Human Sexuality &

Sexual Dysfunction
Normal Sexuality
Sexuality
determined by:
• Anatomy
• Physiology,
• culture in which a person lives,
• relationships with others,
• developmental experiences throughout the
life cycle
Includes:
• perception of being male or female
• private thoughts
• fantasies
• behavior
History

 Classical Era Victorian

• Hippocrates • H. Ellis & R. von Krafft-
- Clitoris – Female Ebing
sexual arousal • Diverging perspectives
Middle Ages on sexual behavior
• Islamic Physicians • Sigmund Freud
• coitus interruptus - • Theories on libido,
Birth control childhood sexuality, and
the effects of the sexual
 End of Renaissance & impulse on human
Beginning of Reformation behavior
• Linen sheath as condom
• Protection against
Syphilis
History

 Modern Era
• Contraceptive drugs
• Drugs that aid in
erection
• Hormonal replacement
in menopause
Normal Sexual Behavior
• Pleasure to oneself & one's partner
• involves stimulation of the primary sex organs
including coitus
• it is devoid of inappropriate feelings of guilt or
anxiety & is not compulsive
Psychosexual
• Personality development & functioning
• Applies to more than sexual feelings and behavior
• It is not synonymous with libido
Childhood Sexuality
• The universality of sexual activity and sexual
learning in children was unrecognized
• Most sexual learning experiences in childhood
occur without the parents' knowledge, but
awareness of a child's sex does influence
parental behavior .
• Genital play in infants is part of normal
development.
Freud’s Stages of Psychosexual Development
• Oral – 0- 1 year old
• Anal – 1-3 years old
• Phallic – 3-5 years
old
• Latent – 6 years old
to puberty
• Genital – puberty to
adult
Psychosexual Factors
Sexuality depends on 4 interrelated psychosexual
factors:

1. Sexual identity
2. Gender identity
3. Sexual orientation
4. Sexual behavior

note: These factors affects personality, growth,

development & functioning
Sexual Identity
- Pattern of a person’s
biological sexual
characteristics:
• Chromosomes
• XY – genetically male
• XX- genetically
female
• external genitalia
• internal genitalia
• hormonal composition
• Gonads
• secondary sex
characteristics
Sexual Identity
 Differentiation of Male from Female
• Fetal Androgen
• Begins at 6th week of embryonic life
• Completed at end of 3rd month
Key genes in fetal sexual development:
• SRY & SOX9 – testis
• DAX1
• WNT4 – mullerian ducts in female fetus
Sexual Identity: Classification of Intersexual
Disorders
GENDER IDENTITY: “I am Male , I am Female”
• person's sense of maleness or femaleness.
• Developed by age 2 - 3
• Connotes psychological aspects of behavior
related to masculinity and femininity . –
Robert Stoller
• Gender social & sex biological “ Male, manly
& Female, womanly”
Formation of gender identity arises from:

• parental and cultural attitudes

• the infant's external genitalia
• genetic influence
• Active at 6 weeks of life

note: Although family, cultural, and biological

influences may complicate establishment of a
sense of masculinity or femininity, persons
usually develop a relatively secure sense of
identification with their biological sex-a stable
gender identity
Gender Role
• Based on the external behavioral pattern that
reflect the person’s inner sense of gender
Identity
• John Money and Anke Ehrhardt :
• gender role behavior as all those things that a
person says or does to disclose himself or
herself as having the status of boy or man,
girl or woman, respectively
Gender Role
• Not established at birth but is built up
cumulatively through:
1.experiences encountered and transacted
through casual and unplanned learning
2.explicit instruction and inculcation
3.spontaneously putting two and two together to
make sometimes four and sometimes five
Notes:
-The usual outcome is a congruence of gender
identity and gender role
- Although biological attributes are significant, the
major factor in achieving the role appropriate to a
person's sex is learning.
Sexual Orientation
• the object of a person's sexual impulses:

• Heterosexual (opposite sex)

• Homosexual (same sex)
• Bisexual (both sexes)
• Asexual (no sex)
Sexual Behavior
The Central Nervous System and Sexual Behavior
 The Brain • Limbic System
• directly involved with
• Cortex.
elements of sexual
• controlling sexual impulses functioning
• processing sexual stimuli that
• Brainstem
may lead to sexual activity
• exert inhibitory and
• Orbitofrontal cortex
excitatory control over
• emotions spinal sexual reflexes
• Left anterior cingulate cortex • The nucleus
• Hormone control paragigantocellularis
• Sexual arousal proj ects directly to
• Right caudate nucleus pelvic efferent neurons
• Activity is a factor in in the lumbosacral
whether sexual activity spinal cord
follows arousal • Secretes serotonin –
inhibit ogasams
• Brain • Spinal Cord
Neurotransmitters • Sexual arousal and
• Dopamine climax are ultimately
• Increase libido organized at the
• Epinephrine spinal level
• Norepinephrine
• Serotonin • Sensory stimuli
related to sexual
• Inhibitory effects function are
in sexual function conveyed via
• Oxytocin afferents from the
• Release with pudendal, pelvic, and
orgasm hypogastric nerves
• Reinforce
pleasurable
activities
Physiological Responses • Masters and Johnson
• Sexual response • physiological process
involves:
• a true psychophysiological
experience • Vasocongestion and
myotonia (tumescence)
• Arousal • The subsequent release
• triggered by both of the vascular activity &
psychological and physical muscle tone as a result
stimuli of orgasm
• levels of tension are (detumescence)
experienced both
physiologically and
emotionally
• with orgasm, normally a
subjective perception of a
peak of physical reaction and
release occurs along with a
feeling of well-being
Hormones and Sexual Behavior
• Testosterone
• Increase libido in both men & women
• Estrogen
• Key factor in lubrication, increase sensitivity to
stimulation
• Progesterone
• Mildly depresses desire in men & women
• Oxytocin
• Pleasurable sensations during sex
• Found in higher level in men and women
following orgasms
Gender Differences in Desire and Erotic Stimuli
• males generally • women they may
possess a higher include a wish to
baseline level of reinforce the pair
desire than do bond, the need for a
women feeling of closeness, a
• Motivations for way of preventing the
having sex, other than man from straying, or
desire, exist in both a desire to please the
men and women, but partner
seem to be more
varied and prevalent
in women
 Sexual Fantasies
- Common in both men and women but external
stimuli differs in both men and women
• Men • woman's subjective sense of
arousal is not always
• Many men respond sexually congruent with her
to visual stimuli of nude or physiological state of
barely dressed women arousal
• sense of excitement may
• Women reflect a readiness to be
aroused rather than
• responding sexually to physiological lubrication
romantic stories such as a • may experience signs of
demonstrative hero whose arousal, including vaginal
lubrication, without being
passion for the heroine aware of them. This situation
impels him toward a lifetime rarely occurs in men.
commitment to her
MASTURBATION
• usually a normal precursor of object-related sexual
behavior.
• No other form of sexual activity has been more
frequently discussed, more roundly condemned,
and more universally practiced than masturbation.
• According to research by Kinsey, prevalence of
masturbation indicated that nearly all men and
three fourths of all women masturbate sometime
during their lives.
MASTURBATION
• Longitudinal studies of development showed that
sexual self-stimulation is common in infancy and
childhood. Just as infant learn to explore the functions
of their fingers and mouths, they learn to do the same
with their genitalia.
• 15 to 19 months of age, both sexes begin genital self-
stimulation
• Pleasurable sensation results from any gentle touch to
the genital region. Those sensations, coupled with the
ordinary desire for exploration of the body, produce a
normal interest in masturbatory pleasure at that time.
MASTURBATION
• Children also develop increased interest in the genitalia
of others – parents, children, and even animals.
• As youngster acquires playmates, the curiosity about
their own and other’s genitalia motivates episodes of
exhibitionism or genital exploration. Such experiences,
unless blocked by guilty fear, contribute to continued
pleasure from sexual stimulation.
• At puberty, upsurge of sex hormones and the
development of secondary sex characteristics, sexual
curiosity intensifies and masturbation increases.
MASTURBATION
• Adolescents are physically capable of coitus and
orgasm but are usually inhibited by social
restraints.
• The dual and often conflicting pressure of
establishing their sexual identities and controlling
their sexual impulses produce a strong
physiological sexual tension in teenagers that
demands release, and masturbation is a normal
way to reduce sexual tension.
• Male learns to masturbate to orgasm earlier that
than female and masturbate more frequently
MASTURBATION
• An important emotional difference between
adolescent and youngster of earlier years is the
presence of coital fantasies during masturbation in
the adolescent.
• These fantasies are an important adjunct to the
development of sexual identity; in the comparative
safety of the imagination, adolescents learn to
perform the adult sex role.
MASTURBATION
• This autoerotic activity is usually maintained into
the young adult years, when it is normally replaced
by coitus. Couples in a sexual relationship do not
abandon masturbation entirely because when
coitus is unsatisfactory or is unavailable due to
illness or the absence of the partner, self-
stimulation serves as an adaptive purpose,
combining sensual pleasure and tension release.
MASTURBATION
• According to Kinsey, when women masturbate,
most prefer clitoral stimulation
• Masters and Johnson stated that women prefer the
shaft of the clitoris to the glans because the glans is
hypersensitive to intense stimulation. Most men
masturbate by vigorously stroking the penile shaft
and glans.
MASTURBATION
• Several studies found that in men, orgasm from
masturbation raised serum PSA significantly thus
male patients scheduled for PSA test should be
advised not to masturbate or have coitus for atleast
7 days prior to the examination.
• Moral taboos against masturbation have generated
myths that masturbation causes mental illness or
decreased sexual potency.
• Masturbation is a psychopathological symptom
only when it becomes a compulsion beyond a
person’s willful control.
MASTURBATION
• Then it is a symptom of emotional disturbance, not
because it is sexual but because it is compulsive.
• Masturbation is probably a universal aspect of
psychosexual development and in most cases, it is
adaptive.
COITUS
• First coitus is a rite of passage for both men and
women.
• The young man experiencing intercourse for the
first time is vulnerable in his pride and self-esteem
• Cultural myths still perpetuate the idea that he
should be able to have an erection with no, or little,
stimulation, and that he should have an easy
mastery over the situation, even though it is an act
that he has never before experienced.
COITUS
• Cultural pressure on the woman with her first coitus
reflects remaining cultural ambivalence about her loss
of virginity, despite the current era of sexual liberality.
• Young women with history of masturbation are more
likely to approach intercourse with positive
anticipation and confidence.
• Coitus has been part of the sexual repertoire of elderly
adults, due to the development of sildenafil type drugs
which facilitate erection in men, and hormonally
enhanced creams and hormonal pills, which counteract
vaginal atrophy in postmenopausal women
• Prior to development of these drugs, many elderly
adults enjoyed gratifying sex play, exclusive of coitus.
HOMOSEXUALITY
• 1973 – homosexuality was eliminated as a diagnostic
category by the American Psychiatric Association
• 1980 – it was removed from the Diagnostic and
Statistical Manual of Mental Disorder
• According to the 10th revision of the International
Statistical Classification of Diseases and Related Health
Problems, sexual orientation alone is not to be
regarded as a disorder
• Now considered to occur with some regularity as a
variant of human sexuality, not as a pathologic disorder.
HOMOSEXUALITY
• As David Hawkin’s wrote, the presence of
homosexuality does not appear to be a matter of
choice; the expression of it is a matter of choice
• Often describes a person’s overt behavior, sexual
orientation, and sense of personal or social identity
• Many person prefer to identify sexual orientation
by using terms like lesbian and gay men which may
imply pathology and etiology based on its origin as
a medical term
• Refer to sexual behavior with terms same sex and
male-female
HOMOSEXUALITY
• According to Hawkin’s, terms gay and lesbian refer
to a combination of self perceived identity and
social identity
• They reflect a person’s sense of belonging to a
social group that is similarly labeled
• Homophobia – negative attitude toward, or fear of,
homosexuality or homosexuals
• Heterosexism – a belief that a heterosexual
relationship is preferable to all other. It implies
discrimination against those practicing other forms
of sexuality
HOMOSEXUALITY
A. prevalence
• Some lesbian and gay men, particularly the latter,
report being aware of same sex romantic
attractions before puberty.
• According to Kinsey’s data, about half of all
prepubertal boys have had some genital experience
with a male partner.
• Most gay men recall the onset of romantic and
erotic attractions to same sex partners during early
adolescence
HOMOSEXUALITY
• For women, the onset of romantic feeling towards
same sex partners may also be in preadolescence
but the clear recognition of same sex partner
preference typically occurs in the middle to late
adolescence or in young adults
• More lesbians than gay men appear to have
engaged in heterosexual experiences
HOMOSEXUALITY
B. Theoretical issues
1. Psychological factors
- Freud: an arrest of psychosexual development and mentioned
castration fears and fears of maternal engulfment in the
preoedipal phase od psychesexual development
- Psychodynamic theory: earl life situations that can result in
male homosexual behavior including:
- Strong fixation on the mother
- Lack of effective fathering
- Inhibition of masculine development by the parents
- Fixation at, or regression to, the narcissistic stage of development
- Losses when competing with brothers and sisters
HOMOSEXUALITY
‐ Freud’s view on the causes of female homosexuality
‐ Lack of resolution of penis envy in association with unresolved
oedipal conflicts
‐ Freud did not consider homosexuality a mental illness.
He wrote that “It is found in persons who exhibit no
other serious deviations from the normal whose
efficiency is unimpaired and who are indeed
distinguished by especially high intellectual
development and ethical culture.”
‐ He also wrote that “Homosexuality is assuredly no
advantage, but it is nothing to be ashamed of, no vice,
no degradation, it cannot be classified as an illness; we
consider it to be a variation of the sexual function
produced by a certain arrest of sexual development.”
HOMOSEXUALITY
• 2. New concepts of Psychoanalytic Factors
- Richard Isay: gay men have described same sex fantasies
that occurred when they were 3 to 5 years of age, at
about the same age that heterosexuals have male-
female fantasies.
- Isay wrote that same sex erotic fantasies in gay men
center on the father or the father surrogate
- Child’s perception of, and exposure to, these erotic
feelings may account for such “atypical” behavior as
greater secretiveness than other boys, self-isolation, and
excessive emotionality
- Some feminine traits may also be caused by
identification with the mother or a mother surrogate.
 - such characteristics usually develop as a way
of attracting the father’s love and attention in a
manner similar to the way the heterosexual boy may
pattern himself after his father to gain his mother’s
attention
- the little girl does not give up her original
fixation on the mother as a love object and continues
to seek it in adulthood.
HOMOSEXUALITY
• 3. Biological Factors
- Gay men reportedly exhibit lower levels of circulatory
androgens than heterosexual men
- Prenatal hormones appear to play a role in the organization
of the CNS
- Effective presence of androgen in prenatal life is purported to
contribute to a sexual orientation towards female, and a
deficiency of prenatal androgens may lead to sexual
orientation toward males.
- Preadolescent girls exposed to large amount of androgens
before birth are uncharacteristically aggressive
- Boys exposed to excessive female hormones in utero are less
athletic, less assertive and less aggressive than other boys
HOMOSEXUALITY
• women with hyperadrenocorticalism are lesbian and
bisexual in greater proportion than women in the
general population

• 4. Sexual Behaviour Patterns

• gay men and lesbian engage in same sexual practices as
heterosexual, with the obvious differences imposed by
anatomy
• Many ongoing relationship patterns occur among
homosexual
• Same sex pairs live in a common household in either a
monogamous or primary relationship for decades
• Others have only fleeting sexual contacts
HOMOSEXUALITY
• Gay-male couple are subjected to civil and social
discrimination without legal social support system of
marriage or biological capacity for childbearing that
bonds some otherwise incompatible heterosexual
couples
• Lesbian couples appear to experience less social
stigmatization and to have more enduring monogamous
or primary relationships.
• As of 2014, 18 states legalizes marriage between
homosexuals
HOMOSEXUALITY
• 5. Psychopathology
- Range of psychopathology found among distressed
homosexuals parallels that found among heterosexual; with
higher suicidal rate however
- Distress resulting from conflict between gay men or lesbian
and societal value structure is not classified as a disorder.
- If distress is sufficiently severe to warrant a diagnosis,
adjustment disorder or a depressive disorder should be
considered
- Some with major depressive disorder may experience guilt
and self-hatred that become directed toward their sexual
orientation
- Then the desire for sexual reorientation is only a symptom of
the depressive disorder
HOMOSEXUALITY
• 6. Coming Out
- A process by which an individual acknowledges his or
her sexual orientation in the face of societal stigma and
with successful resolution accepts himself or herself
- Difficulty negotiating coming out and disclosure is a
common cause of relationship difficulties
- For each person, problems solving the coming out
process can contribute to poor self-esteem caused by
internalized homophobia and leads to a deleterious
effect on the person’s ability to function in the
relationship
- Conflicts can also arise within a relationship when
partners disagree on the degree of disclosure
LOVE AND INTIMACY
• Freud: psychological health could be determined by a
person’s ability to function well in 2 spheres, work and
love
• A person able to give and receive love with a minimum
of fear and conflict has the capacity to develop
genuinely intimate relationship with others.
• A desire to maintain closeness to the love object
typifies being in love
• Mature love is marked by the intimacy that is a special
attribute of the relationship between two persons
LOVE AND INTIMACY
• When involved in an intimate relationship, the person
actively strives for the growth and happiness of the loved
person
• Sex frequently acts as a catalyst in forming and maintaining
intimate relationship
• The quality of intimacy in a mature sexual relationship is
what Rollo May called “active receiving”, in which aperson,
while loving, permits himself or herself to be loved.
• May describes the value of sexual love as an expansion of
self-affirmation and pride, and sometimes, at the moment
of orgasm, loss of feeling of separateness.
• In that setting, sex and love are reciprocally enhancing and
healthily fused
• Conflicts prevent persons from fusing tender and
passionate impulses.
• This can inhibit the expression of sexuality in a
relationship, interfere with feelings of closeness to
another person, and diminish a person’s sense of
adequacy and self-esteem
• When these problems are severe, they may prevent
the formation of, or commitment to, an intimate
relationship
SEX AND LAW
• Appropriateness or legality of sexual behaviour is not
always viewed the same way by professionals in
medicine and law.
• The issues at the interface of sexual science and the law
often are emotionally charged and reflect cultural
division about acceptable sexual mores. They include:
• Abortion, pornography, prostitution, sex education, the treatment of sex
offenders and the right to sexual privacy.
• Law regards these issues (e.g. criminalization of oral or
anal sex by consenting adults or the need for parental
permission by minors who are requesting abortion)
vary from state to state.
TAKING A SEX HISTORY
• Sex history provides important information about
patients, regardless of the presence of a sexual
disorder or whether that is the patient’s chief
complaint. The information can be obtained
gradually, through open-ended questions.