Human Sexuality

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Slide 1 :

Human Sexuality Rob Averbuch, MD

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Why Study Sexuality? Important roles in… Relationships/ intimacy Perpetuation of the species/ Reproduction Identity: part of how we define ourselves Pleasure/ reward Status/ power

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Why Sex is Difficult to Study Patients don’t spontaneously report sexual concerns, behaviors Physicians often neglect to ask Result: much of our understanding is anecdotal

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Potential Pitfalls for Physicians Lack of awareness of our own feelings, biases Making false assumptions about a patient’s sexuality- don’t assume anything Conveying a judgmental attitude about what’s “normal”

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Determinants of Sexual Behavior Sexual urge is primitive (ID), powerful Determined, in part, by anatomy and physiology (biological aspects) Often shaped by experience (including trauma, cultural taboos, etc.); ie, socially and culturally determined Significant differences between males and females

Slide 6 :

Lecture Overview Historical context: The Study of Human Sexuality Defining Terms: Sexual Identity, Sexual Orientation, and Gender Identity Sexual Development Sexual Response Cycle Sexual Dysfunctions

Slide 7 :

Historical Context

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Historical Context: Freud Introduced concept of childhood sexuality Substantiated by recent studies- occurrence of genital play in infants and genital exploration in childhood- normal Psychosexual Stages Introduced concept of libido- mind’s representation of sexual instinct

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Defining “Normal”- Kinsey First extensive studies of people’s sexual attitudes and behaviors Attempted to expand public conceptualization of “normal”

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Historical Context: Kinsey The epidemiology of sexual behavior Findings controversial/ provocative- ex. higher incidence of homosexuality, masturbation, taboo behaviors than previously thought Published findings in 1948, “Sexual Behavior in the Human Male”

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History: Masters and Johnson Studied physiology of sexual response cycle 1966, “Human Sexual Response” 1970, “Human Sexual Inadequacy”- follow up publication about sexual dysfunction

Slide 12 :

Defining Key Terms

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Defining Key Terms Sexual Identity Sexual Orientation Gender Identity

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Sexual Identity Biological Sex Defined primarily by anatomy and physiology Combination of Genotype (chromosomes) and Phenotype (expression of genes)

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Sexual Orientation Which sex a person is attracted to Determined, in part, by brain’s exposure to prenatal hormones (sexual differentiation) Evolves by adolescence

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Sexual Orientation: Homosexuality Normal variant- As of 1980, no longer considered a disorder in Psychiatric diagnostics Higher prevalence in males Biology plays significant role: Genetics: higher concordance rates in monozygotes Analogous behaviors in 60 species

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Gender Identity (Gender Awareness) Innate sense of being male or female Established by age 2 or 3 Results from interaction of multiple factors…

Slide 18 :

Factors in Gender Identity Environmental Influences: societal attitudes- family, friends, teachers, culture interacting with… Sexual Identity (biological sex) and… Prenatal Sexual Differentiation of brain: exposure to prenatal hormones leads to feelings attitudes about gender

Slide 19 :

Sexual Development

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Sexual Development Differences in prenatal hormones cause gender differences in certain brain areas Not just in formation of genitals, etc., but in attitudes about gender, orientation, etc.

Slide 21 :

Primary vs. Secondary Sex Characteristics Primary Sex Characteristics: physical attributes directly related to reproduction- genitalia Secondary Sex Characteristics: traits that distinguish male from female but not directly part of reproduction- pubic hair, facial hair, breast development, deepening of voice, etc.

Slide 22 :

Puberty Progressive development of primary and secondary sexual characteristics Tanner Stages: describe normal progression of puberty in males and females

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Sexual Development Gender Identity: established by age 2-3 Sexual Orientation: established by early adolescence Both gender ID and Sex Orientation are influenced by brain development during 2nd Trimester- sexual differentiation

Slide 24 :

Sexual Response Cycle

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Sexual Response Cycle: 4 Phases 1. Desire/ Appetitive Phase 2. Excitement 3. Orgasm 4. Resolution

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Phase 1: Desire Sexual fantasies, interest in having sex No physiological changes during this phase Men respond more to visual stimuli

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“What Women Want” Women respond more to romantic stories with tender demonstrative heroes who’s passion for the heroine impels him toward a lifetime commitment to her

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Phase 2: Excitement/ Arousal Aka Foreplay Initiated by psychological or physical stimulation Subjective sense of pleasure Can last for minutes to hours

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Phase 2: Excitement Physiological Changes Women: clitoral engorgement, vaginal lubrication, labial swelling, breast enlargement Men: penile erection (parasympathetic phenomenon), testicular enlargement Both Sexes: Increases in blood pressure, pulse, respirations; increased muscle tension; nipple erection

Slide 30 :

Phase 2: Excitement (cont) Includes a Plateau Phase A short or absent Plateau may lead to Premature Ejaculation (2nd most common sexual dysfunction)

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Phase 3: Orgasm Peak of pleasure In men: ejaculation (sympathetic phenomenon) In women: muscular contractions of uterus and vagina

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Phase 4: Resolution Disgorgement/ detumescence of genitalia Muscle relaxation, sense of well-being Refractory period (males only)- during which male is not receptive to excitement/stimulation Duration increases with age

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Sexual Response Cycle- General Points Mean time for the full cycle: Men: 3 minutes Women: 15 minutes Testosterone plays a key role in libido for both genders Secreted by adrenals, ovaries, and testes

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Sexual Disorders Dysfunctions Gender Identity Disorder Paraphilias

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Sexual Dysfunctions Disturbance in one or more phases of the sexual response cycle, or pain with sex Examples include an aversion to sex, erectile dysfunction (ED), premature ejaculation, anorgasmia, and others…

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Painful Sexual Dysfunctions Vaginismus: recurrent spasms/contraction of vaginal muscles that interfere with penetration Dyspareunia: frequent genital pain with intercourse

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Causes of Sexual Dysfunction: Medical Cardiovascular: Post-MI, etc. Endocrine: Hypothyroidism, Hyperprolactinemia, Hypogonadal states,etc. Gynecologic: Uterine Prolapse, Pelvic Inflammatory Disease, etc. Urologic: Post- prostatectomy

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More Medical Causes of Sex Dysfunction Metabolic: Cirrhosis Neurological: Multiple Sclerosis, Spinal Chord injury, Diabetic Neuropathy Chronic Illness Prescription Drugs Drugs of Abuse: Stimulants increase libido, but THC, Opiates, Etoh decrease

Slide 39 :

Psychogenic Causes of Sex Dysfunction Stress, in general decreases desire, functioning Developmental trauma/abuse Relationship problems Depression, Anxiety, and other psychiatric disorders

Slide 40 :

Clues to Psychogenic Etiology Presence of nocturnal (during REM) and early AM erections The “Stamp Test” Dysfunction is situation-specific Masturbation is unaffected

Slide 41 :

The End (for now) To Be Continued…

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