1 Module

Understanding sexuality

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1.1.2. Dimensions of sexual health

Sexual health

Sexual health is a state of physical, emotional, mental and social well-being relating to sexuality. It's not merely the absence of disease, dysfunction or infirmity.

Sexual health is about having a positive and respectful approach to sexuality and sexual relationships. It's also about the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.

To get and maintain sexual health, a person's sexual rights must be respected, protected and fulfilled.

Human rights means each person must respect the rights of each other person, including respect for cultural and societal norms.

Sexual rights embrace human rights already recognised in national laws, international human rights documents and other consensus statements.

The sexual rights concept means a person has the right, free of coercion, discrimination and violence, to:

  • the highest attainable standard of sexual health, including access to sexual and reproductive health care services
  • seek, get and give out information related to sexuality
  • sexuality education
  • gain respect for their body
  • choose their partner
  • decide to be sexually active or not
  • enter into consensual sexual relations
  • enter into consensual marriage
  • decide whether or not, and when, to have children
  • pursue a satisfying, safe and pleasurable sexual life.

Human sexual response

Masters and Johnson published their groundbreaking book in 1966: 'Human Sexual Response'. It's based on clinical research proposing a linear model of sexual response for men and women.

Summary of Masters and Johnson's Human Sexual Response Cycle[1]

PhaseResponse
Excitement
  • Heart rate & blood pressure increase
  • Blood flow to genitalia increases
  • For women
    • Enlargement of the clitoris
    • Engorgement of the labia
    • Upper two thirds of vagina grow bigger & walls of vagina thicken
    • Walls of vagina secrete a fluid that facilitates penetration
    • Breasts enlarge & reddish flush appears on chest & neck
  • For men
    • Penis becomes erect as blood flows into spongy tissue
    • Skin of scrotum thickens
    • Testicles grow bigger
    • Entire scrotum elevates & moves in toward the body
Plateau
  • Blood pressure & heart rate continue to increase; breathing becomes rapid
  • Some experience myotonia, causing involuntary facial grimaces; contraction of hands and feet
  • In women
    • Lower third of vagina (at the vaginal introitus)swells
    • Upper two thirds of vagina continues to expand
    • Uterus moves into upright position
    • Labia minora engorges with blood & colour changes to darker hue
  • In men
    • Testicles continue to enlarge and move closer to the inside of abdomen
    • Head (glans) of the penis shows evidence of vasocongestion by changing to a deeper colour
    • Cowper glands secrete fluid which may be visible at the tip of the penis
Orgasm
  • Respiration & heart rate peak
  • Major muscles in the body contract and go into spasm
  • Subjective feelings of intense pleasure
  • In women
    • Pelvic muscles contract between 3 and 15 times - first contractions strong and close together followed by 3 or more slower contractions
    • Muscles of uterus and anal sphincter contract
  • In men
    • Stage 1:
      • Seminal fluid forced into bulb of penis by contractions of the vas deferens; seminal vesicles; ejaculatory duct & prostate gland
      • Bladder neck sphincter closes off
      • Experience a brief sensation called ejaculatory inevitability
    • Stage 2:
      • Opening of the second sphincter lower in the urethra
      • Muscles around the urethra contract, and fluid is propelled along the urethra and out of the urethral meatus
      • First contractions more intense and closer together than later contractions
      • Contractions accompanied by feelings of intense pleasure
Resolution
  • Vasocongestion resolves, body returns to non aroused state
  • Muscle tension dissipates; heart rate, blood pressure and respirations return to normal
  • In women
    • Blood moves out of pelvic organs
    • Labia return to normal size and colour
    • Uterus regains its usual size and position
    • Vagina regains its usual size
    • Clitoris regains its usual size
    • Breasts return to normal size and flushing of the skin disappears
    • Do not experience refractory period and may have multiple orgasms with continued stimulation
  • In men
    • Phase 1: half the volume lost as blood leaves the corpus cavernosum
    • Phase 2: remaining blood leaves the corpus spongiosum; testicles and scrotum shrink in size
    • Refractory period follows where ejaculation and orgasm is physiologically not possibl

Adapted from Katz. A, (2007. p10-15) [2]

 

Sexual therapist Helen Singer Kaplan then included the concept of desire to this model and condensed the response into 3 phases: desire, arousal and orgasm.[3]

Both frameworks have since been criticised, because they don't account for non-biological experiences, such as pleasure and satisfaction. They don't place sexuality in the context of the relationship and assume men and women have similar sexual responses.

They also assume a linear progression from an initial awareness of sexual desire to one of arousal. They focus on genital swelling and lubrication through to orgasmic release and resolution. [4]

One of the most common causes of sexual dissatisfaction between couples is 'desire discrepancy', where one partner desires more sexual activity than their partner.

Sexual dysfunction

Alterations in sexual health or sexual dysfunction can be understood in different ways.

For example, to a non-professional, sexual alterations may be:

  • a change in the person's perceptions of themselves or their body image
  • a change in their physical functioning
  • a change to their intimate relationships.

The World Health Organization (WHO) defines sexual dysfunction as 'the various ways in which an individual is unable to participate in a sexual relationship … he / she would wish'. [5]

Experiencing sexual dysfunction is relatively common in the community.

One large survey of Australian women reported that 70% experienced sexual difficulties (including the inability to orgasm and not feeling like sex) in the year before the survey.

Women over 50 were most likely to experience sexual difficulties, although they were common in all age groups (over 60% of women aged over 50 reported lack of interest in sex, and more than half of women aged 16-49 also reported this difficulty). [6]

Sexology

From a biomedical perspective, 'sexology' refers to the scientific study of human sexuality.

It's the bio-medical approach to the study of human sexual behaviour and focuses on function and dysfunction.

In the past, sexologists focused primarily on human reproduction and sexual health as topics for learning and research. They also focused on the outcomes of sex, rather than the experience of sexuality.

Today, this is a growing area of research interest and includes the study of:

  • human sexual response
  • sexual emotions
  • sexual function
  • human relationships
  • sexual pleasure
  • sexual changes throughout life
  • sexual diversity.

Sexual disorders ‒ the DSM-IV Classification

  1. American Psychiatric Association: DSM-IV: Diagnostic and Statistical Manual, 4th edition, 1994.[7]
  2. World Health Organization: International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10), 1992.[8]

The two resources above contain a classification system for male and female sexual disorders based on the Masters and Johnson and Kaplan model of the female sexual response. [1][3]

The DSM-IV Classification focuses on psychiatric disorders and provides a ‘Consensus-Based Classification of Male and Female Sexual Dysfunction’ (CCFSD).

This classification defines a sexual disorder as a ‘disturbance in sexual desire and in the psychophysiological changes that characterise the sexual response cycle and cause marked distress and interpersonal difficulty.’

This classification system has come under scrutiny and criticism, because it focuses only on the psychiatric component of sexual disorders, and because it’s based on the Masters and Johnson and Kaplan linear model of the sexual response.

However, the classification improves on the older systems, because it includes both psychogenic and organic causes of desire, arousal, orgasm and sexual pain disorders.

The diagnostic system also includes the criterion of ‘personal distress’, stating a condition is considered a disorder only if a person is distressed by it. [9]

Male & female sexual & gender identity disorders

DSM-IV identifies the following male and female sexual and gender identity disorders:

  1. sexual desire disorders
  2. sexual arousal disorders
  3. orgasmic disorders
  4. sexual pain disorders
  5. gender identity disorder
  6. sexual dysfunction due to a medical condition
  7. sexual dysfunction NOS (not otherwise specified).

The first 4 categories from the DSM-IV and ICD-10 classifications structure the CCFSD system.

In this module, we focus on understanding female sexual disorders. However, a woman's experience of sexuality is closely linked to her partner's sexual health and wellbeing. Male sexual disorders should also be understood. Those wishing to learn more about male sexual disorders should access the following readings for more information. [7][9][10][11]

Diagnosis for females – definitions

  1. There are 2 types of sexual desire disorders:[12][13][14][15][16]
    1. Hypoactive sexual desire disorder is the persistent or recurrent deficiency (or absence) of sexual fantasies / thoughts, and / or desire for or receptivity to sexual activity, causing personal distress.
    2. Sexual aversion disorder is the persistent or recurrent phobic aversion to and avoidance of sexual contact with a sexual partner, causing personal distress.
  2. Sexual arousal disorder is the persistent or recurrent inability to attain or maintain sufficient sexual excitement, causing personal distress. This may be expressed as a lack of subjective excitement, or genital (lubrication / swelling) or other somatic responses.
  3. Orgasmic disorder is the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal, causing personal distress.
  4. There are 3 types of sexual pain disorders, and all can cause personal distress:
    1. Dyspareunia is the recurrent or persistent genital pain associated with sexual intercourse.
    2. Vaginismus is the recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with vaginal penetration.
    3. Non-coital sexual pain disorder is the recurrent or persistent genital pain induced by non-coital sexual stimulation.
    Note: The above definitions provide a biomedical perspective on sexual disorders. There are also many psychological (eg. anxiety, depression, low self-esteem), social factors (tensions in relationships, differential power relationships), or environmental factors (eg. privacy, comfort) that can contribute to sexual dysfunction. These are reviewed in 1.2 Factors influencing sexuality.

References

1 Human sexual response
Authors: Masters, W.H., & Johnson, V.E. (1966).
Boston: Little, Brown.

2 Breaking the silence on cancer and Sexuality: A Handbook for Healthcare Providers.
Authors: Katz, A. (2007).
Pittsburgh, PA. Oncology Nursing Society.

3Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy
Author: Kaplan HS.
New York, NY: Brunner/Hazel Publications; 1979

4 Women's sexual dysfunction: revised and expanded definitions
Author: Basson, R.
In: Canadian Medical Association Journal - Volume 172, Issue 10 (May 2005)

5 WHO: Measuring sexual health: conceptual and practical considerations and
related indicators (PDF, 291kb)

6 Sex in Australia: Sexual difficulties in a representative sample of adults
Authors: Richters J, Grulich, AE, Visser, RO, Smith, AM, Rissel, CE (2003).
In: Australian and New Zealand Journal of Public Health Volume 27, Issue 2 , Pages164-170.

7 Google books - Diagnostic and Statistical Manual of Mental Disorders.
Fourth Edition (DSM-IV)

In: American Psychiatric Association, Washington, D.C., 1994.
(please note pp 539 - 545 unavailable in some limited previews)

8 World Health Organization: International Statistical Classification of Diseases
and Related Health Problems-10 (ICD-10), 1992.

9 Integrated treatment of female and male sexual arousal disorders.
In: European psychiatry (0924-9338), 23, p. S1

10 Male sexual dysfunction.
Author: Diaz VA.
In: Journal: Primary Care 2010; 37(3): 473-89, vii-viii

11 Endocrine Aspects of Male Sexual Dysfunctions.(Disease/Disorder overview)
Author: Torres, LO (2010).
In: Journal of sexual medicine (1743-6095), 7 (4), p. 1627.

12 Definitions of women's sexual dysfunction reconsidered: Advocating expansion and revision
Authors: Basson R, Leiblum S, Brotto L, Derogatis L, Fourcroy J, Fugl-Meyer K, Graziottin A, Heiman JR, Laan E, Meston C, Schover L, van Lankveld J, Weijmar Schultz W. (2003).
In: Journal of Psychosomatic Obstetrics & Gynecology, Vol. 24, No. 4, Pages 221-229

13 Report of the International Consensus Development Conference on female
sexual dysfunction: definitions and classifications

Authors: Basson R, Berman J, Burnett A, et al.
In: J Urol 2000;163:888-893.

14 Medical human sexuality in family medicine practice
Authors: Eyler AE, Biggs WS.
In: Rakel RE. Textbook of Family Medicine. 7th ed. Philadelphia, Pa.Saunders Elsevier; 2007: chap 55.

15 Talking About Sexuality, Body Image and Cancer: A Teaching Resource
for Health Professionals

The Cancer Council of New South Wales. Kings Cross, NSW: The NSW Cancer Council; 2002.

16 Older women’s sexuality
Authors: Yee L, Sundquist K. (2003).
In: MJA 2003; 178: 640–642.

 

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