to determine sexuality by a person’s facial features. The prevalence of same-sex attraction depends greatly on the way a person is assessed for this feature. Most of the statistics indicate that same-sex attraction is about 3 to 9 percent in males and about 1 to 5 percent in females. The figures are higher in urban

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areas than they are in rural areas. In contrast, the prevalence of asexuality is about one percent. Bisexuality is difficult to assess because people vary in how they define bisexuality.

TYPES OF ORIENTATION A heterosexual is someone who is attracted sexually or romantically to the opposite sex. This is by far the largest proportion of people in the world. Like any type of sexual orientation, heterosexuality is not considered a choice but is somehow determined at birth or at least early in life. The term “straight” is often referred to as the same thing as being heterosexual. Heterosexuality is supported by most religions and those who sanction marriage, although this is changing as the laws and society change regarding sexual orientation. About 89 to 98 percent of people say they have only had heterosexual contacts in their lifetime. When it comes to identification, about 90 to 93 percent of people self-identify as being heterosexual. The heterosexual couple is what forms the basis of the nuclear family, with marriage thought to be a necessary part of this in many societies. Other jurisdictions recognize common-law marriage, in which an unmarried woman and man live together for a period of time, suggesting they are in a long-term and established relationship. The term “heteronormativity” is involved in the world view that promotes being heterosexual as being normal. This relates also to heterosexism, which is a bias in favor of opposite sex sexuality and heterosexual relationships. Some who subscribe to heterosexism assume that everyone is heterosexual, harboring some type of personal or systemic discrimination against those who are not strictly heterosexual. Conservative and some religious groups have derived the slogan “straight pride” as an alternative to the “gay pride” slogan used by different LGBT groups. Homosexuality is one of the three main sexual orientation groups, along with heterosexuality and bisexuality. Not all people believe that the term “asexual” should be used to describe sexual orientation. Homosexuality can also refer to a person’s sexual identity, which is what orientation a person feels the closest membership to. 165

The terms “homosexual” and “heterosexual” were not widely used in medicine or society until about 1886, when books began to be written on the subject. In today’s time, the term “homosexual” is not generally referred to in noun form, so that the terms “lesbian” and “gay” are used instead to refer to the person who engages in homosexual behaviors. The term “LGBT” refers to “lesbian, gay, bisexual, and transgender” individuals. The term “homophilia” refers to same-sex love rather than strictly a sexual relationship. MSM means “men who have sex with men”, which refers strictly to sexual behavior. Society has changed over time and place in the course of history. In some cultures, men were expected to have same-sex relationships, while in others, it is seen as a minor sin or even something punishable by death. A study of preindustrial cultures in history indicates that about 41 percent of cultures strongly disapproved of homosexuality, while 21 percent accepted or ignored it and 12 percent did not have a concept of it. In some cultures, homosexuality was considered absent or rare, while in others, it was considered not an uncommon phenomenon. Older cultures did not speak of homosexuality itself but talked instead about sodomy, which was believed to be a criminal behavior. Anal sex, on the other hand, was frequent among couples in Ancient Greece. Essentialists believe that sexual preferences are biologically based, while constructionists believe sexual preference is largely a learned behavior. In the US, sodomy was still considered criminal in 1986 but this was overturned in 2003 so that homosexuality was legalized. The first same-sex marriage state was Massachusetts in 2004. By 2105, same-sex marriage was legalized in every state. In East Asia, on the other hand, homosexuality has been written about and somewhat tolerated since 600 BCE. More recently, however, there has been opposition to homosexuality, particularly when China became westernized. Less is known about lesbianism or female homosexuality. The Greek poet, Sappho was born on the island of Lesbos near Greece; she wrote about her attraction and relationships to young women on the island in about 400 BCE. Lesbian literature of old often spoke of love and infatuation between women but not of the sexual acts between women.

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In the Middle East, Israel is by far the most tolerant country in the area toward homosexuality. Tel Aviv is considered to be the “gay capital of the Middle East” and hosts an annual gay pride parade. Other countries and cultures deny or ignore homosexuality. In Muslim countries, same sex contact is illegal, with same-sex intercourse punishable by death in many Middle Eastern countries. This was not always the case in pre-Islamic times. About half of all gay men and up to 80 percent of lesbians are involved in a same-sex romantic relationship. Between 18 and 28 percent of gay men have been involved in their relationship for longer than 10 years. The same is true of between 8 and 21 percent of lesbian couples. These individuals have about the same satisfaction with their relationship as opposite-sex couples. The same ideals and expectations are seen in same-sex romantic relationships as is seen in opposite-sex romantic relationships. The process of coming out involves disclosing one’s sexual orientation or gender identity. It starts with knowing oneself and what each person feels about same-sex relationships. The second phase involves coming out to close friends and loved ones. The third phase involves living one’s life openly as an LGBT person. Most people come out in the US during high school or college. Not everyone decides to fully come out to family or colleagues. This is complicated by the fact that most gay people are not raised in an environment that supports homosexuality. Some people are “outed” by others against their personal preference. Homosexuality was considered a disorder by the American Psychiatric Association in 1952. This was relatively immediately criticized by other health professionals. This resulted in homosexuality being removed by the APA in 1973. It was listed as a mental illness by the World Health Organization in 1977 but was removed by 1990. What still existed, however, was the idea that there could be ego-dystonic sexual orientation, which defined anyone who was distressed or wanted to change their sexual orientation. Gay and lesbian parents have been shown to be just as psychologically fit to be parents as heterosexual parents. Children raised by same-sex couples are raised in more sexual and gender tolerant circumstances but have equal chances of being heterosexual or homosexual later in life, regardless of the orientation of their parents.

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Gay and lesbian young people have an increased risk of school problems, social isolation, substance abuse, and suicide. There tends to be a more hostile environment with more bullying, hostile behavior toward them, and verbal or physical abuse experienced by gay and lesbian youth. They also are at an increased risk for sexual abuse, sex with multiple partners, and running away from home. Depression and STDs are more common in LGBT youth. Gay people in general face a wide range of legal repercussions, depending on where they live in the world. There are parts of the world where being gay is not illegal and gay marriage is accepted as being legal. There are other parts of the world where homosexual activities are not only illegal but such activities are punishable with the death penalty. In parts of the world where homosexual activity is illegal, these laws are not always enforced. The illegality of homosexual behavior is the greatest in Islamic countries, particularly in the Middle East.

SAME-SEX SEXUAL BEHAVIORS Gay sexual practices involve any sexual activity in which a man has sex with another man. As you have learned, such practices can occur with any type of self-proclaimed sexual identity or sexual orientation. In the Kinsey Reports, which were published in 1948, about 37 percent of men indicated they’d had at least one sexual encounter with another man. Even so, this number may have been underreported because there is social bias against these types of behaviors. As mentioned, while anal sex is most associated with MSM or men having sex with men, most do not engage in this sexual activity. Oral sex, frottage or rubbing penises together, and mutual masturbation are more popular than anal sex in this population. Oral sex is the most popular behavior in men who have sex with men. Recent self-report surveys indicate about five to nine separate sexual behaviors practiced by men who have sex with men. The insertive partner in anal sex is often called the top, while the receptive partner is called the bottom. Men who are versatile are comfortable with either position. Pain and pleasure together are often a part of anal sex. Receptive men who have an orgasm often

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get it through prostate stimulation. Receptive males are just as likely to achieve an orgasm as the insertive males. Pain, however, is a factor in about 14 percent of receptive anal sex situations. Frottage is a non-penetrative form of sex in MSM behavior. It involves stimulating the frenulum nerve bundle located on the underside of the penile shaft through mutual penis-to-penis contact. Docking involves the insertion of a man’s penis into the foreskin of another man; this is another practiced behavior in MSM. Sex positions used by men who have sex with men include doggy style, the missionary position, and the sixty-nine position. These men also participate in BDSM and sometimes use sex toys. About 25 percent of gay and bisexual males indicate that spanking is part of their sexual practices. Vibrators are used by about half of gay men at some point. Men who have sex with men are more likely to have an orgasm if the sex happens within the context of a stable or loving relationship. This happens at the same rate as heterosexual men. Trans men who retain their vagina will sometimes have sex with a cisgender man; such sexual activity can include vaginal penetration. Men who have sex with men have the same numbers of sexual encounters involving unprotected sex as heterosexual men and heterosexual women. HIV disease is an issue with MSM behavior with about 5 to 10 percent of HIV infections caused by this kind of sex. About 55 percent of new HIV cases happen in gay or bisexual men because of MSM behavior. Syphilis and anal warts also connected to MSM behavior and unprotected sex. Other STDs, such as herpes, gonorrhea, and chlamydia are not increased with this type of behavior. Lesbian sexual practices or WMW behaviors involve any kind of sexual behavior practiced between two women, regardless of their self-identified sexual orientation. Women in these types of sexual encounters will engage in sexual affection, including touch, hugging, or kissing. There are many forms of lesbian sexual behaviors that women can engage in. Things like erogenous touch and disrobing in front of the other women can both indicate the desire for sex. Foreplay often involves stimulation of the sexual partner’s 169

breasts or nipples or other forms of oral to skin connection, particularly of the erogenous zones. Nipple stimulation is, in fact, a common way for lesbian women to indicate the desire for sexual activity. This behavior releases prolactin and oxytocin, which are important bonding hormones. Among lesbian sexual practices, the attainment of an orgasm can be gotten through stimulation of the nipples or the clitoris. There will be orgasmic muscle contractions and vocalizations that lead to further release of hormones that lead to relaxation during a refractory period. Women are more likely than men to have the ability to have more than one orgasm during a short period of time. Common lesbian sexual practices include oral stimulation of the nipples and clitoris, called cunnilingus. Anilingus is less commonly practiced. Fingering or manual stimulation of the clitoris or other genital organs is also common. Some women have sexual stimulation with manipulation of the G spot. Sex toys or a strap-on dildo can also be used. Tribadism is a common practice in lesbian women. This is also referred to as frottage and involves stimulation of the vulva against the other woman’s stomach, thigh, or other body part. It is sometimes referred to as the scissoring position or as dry humping. Several different sex positions can be used. As with heterosexuals or gay men, the practices of dominance, submission, or BDSM can be used in lesbian couples. In such cases, there would be an active partner and a submissive partner, with the active member engaging in the use of sex toys, spanking, or various types of sexual stimulation. Bondage or handcuffs can be used. Both the active and submissive sex partner can derive sexual satisfaction from this type of behavior. According to Alfred Kinsey’s work on sexual behavior among females, more women report having an orgasm when having lesbian sex than women who have heterosexual sex. Masters and Johnson reported essentially the same thing and indicated that emotional as well as full-body sexual contact is seen in lesbian contacts. On the other hand, lesbian couples tend to have less sex over time in their sexual relationship when compared to straight couples. What has been discovered, however, is that the sexual

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frequency decreases in lesbian couples but the time spent per encounter is higher than is seen in heterosexual couples. Many people associate lesbian sexual encounters with cunnilingus, which may or may not be a part of these types of encounters. Some women like to participate in that, while others do not, for various reasons. Among sexual encounters in lesbian relationships, 80 percent report tribadism, while more than 90 percent engage in fingering or other forms of oral sex. About 7 percent engage in anal sex at least some of the time. The most common sexual practice among lesbians is oral sex, followed by digital penetration, mutual masturbation, and tribadism. The use of sex toys is less frequent. Lesbian sexual practices can cause sexually transmitted diseases, although this is less possible with non-penetrative sex. HIV can be passed through menstrual blood, breast milk, or vaginal fluids. Things like trichomoniasis, human papillomavirus, and syphilis can be passed through lesbian sex. For this reason, some doctors suggest covering sex toys with condoms, using dental dams, and using lubricated gloves in order to decrease the risk of STDs. In actual practice, however, these practices are rarely done because of the perception of less vulnerability to getting a sexually transmitted infection.

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KEY TAKEAWAYS •

Sexual orientation refers to the level of attraction a person has to the different genders.

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Sexual orientation is believed to have a biological basis rather than a social or learned basis.

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There are different levels of comfort with homosexuality in different parts of the world and in different time periods.

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MSM behavior refers to the sexual practices between two consenting men and includes several types of sexual behavior other than anal sex.

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WMW behavior refers to sexual practices between two consenting women and includes a variety of sexual behaviors other than cunnilingus.

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QUIZ 1. A female person who is attracted to other females exclusively would be called what? a. Pansexual b. Asexual c. Sapiosexual d. Lesbian 2. A person who is attracted to any other person, regardless of their gender is called what? a. Pansexual b. Polysexual c. Asexual d. Sapiosexual 3. What term is the same thing as gender identity? a. Sexual orientation b. Biological sexual assignment c. Sexual identity d. None of these 4. What is true of sexual fluidity? a. It involves changing one’s gender identity. b. It involves being attracted to more than one gender at different times and in different circumstances. c. It involves being equally attracted to males and females. d. It involves not being attracted to either gender.

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5. What homosexual term refers strictly to a person’s sexual behavior? a. MSM b. LGBT c. Homophilia d. Androphilia 6. Where in the Middle East is homosexuality the most tolerated? a. Iran b. Egypt c. Saudi Arabia d. Israel 7. What is the insertion of one man’s penis into the foreskin of another man called? a. Frottage b. Docking c. Tribadism d. Pegging 8. What percent of HIV disease happens because of MSM behaviors? a. 10 percent b. 29 percent c. 55 percent d. 87 percent 9. What is true of the sexual responsiveness of women in lesbian relationships versus heterosexual relationships? a. There is an increased incidence of orgasms in a lesbian sexual encounter. b. Women have greater sexual satisfaction in heterosexual encounters. c. Women in a lesbian encounter reach an orgasm faster than in heterosexual encounters. d. Women in lesbian relationships have increased sexual desires over time. 10. What is the most common lesbian sexual practice? 174

a. Tribadism b. Oral sex c. Vaginal penetration d. Anilingus

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CHAPTER TEN: SEXUALITY AT DIFFERENT AGES This chapter includes the topics of childhood sexuality, adolescent sexuality, sexuality and aging, and sex among people with disabilities. Sexuality develops first in childhood, usually with sexual curiosity and simple sexual behaviors that develop into adolescent sexual behaviors that increasingly approach adult sexual activity. These are discussed in the chapter as well as the changes in sexuality that occur with aging. Also covered in the chapter is sex in individuals with disabilities. As you will see, sexual behavior persists throughout life and in different life circumstances.

CHILDHOOD SEXUALITY While children are developing physically and emotionally, they are also developing as sexual beings. There is a wide range of normal sensations, emotions, and sexual activity that can happen in children prior to the development of puberty and before full sexual maturity has been reached. There are social and cultural influences in how adults perceive the child and his or her sexuality. Until Sigmund Freud published his work on sexuality in 1905, it was believed that children were completely asexual. Freud studied childhood sexuality and, while most of his theories have since been rejected, he was instrumental in identifying children as being sexual beings. Children have a natural curiosity about their bodies, understand the differences between boys and girls, and wonder where babies come from. Many will engage in sexual touch and masturbation. Children learn to “play doctor” and are known to be curious about their genitals. This type of sex play is most common in preschoolers and kindergarteners; it decreases in elementary school, while romantic interest increases. Curiosity escalates at the time of puberty, when there is an increase in sexual interests and sexual activities. It is known that children find genital stimulation pleasurable and will engage in behaviors that promote this. Mutual masturbation and manual stimulation occur 176

during adolescence. There is a strong cultural influence on what type of behavior is acceptable. In the Western world, it is believed that, because of media and other exposures, children have been sexualized. This has been coupled with a lack of parental oversight of their behaviors and poor sex education offered in schools. This sexualization, particularly of girls, inhibits their self-image and blocks healthy development. We will talk about sexual abuse of children in the next chapter. It involves adults or older adolescents having sexual relationships with a child. This increases anxiety and depression; this further victimizes the child as he or she is an adult and leads to posttraumatic stress disorder. Research on child sexual behavior is difficult because of ethical concerns. For this reason, sexual behavior in children is studied through observation, adult recollections, and observing children who have problems related to their sexual behavior. Much of the research has been done in Western societies. One of the goals is to understand what behavior is normative and what behavior is not. Normative behaviors include explorative sex play, such as “playing doctor”. Childhood sexuality is less driven by goals and more driven by feelings. Oral-genital contact and genital penetration are not common in children unless they have been abused sexually. Abused children are more likely to have higher degrees of sexualized behavior, such as public masturbation and coercive sex. Child on child sexual abuse is not normative sexual behavior. Normal sexual behavior in the child under seven years includes attachment to the opposite-sex parent, curiosity about where babies come from, exploring other children’s bodies, learned modesty about what is private and what is not private, and genital touching. Around five to seven years of age, there is the intentional choosing of same-gender children to play with, disparagement of the opposite sex, increased attachment to the same-sex parent, and masturbation. Girls in particular have an increased awareness of privacy. All children will make use of bathroom humor regarding sexual issues.

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In middle childhood, there is continued attachment to same-sex friends, more disparagement of the opposite sex, increased fantasy, and an awareness of erotic sensations as being sexual. There is about a ten to fifteen percent incidence of sexual experiences with siblings, a portion of which is coercive or exploitative in nature. While there are normative sexual behaviors in children, some children have sexual behaviors considered to be problem behaviors. This often indicates an abusive background. Children who have been abused sexually at a younger age, had family members abuse them, or who had abuse that was penetrative have an increased risk of sexual behavior issues. The increase in media access, particularly through chat rooms and the internet, has resulted in children getting sexually explicit information at a younger age. Music and television expose children to sexual innuendo and sexual behaviors. Even so, not all of this exposure leads to problem behaviors in children. While sexual play and some sexualized behaviors are seen frequently in children who are not at risk for having had a history of sexual abuse. However, sexual acting out, coercive sex, and sexual behavior inconsistent with the child’s development are all considered sexual behavior problems that are associated with sexual abuse. Children with these behaviors are often called “sexually reactive children”. Hand to genital contact is the most common sexual behavior in infancy. Sexual curiosity and physiological pleasure associated with the genitals increases in toddlers. The child over five becomes more aware of privacy issues so they are more likely to conceal their sexual behaviors. The elementary school-aged child will have an increase in sex-related topics and an increased attraction to the opposite sex. Most children do not have goaldirected sexual behavior and are not as interested in sexual gratification. While there are certainly normative behaviors in all age groups, if the frequency is higher than most children, this could indicate a sexual behavior problem. At aged 10 to 12 years, interest in the opposite sex and interest in nudity is common as well as touching the genitals in private. Some will show an interest when dealing with a nude person. Children of this age know more about sex; girls can be more flirtatious at this age.

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Children exposed to sexual activity in adults, nudity, less overall privacy, and bathing without privacy are more likely to exhibit sexual behaviors. If parents knowingly expose their child to harmful sexual media or pornography, this is abnormal and requires social services referral. Parents should expect the highest degree of overt sexual behavior in the three to five-year-old, which should decrease with age until puberty. In looking at sexual behavior problems in children, one needs to look at their developmental age. Sexual contact with others and sex with other people are less likely to be normative. Children with intellectual disabilities can display what is considered abnormal behaviors because of their younger developmental age. Sexual behavior problems in children include the following: •

Self-penetration of their anus or genitals with objects or fingers

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Persistent or frequent sexual activity

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Sexual behaviors involving another who is more than three years in age apart from them

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Any type of coercive sexual activity

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Explicit imitation of adult sexual behaviors

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Asking adults for sex

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Oral to genital contact

There is a higher than average risk of ADHD, conduct disorder, and oppositional defiant disorder among children who have problem sexual behaviors. These are children who externalize their emotional problems and who often need to have other things addressed besides their sexual behavior issues. There is also a high risk of abuse of all types in children who have sexual behavior problems.

SEXUALITY IN ADOLESCENTS Sexuality changes in adolescence but is intensified by puberty and the onset of puberty. Adolescents engage in kidding, flirting, masturbation, and sex with others. As with children, there are social influences on what is acceptable in adolescents as far as 179

sexuality is concerned. There are also different laws as to when the age of consent is for adolescence. This is a time when things like unintended pregnancy and sexually transmitted infections increase. The brain is not fully mature in adolescence, which influences control over sexual behaviors. Thoughts about sex and sexual interests change and increase with puberty. Hormones influence these things to a great degree and, as already discussed, the secondary sexual characteristics are matured. Studies on sexual activity in teens show that fewer girls report sexual activity than boys. Girls also indicate less pressure to have sex from peers, while boys have increased social pressure. Boys see sex and having sex as a positive link to their social standing, which is not a phenomenon in girls. Boys are less concerned about the risks of sex itself and more interested in the perceived social risks of being abstinent. More teens turned to oral sex after programs were initiated in the US about the risks of sexual intercourse. About a third of adolescents see oral sex as being the same thing as abstinence. Girls see their virginity as a gift and something special so they expect some type of intimacy if they are going to “give away” or give up their virginity. Many do not feel they have gotten this from their sexual partner when the do lose their virginity. Boys are more likely to be stigmatized around still being virgins. They are more likely to see a loss of virginity as a good thing. Among teens who are sexually active use birth control of some type at a rate exceeding 80 percent. Most of the time, girls make use of combination estrogen and progestin birth control pills, while some use progestin-only pills or non-oral forms of hormonal contraception. There is a much higher risk of depression related to the use of hormonal birth control in girls. Much of the risk is associated with progestin use rather than estrogen use. Studies of older adolescents show no differences between the genders and sexual satisfaction or sexual problems. The most common problem in older teen males was anxiety around sexual performance, followed by premature ejaculation. In females, the most common problem was difficulty in attaining an orgasm, followed by lack of sexual interest, poor vaginal lubrication, anxiety, and painful sex.

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Those that had more sex were more likely to enjoy sexual pleasure. Sexual difficulties often lead to sex avoidance, although many will still have regular sex even if they have a decreased libido. Pain with sex was higher in those who had low arousal levels. Girls have increased social pressure to be “good girls” and are more often to think their sexual desires are bad. This can increase sexual problems. Same-sex attraction in adolescents depends on their social surroundings. Those who hide their feelings to the greatest degree are those in girls’ schools that prohibit samesex attraction and girls belonging to conservative religious communities. Schools in general place a greater emphasis on girls to date boys with a high emphasis on heterosexuality. Male gender role expectations can inhibit boys from expressing their attraction to the same sex. There is less flexibility around same-sex attraction in boys than there is in girls. Adolescents have the highest risk of getting an STI compared to adults. They are more likely to have sex with an infected person and often do not believe they will contract an infection. They are less likely to seek healthcare when infected and are less likely to be compliant with treatment efforts. They are more likely to have more than one infection at the same time. Media in general and exposure to sexuality on television shows do not necessarily affect adolescent sexual behavior but the type of messages they receive does have an influence. Sexual scenes with typical gender stereotypes do affect sexual behavior to a greater degree, with girls getting messages that they are not in control of their sexuality. Settings where girls are less submissive are empowering to girls. Boys seem to be less influenced by these things. Teen girls can get pregnant after menarche. There are increased pregnancy and childbirth risks in pregnant teens, especially if under 15 years or if they live in a developing country. There are, of course, socioeconomic problems associated with teen pregnancy and an increased risk of low birth weight. The rates of teen pregnancy is higher in some parts of the world, such as sub-Saharan Africa, and lower in places like industrialized countries in Asia. In developed countries, teen pregnancy is often found

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outside of marriage and social stigma is common. This is not the case in developing countries. Sexual contact prior to the age of consent with adults is illegal in all countries, while sex outside of marriage at all in Islamic countries is illegal. If teens are close in age, this is generally not prohibited. The average age of consent in the world is 16 years of age. This may or may not correlate with the age of majority or the age of legal marriageability. Statutory rape is sex between an adult and a child under the age of consent. It is important to develop a sexual self-concept in the adolescent years. Unfortunately, societal influences have led girls to objectify their bodies and to be unattached to their own sexual feelings. Adolescents in general must learn to understand their personal motivations for sexual behavior. This affects their later relationship development. Sexual self-concept development begins before sexual experiences in some cases. The media and sex education can help modify a teen’s sexual self-concept. Boys tend to have greater sexual anxiety and lower self-esteem around their sexuality. They are also less likely to resist having sexual activity, while girls are trained to do this to a greater degree. There are hyper-masculine ideals that contribute to a boy’s sexual inadequacies. Older teen girls have greater comfort with sexuality and experience less anxiety. Sex education is an avenue for schools, parents, and public health campaigns to teach the important issues regarding sex for teens and pre-teens. It is not taught in the same way in every country with some European countries having sex education in schools since about 1970. In the US, parents are the major sex educators of their teens, although the school system can also be involved. Schools are more likely to be objective in teaching sex than parents. While many schools place an emphasis on abstinence, it is believed to have no positive effect on teen behavior. More than 95 percent of Americans have sex before marriage, often in the teen years. Religious programming can also involve sex education. Lack of access to sex education has a negative impact on teen health.

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AGING AND SEXUALITY Sexuality in older people is not emphasized and is often overlooked or misunderstood. In fact, in humans, it is generally not possible to be “too old” for sex and intimacy. It is assumed that people over sixty do not have sexual desires or the ability to perform in old age. This is a more common worry among older males. Older women may feel ashamed about their sexual desires. Even so, older people see sex as a way to express affection, passion, romance, and life affirmation. It affirms their physical functioning and preserves their self-confidence and sense of identity. Sex is pleasurable to older people as much as younger people. Things like physical disability, fear, fatigue, and boredom can adversely affect an older person’s sexual desire. These things can be made worse by loss of a sex partner, medical problems, medications, or depression. Research has been done to interview older adults about their sexuality. It should be noted that asking about sexuality in the older population is not often done. About 70 percent of individuals feel that sex is negatively impacted by their older age with half indicating that age was mainly responsible for their lowered sexual desires. More men blame poor health on loss of sexual function than women, while more women say that loss of a spouse affected their sexual desire. Roughly equal numbers simply blame advancing age or things like finances and job loss on lack of sexual desire. Women are more likely to say that their sexual desire has dropped a great deal with age. Nonworking adults have a greater degree of sexual desire losses than working adults. About half of all older people still want sexual activity of some kind at least one a week, even though only 40 percent actually follow through on this. The older the person, the less likely they were to want regular sex or to have regular sex. Sex at a rate of at least once per month was experienced by about 70 percent of older adults. Older men are more likely to be sexually active than older women. There is a decreased interest in non-sexual activities, like hugging, kissing, or other expressions of intimacy, particularly in older women. Twice as many men are sexually active as older women. Men are more interested in both non-coital and coital activity

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than women. More women stop sexual activity compared to men at some point in their lives, but for a variety of reasons. Nearly all older individuals say that it takes longer for sexual arousal than it once took in their lives with about 29 percent of men over sixty reporting some degree of erectile dysfunction. Men also reported a large decrease in ejaculatory volume but this was not considered distressing. Women have less vaginal lubrication in older age. Those with health problems say they have worsened orgasm intensities. More than 75 percent say they have no sexual dreams. More than 95 percent do not masturbate at all. Medications, endocrine, neurological, and vascular factors can interfere with sexual function in older individuals. These can include diabetes, arthritis, surgery, dementia, and cardiovascular disease. Unfortunately, many older people feel they should just live with their sexual dysfunctions and do not often seek treatment for it. Sexual function and activity in old age have been inadequately studied world over. It is important to know that aging processes are not confined to persons beyond the age of 60 years; many changes in elderly have their antecedents in the middle age.

AIMS: This study sought to determine the patterns of sexual activity and function in individuals over 50 years of age. It also sought to discuss barriers such as chronic illness that may interfere with sexual function.

MATERIALS AND METHODS: We conducted a study of subjects above the age of 50 years in various outpatient departments (OPDs) of a teaching municipal hospital in Mumbai, by interviewing 60 individuals who attended the OPDs, after taking their informed consent. Sociodemographic and other information on their sexual function and activities were obtained. Data was analyzed using statistical package for social sciences v15.

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RESULTS: 72% individuals below 60 were sexually active, while only 57% above 60 were active. Others had become completely abstinent at some time in their lives. Statistical analysis revealed significant gender, health and educational status based differences in the sample.

CONCLUSION: Our study showed significant presence of sexual desire, activity and function even after the age of 50 years; a decline by the age of 60 and above was a finding that reflected more in women. Chronic illness did affect sexual function and desire. Keywords: Elderly, illness, sexual activity, sexual desire, sexual function, sexuality

SEX AND DISABILITIES People with disabilities have a wide range of sexual desires and can be different in how they express themselves sexually. Disabled people are not asexual and some are sexually active. Some of the bias against disable people and sexuality date back to antiquity. Religious groups have generally associated sex with procreation, which led to the idea that disabled people shouldn’t reproduce and therefore, should not have sex. It has only been in the last 100 years that sex for pleasure has become normal. The problem with that was that it was then believed there was no point in having sex if one could not have an orgasm. Self-image in disabled people is still a problem. They may feel rejection is more likely if they have a disability. There is fear associated with being sexual and being disabled. Some believe that sex will be harmful to them somehow. There are those who feel judged about their sexuality with disabilities. In modern society, the disabled are felt not to be sexy or even able to be sexually active. There is a great deal of misinformation about disabilities and sex. This is especially true of women who are disabled, who are felt to be child-like. Many people confine

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themselves to certain images of what sex should be like and cannot imagine a disable person having sex. Finally, there is little research on sexuality among the disabled. Disabled people may require increased communication, devices, medications, and a good deal of experimentation in order to have sex. Sex among the disabled may or may not involve intercourse. A person with a spinal cord injury, for example, may be able to have pleasure sexually if stimulated above the level of their injury. In fact, men with spinal cord injuries can have an orgasm in up to 80 percent of cases. Positioning devices can help to aid sexual activity and sex toys may be used. There are people who become sexually aroused by people with disabilities. This is called devotism or abasiophilia. There is a condition called apotemnophilia, where a person chooses to amputate their own limb in order to have sexual pleasure. Little is known about this fetish, other than that it exists and that some people are successful in doing this. The presence of devotism gives some disabled people more confidence in feeling sexual. There is fetishism associated with having sex with disabled girls or women, which results in an increased risk of sexual abuse. Historically, disabled people were institutionalized and often sterilized, even if it was against their will. People with intellectual disabilities were most often treated this way and had their sexuality denied or otherwise oppressed. People with intellectual disabilities have a higher chance of being vulnerable to abuse in sexual situations or to sexual exploitation. The incidence of sexual abuse perpetrated on those with intellectual disabilities is believed to be about 70 percent, usually by their fathers or stepfathers. A number of US states have prevention programs for people with intellectual disabilities.

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KEY TAKEAWAYS •

Children can masturbate in infancy and will exhibit normal sexual behaviors.

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Sexual activity in children becomes more private after the age of five years.

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There are certain problem behaviors in children that indicate possible sexual abuse.

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Adolescents are charged with finding their sexual identity during adolescence.

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While many schools offer sex education, programs that promote abstinence rarely are successful.

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The older adult will have a longer time to sexual arousal and some decrease in sexual interest, although many remain sexually active throughout life.

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Older men tend to be more sexually active than older women.

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Disabled people are often marginalized and thought not to be sexual at all.

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People with intellectual disabilities have an increased chance of sexual victimization.

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QUIZ 1. What is true of the sexualization of children? a. It has occurred throughout the ages. b. It was promoted by Freud. c. It causes an improvement in well-being in children. d. It can be harmful to healthy development. 2. What is most likely to indicate a normal sexual behavior in children? a. Oral-genital contact b. Genital penetration c. Masturbation d. Coercion of other children 3. When should parents most likely observe overt sexual behaviors in their child? a. One to three years of age b. Three to five years of age c. Six to eight years of age d. Nine to twelve years of age 4. What other psychiatric problem is least likely to be present in children who have problem sexual behaviors? a. ADHD b. Oppositional defiant disorder c. Conduct disorder d. Obsessive-compulsive disorder

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5. What is the most common method of contraception used by adolescent females? a. IUD b. Injectable progestin c. Progestin-only oral medication d. Combination estrogen and progestin birth control pills 6. What is increased to the greatest degree by girls who use progestin as a form of birth control? a. Endometrial cancer b. Depression c. Anxiety disorders d. Pelvic inflammatory disease 7. What is least likely to be true of sexually transmitted infections in adolescents. a. Adolescents are more likely to have more than one infection at the same time. b. Adolescents are less likely to see themselves as vulnerable to STIs. c. Adolescents are less likely to seek healthcare for STI symptoms. d. Adolescents have the same incidence and prevalence of STIs as adults. 8. What is the average age of consent to have sex considered to be in the world? a. 13 b. 16 c. 18 d. 21 9. What is not true of sexual activity comparing older men and older women? a. Older men are more likely to be sexually active. b. Older men are more impacted by poor physical health. c. Older men have more interest in non-sexual behaviors than women. d. Actual sexual desire is greater in women than in men.

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10. What is not true of sexual arousal in older individuals? a. Most older people do not have sexual dreams. b. Most older people still masturbate c. Most older people say it takes longer to be sexually aroused. d. Most older men say they have decreased ejaculatory volume.

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CHAPTER ELEVEN: SEXUAL AGGRESSION, SEXUAL HARASSMENT, RAPE, AND CHILD SEXUAL ABUSE The focus of this chapter is sexual aggression, which can involve sexual harassment, sexual abuse, rape, and child sexual abuse. In no culture are these things considered to be normal sexual behavior, although it certainly does exist in all societies of the world. Sexual harassment usually involves unwanted sexual attention or behaviors directed at one person by another, often in the workplace. Sexual assault involves many different types of sexual aggression, including rape, which is discussed in the chapter. Child sexual assault is also covered, which involves sexual aggression directed at children.

DEFINING SEXUAL AGGRESSION Sexual aggression has been increasingly talked about in recent years, especially in highprofile positions, where a famous person was alleged to have committed an act of sexual aggression against one or more others. Most people think of rape as the only form of sexual aggression and it was felt to be primarily as a way to have sexual gratification by the perpetrator. It is now seen simply as a category of sexual aggression. True sexual aggression can involve any type of sexual activity, including unwanted touch, oral sex, and any type of penetration or intercourse done by one person against the will of another. Sexual harassment is considered by some to also be a form of sexual aggression. Sexual aggression victims can be male or female. Researchers know that power, hatred, and sexual aggression are all motivating forces leading to sexual aggression. It is not something the victim “asks for” and it is not just done by strangers. The most common perpetrators of sexual aggression are dates, husbands, acquaintances, fathers, or other members of the victim’s family. Alcohol and drug use are often involved in the different types of sexual aggression. In the case of date rape, there can be the added factor of miscommunication along with anger and the assertion of power that contribute to the phenomenon.

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Victims of sexual violence often feel helpless and out of control after being raped or otherwise violated. Depression, anxiety, and PTSD commonly follow being sexually violated, particularly if they do not report the crime or do not get the kind of help that they need from hospitals, police, family, and friends. There are those who continue to blame the victim, which makes it difficult for the victim to cope with what has happened to them.

SEXUAL HARASSMENT Sexual harassment involves unwelcome or inappropriate speech or actions perpetrated by one person upon another, often in schools, workplaces, churches, and the military. It can range from inappropriate speech to sexual assault. Both men and women can be victims. In most modern societies, sexual harassment is illegal, although it can sometimes be difficult to prosecute people for offhand comments or teasing that is sexual in nature. It becomes illegal when it is frequent or when it creates a hostile environment for the victim or cases them adverse consequences. In the US, the legal aspects of sexual harassment were developed in the 1970s. This was when the term “sexual harassment” was first widely written about and when some organizations created standards and policies to combat the problem. There were many activists at the time who brought the discussion of this issue to the attention of lawmakers and the public at large. Laws were first created in the early 1980s addressing sexual harassment. The perpetrator of sexual harassment usually has some type of authority or power over the victim, which can be real or perceived between the victim and perpetrator. Parents, teachers, coworkers, and even clients can be perpetrators of this crime. There does not have to be a witness for sexual harassment to occur and the perpetrator may not know their behavior is against the law. Even the victim may not be aware of it as a problem. Even so, victims of sexual harassment can experience sleep problems, poor health, eating difficulties, social withdrawal, depression and increased stress, even if the event was a one-time thing. The victim and perpetrator can be of the same gender and the

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incident or incidents can happen because of misunderstandings of the law or of the situation between victim and perpetrator. Sexual harassment can happen in the workforce and can involve unwelcome advances of a sexual nature, verbal or physical sexual misconduct, or requests for sexual favors. In the workplace, it can lead to a hostile workplace environment. More than 75 percent of victims are women and more than half of perpetrators are supervisors. It can happen in any environment but is most likely to occur in finance, business, banking, and trade. About 10 percent of victims are threatened with termination if they do not comply. Sexual harassment is commonly seen in the military and is more common in the military than in civilian workplaces. This is partly because military people tend to be young and because the environment is more isolated than in other workplaces. Women are often the minority and more men are supervisors or above the rank of the women. The military also rewards men for masculine behaviors and there is an increased emphasis on obedience. Deployment in the military increases the incidence of sexual harassment. It often involves a male perpetrator and a female victim. Detained people in a wartime situation are also common victims. Child recruits in the cadet forces have an increased risk of military sexual harassments. Because of the culture of the military, the problem is acknowledged but less often reported out of fear of repercussions. Victims will later have an increased risk of mental illness and PTSD after their experiences. There are four types of harassers in sexual harassment. The most common perpetrator is called a dominance harasser, who gets an ego boost out of their behavior. Others can be predatory harassers, who get a sexual thrill out of humiliating the victim. Street harassers will do their activities in a public place, where the victim is a stranger. Strategic harassers perpetrate because they get to maintain their job-related privileges. Research has been done on the effect of sexual harassment on the victim. Most of the female victims feel subsequent anger, annoyance, and embarrassment. Fear is another common emotion as is shame. Stress ad depression can also follow sexual harassment and victims of frequent sexual harassment experience symptoms similar to being sexually assaulted.

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Sexual harassment results in the sexualization of the victim, who can feel objectified or humiliated. Work or school performance can suffer and it can affect the future career goals of the victim. Relationships between the victim and loved ones can suffer and those who accuse the perpetrator are sometimes the subject of attacks by others. There are widespread losses of trust on the part of the victim. Physical problems can result as a part of being repeatedly harassed. PTSD, social withdrawal, and suicidal ideation or behaviors can occur. Surprisingly, the victim turned accuser faces problems almost as big as not reporting the crime. Women who work with the accuser are often hostile or simply back off from the victim, which adds to a feeling of isolation. Aspects of the victim’s life are put under scrutiny. They may lose friends as part of reporting the crime. Retaliation is always a possibility the victim can face. Sometimes, however, there will be others who will later come forward to report similar experiences. Many countries have laws that say sexual harassment is a form of abuse and that it is illegal to do this in the workplace. The European Union and the United States have relatively clear laws in support of the victim and condemning workplace harassment. China and Egypt have also developed laws against it but it remains legal in other places in the Middle East. Most of these laws are relatively recent and there are variable interpretations of what constitutes harassment and what the punishments should be

SEXUAL ASSAULT In this section and in the next sections, we will talk about sexual assault and the forms it comes in. It involves any act in which a person is sexually touched by another, often without the victim’s consent or because of coercion of the victim. Sexual assault can involve rape, groping, sexual torture, and child sexual abuse. In general, sexual assault involves some type of sexual contact. Sexual contact through a person’s clothing without their consent is considered sexual assault. The definition of consent assumes that the victim is not incapacitated by drugs or by intellectual deficits. There are several types of sexual assault, some of which are discussed later in this chapter. Child sexual abuse is sexual assault perpetrated upon a child and can include

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indecent exposure to a child, showing a child pornography, touching the child’s genitals, or taking pictures of an unclothed child for the purposes of child pornography. Child sexual abuse leads to PTSD or post-traumatic stress disorder, anxiety, depression, and an increased risk of victimization later in life. The child may be physically injured and male victims can later be sexual perpetrators. Incest is sexual assault by a family member and is the most common and most potentially serious type of assault on a child, especially if the perpetrator is a parent. It is believed that 15 to 25 percent of adult women and between 5 and 15 percent of adult men have been sexually traumatized as a child. About 30 percent of perpetrators are related to the victim, while 60 percent are unrelated but close to the victim. Strangers make up 10 percent of child sex abuse cases. As mentioned, parental perpetrators cause the most severe psychological damage. Child sex abuse is often not reported because the victim is too young to be verbal about what happened, the victim was threatened or bribed, the victim is confused, the victim does not feel like they will be believed, or the victim feels they themselves are to blame. Some feel guilty about the effect that saying something will have on the perpetrator. Domestic violence can be of a sexual nature or part of a wider phenomenon between members of the same family. Elder sexual assault can be part of this and often involves victims who are weak and reliant on a caretaker. Only about 30 percent of victims will involve the police. Perpetrators can be adult children, spouses, caretakers, or people who live in a nursing facility with the victim. There can be psychological and physical damage to the victim as a result of their assault. Rape usually involves sexual penetration against the victim’s consent. While rape and sexual assault are sometimes used interchangeably, sexual assault can involve other forms of non-consensual sexual behaviors. Male victims are more likely to be physically injured by rape. Interestingly, acquaintance rape of any kind is reported more frequently than stranger rape. Men are more likely to have had multiple assailants. Rape usually happens to young people, although it can happen to any age of victim. About 18 percent of women experienced attempted or completed rape at some time in their lives.

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There are emotional and physical effects of rape and sexual assault, especially if the victim was a child. Learned helplessness, self-blame, anxiety, depression, PTSD, addiction, promiscuity, and social anxiety are part of what the victim experiences emotionally. Physical trauma can be the result of rape but does not have to be a requirement. Many types of sleep, eating, and health effects can come from being assaulted. The treatment of sexual assault begins in the emergency department, with emergency contraception and STD prevention a part of the early treatment. Victims are sometimes given a tetanus shot if there has been physical trauma. Medications for anxiety are sometimes given and antidepressants are used if depression becomes a problem. Many are treated with psychological therapy, which can be short-term or long-term in nature. Victims of sexual assault are sometimes victimized afterward by people who blame them or question their credibility. For this reason, some victims are protected by law from being exposed as the accuser. The negative effects of post-assault mistreatment can increase the risk of low self-esteem and PTSD. Prevention programs exist to combat sexual abuse and sexual harassment. Some programs have been successful in reducing the chances that a victim will turn to sexual aggression themselves; others increase the likelihood that people who are bystanders will intervene if they see abuse happening. Other programs are directed at educating the potential perpetrator. Data on sexual assault indicate that 80 percent of victims are under the age of 30, with the peak ages being 12 to 34 years of age. Teens are the most common victims. About 89 percent of victims are women, while the rest are men. About 3 percent of men have been victims of either attempted or completed rape at some point in their lives. The risk of rape in men increases with child and prison-related victims. About 68 percent of sexual assaults are not reported at all. Gay men have an increased risk of rape than heterosexual men. The average age of a rapist is 31 years of age and slightly over half are white. About 22 percent of rapists are married men, although juveniles account for 16 percent of all rape

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arrests. Only 11 percent of assaults involve some type of weapon. Most rapists know their victim and a fourth of rapes happen between intimate partners. The definition of what constitutes consent varies from jurisdiction to jurisdiction. In Canada, for example, consent means the voluntary agreement to engage in the activity in question. There is no consent when the perpetrator uses their position of trust or authority over the victim, when the victim later refuses what they initially agreed to, when the victim expresses they do not want to engage in sexual activity, and when the victim cannot give proper consent because of their mental, physical, or emotional status.

RAPE Rape, as mentioned, involves some type of penetrative act that happens because of abuse of authority, coercion, physical force, or the incapability of the victim to give consent. The incapability of giving consent can be because of the age of the victim being below the age of consent, unconsciousness, intellectual disability, or incapacitation. Culturally, the rate of rape in a population differs greatly in different countries. As mentioned, most rape is between people who know each other, with prison rape and rape during wartime being especially prevalent. Most jurisdictions indicate that rape is an act of sexual penetration. Historically, rape did not always mean intercourse or even sexual intent. It was considered to be just an act committed by a man against a woman by the FBI until 2012. This was changed to involve penetration of any type by anything or any body part of the anus or vagina, or of the genital organs into the mouth. Gender of the perpetrators and victims are not described. Victims of rape can be of many different types, including different sexual orientations, ethnicity, ages, genders, degrees of impairment, disability, culture, and geographical location. The different types of rape described as subcategories include incestual rape, sexual assault on a child, date rape, gang rape, prison rape, marital rape, statutory rape, and acquaintance rape. It can be present with or without physical injury to the victim.

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Duress is often a part of rape. This can be the threat of violence, force, or the presumption of consent. Blackmail itself can be a type of duress as can abuse of power. Some countries define rape in terms of coercion without even mentioning consent. Marital rape is often a part of domestic violence. It was once not considered criminal behavior but is now criminalized in many but not all countries. Even where it is illegal, it is often more tolerated than other types of rape. It is not prosecutable in some states of the US. According to the World Health Organization, there are several factors that lead to the motivations behind rape. These include poor legal sanctions against sexual violence, male entitlement in a society, beliefs about family honor, anger, sexual gratification, power, and sadism. Many rapists are hypermasculine, have poor empathy, and desire control over women. Men who perpetrate believe they are somehow rewarded among male peers. Gang rape can be done to punish immoral behavior as perceived by men of women. There are many ill effects on the victims of rape, including reproductive issues, STDs, infertility, and sexual dysfunction. Psychological effects include psychosomatic disorders, depression, anxiety, and an increased risk of suicide. Some victims deny they have been raped, especially if they were psychologically coerced. There is confusion about what constitutes rape and a general lack of uniform legal definitions of the actions. Most victims will freeze up while being raped, although others will become extremely passive and still others will fight. These are all common survival mechanisms. Many victims believe that, if they did not struggle or call for help, they were not actually raped, which is not the case. Some individuals dissociate during the rape and, perhaps most confusing for the victim, is having an orgasm during the incident. After the rape, victims will have typical symptoms of PTSD, including an exaggerated startle response, numbness, and high levels of anxiety. Severe symptoms are seen if the victim’s life was threatened, the victim is very old or very young, and if the rapist is someone they already knew. If there is lack of social support or blaming the victim, the symptoms are also likely to be severe.

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The treatment of the victim after the assault can worsen the trauma they experience, particularly if the victim is held partially responsible or blamed. Certain attitudes toward victims in a society can underly this problem. Some believe that the lack of resistance of the victim is token reinforcement of the crime, which leads to victim blaming. Gender role stereotyping can make it difficult for a man to feel like he was the victim of rape. In some cultures in the world, the victim is physically threatened or killed by their family after being raped—a phenomenon known as honor killing. While many rapes do not result in actual physical injury, genital and non-genital injuries can occur. Non-genital injuries include gunshot or stab wounds, bites, bruising, and scratching. The goal of treatment is to both treat the injuries and gather forensic information with the patient’s consent. The gathering of evidence does not necessarily mean that the victim must file a legal complaint. The chain of evidence, however, is nevertheless preserved. Genital injuries do not have to be present but can happen in rape. Injuries can happen to the mouth, anus, vulva, or vagina. Swabs are taken of the mouth, anus, and vagina for DNA and other physical evidence of rape. Genital injuries are more common in women after menopause and in young children. Children can have scarring if the trauma was severe or repetitive. STDs cannot be detected until a minimum of 72 hours have passed. There is likely to be emotional after-effects following a rape that will be apparent in the immediate hours. Other effects do not occur until some period of time has passed. Anxiety, fear, eating disorders, depression, anger, PTSD, suicidal ideation, and sexual disorders can follow a rape experience. For some victims, there will be counseling, shelters, and hotlines that can be helpful. Professional treatment in an individual or group setting will often be necessary. Perpetrators themselves may be required to have treatment. Some will respond to treatment, while others will not. Motivations for rape perpetration are complex and often involve a look into the perpetrator’s developmental background. Some will have an abuse history themselves, which can be addressed. Child and adolescent offenders are

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not as common; some will respond to treatment. Treatment can identify those at a high risk of recidivism.

CHILDHOOD SEXUAL ABUSE Child sexual abuse is also referred to as child molestation. It often involves an older adolescent or adult perpetrator and a child victim. As mentioned, there are many forms of child sexual abuse that both include and do not include actual physical contact. Child abuse of this form is worldwide and, in parts of the world, child marriage is the most common type of this abuse. Most child sexual abuse happens when the perpetrator knows the victim in some way. About 20 percent of females and 8 percent of males undergo this type of abuse globally. The majority of perpetrators are male; female offenders will commit acts of abuse against boys mainly but sometimes against girls. Being a child abuser does not necessarily mean the person is a pedophile. A pedophile is someone who has a sexual interest mainly in children who have not yet reached puberty. Child sexual abuse is a broader term that can mean any type of sexual exploitation of a child; it can also include child on child sexual abuse and sibling sexual abuse. Because children cannot consent, all such acts are considered criminal behavior. Child sexual abuse survivors are harmed in many ways. There is an increased risk of depression, PTSD, dissociation, anxiety, sleep problems, somatization, substance abuse, and eating disorders. The strongest indicator of sexual abuse in a child is sexual acting out, although things like regressive behaviors, social withdrawal, conduct disorders, ADHD, and animal cruelty can be signs of abuse. Self-harm behaviors are particularly common in sex abuse survivors. Surprisingly, only about 59 to 79 percent of sexually abused children will have psychological symptoms. The risk of symptoms is greater if the abuser is the child’s relative, if threats of force are used, or if intercourse or attempted intercourse has occurred. The duration and frequency of the abuse also plays a role.

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Chronic and early sexual abuse is linked to an increased risk of dissociation, which can include amnesia of the events. These children often experience emotional numbness and feel cut off from others, which can exacerbate the degree of poor psychological and social functioning. Many of these children grow up to have substance abuse as a way to self-medicate their symptoms. Other phenomena in these children include dissociative identity disorder, personality disorders, certain eating disorders, and complex PTSD. There can be many physiological and neurological effects of child sexual abuse. Injury to the anus and genitals can be permanent or can lead to death. The child will also have a higher risk for STDs and other vaginal infections. There are changes in the central nervous system, including a reduction in certain areas of the brain and simultaneous excitation and under-development of the limbic system. Incest is sexual contact between a child and a related adolescent or adult. This is a widespread form of abuse that has a great chance of psychological damage to the child. Most incest is between a father and daughter or between a stepfather and daughter, although mother to son incest does exist as does father to son incest. Sibling incest is more common than it was once believed to be. There are several forms of child sexual abuse. Sexual assault involves rape, sodomy, or other penetrative behavior in order to achieve sexual gratification. Sexual exploitation involves child pornography or prostituting a child for profit or sexual gratification. Sexual grooming involves preparing a child to accept their sexual advances. The child who received some type of personal or social support after disclosing the abuse tend to do better or suffer for a shorter period of time than those who did not get any support. Negative support is associated with a worsened outcome in the child. Lack of support by the child’s primary caregivers probably indicates prior relational disturbances in the family; this also worsens the outcome for the child. Treatment of the child survivor depends on when they present for treatment, the circumstances surrounding their presentation, and the presence of other comorbidities. Children and adolescents respond to individual therapy, group therapy, or family therapy. The younger the child, the more likely it is that parental involvement is necessary.

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Adults with a sexual abuse history often have a different presenting complaint than that of abuse. Common complaints are eating disorders, substance abuse, depression, interpersonal conflict, and personality disorders. Some will need to be treated for the presenting complaint rather than the abuse itself. Ultimately, things like cognitive restructuring and treatments like eye movement desensitization and reprocessing or EMDR may be necessary. Perpetrators of sexual abuse know their victim 82 percent of the time. More than 95 percent of offenders are male. There are two types of offender motivation. One is called “fixated motivation” and the other is called “regressed motivation”. Those who are fixators have an attraction to children primarily, while regressors have a greater range of adult relationships. Some will offend against anyone; it doesn’t necessarily have to be a child. Others will exhibit violent and sadistic motives against both those known to the victim and strangers. Because most sexually abused children do not offend as adults and because most perpetrators do not report sexual abuse themselves, it is less common than it used to be to believe that there is some type of cycle of violence that indicates a relationship between the two. Remember too that not all sexual offenders against children are pedophiles. The rate of recidivism is lower for sex offenders than it is for other types of criminals. About 42 percent of offenders will do it again after being released from prison. The risk is highest shortly after being released from incarcerations. Some children are abused by one or more juvenile offenders without an adult being involved in the abuse. Usually this involves some type of coercion or force and is called child on child sexual abuse. Inter-sibling abuse or just sibling sexual abuse happens between siblings in a nuclear family. Children who abuse other children are more likely to have been abused themselves, which is not necessarily the case for adult offenders. There is no known cure for pedophilia, although there are treatments that are used for both child sexual abusers and pedophiles. Some treatments are focused on changing the offender, while others are focused primarily on reducing recidivism. Offenders are taught to spot the warning signs of relapse and to intervene before this occurs.

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Child sexual abuse is against the law practically everywhere in the world and there are usually sever penalties for the behavior. The United Nations has specific treaties that protect children’s rights in this area, condemning all forms of sexual abuse, including child prostitution and child pornography. There are directives in parts of the world that specifically address the commercial exploitation of children for sexual purposes.

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KEY TAKEAWAYS •

Sexual aggression can involve several types of behavior where force, coercion or positions of power are used to sexually abuse or exploit another person.

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Sexual harassment usually involves supervisors or other authority figures and one or more persons who are subjected to sexual talk, forced sexual acts, or sexual denigration.

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Sexual assault usually involves some type of sexual contact that may or may not be associated with penetration.

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Rape usually involves sexual penetration of some sort. The incidence is higher among people who know each other rather than strangers.

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Child sexual abuse can involve sexual acts, exposing oneself to a child, sharing pornography with a child, or using a child as a subject of child pornography or prostitution.

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There are many short-term and long-term psychological and physical effects of child sexual abuse.

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QUIZ 1. What is not true of sexual aggression? a. It is usually done by strangers against someone they do not know. b. It leads to men, women, and children as victims. c. It can include any type of sexual activity against the will of another. d. It can include different forms of sexual harassment. 2. What is least likely to be a factor in the phenomenon of date rape? a. Alcohol and drug use b. Anger c. Miscommunication d. Relaxed sexual rules in society 3. What is not true of sexual harassment in the workplace? a. It can lead to a hostile or offensive work environment. b. Most of the victims are women. c. Often the perpetrators are supervisors. d. Most victims are threatened with termination as part of the harassment. 4. What is not true of sexual harassment in the military? a. The culture of the military supports sexual harassment. b. Most victims are men who have been perpetrated on by other men. c. The young age of military personnel contributes to sexual harassment. d. Deployment increases the risk of sexual harassment. 5. What does not constitute sexual abuse against a child? a. Showing pornography to a child b. Taking pictures of an unclothed child c. Parental bathing of a child d. Exposing one’s genitals to a child

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6. What type of sexual abuse of children is considered to be potentially the most damaging to the child? a. Child on child sexual abuse b. Incest with a parental perpetrator c. Child pornography d. Stranger rape 7. What is not true of physical effects of rape and sexual assault? a. Sleep and eating difficulties can happen after an assault. b. Physical trauma to the genitals is usually a requirement in reporting an assault. c. Poor physical health can come out of being sexually assaulted. d. Physical trauma to the genitals is more likely after rape than after consensual sex. 8. What is not true of the statistics of sexual assault? a. The majority of victims are women. b. The teen years involve the highest risk of being assaulted. c. Men in the prison population are at an increased risk of rape. d. Heterosexual men have a greater risk of being raped compared to gay men. 9. What is not a major motivation behind rape? a. Anger against women b. Insecurities c. Hypermasculinity d. Poor impulse control 10. What least likely leads to severe symptoms after a rape? a. Dissociation during the event b. The perpetrator was known to the victim c. The victim was blamed for the event d. The victim was very young or very old

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CHAPTER TWELVE: SEXUAL FETISHISM AND PARAPHILIC DISORDERS The subjects discussed in this chapter include sexual fetishism and paraphilic disorders. The vast majority of sexual fetishes are completely benign and do not necessarily represent a sexual disorder. Paraphilic disorders are intense sexual feelings and behaviors not experienced by most people because of their extreme nature. These disorders are usually considered problematic if they cause the individual to have distress about their sexual feelings or behaviors, or if there is a victim involved with the paraphilia. The different fetishes and paraphilias are covered as part of this chapter.

SEXUAL FETISHISM Sexual fetishism is also referred to as erotic fetishism. It generally refers to being sexually fixated on some type of object or a part of the body that is non-genital. The sexualized object of interest is called the fetish. Most fetishes are not pathological, while some can be considered mental disorders if they are particularly distressing, harmful to the person, or harmful to another person. Fetishes in common terms can also refer to a particular sexual or nonsexual activity but this isn’t how the term is used medically. Certain paraphilias, which will be described later, can also be referred to as fetishes. Partialism refers to attraction to a specific body part. The most common fetish is that to certain clothing. Other fetishes are to rubber, footwear, body parts, leather or fabrics. Body part fetishes are generally related to feet, certain bodily secretions, hair, and muscles. There are fetishes to a great number of things, including hats, diapers, stethoscopes, and wristwear. Autoerotic asphyxiation is not generally a true medical fetish but it is still a practice some people engage in. It involves choking oneself while masturbating, usually with something that can partially suffocate the person but will not lead to death. The idea behind it is that it activates the pleasure centers of the brain in order to get a more

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intense orgasm. The danger in this is that the person can actually suffocate and die from this type of behavior. Fetishism first develops in puberty. There is no single cause for this sexual issue. Some of it may be secondary to being conditioned by certain objects, which become sexually arousing. It may also involve early childhood imprinting on certain objects or due to some type of neurological condition. Because fetishes are mainly visual, they are seen to a greater degree in men, who are more stimulated by things that are visual than is true of women. Male sexuality is relative fixed once it has been established, which is not true for women. Fetishism is diagnosed as being a sexual disorder it the person is relatively unable to get sexual arousal through any other sexual means or if it becomes distressing. The fetish is a disorder also if it is acted on and if it has been present for a minimum of six months. A fetish excludes cross-dressing behaviors and the use of sex toys. The DSM-5 merges fetishism and partialism. Some argue the abolishment of fetishism because it stigmatizes the phenomenon. Fetishism and fetishistic fantasizes are extremely common. The main treatment involves decriminalizing related activities, such as stealing underwear, and be reducing the reliance on the fetish in order to be sexually satisfied. Relationship skills are emphasized and the arousal to the fetish is reduced. The research on the treatment of fetishes is somewhat lacking with cognitive behavior therapy and aversion therapy sometimes used. Some people improve with psychodynamic therapy as well. Drugs used include antiandrogen drugs to reduce the sex drive and drugs that reduce libido. SSRIs can also be used instead of antiandrogens. No one knows the prevalence of fetishism, which is largely seen in men. About 30 percent of men say they have fetishistic fantasies, while 25 percent of men engage in some types of fetishistic acts. Surprisingly, about 26 percent of women have fetishistic fantasies as well. Fetishism is rarely an actual sexual disorder.

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WHAT IS A PARAPHILIA A paraphilia is a medical/psychological condition in which an individual arrives sexual arousal and sexual gratification about the engagement in certain behaviors considered by most to be extreme and atypical. It is a disorder when it distresses the individual or when it is harmful to others. Children, underwear, and animals can be the object of the paraphilia or the person can derive pleasure out of inflicting pain, receiving pain, or exposing themselves. These become the source of most of the person’s gratification. Men have paraphilias to a greater degree than women. Most paraphilias are fixed and do not branch out to other paraphilias. There are dozens or paraphilias as you will see. The most common ones are pedophilia, which is a sexual attraction to children, exhibitionism, which is the exposer of one’s genitals to others, voyeurism, which is the sexual pleasure gotten from watching others’ sexual or personal activities, and frotteurism, which is the need to rub one’s body against a nonconsenting individual. Less common paraphilias are fetishism, sexual masochism or arousal from being harmed or humiliated, sexual sadism or the infliction of pain upon others, and transvestic disorders or arousal from cross-dressing. There are many rare paraphilias. Some paraphilias are illegal and many appear extreme. Most of them involve things a normal person might fantasize about but that are taken to extremes in paraphilias. If certain behaviors are practiced and shared by a couple who are consenting adults, these might not be considered paraphilias. The key features of paraphilias are psychological dependence on them, the presence of extreme distress, or the victimization of others. There are many theories of what causes paraphilias. Psychoanalytic theory indicates that they are developed from early life experiences. Behaviorist theories indicate conditioning is a major factor in causing a paraphilia. Difficulty with interpersonal relationships is also believed to be causative. Imitation can also play a role as is deprivation from normal sexual contacts. Male hormones and aggression also play a role.

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There are several treatment strategies, some of which will be discussed later. Patients with paraphilias can be treated with hypnosis, psychoanalysis, drugs that combat antigens, and behavioral therapy. The drugs will lower the male libido, which can reduce paraphilic imagery and fantasies. Cognitive-behavioral therapy can help as well as aversion therapy. Some patients are exposed to videos of deviant behaviors along with drastic consequences such as castration. Improving social skills will help along with biofeedback to mellow out the sexual arousal response.

DEVELOPMENT OF PARAPHILIAS There appears to be biological factors that increase the risk of paraphilias. Males paraphilias tend to do more poorly on IQ testing, particularly in pedophiles. They also tend to fair more poorly in schools. There may also be an arrest of psychosocial development along with an abnormal defense against interpersonal anxiety. There may have been an event that reinforced an orgasm under abnormal circumstances. There appears too to be an obsessive-compulsive component to paraphilias. Thes who choose to act on their paraphilias often have distorted thinking to justify offending as a way to get their sexual needs met. They also see their needs as being out of their control. Certain temperaments and early relationships may also play a role. Some may have been abused and have learned to identify with the accuser. These patterns tend to form by the time of adolescence and are seen in people raised in both permissive and constricted sexual environments.

TYPES OF PARAPHILIAS As you will see, there are dozens of named paraphilic disorders. In this section, we will talk about some of the more common ones. Pedophilia is considered a type of paraphilic disorder that causes harm to others. As you have learned, sexual offenses directed at children are relatively common. It becomes more of an issue when a person is older than middle teens and persists in an interest in prepubertal children. Almost all pedophiles are male who are attracted to

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prepubertal boys, girls, or perhaps both. Twice as many have specific attractions to the opposite sex. Most pedophiles select a child known to them. It could be a family member, a coach, teacher, or a member of the clergy. Most prefer to look or touch the child rather than have sex with them. Some are nonexclusive and are attracted also to adults. Others are attracted only to children who are related to them. Predatory pedophiles often have antisocial personality disorder and use both force and threats to physically harm the child they abuse. The disorder is chronic and things like depression or substance abuse are common. Some will have a personal history of sexual abuse. Other comorbidities include ADHD, anxiety, and PTSD. People who use child pornography have a high risk of sexual attraction to young children. This may be the only noticeable thing, although use of child pornography does not indicate that pedophilia is present. Penile plethysmography can be used to identify those who deny their attraction to children but who behave otherwise. The diagnosis is made by identifying intense fantasies, urges, or behaviors that are directed at prepubescent children. The person has probably acted on their urges or feel distressed by their urges. The person must be at least 16 years of age and is attracted to children more than five years their junior. Treatment can be psychological or pharmacological. Group therapy can be particularly helpful. It is less helpful when it is ordered by the court, although drug therapy often works. Some will be able to return to society and may not reoffend. Voyeurism is the finding of arousal through observation of people who are naked or having sex. This is illegal when it involves watching nonconsenting adults. It is also considered a disorder when it causes functional impairment or significant distress in the individual. It should be noted that most people with voyeuristic tendencies do not have a true disorder because none of the previously mentioned issues exist. In other words, having voyeuristic tendencies is a relatively normal thing. When present, it starts in adolescence or early adulthood. It is taken more seriously in older adults. True voyeurism involves spending a lot of time on the behavior to the exclusion

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of other things in the person’s life. It is often augmented by masturbation during or after the event. No sexual contact is desired. I Desire to watch others in sexual situations is common and not in itself abnormal. Voyeurism usually begins during adolescence or early adulthood. Adolescent voyeurism is generally viewed more leniently; few teenagers are arrested. When voyeurism is pathologic, voyeurs spend considerable time seeking out viewing opportunities, often to the exclusion of fulfilling important responsibilities in their life. Orgasm is usually achieved by masturbating during or after the voyeuristic activity. Voyeurs do not seek sexual contact with the people being observed. Voyeurism is not included in those who look at explicit videos or photos on the internet because true voyeurism involves some type of secret intent. About 12 percent of males and 4 percent of females likely have the disorder but rarely seek treatment. The diagnosis of voyeurism involves repeatedly being aroused by observing unsuspecting people in sexual situations. The person has generally acted on their impulses and have fantasies about this behavior. It should involve a victim, interpersonal dysfunction, or significant distress and involves behaviors that have lasted longer than six months. It is not diagnosed in people under the age of 18 years. Treatment involves antiandrogen drugs, SSRI drugs, psychotherapy, or support groups. Some patients must enter treatment as part of a court order. The antiandrogen drugs will lower the testosterone level in order to reduce libido. While most people who cross-dress do not have a paraphilia, transvestism is listed as a form of paraphilia. The problem becomes a disorder when it harms others, impairs psychosocial functioning, or cause distress. A minimum of six months must pass in order to qualify for the disorder. This is probably one of the most controversial of paraphilias because there are rarely any victims. As mentioned, the term cross dressing is preferred over transvestite. The incidence is very rare in females. The problem usually starts in late childhood and causes some type of sexual stimulation. The sexual arousal comes from the clothing itself and is also considered a form of fetishism in some but not all cases. This may be a behavior performed between consenting adults; if not, it leads to shame, guilt, and depression. 212

The diagnosis is made when the cross-dressing is associated with sexual arousal. It is a part of the person’s urges, fantasies, and behaviors. Some will have intense distress because of this. It needs to be present for a minimum of six months. Most cross-dressers do not request treatment unless their spouse is markedly distressed. Support groups and psychotherapy can be helpful in treating the disorder. There is an increased risk of substance abuse, depression, and gender dysphoria in this group. There are no drugs that can be used for this problem. Exhibitionism is the achievement of sexual arousal through exposure of one’s genitals to an unsuspecting stranger. There may also be the desire to be observed by others when they are sexually active. The person who acts on these urges is considered to be engaging in illegal activity. Not every exhibitionist meets the criteria for a paraphilic disorder. It requires a victim or interpersonal distress or impairment in functioning. This is true of all paraphilias. About 2 to 4 percent have this disorder, which is rare in females. The media in fact sanctions some exhibitionism in females. Masturbation can be a part of the exposure process and there often needs to be some type of shock factor. The victim is often a child of either gender or a female adult. Actual contact is not usually desired. Exhibitionism has a high recidivism rate with up to 50 percent arrested again. Most of these men are married but often do not have a healthy marriage. Conduct disorder and antisocial personality disorder are more common with this disorder. Those who want to be sexually observed usually are not looking for a shock factor but wish for consenting adults to watch. Some will make pornographic videos. The treatment involves SSRI drugs, support groups, and psychotherapy. Antiandrogens to reduce libido have often been found to be effective in treating the disorder. Patients are monitored through arrest records and penile plethysmography.

SOME SPECIFIC PARAPHILIAS These are a few of the many specific paraphilias: •

Algolagnia—this involves attraction to pain associated with an erogenous zone.

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•

Anthropophagy—this is an attraction to eating human flesh.

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Apotemnophilia—this is an attraction to being an amputee.

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Asphyxiophilia—this is a attraction to being strangled or asphyxiated.

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Raptophilia—this involves having a consensual rape fantasy.

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Coprophilia—this is an attraction to feces; it is also called scatophilia.

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Dendrophilia—this is an attraction to trees.

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Emetophilia—this is an attraction to vomit.

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Erotophonophilia—this is an attraction to murder, usually of strangers.

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Gerontophilia—this is an attraction to elderly people.

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Lactophilia—this is an attraction to breast milk.

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Masochism—this is a desire for suffering or humiliation.

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Mucophilia—this is an attraction to mucus.

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Paraphilic infantilism—this is wanting to be dressed or treated like a baby.

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Sexual sadism—this is attraction to inflicting pain on others.

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Telephone scatologia—this is an attraction to making obscene phone calls to strangers.

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Urolagnia—this is an attraction to being urinated on or urinating in public.

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Zoophilia—this is a sexual attraction to animals.

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KEY TAKEAWAYS •

Strictly speaking, a fetish involves sexual arousal by specific body parts or inanimate objects.

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Autoerotic asphyxiation involves the desire to have an orgasm while being choked or strangled.

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Paraphilic disorders are not necessarily disorders, unless there is dysfunction, a victim, or significant distress.

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Drugs and different forms of therapy can be used to treat some paraphilic disorders.

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QUIZ 1. When referring to the medical definition of fetishism, what would not be considered a fetish? a. Attraction to a specific body part b. Attraction to shoes as sexual objects c. Attraction to a certain type of clothing d. Attraction to autoerotic asphyxiation 2. What is the definition of partialism when it comes to fetishes? a. Attraction related to dressing like the opposite gender b. Attraction to certain body secretions c. Attraction to a specific body part d. Attraction to certain sexual behaviors 3. What is not true of fetishism as a sexual disorder? a. It is something that causes marked distress. b. It has been persistent throughout life. c. It interferes with normal sexual functioning. d. It is something the person acts on rather than just thinks about. 4. What is least likely to be a treatment for fetishes? a. Antiandrogen drugs b. Cognitive-behavioral therapy c. Aversion therapy d. Surgical interventions like castration 5. What is not considered a characteristic feature of a paraphilic disorder? a. Causes significant distress to the individual b. Practiced between consenting adults c. Involves the presence of a victim d. Involves a sexual or psychological dependence

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6. What do psychoanalysts think paraphilias come from? a. Early conditioning b. Excesses of male hormones c. Lack of adequate sexual contact with humans d. Early childhood conflicts 7. What is the specific interest involved in pedophilia? a. Interest in a person younger than themselves. b. Interested in having sex with a minor who has not reached the age of consent. c. Interest in child pornography. d. Interest specifically to prepubertal children 8. What is true of a nonexclusive pedophile? a. They are attracted to girls as well as boys. b. They are also attracted to adults. c. They only are attracted to those they are related to. d. They are only attracted to strangers. 9. What is not true of voyeurism? a. It starts in adolescence or early adulthood. b. It does not involve actual sexual contact. c. Masturbation is often involved. d. Internet viewing of others having sex is part of this. 10. Which paraphilia is most controversial because it does not usually involve a victim or cause psychological harm? a. Pedophilia b. Transvestism c. Voyeurism d. Exhibitionism

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CHAPTER THIRTEEN: SEX ADDICTION, PROSTITUTION, AND PORNOGRAPHY This chapter talks about the interplay between sex addiction, prostitution, and pornography. People with sexual addictions often have impulses and compulsiveness related to engaging in sexual activity. They often turn to soliciting prostitution to handle their need for frequent sexual behaviors, as you will see in the chapter. A related addiction is pornography addiction, some of which is related to internet sex or pornography addictions, which are relatively recent phenomena.

SEX ADDICTION Sexual addiction or just sex addiction happens when a person compulsively desires and engages in sexual activity, especially in sexual intercourse, even if there are negative outcomes in doing this. It is part of what is referred to as hypersexual disorder, which are also referred to as nymphomania or satyriasis, except that, with hypersexuality, the focus is on sexual fantasies and urges, and not so much on behavior. None of these is necessarily related to erotomania, in which the person is delusional and believes that another person is infatuated or in love with them. It is a subject of debate in the psychological world as to whether or not this type of compulsive behavior actually constitutes an addiction or even a diagnosable psychiatric problem. Even so, there has been research in animals showing genetic influences that seem to indicate similarities to sex addiction and addiction to substances. It is not currently a diagnosis in the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases. The DSM-5 was published in 2013 and was not listed as disorder but a new diagnosis of hypersexuality was suggested but not added. The ICD is published by the World Health Organization; it includes the phenomenon of “excessive sexual drive” as a diagnosis, divided into satyriasis in males only or nymphomania in females only. They are

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considered impulse control disorders and not addictive disorders. The Chinese Classification of Mental Disorders also does not include sexual addiction. Compulsive sexual behavior in rats has been found to be similar to the brain mechanisms that are also involved in drug addiction. There is an intrinsic reward in sexual activity that activates reward systems in the brain that reinforces the behavior. There is a buildup of a protein that activates certain genes in the nucleus accumbens, called Delta FosB. This is what leads to compulsive behavior and ultimately to addiction. Humans who take certain dopamine-activating medications can have dopamine dysregulation that will lead to compulsive gambling or compulsive sexual activity. The transcription factor Delta FosB is involved in addiction in humans; it is also active in the nucleus accumbens of the brain and may account for the phenomenon of certain addictions. The same transcription factor has been implicated in a variety of drug addictions. There is another transcription factor called Delta JunD that opposes addiction in the nucleus accumbens. Delta FosB is important in managing the behavior responses in humans to what can be described as natural rewards, such as sex, food, and exercise. Drugs of abuse are also natural rewards. There appears to be a relationship between psychostimulant use and the desire for a sexual reward. Sex addiction is not accepted as a separate sex addiction by any regulatory bodies involved in sex therapy or the treatment of sexual problems. For this reason, sex addiction is more often treated by addiction specialists rather than psychosexual therapists. Cognitive-behavioral therapy and dialectical behavioral therapy will improve outcomes of hypersexuality and sex addiction. There are online and in-person support groups, including Sex Addict Anonymous and Sexaholics Anonymous that can be successful. Hypersexuality and sex addiction has a prevalence rate of about 3 to 6 percent. About 80 percent of people with this issue are male. This first became part of mainstream thinking in the middle of the 1970s, when 12-step programs were first attached to sex addiction, particularly in those who had issues with serial infidelity. In 1994, the Mayo

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Clinic indicated that sex addiction was a type of obsessive-compulsive disorder rather than a true addiction.

PROSTITUTION Prostitution is a commercial industry in which a person engages in sex for some type of payment. A prostitute is a type of sex worker who participates in this type of activity for money. It is legal in some parts off the world and illegal in other parts. In some places, it is highly regulated, while in others, it is illegal but the laws are not enforced. It is a subset of commercial sex, along with stripping, erotic dancing, and pornography. A prostitute can work in a brothel or be an escort. Still others can be street prostitutes. There are more than 40 million prostitutes in the world, with some countries taking part in sex tourism. About $100 billion USD are spent on prostitution in the world. Most prostitutes are female and have clients who are male. It becomes an even more questionable behavior when it involves children, violence against women, and human sex trafficking. Some international organizations are in favor of completely decriminalizing prostitution. Activist groups prefer the term “sex worker” to refer to these individuals. The different terms used to describe sex workers other than prostitutes include sex trade worker, commercial sex worker, hooker, escort, call girl, streetwalker, hustler, ho, or gigolo, which as a male sex worker. Again, while each of these terms is used, most are considered derogatory other than sex worker or commercial sex worker. People who organize prostitution are called pimps or madams. Clients are called tricks, punters, or johns. In some parts of the world, these are called kerb crawlers. Janes or sugar mamas refers to a female who wishes to solicit a prostitute. Prostitution has been around for millennia. The ancient Greeks commonly made use of prostitutes. In that culture, both boys and women were prostitutes, who were highly regarded. Prostitution was considered legal and common in Ancient Roman culture. Prostitutes were sometimes slaves or were abandoned children raised to be prostitutes. It was outlawed in Muslim countries that instead believed in temporary marriages. It was widespread in early Japan but is illegal in today’s time.

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Attitudes in the 1500s around prostitution changed, in part because of outbreaks of syphilis that occurred in Europe. Brothels were outlawed as was prostitution in general. The churches of the time indicated that, while prostitution was inevitable, it should be condemned, with prostitutes encouraged to be repentant. In the 1700s, most masseurs were men who also engaged in sex work, particularly in the Ottoman Empire. By the 1800s, some European countries began to regulate prostitution. By the twentieth century, prostitution was once legal in most states. In the UK, prostitution itself was not illegal but running a brothel was considered illegal. Soliciting sex was declared illegal. There was the development of penalties by the 1980s against HIV-positive prostitutes. Sex tourism was developed in the late twentieth century. Nowadays, prostitution is common among Eastern European countries, although the women are not always consenting participants. The attitudes around prostitution vary in today’s society. There are those who believe prostitution should be decriminalized or simply regulated. In places like Nevada and Australia, prostitution is regulated. Others indicate that prostitution should not be tolerated. Abolitionists think that prostitution itself is okay but activities related to prostitution are illegal, such as operating a brothel or being a pimp. Neo-abolitionists believe that prostitution is nothing more than violence against women. Prohibitionists believe that all prostitute behaviors are immoral. This is the attitude throughout the US, except in some areas of Nevada. The issues related to the legality of prostitution include the potential for the prostitute to be victimized, the ethics or morality of prostitution, the freedom of a woman to choose, and the possible harm or benefit to society because of prostitution. In some places, it is considered to be part of the exploitation of women, which leads to the illegality of buying sex but not selling sex. In other countries, such as Germany and the Netherlands, prostitution is legal but regulated. It is greatly prohibited in most Muslim countries. The prostitution of children below the age of consent is illegal in almost all parts of the world. In India, however, about 40 percent of all prostitutes are children. In some parts of Asia, child prostitutes take dexamethasone in order to “fatten them up” so they

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appear bigger and older. This can be dangerous because it can be addictive, can raise blood pressure, and can cause diabetes. Parts of Asia participate in sex tourism that allows people to have sex with children that cannot happen in their home country. In South Korea, some elderly people become prostitutes to make money. Prostitutes are at a greater risk of sustaining injuries from violent crime, particularly if they are street prostitutes. About 200 out of 100,000 prostitutes are murdered. Prostitution is also linked to dangerous and illegal activities. It is controversial as to whether the legalization of prostitution can help these problems. Sex trafficking is linked to prostitution and involves forcing or coercing individuals into prostitution or other sexual activities through their transport to another area. About 80 percent of human trafficking is for sex purposes. It is a crime that is increasing in incidence. Up to half of all people trafficked are children. Some children are sold by their families, kidnapped, or orphaned in order to be sold into the sex trade. This is more prominent in parts of Asia. Eastern Europeans are also more often trafficked. The different types of prostitution include street prostitution, in which the person waits for tricks on street corners. These are called “streetwalkers”. Sex is done in a rented room, an alley, or in the john’s car. There are open markets for prostitutes in Russia and there are prostitutes that are stationed around truck stops. Window prostitution involves a woman renting a workspace for a period of time during the day. Brothels or bordellos are places that are used specifically for prostitution. Some massage parlors and barber shops offer prostitution services. Escorts or call girls are those who make appointments for sex using the phone or internet. There can be independent call girls or escort agencies that offer these services. The use of the internet is much more common than it used to be. Sex tourism involves travel to another area for sex, which is legal except when a child is involved. Virtual sex involves phone sex, webcam sex, or other cybersex. One of the biggest risks of prostitution is the transmission of sexually transmitted diseases. This is especially true in Africa, where prostitution leads to 84 percent of new HIV cases in some parts of the continent. Education and regulation have been used to

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counteract this problem, although outright banning of prostitution seems to make the problem worse by increasing secrecy.

PORNOGRAPHY ADDICTION Addiction to pornography involves compulsively using pornographic material to have sexual satisfaction, even when there are negative consequences to doing it. It is not classified as an addiction or mental disorder by the DSM-5 or by the ICD-11 manuals. Related to this is internet pornography viewing, which can lead to decreased productivity, depression, career loss, and social isolation. Pornography viewing becomes a problem if the frequency is high and when there are negative consequences. As mentioned, while pathological gambling is a mental disorder, pathological viewing of pornography is not listed in the same way. It is believed to be a subtype of hypersexual disorder. Even so, there is evidence of brain changes, cravings, dysphoria, and impulsiveness in pornography addiction that are similar to certain drug addictions. Pornography addiction is uncommon in women and represents about 0.5 percent of women. It is more prevalent in men. One study of college-aged males indicated that 20 to 60 percent of men in this age group felt that their viewing of pornography was problematic. Other studies have shown that addiction to internet pornography is about 1 to 8 percent. It is sometimes treated with cognitive behavioral therapy or support groups, such as Sexaholics Anonymous or Sex Addicts Anonymous.

INTERNET PORNOGRAPHY Internet sex addiction or cybersex addiction involves engaging in sexual activity on the internet, despite the negative consequences in the person’s life. It is a subset of internet addiction disorder, although none of these is listed in the DSM-5 as being actual mental disorders. Those who practice this have cybersex relationships, masturbate while engaging in internet virtual sex, and view or trade online pornography.

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People with cybersex addiction can also have certain psychological problems, such as a distortion in their self-image, low self-esteem, social isolation, previous sex addiction, and depression. Often their spouse is adversely affected with things like obesity, depression, and poor self-esteem.

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KEY TAKEAWAYS •

Sex addiction often involves a compulsion and problems with impulse control related to sexual activity, such as sexual intercourse.

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There are brain changes and epigenetic factors that may play a role in sex addiction.

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Sex addiction is not a separate mental disorder but can be part of hypersexual disorder.

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Prostitution involves exchanging sexual favors for money. It can be organized or an independent practice.

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One of the problems of prostitution is human sex trafficking, which includes the trafficking of children and sex tourism.

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Prostitution tends to spread sexually transmitted diseases, including HIV disease.

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Pornography addiction does not exist as a separate mental disorder but involves the compulsion to view pornography, even if there are negative consequences.

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Cybersex can involve pornography or webcam sex that takes place over the internet. Some people participate in this behavior in order to make money, similar to prostitution.

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QUIZ 1. The belief that another person is in love with them or infatuated with them, which is a major phenomenon seen in women rather than men, is called what? a. Nymphomania b. Satyriasis c. Hypersexuality d. Erotomania 2. What is the result of the current debate on sexual addiction? a. It is not clear if it is present in women so it is only diagnosed in men. b. It is not listed as a disorder by the DSM or the ICD. c. It is thought to be an addiction if there are fantasies without actual actions associated with them. d. It is defined by psychologists as related to behavior and not to urges or fantasies. 3. What is it called when a male has excessive sexual fantasies and increased sexual behaviors? a. Satyriasis b. Sex addiction c. Nymphomania d. Erotomania 4. What is true of sexual activity as a reward in the addiction model? a. Sex itself is not an intrinsic reward. b. Sex does not trigger compulsive behaviors in laboratory animals. c. There are no physiological mechanisms proposed to explain sex addiction. d. Sex itself is an intrinsic reward that can be reinforced.

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5. What is least likely to be a form of treatment used to treat sex addiction? a. Cognitive behavioral therapy b. In-person support groups c. Antiandrogen therapy d. Dialectical behavioral therapy 6. What is not true of prostitution? a. Most prostitutes are female. b. Prostitution does not include human sex trafficking. c. There are parts of the world that engage in sex tourism using prostitutes. d. There are worldwide efforts to decriminalize prostitution. 7. What term is the preferred term for activist organizations for a woman who sells herself in exchange for money? a. Sex worker b. Prostitute c. Escort d. Hooker 8. What is not a term used to describe a person who hires a sex worker? a. Jane b. Kerb crawler c. Trick d. Madam 9. What is true of the attitudes toward prostitution in the US? a. Prostitution is okay but being a pimp or operating a brothel is wrong. b. Prostitution is a crime against women. c. Prostitution and all of its activities are immoral. d. Prostitution is a woman’s right and should be legalized.

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10. What is not true of sex-trafficking? a. Almost all people trafficked in the sex industry are children. b. Sex trafficking is part of a larger problem with human trafficking. c. The incidence of sex trafficking is increasing. d. Sex trafficked countries include finding children from Asia and Eastern Europe.

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SUMMARY The purpose of this course has been to introduce the student to matters related to human sexuality. As you have learned, the research and understanding of human sexuality are rather recent events compared to the study of other sciences and research on this subject is still ongoing. The course touched on the anatomy and physiology of the human reproductive system as well as what is known about the human sexual response, sexual arousal, and intimate relationships in humans. How sexuality figures into contraception, conception, pregnancy, and childbirth were also important issues covered in the course. As you have seen, there are complex issues involving sexual and gender orientation, sexual dysfunction, and behaviors considered to be sexually deviant in today’s society that were part of what was discussed in this course. Chapter one in the course opened up the discussion of human sexuality by talking about the anatomy and physiology of the male and female reproductive system. While not all of sexual behavior and sexuality is focused on the reproductive system, discussing these systems was important to understanding human sex. As you have seen, the study of the brain in human sexuality is not well understood but it is important to recognize its role in sexuality. Some of the cultural issues about the sexual organs was covered in this chapter, including male circumcision and female genital mutilation, sometimes referred to as female circumcision. The topics of chapter two were the human sex drive or libido, sexual responsiveness, and the study of aphrodisiacs. As you learned, there are differences between men and women when it comes to the sex drive. The sexual response cycle is a relatively predictable pattern of physiological variables that change during sexual activity. There are drugs and supplements considered to be aphrodisiacs. What these substances are and how they are studied were discussed in this chapter. Chapter three in the course looked into the psychology of intimate relationships. Intimacy starts with attachment, and attachment, as you learned, begins in infancy. The type of attachment a person develops in childhood determines how they will respond to

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intimate relationships in adulthood. Many times, intimacy involves some type of physical attraction, which was discussed in the chapter. There are several theories on what love really is, some of which is neurobiological. The chapter ended with a look at intimate relationships and the different types of intimate relationships that can be part of this or other societies. Chapter four looked into different types of sexual behavior performed in human sexual experience. Sexual behavior can be a singular activity as is seen in masturbation. Some people practice oral sex, which was one of the sections in this chapter. The most common sexual activity in heterosexuals is sexual intercourse, while both homosexual and heterosexual couples can practice anal sex, which are covered in the chapter. The focus of chapter five in the course was sexual dysfunction or sexual disorders in men and women. There are problems associated with low libido or low sexual arousal as well as problems with attaining an orgasm, which were discussed in the chapter. Men can have erectile dysfunction as a sexual problem, while women can have vaginismus that affects sexual satisfaction. Sexual problems in men that were discussed in the chapter included premature ejaculation and delayed ejaculation. Sexually transmitted diseases and the risks of getting them were the topics of chapter six. As you learned, certain sexual behaviors predispose a person to getting a sexually transmitted disease and there are ways to decrease their transmission. The different sexually transmitted diseases, which can be viral, bacterial, protozoal, or parasitic, were discussed in the chapter. For a couple of sexually transmitted diseases, there are vaccines that can be used in the prevention of these infections, which were covered in the chapter. Chapter seven in the course talked about several issues related to conception, pregnancy, birth, and contraception. Many sexually-active couples and single people practice contraception in order to avoid an unintended pregnancy. The process of conception, when it does occur, was discussed in the chapter. The changes seen in pregnancy, including changes in sexuality with pregnancy, were covered. The process of childbirth was explained in this chapter along with the practice of terminating a pregnancy, which is referred to as having an abortion.

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Chapter eight talked about the development of sex differences and gender in humans as well as the different issues that come out of gender identification, such as gender roles and stereotypes. There are individuals who are born with a specific sex assignment who feel as though they do not belong to that gender. These transgender people and their issues were discussed in this chapter. The topic of chapter nine in the course was sexual orientation. This refers to the longlasting sexual or romantic attraction to a person of a certain gender. There is a wide range of choices for sexual orientation, which were described in this chapter. The specific issues related to what it means to be heterosexual, homosexual, bisexual, gay, or lesbian were covered in this chapter as were the different sexual practices involved in sexual relationships between same-sex couples. Chapter ten included a discussion of the topics of childhood sexuality, adolescent sexuality, sexuality and aging, and sex among people with disabilities. Sexuality develops first in childhood, usually with sexual curiosity and simple sexual behaviors that develop into adolescent sexual behaviors that increasingly approach adult sexual activity. These were discussed in the chapter as well as the changes in sexuality that occur with aging. Also covered in the chapter was sex in individuals with disabilities. As you have learned, sexual behavior persists throughout life and in different life circumstances. The focus of chapter eleven in the course was sexual aggression, which can involve sexual harassment, sexual abuse, rape, and child sexual abuse. In no culture are these things considered to be normal sexual behavior, although it certainly does exist in all societies of the world. Sexual harassment usually involves unwanted sexual attention or behaviors directed at one person by another, often in the workplace. Sexual assault involves many different types of sexual aggression, including rape, which was discussed in the chapter. Child sexual assault was also covered, which involves sexual aggression directed at children. The subjects discussed in chapter twelve included sexual fetishism and paraphilic disorders. The vast majority of sexual fetishes are completely benign and do not necessarily represent a sexual disorder. Paraphilic disorders are intense sexual feelings

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and behaviors not experienced by most people because of their extreme nature. These disorders are usually considered problematic if they cause the individual to have distress about their sexual feelings or behaviors, or if there is a victim involved with the paraphilia. The different fetishes and paraphilias were covered as part of this chapter. Chapter thirteen in the course talked about the interplay between sex addiction, prostitution, and pornography. People with sexual addictions often have impulses and compulsiveness related to engaging in sexual activity. They often turn to soliciting prostitution to handle their need for frequent sexual behaviors, as you have learned in the chapter. A related addiction is pornography addiction, some of which is related to internet sex or pornography addictions, which are relatively recent phenomena.

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CHAPTER QUESTION ANSWERS CHAPTER ONE 1. Answer: b. The male hormone responsible for male sexual and reproductive capabilities is testosterone. Without this hormone, males will have little libido and greatly diminished sexual functioning. 2. Answer: c. The entire reason why the scrotum houses the testes is outside the body is that sperm cells do not mature easily at core body temperatures so the scrotum keeps this testicular temperature below that level. 3. Answer: c. The sperm cell gets its tail in the epididymis, which is the site for sperm cell maturation. 4. Answer: d. The final state of semen isn’t created until the fluid has been lubricated by secretions of the Cowper’s glands. Prior to this, the semen is called pre-ejaculate. 5. Answer: c. These processes make differing numbers in males and females. Four male gametes are made per spermatogonium in males, while just one gamete is made per oogonium in females. 6. Answer: b. Ovulation takes place every four weeks or every 28 days in women from the time of puberty to the time of menopause. 7. Answer: c. Because of the activity of the corpus luteum, which makes progesterone, the secretory phase is represented by the highest progesterone levels. 8. Answer: a. The estrogen made by the developing follicles will cause thickening of the endometrial lining in the proliferative phase of the menstrual cycle. 9. Answer: c. Circumcision is practiced by each of these groups but it is not generally commonly practiced in Europe.

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10. Where in the world is infibulation or sewing together of the female genitalia usually performed? e. Asia f. Australia g. Middle East h. Africa Answer: d. Infibulation is primarily a cultural practice in Africa, where what remains of the genitals is a two to three-millimeter hole for the passage of menstrual blood and urine.

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CHAPTER TWO 1. Answer: b. The activity of dopamine on certain parts of the brain is most associated with the regulation of libido in humans. 2. Answer: a. Freud believed that libido is a type of energy that comes from subconscious desires of part of the psyche called the id. It was believed that libido was a natural desire like hunger and thirst. 3. Answer: d. Men have twice as many fantasies and will have more varied fantasies when compared to women. 4. Answer: b. Men are much less likely to be aroused by the gender opposite to their orientation. In contrast, women are more fluid with regard to what they are aroused by. 5. Answer: b. The vagina itself is not very erogenous but some women will have sensitivity of the anterior vaginal wall, sometimes referred to as the G-spot. 6. Answer: c. Each of these areas are likely to be erogenous, except for the midback, which doesn’t have very many nerve endings so it is not likely typically sensitive. 7. Answer: c. The orgasm phase is when there is the sudden discharge of sexual energy that has built up during the excitement and plateau phases of the sexual response cycle. 8. Answer: a. Each of these is a hormone released by the body as a result of an orgasm, except for testosterone. These all lead to feelings of relaxation and euphoria. 9. Answer: c. Each of these is untrue except that orgasms last longer in women compared to men. 10. Answer: d. Herbal substances are difficult to study in humans, particularly as aphrodisiacs, because of a high risk of experiencing a false positive effect because of what’s called the placebo effect.

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CHAPTER THREE 1. Answer: d. In disorganized attachment, the child lacks attachment behaviors for the most part. This is sometimes seen when a child has had early neglect or parental separation. 2. Answer: b. The child with anxious-ambivalent attachment experiences separation anxiety and does not feel better when the parent returns to the child’s environment. 3. Answer: b. The anxious-preoccupied adult often feels the need to be close to their partner and to get constant reassurance about how the relationship is going. 4. Answer: d. The fearful avoidant individual is most likely to be in an abusive relationship and tends to have rockier relationships overall. 5. Answer: d. Each of these is true of men with facial symmetry. While they may be perceived as being more honest, they are not necessarily actually more honest. 6. Answer: a. When it comes to male scent, women factor this into physical attractiveness. Body odor attraction is related to a man’s genetic makeup and to his diet. 7. Answer: c. Love toward an inanimate object is also referred to as a paraphilia, which also implies some type of sexual feeling toward the object. 8. Answer: d. Attachment is the last stage of love and is the most long-lasting, often lasting for many years or for a lifetime. 9. Answer: d. There are specific pathways in the dopamine system of the brain that get activated in the phenomenon of intimacy. 10. Answer: b. While we consider intimacy to be sexual contact, there is both sexual or physical intimacy as well as emotional intimacy, which is not sexual.

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CHAPTER FOUR 1. Answer: d. Sounding involves inserting an object into the urethra for the purposes of attaining sexual pleasure, which may be injurious to this delicate structure. 2. Answer: b. Onanism is an older term used to describe masturbation. 3. Answer: b. Prone masturbation involves masturbating lying face down and masturbating with a pillow or mattress. It is a practice involving both men and women. 4. Answer: a. Masturbation and orgasm have been observed in infants, even at a very young age. It is believed to be universal in both boys and girls. 5. Answer: a. The most common type of sexual fantasy is that of having oral sex with another person. 6. Answer: c. Men have more dominant than submissive fantasies than women, who tend to have more submissive fantasies. 7. Answer: a. Copulation is usually done for reproductive purposes and is done for reproductive purposes in individuals who are not generally human, such as primates and other types of mammals. 8. Answer: d. Of these choices, only anilingus is considered non-penetrative because it involves oral sex between the mouth and the anus. 9. Answer: a. Each of these is a potential risk with having sexual intercourse but the risk of having an STD is the greatest risk. 10. Answer: d. Fisting is a relatively rare sexual practice because it is difficult to relax enough to allow the fist into the rectum.

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CHAPTER FIVE 1. Answer: d. The patient with hypoactive sexual desire disorder who is a female used to be called frigid or was said to have frigidity. The disorder is controversial and cannot exist unless the patient has distress about it. 2. Answer: a. The person with lifelong HSDD has a problem with hormones, medical problems or psychiatric disease. The person is least likely to have it because of a past bad experience with sex. 3. Answer: d. SSRIs used for depression can lead to hormone and neurotransmitter factors that contribute to sexual arousal disorder. 4. Answer: c. Each of these is used to treat sexual arousal disorder except for SNRIs, which can sometimes be contributory to having the problem. 5. Answer: c. Diabetics have nerve-related and vascular reasons why they might have secondary anorgasmia so this should be looked for in evaluating the disorder. 6. Answer: a. The problem is associated with each of these things but it is not due to an anatomical problem affecting the vagina. 7. Answer: c. The problem with erectile dysfunction is found to be physical about 80 percent of the time, accounting for the fact that it is best treated with medications for the disorder. 8. Answer: a. Each of these is a factor in the development of secondary erectile dysfunction, except that most of them are physical and not psychological. 9. Answer: d. While there have been many theories suggested as a cause or premature ejaculation, the exact cause is currently unknown. 10. Answer: a. Each of these is a medical treatment used to manage premature ejaculation except for sildenafil, which is used to treat erectile dysfunction.

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CHAPTER SIX 1. Answer: b. Trichomoniasis is caused by a single-celled protozoan called Trichomonas vaginalis. It can be passed through sexual activity. 2. Answer: a. Pediculosis pubis or pubic lice is a parasitic disease passed through sexual behavior; the other disorders are viral in nature. 3. Answer: d. About half of all exposed infants will get conjunctivitis from an exposure to chlamydia. A lesser percentage can develop pneumonia. 4. Answer: b. If a person says they have the clap, they are referring to the fact that they have gonorrhea. 5. Answer: c. Each of these can be a complication of having chronic hepatitis B, except for gallbladder cancer, which is not a complication of this STD. 6. Answer: d. HIV cannot be transmitted through casual contact, hugging or kissing, unless broken skin is involved. 7. Answer: c. HIV does not infect the B cells but instead infect T helper cells and cells that phagocytize other cells, like macrophages, dendritic cells, and microglial cells. 8. Answer: c. If a person is still has not tested positive for HIV after six months, they have not contracted the disease. 9. Answer: c. Each of these is caused by HPV infections except for esophageal cancer. Almost all cervical cancers are believed to be caused by the HPV virus. 10. Answer: a. HPV can be transmitted through each of these routes but it cannot be passed through contact with a toilet seat.

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CHAPTER SEVEN 1. Answer: b. Spermicides are not a very effective method of contraception. The other methods have better effectiveness in preventing a pregnancy. 2. Answer: c. Teaching abstinence only to teens can actually increase the pregnancy rate because it is not always combined with birth control education and teens will not comply with just abstinence. 3. Answer: c. The contraceptive sponge must remain in place for a minimum of six hours after sex in order to prevent pregnancy. 4. Answer: a. These are all problems and risks with using the contraceptive sponge, except that it does not cause blood clots. 5. Answer: a. Each of these is the same and starts at the time of fertilization, except for the gestational age, which is measured from the first day of the last menstrual period. 6. Answer: d. Because half of all women feel that sex can damage the pregnancy, the level of sex in pregnancy tends to decrease. 7. Answer: c. The first trimester ends at 12 weeks’ gestation; it is followed by the second trimester. 8. Answer: d. A primigravida is a woman who has been pregnant once or who is currently pregnant. Technically, the person could be called nulliparous if she doesn’t carry the pregnancy past 20 weeks’ gestation. 9. Answer: c. As you’ll remember, oxytocin is released after an orgasm to enhance bonding. It also increases bonding to the infant, increases contentment, and increases uterine contractions. It causes the letdown reflex but does not cause milk production. 10. Answer: d. In a selective abortion, there is the termination of some fetuses’ lives in order to reduce the total number in a multiple gestation pregnancy.

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CHAPTER EIGHT 1. Answer: b. Each of these is an effect of testosterone on the brain, except that it doesn’t decrease lateralization of the brain. In fact, it increases lateralization of the brain. 2. Answer: d. The SRY gene is only found on the Y chromosome. It allows for the production of testosterone so that male gonads can be made in utero. 3. Answer: d. The major cognitive/behavioral issue seen in boys who have Klinefelter syndrome is poor language skills. 4. Answer: a. The person with Klinefelter syndrome has an XXY genotype, which makes them male but with a lack of aggression commonly seen in males. 5. Answer: b. Children are the most rigid about their sexual and gender stereotypes at about five to six years of age and then they become more flexible in their expectations of the gender differences. 6. Answer: a. Prior to five years of age, in the preschool years, there are some children who are “gender enforcers” that exhibit more sexism than other children and dictate the behavior of other children. 7. Answer: a. In most Pentecostal faiths, women are allowed leadership positions, which is generally not allowed or tolerated as well in other cultures. 8. Answer: d. Women are more indirect in expressing their sexual desires but, when it comes to sexual refusal, they are more direct and clearer about this. 9. Answer: d. Intersex is when a person has ambiguous genitalia at birth. They will have a specific genotype indicating one sex but will have genital characteristics of both sexes. 10. Answer: b. A transvestite or cross-dresser is a person who chooses to dress in clothing of the opposite gender. It is generally not a fetish and most of these individuals are heterosexual. It is not the same thing as transgender.

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CHAPTER NINE 1. Answer: d. A lesbian describes a female who is attracted to other females exclusively. This applies to their sexual attraction to another. 2. Answer: a. A pansexual person is attracted to any other person, regardless of their actual gender. They do not generally see gender in their attraction to another person. 3. Answer: d. It should be clear that gender identity and things like sexual identity and biological sexual assignment are not completely the same. Gender identity refers to the identification with one’s genitals, while sexual identity is more all-encompassing and can be related to sexual orientation as well. 4. Answer: b. Sexual fluidity involves being attracted to more than one gender at different times and in different circumstances. Sexual fluidity is more common in women rather than men because women are naturally more fluid about their sexual orientation. 5. Answer: a. MSM stands for “men who have sex with men” and refers basically to the sexual behaviors of a male person rather than to actual sexual attraction. 6. Answer: d. In most Muslim countries of the Middle East, homosexuality is denied or criminalized but in Israel, it is often tolerated, accepted, and even celebrated. 7. Answer: b. Docking is a non-penetrative form of sex in which a man inserts his penis into the foreskin of another man. 8. Answer: c. About fifty-five percent of new HIV cases happen directly as a result of MSM behavior. 9. Answer: a. Women in a lesbian encounter are more likely to have an orgasm in their encounter than they do in a heterosexual encounter. 10. Answer: b. Oral sex is the most common lesbian sexual practice, although they will report any of the other sexual practices to a variable degree.

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CHAPTER TEN 1. Answer: d. The sexualization of children is different from healthy sexual development and is a more recent phenomenon promoted by access to media. It can be harmful for a child’s self-esteem and overall healthy sexual and emotional development. 2. Answer: c. Sexual self-touch and masturbation are considered normative sexual behavior in children. The other choices are considered abnormal sexual behaviors in children prior to puberty. 3. Answer: b. As children learn more about privacy issues and modesty, the incidence of overt sexual behaviors decreases after about five years of age. 4. Answer: d. Each of these is seen in a high degree among children with problem sexual behaviors except for obsessive-compulsive disorder. 5. Answer: d. The most common form of birth control practiced by adolescent females is a combination of estrogen and progestin birth control pills. 6. Answer: b. Progestin in particular in oral or non-oral contraception greatly increases the risk of depression in teen girls. 7. Answer: d. Each of these is true of STIs and adolescents except for the fact that they do have the highest incidence and prevalence of STIs compared to other age groups. 8. Answer: b. The age of consent varies in different parts of the world but is on average about 16 years of age. This may or may not be the same as the age of marriageability or the age of majority. 9. Answer: d. Each of these is true of sexual activity among older men and women, except that sexual desire of all types is greater in men than in women who are older.

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10. What is not true of sexual arousal in older individuals? i. Most older people do not have sexual dreams. j. Most older people still masturbate k. Most older people say it takes longer to be sexually aroused. l. Most older men say they have decreased ejaculatory volume. Answer: b. Each of these is true except that more than 95 percent of older adults do not masturbate at all.

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CHAPTER ELEVEN 1. Answer: a. Sexual aggression is not always about a stranger perpetrating a sexual act on another; many perpetrators are known to the victim. 2. Answer: d. Date rape can be about anger, power, and miscommunication and can be made worse by alcohol and drug use. It is generally not around relaxed sexual rules in society. 3. Answer: d. Most victims of sexual harassment have more subtle threats and implications if they do not comply; only about 10 percent are threatened with termination if they do not go along with the perpetrator. 4. Answer: b. The majority of victims of sexual harassment in the military are women who have been perpetrated on by a male of higher rank or one in a supervisory position over the victim. 5. Answer: c. In general, each of these is a form of sexual abuse against a child; however, a parent bathing a child, as long as their physical boundaries are respected, does not have to be sexual abuse. 6. Answer: b. Incest with a parental perpetrator is considered to have the greatest potential damage to the child victim and is a common form of sexual abuse against children. 7. Answer: b. Each of these is true of the physical effects of rape and sexual assault except that the presence of physical damage to the genitals is not a requirement in reporting an assault. 8. Answer: d. Each of these is true except that gay men have an increased risk of rape compared to heterosexual men. 9. Answer: b. Each of these is a motivation behind rape except for male insecurity. Most of these men feel they will be somehow held in high-esteem by their male peers for their behavior. 10. Answer: a. Each of these increases the likelihood of severe symptoms after the event, except for dissociation, which can occur but does not necessarily affect symptom severity.

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CHAPTER TWELVE 1. Answer: d. Fetishism in the medical sense requires some type of object or body part as a source of sexual arousal. Strictly speaking, it does not occur with an attraction to a sexual behavior or activity. 2. Answer: c. Partialism refers to a sexual attraction to a specific body part, usually one that is not normally related to sex. 3. Answer: b. Each of these describes a sexual disorder and fetishism but it only needs to be present for six months to be called a sexual disorder. 4. Answer: d. Each of these is successful in reducing the effect of fetishes on the individual but surgical interventions are likely too extreme for this type of sexual issue. 5. Answer: b. Each of these is characteristic of a paraphilic disorder except that it is not necessarily a disorder if it is practiced between two consenting adults. 6. Answer: d. Psychoanalysts think that paraphilias have to do with early childhood conflicts, although the other causes seem to also be viable theories. 7. Answer: d. Those with pedophilia have a specific interest in prepubertal children as the object of their sexual fantasy. 8. Answer: b. Nonexclusive pedophiles are attracted to adults as well as to prepubescent children. Some can actually be married and will carry on adult relationships. 9. Answer: d. Each of these is true of voyeurism but internet viewing does not have secret observation or intent so it is not included as part of this. 10. Answer: b. Transvestism is controversial because there is rarely any victim and it does not often cause a person much psychological distress.

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CHAPTER THIRTEEN 1. Answer: d. Fetishism in the medical sense requires some type of object or body part as a source of sexual arousal. Strictly speaking, it does not occur with an attraction to a sexual behavior or activity. 2. Answer: c. Partialism refers to a sexual attraction to a specific body part, usually one that is not normally related to sex. 3. Answer: b. Each of these describes a sexual disorder and fetishism but it only needs to be present for six months to be called a sexual disorder. 4. Answer: d. Each of these is successful in reducing the effect of fetishes on the individual but surgical interventions are likely too extreme for this type of sexual issue. 5. Answer: b. Each of these is characteristic of a paraphilic disorder except that it is not necessarily a disorder if it is practiced between two consenting adults. 6. Answer: d. Psychoanalysts think that paraphilias have to do with early childhood conflicts, although the other causes seem to also be viable theories. 7. Answer: d. Those with pedophilia have a specific interest in prepubertal children as the object of their sexual fantasy. 8. Answer: b. Nonexclusive pedophiles are attracted to adults as well as to prepubescent children. Some can actually be married and will carry on adult relationships. 9. Answer: d. Each of these is true of voyeurism but internet viewing does not have secret observation or intent so it is not included as part of this.

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10. Which paraphilia is most controversial because it does not usually involve a victim or cause psychological harm? m. Pedophilia n. Transvestism o. Voyeurism p. Exhibitionism Answer: b. Transvestism is controversial because there is rarely any victim and it does not often cause a person much psychological distress.

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COURSE QUESTIONS AND ANSWERS 1. What is the purpose of the dartos and cremaster muscles? a. To regulate testicular temperature b. To contract during ejaculation c. To protect the scrotal contents d. To propel sperm to their maturation site in the scrotum 2. What is the tough outer layer of the testis itself? a. Parietal tunica vaginalis b. Visceral tunica vaginalis c. Seminiferous tubule d. Tunica albuginea 3. What does the term cryptorchidism mean? a. Failure of the testes to develop in utero b. Failure of the testes to descend in utero c. Failure of separation of the scrotum into two compartments d. Development of a dilated vein or veins in the scrotum 4. What structure forms the blood-testes barrier to prevent autoantibodies to get to the developing male sperm cells? a. Rete testes b. Tunica albuginea c. Sertoli cells d. Tunica vaginalis

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5. What is a sperm stem cell called? a. Spermatid b. Primary spermatocyte c. Spermatozoon d. Spermatogonium 6. What does the process of spermiogenesis do? a. Take the stem cell from a diploid cell to a haploid cell. b. Change the structure of the sperm cell look more like a mature sperm. c. Participates in cell division of the sperm stem cell. d. Causes the sperm to travel to the outside of the body. 7. Which structure of the sperm cell is also referred to as a cap? a. Acrosome b. Mitochondrion c. Centriole d. Flagellum 8. What part of the penis contains the most nerve cell endings so it is the most sensitive part? a. Glans penis b. Shaft c. Prepuce d. Urethra 9. What part of the penis is removed during a circumcision? a. Glans penis b. Shaft c. Prepuce d. Urethra 10. Which hormone is produced by the pituitary gland in order to stimulate the Leydig cells’ production of testosterone?

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a. Follicle stimulating hormone b. Luteinizing hormone c. Gonadotropin releasing hormone d. Inhibin 11. What part of the female external genitalia has the greatest number of nerve endings? a. Clitoris b. Labia minora c. Vaginal introitus d. Labia majora 12. What part of the female vulva is a hair-covered fat pad? a. Perineum b. Vaginal introitus c. Labia minora d. Mons pubis 13. What is the purpose of Lactobacillus in the vagina? a. They can cause certain infections in the vagina b. They can prevent certain infections in the vagina c. They secrete lubricating mucus d. They make it easier for sperm to travel in the vagina 14. When does meiosis start in the female ovary in order to lead to mature egg cells? a. In utero b. At puberty c. Every 14 days d. Every 28 days 15. What are the supporting cells in the female ovary called? a. Theca cells b. Primary oocytes 252

c. Granulosa cells d. Oogonia 16. Which cells in the follicle of the ovary make estrogen within this structure? a. Theca cells b. Primary oocytes c. Secondary oocytes d. Oogonia 17. Which type of follicle in the female ovary is called an antral follicle? a. Primordial follicle b. Primary follicle c. Secondary follicle d. Tertiary follicle 18. A surge of what hormone leads to ovulation in females? a. FSH b. GnRH c. LH d. Inhibin 19. What is the dominant hormone secreted by the corpus luteum of the female ovary? a. Testosterone b. Progesterone c. Estrogen d. Inhibin 20. Where does fertilization mainly occur in the female body? a. Fallopian tube b. Uterine fundus c. Uterine corpus d. Cervix

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21. What uterine layer sheds each month as part of the menstrual cycle? a. Perimetrium b. Myometrium c. Stratum basalis d. Stratum functionalis 22. What is the function of the SRY gene in utero? a. It triggers egg cells and the ovary to develop. b. It triggers sperm cells and the testes to form. c. It causes maturation of secondary male sex characteristics. d. It makes testosterone in the male fetus. 23. What is true of the Wolffian duct and the Mullerian duct in fetuses? a. These two ducts develop simultaneously to make the different reproductive structures. b. The Mullerian duct will be stimulated to develop in the presence of testosterone. c. The Mullerian duct gives rise to male sexual organs. d. The Wolffian duct is stimulated by testosterone and the Mullerian duct is degraded. 24. What factor least likely plays a role in when menarche occurs in girls? a. Nutrition b. Genetics c. Height d. Psychological stress 25. What secondary sexual characteristic in puberty is basically the same in boys and girls? a. Axillary and pubic hair growth b. Laryngeal enlargement c. Fat deposition d. Muscle development

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26. What part of the brain is most responsible for emotions? a. The brainstem b. The limbic system c. The prefrontal cortex d. The occipital lobe 27. What do the inhibitory parts of the brain do for human sexual behavior? a. They cause the cessation of an orgasm after it occurs. b. They diminish overall libido. c. They prevent socially inappropriate urges from being expressed. d. They contribute to infertility. 28. What is not considered a difference between arousal in men compared to women? a. Women respond better to visual stimuli compared to men. b. Women respond better to smell and pheromones compared to men. c. Women respond to the emotional context of a sexual stimulus compared to men. d. Women have certain times of increased and decreased sexual arousal. 29. What is the major medical advantage to doing a male circumcision? a. It increases penile cleanliness. b. It decreases the risk of gonorrhea. c. It prevents cancer of the penis. d. It decreases the incidence of HIV disease. 30. What was the role of smegma in the decision to circumcise male babies? a. It was believed that smegma was cancer-causing. b. It was believed that smegma was dirty and caused disease. c. It was believed that smegma increased the risk of masturbation. d. It was believed that smegma led to certain neurological conditions. 31. When in the woman’s menstrual cycle is libido the greatest?

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a. Menses b. Follicular stage c. Around ovulation d. Luteal or secretory stage 32. Which hormone in women most commonly suppresses the ability to have an orgasm? a. Testosterone b. Luteinizing hormone c. Estrogen d. Progesterone 33. What happens to the levels of estrogen and testosterone with menopause? a. The estrogen will increase and the testosterone will increase. b. The estrogen will decrease and the testosterone will increase. c. The estrogen will increase and the testosterone will decrease. d. The estrogen will decrease and the testosterone will decrease.

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34. Which drugs will most likely increase libido instead of decrease libido? a. Dopaminergic drugs b. Oral contraceptives c. Selective serotonin reuptake inhibitors d. Opioids 35. How long does it take a woman to achieve an orgasm on average? a. Two minutes b. Ten minutes c. Eighteen minutes d. Thirty minutes 36. What is true of using exogenous testosterone to restore libido? a. It works equally well in men and women. b. It does not work exogenously in men or women. c. It is effective in men but less effective in women. d. It is effective in women but less effective in men. 37. Which type of erotic stimulus is least likely to generate sexual arousal? a. Olfactory b. Visual c. Touch or Tactile d. Auditory 38. What body area is least likely to be universally arousable in humans? a. Axilla b. Nipples c. Lips d. Vulva

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39. What type of stimulus is most likely to negatively impact sexual desire in women? a. Olfactory b. Tactile c. Auditory d. Visual 40. What sexual stimulus type is involved in BDSM? a. Dreams b. Erotic literature c. Physical stimulation d. Role playing 41. What least likely happens to the male testes and scrotum during sexual arousal? a. The testes increase in size. b. The scrotum becomes cooler to the touch. c. There is flushing of the scrotum. d. The scrotal skin tightens. 42. What is the phenomenon of “blue balls” related to? a. Increased temperature of the scrotum during sexual arousal. b. Multiple orgasms in men without a refractory period. c. Testicular discomfort from arousal without ejaculation. d. Erectile dysfunction in the setting of adequate stimulation. 43. What is true of male orgasms and the refractory period? a. The refractory period usually precedes the actual orgasm. b. One cannot have a refractory period with a dry orgasm. c. The refractory period means no orgasms are possible. d. The refractory period decreases with age. 44. What is true of vaginal orgasms?

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a. They are equally as strong as clitoral orgasms. b. They explain why most women climax with vaginal penetration. c. They are associated with vaginal ejaculation. d. Most women cannot attain a purely vaginal orgasm. 45. What is the most reliable indicator of female orgasms? a. Pelvic and perianal muscle contractions b. Increase in vaginal secretions c. Increased breath and heart rates d. Clitoral engorgement 46. What does a baby do first if faced with the loss or threatened loss of a caregiver? a. Feels anxious b. Grieves c. Gets angry d. Goes into despair 47. Which type of attachment involves a child who wants attachment but also wants to avoid being rejected by their caregiver? a. Secure attachment b. Anxious-ambivalent attachment c. Anxious-avoidant attachment d. Disorganized attachment 48. What adult attachment style is one where personal independence is valued and trusted? a. Secure attachment b. Anxious-preoccupied c. Dismissive-avoidant d. Fearful-avoidant 49. What feature of physical attractiveness is not seen by both genders? a. Low waist-to-hip ratio 259

b. Facial symmetry c. Clear skin d. Youthful appearance 50. What are women least attracted to in a man? a. V-shaped torso b. Increased physical height c. Wider hips d. Broad shoulders 51. When is a woman more likely to select a classically male face as more attractive? a. Menses b. Follicular phase c. Luteal phase d. On birth control pills 52. What is least likely to be seen as attractive about a woman’s face? a. Small nose b. Narrow-set eyes c. Full lips d. Wide face 53. What is true of the attraction of female body weight? a. Nearly all cultures prefer a thinner woman. b. Cultures where food is scarce still prefer a thinner woman. c. Men prefer women to be thinner than women do. d. Women believe that thinness is more important to men than it is. 54. What is not true of attractiveness differences between men and women? a. Tall women are seen as more attractive and shorter men are attractive. b. Long legs are attractive in women, while shorter legs are attractive in men. c. Facial symmetry is valued in men but not as much in women. d. Small feet are valued in women but not in men. 260

55. What is not a part of Sternberg’s triangular theory on love? a. Passion b. Attachment c. Intimacy d. Commitment 56. In Ancient Greece, what is pure love called? a. Agape b. Eros c. Storge d. Philia 57. Whose theory of love is considered the most commonly accepted theory of love in today’s society? a. Freud b. Rubin c. Sternberg d. Maslow 58. Which type of intimacy involves falling in love and with love itself? a. Emotional b. Physical c. Spiritual d. Cognitive 59. What type of relationship involves couples consensually engaging in casual sex with other couples or other individuals? a. Polyamory b. Polygamy c. Hybrid relationship d. Swinging 60. What type of intimate relationship in which a couple agrees that either member can have other sexual partners? 261

a. Polyamory b. Hybrid relationship c. Open relationship d. Polygamy 61. What is the process of edging about when it comes to masturbation? a. Performing mutual masturbation b. Using anal penetration in masturbation c. Cycles of starting and then stopping masturbation d. Having multiple orgasms in masturbation 62. Where is the male G-spot generally located? a. Prostate gland b. Glans penis c. Dorsal shaft of the penis d. Perineum 63. What sexual area, when stimulated, will most likely lead to male orgasm during masturbation? a. Testicles b. Prostate c. Penile shaft d. Glans penis 64. When did masturbation cease to be considered a psychiatric problem? a. 1954 b. 1942 c. 1968 d. 1982 65. Which group of people are the easiest to study with regard to sexual fantasies? a. Children b. Gay men c. Women 262

d. Heterosexual men 66. What is not true of sexual fantasies? a. They may involve things that are illegal or dangerous. b. They do not usually play a role in real life sexual behavior. c. They can be the only source of an orgasm in some people. d. They can lead to role playing during sex. 67. Oral sex involving stimulating the male penis is called what? a. Face-sitting b. Cunnilingus c. Anilingus d. Fellatio 68. Oral sex involving sexually stimulating the female genitalia with the mouth is called what? a. Face-sitting b. Cunnilingus c. Anilingus d. Fellatio 69. How can STDs be prevented in oral sex? a. Oral sex is safe so it does not transmit STDs. b. Cunnilingus is safe but fellatio will not be safe. c. Using a condom or dental dam will decrease STDs. d. There is no way to reduce the incidence of STDs in oral sex. 70. What is true of pheromones and sexual activity? a. Pheromones are not practically used in any species. b. Pheromones can be used to determine when a female is in estrus. c. Pheromones are a big part of the human sexual experience. d. Men can smell pheromones but women cannot. 71. What is the most common sexual behavior in humans?

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a. Oral sex b. Anal sex c. Vaginal intercourse d. Mutual masturbation 72. The average age at first sexual intercourse among boys and girls in the US is what? a. 13 years b. 15 years c. 17 years d. 19 years 73. What is least likely to be a reason for a male-female couple to engage in anal intercourse? a. There is greater pleasure for the male because the anal muscles are tighter. b. It can help prevent STDs. c. It can be an alternate sexual activity in menstruation. d. It can be an activity used to prevent pregnancy. 74. What sexual practice is most linked to passing on the HIV infection? a. Penetrative anal sex b. Vaginal intercourse c. Receptive anal intercourse d. Anilingus 75. Which activity most describes pegging? a. Female to male anal intercourse b. Male to male anal intercourse c. Male to female anal intercourse d. Using anal beads in anal sex 76. Which hormone or neurotransmitter is believed to inhibit sexual desire? a. Testosterone b. Serotonin 264

c. Dopamine d. Norepinephrine 77. What is not a criterion for hypoactive sexual desire disorder? a. Present in at least 75 percent of sexual situations b. Present for at least six months c. Associated with low testosterone levels d. Associated with distress or interpersonal problems 78. What is the female equivalent of erectile dysfunction? a. Sexual arousal disorder b. Hypoactive sexual desire disorder c. Anorgasmia d. Vaginismus 79. Which group of people is least likely to have anorgasmia? a. Post-menopausal females b. Young men c. Pre-menopausal females d. Older men 80.What drug is least likely to be associated with anorgasmia? a. Hormonal birth control pills b. Heroin c. SSRIs d. Tricyclic antidepressants 81. What is a common cause of anorgasmia in menopausal women? a. Psychological b. Sexual repressive beliefs c. Lack of testosterone d. Lack of estrogen 82. What psychological factor is most associated with vaginismus?

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a. Low sexual desire b. Prior sexual trauma c. Anger issues d. Interpersonal relationship problems 83. What is least likely to be a physical cause of secondary vaginismus? a. Vaginal yeast infections b. Childbirth trauma c. Diabetes mellitus d. Menopause 84. Which drug will least likely be beneficial in treating vaginismus? a. Botox b. Antidepressants c. Anxiolytics d. Testosterone 85. What does the test for nocturnal penile tumescence test for in evaluating erectile dysfunction? a. The presence of an erection with visual erotic stimulation b. The presence of erections during sleep c. The quantitative degree of penile erection d. The blood flow to the penis from the pelvic arteries 86. A penile ultrasound can be done to look specifically for what cause of erectile dysfunction? a. Psychological b. Neuropathy c. Atherosclerosis d. Hormonal 87. What is the least likely route of administration of alprostadil for erectile dysfunction? a. Topical 266

b. Injectable c. Suppository d. Oral 88. What sporting activity is most associated with delayed ejaculation? a. Football b. Cycling c. Jogging d. Hockey 89. What drug for delayed ejaculation can be used to treat the disorder? a. Sildenafil b. SSRIs c. Testosterone d. There are no drugs for this 90. Which STD is considered curable rather than being just manageable with treatment? a. Herpes b. HPV c. HIV d. Syphilis 91. What type of sexual behavior is most likely to increase the risk of getting an STI? a. Anilingus b. Oral sex c. Anal sex d. Vaginal sex 92. What is least likely to be a complication of chlamydia infections? a. Blindness b. Birth defects c. Infertility 267

d. Ectopic pregnancies 93. What percentage of women have no symptoms when they have chlamydia? a. 10 percent b. 30 percent c. 80 percent d. 95 percent 94. By definition, what is least likely to be infected in pelvic inflammatory disease? a. Vulva b. Uterus c. Fallopian tubes d. Ovaries 95. What is not a major complication of gonorrhea in men? a. Antisperm antibodies b. Meningitis c. Epididymitis d. Endocarditis 96. Which organism should be tested for after positive testing for gonorrhea because of a 50 percent coinfection rate between these organisms? a. HIV b. Trichomonas c. Chlamydia d. Syphilis 97. What is not true of genital herpes infections? a. It is not curable. b. It can be caused by HSV-1 or HSV-2. c. Many will be asymptomatic. d. Infection is passed through contact with sores only.

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98. What is the most common STI in the United States? a. Chlamydia b. Human papillomavirus c. Gonorrhea d. Herpes 99. What population of persons has the greatest risk of having herpes infections? a. Sex workers b. African-Americans c. Younger females d. Younger males 100.

How do most children get hepatitis B infections?

a. Medical procedures b. Vertical transmission c. Sexual abuse d. Household contacts 101.

What stage of syphilis involves having a painless chancre?

a. Primary syphilis b. Secondary syphilis c. Latent syphilis d. Tertiary syphilis 102.

Which STD is least likely to get transmitted through vertical transmission?

a. HIV b. Hepatitis B c. Trichomonas d. Syphilis 103.

Which stage of syphilis involves having neurological symptoms?

a. Primary syphilis b. Secondary syphilis

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c. Latent syphilis d. Tertiary syphilis 104.

What is the most common way that syphilis is transmitted?

a. Touching infective surfaces b. Men having sex with men c. Vaginal sex d. Receiving an infected blood transfusion 105.

What is least likely to be able to transmit HIV disease?

a. Saliva b. Vaginal fluids c. Semen d. Blood 106.

What is not seen when a person develops trichomoniasis?

a. Burning on urination b. Prostate inflammation c. Thin watery vaginal discharge d. Shallow ulcers of the genitals 107.

If you are looking for pubic louse eggs, where is the least likely place you

would look? a. Armpit b. Scalp c. Eyelashes d. Moustache 108.

How long do pubic lice live without human contact of some kind?

a. 12 hours b. 2 days c. One week d. One month

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109.

What is not true of the HPV virus?

a. Genital warts are the most contagious b. Immunity to one type of wart does not mean immunity to other warts c. Some HPV strains are cancerous while others are not d. HPV that causes common warts can also cause genital warts 110.

What is not true of the HPV vaccine?

a. It is approved for use by both girls and boys. b. It can decrease cancer risk in girls already infected with the virus. c. It works better for younger girls than older girls. d. All of the vaccines protect against the major cancer-causing viruses. 111.

Which birth control techniques have a high theoretical success rate and an

equally high practical success rate? a. IUD b. Hormonal intravaginal rings c. Lactation d. Birth control pills 112.

Which birth control method does not increase the risk of blood clots?

a. Hormonal intravaginal rings b. Combined oral birth control methods c. Birth control patches d. Mini-pill 113.

What is not a way that hormonal birth control decreases the risk of

pregnancy? a. Alters the uterine lining b. Kills sperm cells c. Creates a hostile environment for sperm d. Inhibits ovulation 114.

What is not a consistent effect of taking high dose estrogen in a birth

control device or pill? 271

a. Nausea b. Headaches c. Cervical cancer risk d. Breast tenderness 115.

What type of birth control method is the most commonly used method

throughout the world? a. Oral contraceptives b. Contraceptive sponge c. Diaphragm d. Male condom 116.

How long after unprotected sex can a woman take emergency

contraception? a. 24 hours b. 48 hours c. 72 hours d. 120 hours 117.

What is the outer layer of follicular cells around the oocyte called?

a. Cone of attraction b. Perivitelline membrane c. Corona radiata d. Acrosome 118.

What is the zona pellucida made from?

a. Lipid bilayer b. Glycoproteins c. Follicular cells d. Peptidoglycan 119.

What is least likely to be a change in sexual responsiveness in the pregnant

woman? a. Congestion of the vulva 272

b. Changes in color of the vulva c. Shortened resolution phase d. Uterine contractions with orgasm 120.

When should sex be allowed to occur after delivery, according to most

researchers and doctors? a. 2 weeks b. 6 weeks c. 3 months d. 6 months 121.

What is not a factor that limits sexual satisfaction in the first trimester of

pregnancy? a. Decreased breast tenderness b. Decreased clitoral sensitivity c. Physical factors like fatigue and nausea d. Fear over the pregnancy 122.

What most affects a woman’s sexual function after having a baby?

a. Body image self-consciousness b. Stress c. Mood changes d. Decreased clitoral sensitivity 123.

At what point in the pregnancy can the uterus first be felt above the pubic

bone? a. 8 weeks b. 12 weeks c. 15 weeks d. 20 weeks 124.

How long is the typical pregnancy in gestational weeks?

a. 20 weeks b. 30 weeks 273

c. 40 weeks d. 45 weeks 125.

Which vitamin is most important in the prevention of spina bifida in the

developing fetus? a. Folate b. Vitamin D c. Omega-3 fatty acids d. Iron 126.

During which stage of labor is the infant delivered in a normal vaginal

delivery? a. First stage b. Second stage c. Third stage d. Fourth stage 127.

What is the most common cause of a miscarriage?

a. Diabetes in the mother b. Chromosomal abnormalities c. Infection in the uterus d. Autoimmune disease 128.

What is the most effective abortion technique in the early first trimester of

the pregnancy? a. Medical abortion b. Dilation and curettage c. Induction of labor d. Suction techniques 129.

What happens to an XY male who does not have an active SRY gene?

a. He becomes phenotypically female. b. He becomes a transgender male. c. He is female until puberty. 274

d. He will have feminine brain characteristics but male genitalia. 130.

What will the person with Turner syndrome look like at adult maturity?

a. Phenotypically a woman b. Phenotypically a girl c. Phenotypically a man d. Phenotypically a boy 131.

What will the person with Klinefelter syndrome look like at adult

maturity? a. Phenotypically a woman b. Phenotypically a girl c. Phenotypically a man d. Phenotypically a boy 132.

What appears to be more true of men compared to women when it comes

to cognitive skills? a. Increased verbal memory b. Increased visuospatial skills c. Increased ability to read facial cues d. Increased spelling ability 133.

When do children first form gender stereotypes?

a. 10 months b. 21 months c. 36 months d. 48 months 134.

When do children first know their own gender?

a. 6 months b. 12 months c. 18 months d. 24 months

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135.

When do children begin to prefer same-sex playmates?

a. 1 year b. 2 years c. 3 years d. 5 years 136.

What is the difference between gender role and gender identity?

a. These are the same thing. b. Gender role is determined by social constructs, while gender identity is determined by biology. c. Gender role is determined by peers, while gender identity is determined by family. d. Gender role is a behavioral concept, while gender identity is a personal determination. 137.

According to some theorists, what is the main goal of those in a masculine

culture? a. Quality of life b. Caring for others c. Individual success d. Collectivism 138.

In which area are men’s rights movements least likely to feel that men are

being discriminated with regard to? a. Reproductive rights b. Jobs and employment c. Domestic violence d. Family law 139.

What is not true of crime and gender roles?

a. There is more domestic violence in heterosexual couples than same-sex couples. b. Women are more involved in prostitution.

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c. Men are more likely to be charged with murder. d. Women and men are equally involved in substance abuse crimes. 140.

What is the major difference between transgender and transsexual?

a. There is no difference between the two. b. Transsexual people do not take hormones, while transgender people do. c. Transsexual people undergo sexual transformation, while transgender people do not necessarily do this. d. This is a political distinction but is not a medical distinction. 141.

What is true of gender dysphoria?

a. It is not a real mental disorder in the DSM-5. b. It defines all people who are transgender. c. It defines people who have distress about their gender assignment. d. It does not refer to people who want to de-transition. 142.

What will most be affected when a trans woman takes hormone therapy?

a. Breast growth b. Hair growth c. Genitalia d. Voice 143.

What is the biological basis for the transgender phenomenon in

individuals? a. There are different hormone levels in transgender and cisgender people. b. There are different hormone receptor levels in the brains of transgender and cisgender people. c. There is a gene that determines if a person is going to be transgender or not. d. There are no clear-cut reasons yet to explain why some people are transgender and others are not. 144.

A person who is attracted to masculinity is generally referred to as being

what?

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a. Celibate b. Androphilia c. Gynephilia d. Sapiosexuality 145.

Which category of sexuality does not necessarily refer to sexual

orientation? a. Asexual b. Gynephilia c. Sapiosexual d. Gay 146.

What influence is believed to be the greatest in the determination of sexual

orientation? a. Biology b. Parental upbringing c. Early childhood experiences d. Culture 147.

Which aspect of sexuality is most based on the psychological concept of

self? a. Biological sex b. Sexual identity c. Gender role d. Sexual behavior 148.

What does the Kinsey scale measure?

a. Degree of homosexuality and heterosexuality b. Relationship between biological sex and gender identity c. Relationship between gender identity and sexual orientation d. Degree of concordance between sexual behavior and sexual orientation 149.

What is the biggest difference between the Klein Sexual Orientation Grid

and the Kinsey Scale?

278

a. They are not very different because both measure sexual orientation. b. The Kinsey Scale focuses exclusively on behavior, which is not the case with the Klein Grid. c. The Klein Grid focuses on past, present, and ideal orientation patterns, which is not the case with the Kinsey Scale. d. The Kinsey Scale does not work for transgender people, while the Klein Grid does work for these people. 150.

According to the Sell scale of Sexual Orientation, what is not one of the

three components of sexual orientation? a. Sexual behaviors b. Sexual attraction c. Sexual identification d. Gender identity 151.

What term is least used to describe a person’s sexual orientation?

a. Heterosexual b. Bisexual c. Asexual d. Homosexual 152.

What is not true of parenting in a same-sex couple?

a. Children are raised in more sexually-tolerant circumstances in same-sex parenting. b. Children of same-sex couples are more likely to be gay themselves. c. Children of same-sex couples are raised in a more gender-neutral environment. d. Children of same-sex couples are equally psychologically healthy as those of opposite-sex couples. 153.

What is not true of LGBT youth in today’s society?

a. There is an increased incidence of depression. b. They have a greater risk of substance abuse.

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c. They are generally accepted by their peers. d. They run away from home more often. 154.

What sexual behavior is most practiced among gay men or men who have

sex with men? a. Oral sex b. Frottage c. Anal sex d. Mutual masturbation 155.

From where do men who participate in receptive anal sex derive an

orgasm? a. From perianal stimulation b. From mutual masturbation c. From prostate stimulation d. They rarely have an orgasm 156.

What STD is least likely to be increased in incidence because of MSM

behavior? a. HIV b. Anal warts c. Syphilis d. Chlamydia 157.

Among lesbian women, what most indicates the desire for sexual activity?

a. Breast or nipple stimulation b. Sexual talk c. Clitoral stimulation d. Vaginal penetration 158.

What hormone would most be considered a bonding hormone released as

part of sexual stimulation in lesbian women? a. Norepinephrine b. Epinephrine 280

c. Oxytocin d. Thyroxine 159.

What term does not fit with any of the other lesbian sexual activities?

a. Frottage b. Tribadism c. Dry humping d. Cunnilingus 160.

What is considered least normal in children aged five to seven years

regarding sexuality? a. Initiating sex with adults b. Bathroom humor c. Increased need for privacy d. Masturbation 161.

What has most led to the sexualization of children and to an increase in

sexual knowledge in today’s children? a. Sexual abuse increases b. Parental neglect c. Media and the internet d. Relaxed social views on sexuality 162.

At what age does masturbation occur first in children?

a. Infancy b. Two to three years of age c. Four to eight years of age d. Nine to thirteen years of age 163.

What most affects the increase in thoughts, fantasies, and increased sexual

behaviors in adolescence? a. Exposure to sexual imagery in the media b. Decreased parental influence c. Hormonal changes with puberty 281

d. Social expectations 164.

What is not true of sexual activity in teens among boys and girls?

a. Boys report more sexual activity than girls b. Boys feel more pressure to have sex than girls c. Boys associate sex with positive social standing d. Boys are more likely to think about the risks of having sex 165.

What is not true of loss of virginity in adolescents?

a. Girls do not feel an attachment to their virginity b. Girls expect some intimacy and attachment with the person they lose their virginity to c. Girls often see their virginity as a gift d. Girls feel less pressure to lose their virginity than boys 166.

What is the most common sexual problem in sexually active adolescent

males? a. Erectile dysfunction b. Premature ejaculation c. Sexual performance anxiety d. Lack of interest in sex 167.

What is the most common sexual problem in sexually active adolescent

females? a. Difficulty attaining an orgasm b. Lack of sexual interest c. Poor vaginal lubrication d. Painful sex 168.

What is not true of same-sex attraction in adolescents?

a. Schools place a high emphasis on heterosexuality. b. There is more flexibility on same-sex attraction in boys than there is in girls. c. Religion can play a role in same-sex attraction and its expression 282

d. Adolescents with gay parents are more likely to be gay themselves. 169.

What is not true of sex education of teens?

a. Sex education by parents is common in the US. b. Most schools offer some degree of sex education. c. Lack of sex education has a positive impact on abstinence. d. Most programs that emphasize abstinence are not effective. 170.

What is not true of sexual desire in older individuals?

a. It drops off dramatically after sixty. b. It can be affected by medications. c. It can reaffirm their physical abilities. d. It can be affected by physical disability. 171.

What do older individuals feel most impacts their sexual functioning?

a. Loss of a spouse b. Medications c. Advancing age d. Mental health issues 172.

What was the effect of the idea that sex was for pleasure on the sexuality of

disabled persons? a. Sex that did not lead to orgasm was not felt to actually be sexual. b. Disabled people became just as free to have sex as non-disabled people. c. More disabled people began to procreate. d. Disabled people developed a better self-image about sex. 173.

What is most true of sexuality and the disabled?

a. People with spinal cord injuries cannot have an orgasm. b. People with mental disabilities tend not to be sexual. c. Assistive devices or sex toys can be used for sex with disabilities. d. Most disabled people prefer not to have sex. 174.

What is not true of people with intellectual disabilities and sexuality?

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a. Historically, many were forced into sterilization. b. They are particularly prone to being victims of incest. c. They often will have sexual feelings. d. There are no programs aimed at protecting these individuals. 175.

What is least likely to be a psychological outcome after being victimized by

sexual aggression? a. Depression b. Obsessive-compulsive tendencies c. Anxiety d. PTSD 176.

When was sexual harassment first written about and understood by larger

groups of people to be a common problem? a. 1950s b. 1960s c. 1970s d. 1980s 177.

What is not true of sexual harassment?

a. The victim often feels increased stress or physical problems after the incident or incidents. b. The victim and perpetrator must be of opposite genders but men or women can be victims. c. The victim and perpetrator both may be unaware of the legalities of the problem. d. Sexual harassment often involves the perpetrator having some authority or social advantage over the victim. 178.

What is the most common type of sexual harasser in harassment

situations? a. The perpetrator who does so in public toward strangers. b. The perpetrator who wants to humiliate the victim.

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c. The perpetrator who is trying to get an ego boost out of dominance over the victim. d. The perpetrator who wants to maintain a position of social or workplace power. 179.

What is not true of the victim of sexual harassment who reports the crime

and becomes the accuser? a. They often feel a greater kinship to others in the workplace afterward. b. They can experience retaliation as a result of reporting the crime. c. They often feel under greater scrutiny after reporting the crime. d. Sometimes, others will also admit their own harassment issues in the same environment. 180.

What would least be considered sexual assault?

a. Groping of the victim b. Vaginal or anal penetration of the victim c. Sexual torture d. Unwanted sexual comments 181.

What is the least common perpetrator of child sexual abuse?

a. Parent b. Other relative c. Family acquaintance d. Stranger 182.

What is the least likely reason why a child will not report sexual abuse?

a. They feel sexually aroused by the abuse. b. They have been threatened or bribed. c. They are too young to verbalize the abuse. d. The feel they are to blame for what happened. 183.

What would constitute sexual assault but not necessarily rape?

a. Anal intercourse b. Fingering of the vagina 285

c. Groping of the genitals d. Vaginal intercourse 184.

What is least likely to be a factor in determining consent on the part of the

victim of rape? a. Sexual arousal on the part of the victim b. Age of the victim c. Use of drugs or alcohol by the victim d. Intellectual capacity of the victim 185.

What is not considered rape in the US under current federal law?

a. Penetration of the mouth by the penis b. Penetration of the anus by an object c. Penetration of the mouth by an object d. Penetration of the vagina by the penis 186.

What is not true of marital rape?

a. It can be a larger part of domestic violence. b. It is illegal in many places but is less commonly prosecuted. c. It is a common form of sexual violence. d. A woman gives consent by marrying her husband. 187.

What can least likely be detected and treated immediately after a rape has

occurred? a. Vulvar injuries b. Human bites c. Anal injuries d. STDs 188.

What sign in children is most associated with having been a victim of

sexual abuse? a. Social withdrawal b. Dissociation c. Sexually acting out 286

d. Regressive behaviors 189.

What is least likely to contribute to psychological symptoms in the child

who has been sexually abused? a. High degree of frequency of abuse b. Perpetrator is a stranger c. Intercourse is attempted or achieved d. Threats of harm were present 190.

What is statistically the most common object of a fetish?

a. Clothing b. Diapers c. Leather d. Fabrics 191.

What is not true of the causation of fetishes?

a. Fetishes may be due to classical conditioning during sexual development. b. Fetishes are more common in males because they involve visual stimuli. c. Fetishes may be caused by sexual trauma in childhood. d. Fetishes may be due to early childhood imprinting on certain objects or body parts. 192.

What is not considered a common paraphilia?

a. Necrophilia b. Pedophilia c. Voyeurism d. Frotteurism 193.

What is the sexual arousal gotten from rubbing one’s body against another

nonconsenting person called? a. Pedophilia b. Transvestitism c. Frotteurism d. Voyeurism 287

194.

What do the drugs for paraphilias actually do?

a. Reduce male libido b. Increase serotonin c. Prolong ejaculatory latency time d. Relax the patient 195.

What is least believed to be a major factor in developing a paraphilia?

a. Certain temperaments found in early childhood. b. Associating an orgasm with an unusual sexual event. c. Elevations in male hormones biologically. d. The development of distorted thinking that promotes offending behavior 196.

What is the usefulness of penile plethysmography in identifying

pedophilia? a. It can help indicate actual arousal when the person denies the fantasies. b. It can help to regulate the arousal through biofeedback. c. It can identify erectile dysfunction in pedophiles. d. It does not help in identifying pedophiles. 197.

What aspect of voyeurism does not necessarily mean the person has a

paraphilic disorder? a. There is a nonconsenting victim involved. b. It involves a loss of normal psychosocial functioning. c. The person has voyeuristic fantasies. d. The person is distressed by their feelings and/or behavior. 198.

When does cross-dressing usually start?

a. Preschool ages b. Older childhood c. Adolescence d. Young adulthood 199.

What comorbidity is least likely to be seen in cross-dressers?

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a. Gender dysphoria b. Substance abuse c. PTSD d. Depression 200. What is least likely to be a factor in identifying all paraphilias as being a true paraphilic disorder? a. Loss of healthy interpersonal functioning b. The presence of a victim c. The finding of high levels of distress d. Frequent fantasies about the behavior

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ANSWERS TO COURSE QUIZ 1. Answer: a. The dartos and cremaster muscles will contract or relax in order to increase or decrease testicular temperature during extremes of the environment around them. 2. Answer: d. The tunica albuginea is the tough outer layer of the testes. It is white in color and internally divides the testis into up to 400 lobules. 3. Answer: b. Cryptorchidism is the failure of the testes to descend in utero, which normally happens during the seventh month of intrauterine life. 4. Answer: c. There are tight junctions between Sertoli cells that provide the blood-testes barrier that can prevent autoantibodies from getting to the germ cells in order to generate an immune response. 5. Answer: d. A sperm stem cell or the least mature of all the sperm cells is called a spermatogonium. It undergoes meiosis to make increasingly mature spermatozoa. 6. Answer: b. Spermiogenesis is what happens to an immature sperm cell in order to change its features to look more like mature sperm. 7. Answer: a. The acrosome is the cap on the front end of the sperm cell that contains enzymes which are responsible for burrowing into the egg cell coating. 8. Answer: a. The glans penis is the most sensitive part of the penis because it contains the most nerve cell endings. 9. Answer: c. The prepuce is also called the foreskin. It is a collar around the end of the penis that retracts during sexual arousal. 10. Answer: b. It is luteinizing hormone that is responsible for the stimulation of the Leydig cells that, in turn, make testosterone. Luteinizing hormone is made by the pituitary gland. 11. Answer: a. The clitoris is the part of the female external genitalia that is analogous to the male glans penis. It has the great number of nerve endings and is highly sensitive to stimulation. 12. Answer: d. The mons pubis is the anterior fat pad in women that covers the pubic bone. After puberty, this is covered with hair. 290

13. Answer: b. Lactobacillus organisms are resident bacteria that lower the pH of the vaginal secretions so as to reduce the incidence of certain infections in the vagina. 14. Answer: a. All stem cells in the ovary start meiosis prior to birth but the cells are arrested during the first stage of meiosis until puberty, when the follicles will continue to mature and develop. 15. Answer: c. Granulosa cells are the supporting cells to the oocytes inside the follicle. 16. Answer: a. The theca cells are found in secondary follicles. They make estrogen that support the ongoing process of folliculogenesis. 17. Answer: d. The tertiary follicle has a central fluid-filled antrum so it is often referred to as an antral follicle. 18. Answer: c. The LH surge or marked increase in luteinizing hormone is what ultimately triggers ovulation in females. 19. Answer: b. The corpus luteum secretes progesterone, which prevents more dominant follicles from developing and is supportive to the beginning stages of pregnancy, should this occur. 20. Answer: a. Fertilization generally happens in the fallopian tube, which gives the growing zygote a chance to grow somewhat before it implants into the uterine lining itself. 21. Answer: d. The stratum functionalis is the innermost part of the uterus. It is shed each menstrual cycle if it is not needed to nourish the growing zygote and embryo. 22. Answer: b. The SRY gene does not make testosterone directly but recruits other genes that ultimately lead to the development of the spermatogonia and the testes in the male fetus. The SRY gene is carried on the Y chromosome. 23. Answer: d. The Wolffian duct is the male reproductive duct. It is stimulated by testosterone. When this happens, the Mullerian or female duct will degrade or degenerate. 24. Answer: c. Each of these plays a role in the determination of menarche in females except for physical height, which does not by itself play a role.

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25. Answer: a. Each of these is a characteristic of either males or females but not both, except for axillary and pubic hair growth, which happens in both males and females. 26. Answer: b. The limbic system is deep within the brain and includes several structures that control one’s emotions and emotional behavior. 27. Answer: c. The inhibitory parts of the brain will limit socially inappropriate urges so that they do not get expressed. If these areas are damaged, people would act out their sexual urges without thought of whether or not they are appropriate. 28. Answer: a. Women actually respond less to visual stimuli compared to men. The other statements are true of sexual differences between men and women. 29. Answer: d. The major medical benefit of doing a male circumcision is that it decreases the incidence of HIV disease in people who live in high-risk areas of the world. 30. Answer: b. Smegma is the whitish substance between the foreskin and the glans penis. It was once considered dirty and it was thought that it contributed to disease so circumcision was recommended by American and British doctors. 31. Answer: c. The peak time of a woman’s libido is the time just before and through ovulation, when she is most likely to conceive a child. 32. Answer: d. In women, the increase in progesterone during the last part of the menstrual cycle will decrease her ability to have an orgasm. 33. Answer: b. After menopause, the estrogen levels will decrease and the testosterone levels will increase. These have the effect of either increasing or decreasing libido after menopause. 34. Answer: a. Each of these drugs will decrease libido except for dopaminergic drugs, which tend to increase libido. 35. Answer: b. It takes women about ten minutes to have an orgasm, while it takes men about four minutes to do the same thing. 36. Answer: c. Exogenous testosterone works quickly and well in men to restore libido but it doesn’t work as quickly nor as well in women.

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37. Answer: d. Auditory stimuli are considered secondary to the other types of erotic stimuli that can cause sexual arousal. 38. Answer: a. Each of these is universally considered to be an erogenous zone in humans, except for the axilla, which may or may or may not be erogenous. 39. Answer: a. Women rate olfactory stimuli the greatest in terms of potentially turning off sexual desire. 40. Answer: d. BDSM has a great deal to do with the attainment of sexual arousal through role playing. 41. Answer: b. Each of these things will happen during sexual arousal in males except that the scrotal temperature will more likely increase due to increased blood flow. 42. Answer: c. The slang term “blue balls” relates to having testicular pain or discomfort from having prolonged sexual arousal without ejaculation. 43. Answer: c. During the refractory period, no orgasms are possible until this period dissipates. 44. Answer: d. Most women cannot attain a purely vaginal orgasm because of a decreased number of nerve endings in this area of the genitals. 45. Answer: a. The presence of pelvic and perianal muscle contractions is the best predictor of the presence of a female orgasm. 46. Answer: a. The first feeling upon the threatened or actual loss of a caregiver is the feeling of anxiety and then sometimes anger. If this does not improve, the child develops grief and despair. 47. Answer: c. The anxious-avoidant child both wants attachment and is anxious about being unattached but wants to avoid being rejected by their caregiver. 48. Answer: c. The dismissive-avoidant attachment style in adults involves a great dependence on personal independence and a denial of the need for intimacy. 49. Answer: a. Each of these is a feature of physical attractiveness seen by both genders as being attractive. A low waist-to-hip ratio is seen as attractive to males with regard to females. 50. Answer: c. Each of these is something a woman is attracted to in a man except for wider hips, which is not considered physically attractive.

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51. Answer: b. The woman is more likely to choose a masculine phase as being attractive if they are in the follicular phase of the menstrual cycle. This is believed to be evolutionarily advantageous. 52. Answer: b. A woman with each of these features is said to be more attractive; however, most of the time, wide-set eyes are considered more attractive. 53. Answer: d. Thinness is more likely to be something women judge about other women rather than men actually preferring thinner women. Most cultures involve men preferring plumper women. 54. Answer: a. In reality, short women are seen as attractive, while taller men are seen as attractive. The other statements are true. 55. Answer: b. The three components of love in the triangular theory of love are passion, intimacy, and commitment—each of which is necessary for complete love. 56. Answer: a. Agape is pure love or complete love. This is different from eros or romantic love, storge, which is parental love, and philia, which is love for one’s community. 57. Answer: c. Sternberg theory on love is the most commonly accepted theory on love today. It is based on three components: commitment, passion, and intimacy. 58. Answer: a. Emotional intimacy is involved most with love and with actually falling in love with another person, although each of these is an aspect of intimacy. 59. Answer: d. Swinging involves different couples who engage in casual or recreational sex with other people as a form of sexual activity. 60. Answer: c. An open relationship or open marriage involves a couple who engages in sexual activity apart from themselves as part of a relationship choice. 61. Answer: c. Edging involves starting and then stopping masturbation just before an orgasm is reached in order to attain an even stronger climax at some point in the process.

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62. Answer: a. The male G-spot is considered to be the prostate gland. It is stimulated by inserting a finger inside the rectum and massaging the prostate gland. 63. Answer: d. The glans penis has the greatest number of nerve endings and will most likely lead to male orgasm when stimulated in masturbation. 64. Answer: c. Masturbation was considered a psychiatric problem until 1868, when it was taken out of the Diagnostic and Statistical Manual of Psychiatric Disorders. 65. Answer: d. Each of these is a category of people who are difficult to study with regard to sexual fantasies; however, research is best able to judge arousal in heterosexual men who fantasize. 66. Answer: b. Sexual fantasies can be very powerful and can affect a person’s real-life sexual behavior. They can be simple or very dangerous and can lead to role playing. 67. Answer: d. Fellatio is the practice of stimulating the male penis with the mouth. It can be practiced by people of either sexual orientation. 68. Answer: b. Cunnilingus is the sexual practice of sexually stimulating the female genitalia with the mouth, which can be practiced by people of any sexual orientation. 69. Answer: c. Both the condom and the dental dam can be used to reduce the incidence of STDs when doing oral sex. 70. Answer: b. In non-human animals, pheromones can be used to determine if a female is in estrus but the role in humans is blunted and probably does not play a major role in intercourse. 71. Answer: c. Vaginal intercourse is the most common sexual activity in all humans—both men and women. It is the most studied sexual behavior as well. 72. Answer: c. The average age at starting sexual intercourse in the US is 17 years, which is true of both boys and girls. 73. Answer: b. Each of these can be a reason for male-female couples to have anal intercourse except that it does not prevent STDs.

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74. Answer: c. Receptive anal intercourse is most associated with passing on HIV disease among any other sexual activity. 75. Answer: a. Female to male anal intercourse with a strap-on dildo is what is referred to as pegging colloquially. 76. Answer: b. Of these, serotonin is considered inhibitory to the desire for sex, while the other hormones and neurotransmitters will be excitatory to the desire for sex. 77. Answer: c. Each of these is a criterion for hypoactive sexual desire disorder except the person does not need to have a documented low testosterone level, although this could be a factor in some people with HSDD. 78. Answer: a. The female equivalent of sexual dysfunction is sexual arousal disorder. It involves a lack of interest in sexual activity when the person is in a situation that should induce sexual arousal. 79. Answer: b. Anorgasmia is most likely to affect women after menopause and is least likely to affect young men. In fact, it is rare in young men. 80.Answer: a. Each of these drugs can contribute to anorgasmia, except for hormonal birth control, which is least likely to be causative of anorgasmia. 81. Answer: d. If you’ll remember, testosterone levels increase after menopause but a decrease in estrogen can cause anorgasmia. Less commonly is the problem psychological or related to one’s belief system. 82. Answer: b. The most common factor related to vaginismus is the presence of prior sexual trauma that leads to involuntary muscle contractions of the pelvic musculature that prevent penetration of the vagina. 83. Answer: c. Each of these can be causative of secondary vaginismus, except for diabetes, which can cause other sexual problems but not vaginismus. 84. Answer: d. Vaginismus is difficult to treat medically but each of these drugs except for testosterone has been used and sometimes will be effective. 85. Answer: b. The presence of an erection during sleep will be assessed by doing a nocturnal penile tumescence test. 86. Answer: c. A penile ultrasound is done on the erect penis in order to assess the patient for atherosclerotic causes of erectile dysfunction.

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87. Answer: d. Alprostadil is a form of prostaglandin that can be used locally but not orally to induce an erection within minutes of administration. 88. Answer: b. Cycling for prolonged periods of time can damage the pelvic nerves, which can lead to a host of male sexual dysfunctions, including delayed ejaculation. 89. Answer: d. There are no drugs for delayed ejaculation. SSRIs can cause the problem and even sildenafil can prolong the latency time. 90. Answer: d. Syphilis is curable with antibiotics, while the others are viral diseases that can be managed with medications but are not considered to be curable. 91. Answer: c. Any type of penetrative sex is likely to cause an STI; however, anal sex is slightly more likely to pass on an STI compared to vaginal penetrative sex. 92. Answer: b. Each of these can be a complication of a chlamydia infection except for birth defects, which do not occur because of these types of infections. 93. Answer: c. About 80 percent of infected women with chlamydia do not have any symptoms of the disease. 94. Answer: a. Each of these is part of an infection called pelvic inflammatory disease except for the vulva, which is not generally a part of this disorder. 95. Answer: a. A major complication of gonorrhea in men is epididymitis. In women, PID or pelvic inflammatory disease can be causative. Other findings can include arthritis, endocarditis, and meningitis. 96. Answer: c. Because of the high risk of coinfection with other organisms, these should be tested for but the highest risk of coinfection occurs with chlamydia. 97. Answer: d. It is possible to pass the infection from one person to another without the presence of actual sores due to skin shedding of the virus. 98. Answer: b. The most common STI in the United States is human papillomavirus. It is not the most reported disease, however, because it is not a reportable disease by the CDC.

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99. Answer: a. Anyone who engages in multiple episodes of unprotected sex with infected partners is at risk for passing on or contracting the disease. Almost all sex workers get herpes at some point in their lives. 100.

Answer: b. Most children are born with hepatitis B from vertical

transmission. These children can be prevented from getting this at birth by giving immune globulin and by starting hepatitis B vaccinations. 101.

Answer: a. The patient with primary syphilis will have a painless chancre

of the genitals or lips. 102.

Answer: c. Each of these can be transmitted through vertical transmission

except for trichomonas. 103.

Answer: d. Tertiary syphilis involves having nerve or neurological

symptoms, which is sometimes referred to as neurosyphilis 104.

Answer: b. Most of the transmission of syphilis involve men having sex

with men. 105.

Answer: a. HIV can be transmitted through contact with all of these fluids

but saliva itself cannot transmit the disease. 106.

Answer: d. Trichomonas can cause each of these symptoms but it does not

generally lead to shallow ulcers of the genitals. 107.

Answer: b. The eggs of the pubic louse exist on coarse hairs. It does not

like to be attached to scalp hair. 108.

Answer: b. Pubic lice do not easily survive outside of the human host and

die within 2 days when not able to receive a blood meal. 109.

Answer: d. Each of these is true of HPV infections but the viruses that

cause common warts do not cause genital warts. 110.

Answer: b. Each of these is true of the HPV vaccine except that it is not

effective in helping those who are already infected with the virus. 111.

Answer: a. Each of these birth control methods has a high theoretical

success rate but a low practical success rate, except for the IUD, which has a high theoretical and practical success rate. 112.

Answer: d. The mini-pill is a progestin-only pill that does not contain

estrogen. Pills and other methods that contain estrogen increase the risk of blood clots. 298

113.

Answer: b. Each of these is a way that hormonal birth control decreases

the risk of pregnancy, except that they do not kill sperm cells. 114.

Answer: c. High-dose estrogen in a birth control device or pill can cause

each of these things but no hormonal birth control method containing estrogen will increase the cervical cancer risk. 115.

Answer: d. The male condom is the most commonly used technique used

throughout the world as birth control. 116.

Answer: d. These forms of birth control done on an emergency basis can

be used within 120 hours after unprotected sex and will decrease the risk of pregnancy. 117.

Answer: c. The corona radiata is a layer of follicular cells outside the egg

cell that must be gotten through in order to mix the sperm and egg cell. 118.

Answer: b. The zona pellucida is made from extracellular matrix material,

namely glycoproteins, that must be gotten through in order to fertilize the egg. 119.

Answer: c. Each of these can be phenomena seen in sexual responsiveness

in pregnant women, except that there is a prolonged resolution phase rather than a shorter resolution phase. This is because of prolonged vulvar congestion. 120.

Answer: b. Most women have sufficiently healed enough to resume sexual

activity at six weeks following the delivery. 121.

Answer: a. Each of these can play a role in decreasing sexual satisfaction in

the first trimester except for decreased breast sensitivity, which does not play a role. 122.

Answer: c. Mood changes play the biggest role in affecting a woman’s level

of sexual functioning after she has a baby. The other factors do not play a role. 123.

Answer: b. At twelve weeks’ gestation, the uterus can first be felt above the

level of the pubic symphysis or pubic bone. 124.

Answer: d. A full-term pregnancy is 40 weeks in total length, from the time

of the first day of the last menstrual period to the delivery of the infant. 125.

Answer: a. Folate is necessary for the prevention of spina bifida in the

developing fetus. It is often recommended before getting pregnant, is found in prenatal vitamins, and is found fortified in many different foods. 299

126.

Answer: b. In the second stage of labor, the infant is expelled from the

uterus through the vagina. This stage can be very short in a multiparous patient or can be up to 2 or more hours in the primiparous patient. 127.

Answer: b. Most pregnancies that end in miscarriage will terminate

because of a major chromosomal abnormality in the fetus. 128.

Answer: a. Medical abortions involve using medications to kill the embryo

or fetus as well as to allow the uterus to contract and expel the products of conception. 129.

Answer: a. The XY person who does not have an active SRY gene will be

born and will develop into a phenotypical female. 130.

Answer: b. The person with Turner syndrome will be phenotypically a girl

at birth and will not mature sexually so she will be phenotypically a girl at the time of adult maturity. 131.

Answer: c. The patient with Klinefelter syndrome has phenotypically male

genitalia but will have decreased body hair and testicles that are not as developed as a normal male. They will still seem like an adult male with subtle differences noticeable on a physical examination. 132.

Answer: b. A major feature seen in men more than women is increased

visuospatial skills. 133.

Answer: a. Children form gender stereotypes by about 10 months of age,

when they can somewhat primitively associate certain tools with specific genders. 134.

Answer: c. Children apparently know the gender they belong to by the age

of 18 months and seek information about what it all means at and after this time. 135.

Answer: c. By the age of three years, children begin to prefer same-sex

playmates. 136.

Answer: d. Gender role is behavioral and is determined by multiple

factors, while gender identity is how you see yourself personally in terms of gender.

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137.

Answer: c. Masculine cultures are focused on individualism and success,

where feminine cultures favor quality of life, caring for others, and collectivism. 138.

Answer: b. Men in the men’s rights movement believe they are

discriminated against with regard to each of these areas except for jobs and employment. 139.

Answer: a. Each of these is true of crime and gender roles, except that

intimate partner violence is the same in same-sex couples compared to heterosexual couples. 140.

Answer: c. Transsexual people undergo sexual transformation, while

transgender people do not necessarily do this as part of their gender identity. 141.

Answer: c. Not all transgender people have gender dysphoria, which is a

DSM-5 classification. It can refer to people who want to undo their transition. Gender dysphoria simply refers to the distress associated with one’s gender assignment. 142.

Answer: a. When a trans woman takes hormone therapy, breast growth

will occur but surgery and things like laser hair removal and voice lessons are necessary to change these things. 143.

Answer: d. While there are many theories, including genetic

predisposition, no one knows exactly why one person will be transgender and another person will not be transgender. 144.

Answer: b. Androphilia is a person who is attracted to masculinity. It is a

term that avoids confusion as to whether a person is straight or gay, particularly if they are transgender. 145.

Answer: c. A sapiosexual person is attracted to the intelligence of another

person. It is not strictly a sexual orientation because it does not refer to sex. 146.

Answer: a. Biology is believed to play the largest role in determining

sexuality. Parental upbringing and early childhood experiences are not believed to play a role. 147.

Answer: b. Sexual identity refers to the psychological feelings a person has

around their sex. It is also referred to as gender identity.

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148.

Answer: a. The Kinsey scale measures the degree to which a person is

either heterosexual or homosexual, implying that individuals exist on a continuum between the two. 149.

Answer: c. The Klein Sexual Orientation Grid focuses on past, present, and

ideal orientation patterns, which is not the case with the Kinsey Scale, which does not discriminate well between behavior and psychological attraction. 150.

Answer: d. Each of these plays a role in sexual orientation; however, one’s

gender identity does not generally play a role in orientation. 151.

Answer: c. While the other three groups are determined to be forms of

sexual orientation, the term “asexual” is not always considered one of these main categories of sexual orientation. 152.

Answer: b. Each of these is true of children raised in a same-sex couple

environment except that they do not have an increased risk of being gay themselves. 153.

Answer: c. LGBT youth have an increased risk of each of these things and

also face more bullying and lack of support by peers. 154.

Answer: a. The most-practiced behavior in this population is oral sex,

followed by mutual masturbation and then anal sex. 155.

Answer: c. Men who are receptive partners in MSM and anal sex often

achieve an orgasm through stimulation of the prostate gland. 156.

Answer: d. Each of these is increased in those who practice MSM behavior,

except for chlamydia, which is not increased in this population. 157.

Answer: a. Breast or nipple stimulation among lesbian women is

commonly part of foreplay or an indication of a desire for sexual activity. 158.

Answer: c. Oxytocin is released with sexual stimulation of the breasts and

nipples. It decreases anxiety and promotes bonding in a lesbian couple. 159.

Answer: d. Each of these terms, frottage, tribadism, and dry humping

mean the same thing, while cunnilingus is a different sexual activity altogether. 160.

Answer: a. Each of these is a normal behavior in children except for

initiating sex with adults, which involves an increase in sexualization and possible history of abuse. 302

161.

Answer: c. Exposure to explicit sex and sexual information in the media

and on the internet have increased the sexualization of children and an increase in sexual knowledge in these children. 162.

Answer: a. Masturbation occurs first in infancy and involves rubbing one’s

genitals or other hand to genital contact. 163.

Answer: c. Much of the increase in sexual thinking and behaviors in

adolescence is caused by a large influx of sex hormones in the adolescent body. 164.

Answer: d. Each of these is true of the differences in sexual activity in boys

and girls, except that boys are less likely to think about the risks of having sex than girls, who are more conflicted about having sex. 165.

Answer: a. Each of these is true of issues regarding loss of virginity in

adolescents except for the fact that girls often feel an attachment to their virginity. 166.

Answer: c. About 80 percent of adolescent males have sexual performance

anxiety as their most common sexual problem. 167.

Answer: a. The most common sexual problem in sexually active adolescent

females is difficulty attaining an orgasm, although there can be a variety of other sexual difficulties. 168.

Answer: b. There is, in fact, less flexibility when it comes to peer

expectations of same-sex attraction in boys than there is in girls, which limits its expression in this population. 169.

Answer: c. Each of these is true of sex education except that lack of sex ed

has a negative impact on teen health and levels of abstinence. 170.

Answer: a. Each of these is true of sexual desire in older individuals except

that it does not drop off dramatically after sixty but persists until older age. 171.

Answer: c. Most older adults simply feel that advancing age most affects

their level of sexual functioning. Others will blame some of the other issues mentioned. 172.

Answer: a. The downside of sex for pleasure was that sex that did not lead

to orgasm was felt to be un-sexual and not worth it.

303

173.

Answer: c. Each of these is an untrue statement except that people with

disabilities can use assistive devices or sex toys to enhance their sexual experience. 174.

Answer: d. The high rate of sexual abuse and incest is known in the

population so there are some states that have programs for the identification and prevention of this type of victimization. 175.

Answer: b. Many victims of sexual violence experience depression, PTSD,

and anxiety after being victimized by sexual aggression. These can be longlasting phenomena if help is not given to them after the event or events. 176.

Answer: c. The term “sexual harassment” was first written about in the

1970s. There were several legal precedents set around this phenomenon, which lead to the first laws being created against it in the early 1980s. 177.

Answer: b. There is no restriction as to the genders of either the victim or

perpetrator of sexual harassment. 178.

Answer: c. These can all be types of sexual harassment perpetrators but

the perpetrator who gets an ego boost by exerting dominance over the victim is the most common type. 179.

Answer: a. it is more likely that the victim turned accuser will experience

isolation and hostility by other coworkers, including people of their same gender, even though others will come forward to admit their own harassment issues. 180.

Answer: d. While the definition of sexual assault is a broad one, it usually

involves some type of actual physical contact with the victim, which puts sexual harassment in a different category of sexual aggression. 181.

Answer: d. Most perpetrators are unrelated but known to the victim, while

30 percent are related to the victim. Stranger perpetrators make up just 10 percent of perpetrators. 182.

Answer: a. Each of these is a reason why a child will not come forward to

speak of their abuse but being aroused or “liking the activity” is generally not one of them.

304

183.

Answer: c. Rape and sexual assault are sometimes terms used

interchangeably but sexual assault can involve non-penetrative sexual activities and rape usually means penetration of some sort. 184.

Answer: a. Each of these is a factor in determining consent of the victim.

While a sexually aroused victim may or may not be consenting to the act, this is not usually a factor in determining the actual fact of consent legallyspeaking. 185.

Answer: c. Under the current federal statutes, rape of the mouth must be

by a genital organ and not necessarily another object. The others represent what rape means. 186.

Answer: d. Each of these is true of marital rape except that a woman does

not automatically give consent to intercourse by marrying her husband. 187.

Answer: d. Each of these can be detected and treated in the immediate

aftermath of a rape, except for STDs, which take a minimum of 72 hours to be able to detect. Sometimes, however, prophylactic treatment can be given for STDs. 188.

Answer: c. Each of these is associated with the child who has been sexually

abused, although sexually acting out is most associated with this type of experience. 189.

Answer: b. Each of these contributes to an increase in the risk of

psychological harm to the child victim except there is increased risk if the perpetrator is known to the victim. 190.

Answer: a. Just about anything can be the object of a fetish, although the

most common fetish is that to clothing. The type of clothing is greatly dependent on the person. 191.

Answer: c. Each of this is a possible relationship between sexual fetishes

and their origin, except that it is not associated with sexual trauma in childhood. 192.

Answer; a. Each of these is a common paraphilia except for necrophilia or

an attraction to having sex with a dead body, which is quite rare.

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193.

Answer: c. Frotteurism is the intentional rubbing of one’s body parts

against those of another nonconsenting adult. This is a relatively common paraphilia. 194.

Answer; a. These drugs are anti-androgens that decrease male libido and

reduce the incidence and intensity of fantasies. 195.

Answer: c. Each of these plays a role in developing a paraphilia but there is

no evidence that increase male hormones actually play any type of role. 196.

Answer: a. Penile plethysmography can detect sexual arousal even when

the person personally denies that such arousal exists. 197.

Answer: c. Each of these describes a feature of voyeurism as a paraphilic

disorder but simply having the fantasies or tendencies is not enough to cause a disorder. 198.

Answer: a. Cross-dressing or transvestism usually starts in late childhood.

It may be a fetish and may not be; it is almost exclusively seen in males. 199.

Answer: c. Each of these is a phenomenon that can be seen in cross-

dressers but the comorbidity of PTSD is not typically seen. 200. Answer: d. Each of these is a major factor in deciding if a paraphilia is a true disorder. The presence of frequent fantasies is not enough to qualify as being part of a paraphilic disorder.

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College Level Human Sexuality

Articles inside

Answers to Course Quiz

Course Questions and Answers

Chapter Thirteen

Chapter Twelve

Chapter Eleven

Chapter Ten

Chapter Nine

Chapter Eight

Chapter Seven

Chapter Six

Chapter Five

Chapter Four

Chapter Three

Summary

Prostitution

Key Takeaways

Chapter Two

Quiz

Quiz

Key Takeaways

Some Specific Paraphilias

What is a Paraphilia

Quiz

Childhood Sexual Abuse

Key Takeaways

Rape

Sexual Assault

Sexual Harassment

Quiz

Aging and Sexuality

Sexuality in Adolescents

Key Takeaways

Quiz

Key Takeaways

Same-Sex Sexual Behaviors

Types of Orientation

Quiz

Transgender Issues

Gender Concepts in Children

Gender Roles and Stereotypes

Key Takeaways

Development of Gender Identity

Quiz

Key Takeaways

Abortion

Pregnancy

The Process of Conception

Sexuality in Pregnancy

Quiz

Human Papillomavirus Infection

The Birth Process

Pubic Lice

Trichomoniasis

HIV Disease

Genital Herpes

Syphilis

Hepatitis B

Quiz

Gonorrhea

Chlamydia

Key Takeaways

Delayed Ejaculation

Premature Ejaculation

Erectile Dysfunction

Vaginismus

Key Takeaways

Anorgasmia

Sexual Arousal Disorder

Anal Sex

Quiz

Key Takeaways

Intimate Relationships

Non-Monogamous Intimacy

Theories on Love

Attachment in Relationships

Female Attractiveness

The Biology of Attachment

Attachment Styles in Adults