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HumanSexualityDiversityinContemporaryAmerica9thedition-BryanStrongWilliamYarberBarbaraSayad.pdf

Home >Science homework help >answer EACH of the discussion questions in well-developed paragraphs.

HUMAN SEXUALITY Diversity in Contemporary America

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HUMAN SEXUALITY Diversity in Contemporary America

NINTH EDITION

William L. Yarber INDIANA UNIVERSITY

Barbara W. Sayad CALIFORNIA STATE UNIVERSITY, MONTEREY BAY

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HUMAN SEXUALITY: DIVERSITY IN CONTEMPORARY AMERICA, NINTH EDITION

Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2016 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Previous editions © 2013, 2010, and 2008. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning.

Some ancillaries, including electronic and print components, may not be available to customers outside the United States.

This book is printed on acid-free paper.

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Student Edition Instructor Review Edition ISBN 978-0-07-786194-0 978-1-259-68062-5 MHID 0-07-786194-9 1-259-68062-2

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Library of Congress Cataloging-in-Publication Data Yarber, William L. (William Lee), 1943- Human sexuality: diversity in contemporary America / William L. Yarber, Indiana University, Barbara W. Sayad, California State University, Monterey Bay.—Ninth edition. p. cm. Includes bibliographical references and index. ISBN 978-0-07-786194-0 (alk. paper) 1. Sex. 2. Sex customs. 3. Sexual health. I. Sayad, Barbara Werner. II. Title.

HQ21.S8126 2016 306.7—dc23

2015015172

The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not guarantee the accuracy of the information presented at these sites.

mheducation.com/highered

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This book is dedicated to Ryan White, an Indiana native-son who died from AIDS on April 8, 1990.

During his illness Ryan experienced public scorn, harassment, and rejection, yet faced these difficulties with courage, dignity, and grace. He became the poster boy for the AIDS crisis, speaking out against the misconceptions about the disease and calling for persons with AIDS to be treated with compassion.

Ryan died at age 18, the spring before he planned to attend Indiana University (IU), Bloomington. To honor the legacy of Ryan, the Rural Center for AIDS/STD Prevention at IU established the Ryan White Distinguished Leadership Award for recognition of significant national/international leadership in HIV/AIDS prevention and the Ryan White Legacy Scholarship for IU Masters of Public Health students.

Sir Elton John said, “I have met a lot of people who were brave and courageous. . . . Ryan White gave a new meaning to these words. . . . He was a miracle of humanity.”

—W. L. Y.

Dedication

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vi Dedication

This book is dedicated to the students of human sexuality who quest for knowledge and understanding, to the instructors who diligently and compassionately support and inspire them, and to a system of governing that advocates for the sexual rights of all people.

I want my family to know that I cannot do this work without their love and support.

—B. W. S.

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vii

1 Perspectives on Human Sexuality 1

2 Studying Human Sexuality 27

3 Female Sexual Anatomy, Physiology, and Response 65

4 Male Sexual Anatomy, Physiology, and Response 102

5 Gender and Gender Roles 122

6 Sexuality in Childhood and Adolescence 155

7 Sexuality in Adulthood 184

8 Love and Communication in Intimate Relationships 214

9 Sexual Expression 253

10 Variations in Sexual Behavior 296

11 Contraception and Abortion 322

12 Conception, Pregnancy, and Childbirth 359

13 The Sexual Body in Health and Illness 393

14 Sexual Function Difficulties, Dissatisfaction, Enhancement, and Therapy 429

15 Sexually Transmitted Infections 479

16 HIV and AIDS 516

17 Sexual Coercion 557

18 Sexually Explicit Materials, Prostitution, and Sex Laws 601 ® McGraw-Hill Education Psychology’s APA Documentation Style Guide

Brief Contents

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viii

PREFACE xxii | LETTER FROM THE AUTHORS xxxiii | ABOUT THE AUTHORS xxxv

1 Perspectives on Human Sexuality 1 STUDYING HUMAN SEXUALITY 2

SEXUALITY, POPULAR CULTURE, AND THE MEDIA 4 Media Portrayals of Sexuality 4 Television and Digital Media 7 Feature-Length Films 9 Gay Men, Lesbian Women, and Bisexual and Transgender People in Film

and Television 9 Online Social Networks 10

■ Think About It BEFORE PRESSING “SEND”: TRENDS AND CONCERNS ABOUT TEXTING, SEXTING, AND DATING 12

SEXUALITY ACROSS CULTURES AND TIMES 14 Sexual Interests 14 Sexual Orientation 16 Gender 18

SOCIETAL NORMS AND SEXUALITY 19 Natural Sexual Behavior 19

■ Think About It AM I NORMAL? 20 Normal Sexual Behavior 21 Sexuality Behavior and Variations 22

■ Think About It DECLARATION OF SEXUAL RIGHTS 23

Contents

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Contents ix

2 Studying Human Sexuality 27 SEX, ADVICE COLUMNISTS, AND POP PSYCHOLOGY 29 Information and Advice as Entertainment 29

■ Think About It DOES SEX HAVE AN INHERENT MEANING? 30 The Use and Abuse of Research Findings 31

THINKING OBJECTIVELY ABOUT SEXUALITY 32 Value Judgments Versus Objectivity 32 Opinions, Biases, and Stereotypes 33 Common Fallacies: Egocentric and Ethnocentric Thinking 34

SEX RESEARCH METHODS 35 Research Concerns 35 Clinical Research 37 Survey Research 37 Observational Research 39 Experimental Research 39

THE SEX RESEARCHERS 40 Richard von Krafft-Ebing 41 Sigmund Freud 41 Havelock Ellis 42 Alfred Kinsey 43 William Masters and Virginia Johnson 45

CONTEMPORARY RESEARCH STUDIES 46 The National Health and Social Life Survey 46 The National Survey of Family Growth 47

■ Think About It SEX RESEARCH: A BENEFIT TO INDIVIDUALS AND SOCIETY OR A THREAT TO MORALITY? 48

The Youth Risk Behavior Survey 49 The National College Health Assessment 50 The National Survey of Sexual Health and Behavior 51

EMERGING RESEARCH PERSPECTIVES 52 Feminist Scholarship 53 Gay, Lesbian, Bisexual, and Transgender Research 54 Directions for Future Research 56

ETHNICITY AND SEXUALITY 56 African Americans 56 Latinos 58 Asian Americans and Pacific Islanders 59 Middle Eastern Americans 61

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x Contents

3 Female Sexual Anatomy, Physiology, and Response 65

FEMALE SEX ORGANS: WHAT ARE THEY FOR? 66 External Structures (the Vulva) 67 Internal Structures 70

■ Practically Speaking PERFORMING A GYNECOLOGICAL SELF-EXAMINATION 74 Other Structures 75 The Breasts 76

FEMALE SEXUAL PHYSIOLOGY 78 Reproductive Hormones 79 The Ovarian Cycle 79 The Menstrual Cycle 81

■ Practically Speaking VAGINAL AND MENSTRUAL HEALTH CARE 86

HUMAN SEXUAL RESPONSE 87 ■ Think About It SEXUAL FLUIDITY: WOMEN’S VARIABLE SEXUAL ATTRACTIONS 88

Sexual Response Models 89 Desire and Arousal: Mind or Matter? 92 Experiencing Sexual Arousal 95

FEMALE SEXUAL RESPONSE 95 Sexual Excitement 95

■ Think About It “DID YOU COME?” WHAT COLLEGE STUDENTS THINK ABOUT WOMEN’S ORGASMS DURING HETEROSEXUAL SEX 96

Orgasm 98

4 Male Sexual Anatomy, Physiology, and Response 102

MALE SEX ORGANS: WHAT ARE THEY FOR? 103 External Structures 103 Internal Structures 106 Other Structures 108

MALE SEXUAL PHYSIOLOGY 110 Sex Hormones 110

■ Practically Speaking SEXUAL HEALTH CARE: WHAT DO MEN NEED? 111 Spermatogenesis 113

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Contents xi

Semen Production 113 Homologous Organs 115

MALE SEXUAL RESPONSE 115 ■ Think About It “OH, TO BE BIGGER”: BREAST AND PENIS ENHANCEMENT 116

Erection 117 Ejaculation and Orgasm 118

■ Practically Speaking CAN AN ERECTION BE WILLED? 119

5 Gender and Gender Roles 122 STUDYING GENDER AND GENDER ROLES 124 Sex, Gender, and Gender Roles: What’s the Difference? 124 Sex and Gender Identity 125 Masculinity and Femininity: Opposites, Similar, or Blended? 127 Gender and Sexual Orientation 128

GENDER-ROLE LEARNING 128 Theories of Socialization 128 Gender-Role Learning in Childhood and Adolescence 130 Gender Schemas: Exaggerating Differences 133

CONTEMPORARY GENDER ROLES AND SCRIPTS 133 Traditional Gender Roles and Scripts 134

■ Think About It THE PURITY STANDARD: DEFINING WOMEN BY THEIR SEXUALITY 136

Changing Gender Roles and Scripts 137

GENDER VARIATIONS 138 The Transgender Phenomenon 139

■ Think About It PSYCHOLOGICAL AND MEDICAL TREATMENT OF GENDER DYSPHORIA 141

Gender Dysphoria 142 Transsexuality 143 Disorders of Sex Development (DSD) 144

■ Think About It A CAUTIOUS APPROACH TO ADDRESSING DISORDERS OF SEX DEVELOPMENT (DSD) IN CHILDREN 149

Unclassified Form of Abnormal Sexual Development 150 Coming to Terms With Differences 150

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xii Contents

6 Sexuality in Childhood and Adolescence 155

SEXUALITY IN INFANCY AND CHILDHOOD (AGES 0 TO 11) 156 Infancy and Sexual Response (Ages 0 to 2) 157 Childhood Sexuality (Ages 3 to 11) 157 The Family Context 160

SEXUALITY IN ADOLESCENCE (AGES 12 TO 19) 161 Psychosexual Development 161

■ Think About It THE “ORIGINS” OF HOMOSEXUALITY 168 Adolescent Sexual Behavior 170 Teenage Pregnancy 174

■ Practically Speaking FIRST SEXUAL INTERCOURSE REACTION SCALE 175 Sexuality Education 178

■ Think About It HEALTHY TEEN SEXUALITY 180

7 Sexuality in Adulthood 184 SEXUALITY IN EARLY ADULTHOOD 185 Developmental Concerns 186

■ Think About It LIFE BEHAVIORS OF A SEXUALLY HEALTHY ADULT 187 Establishing Sexual Orientation 188

■ Think About It BISEXUALITY: THE NATURE OF DUAL ATTRACTION 191 Being Single 193

■ Think About It WHY COLLEGE STUDENTS HAVE SEX 195 Cohabitation 198

SEXUALITY IN MIDDLE ADULTHOOD 199 Developmental Concerns 199 Sexuality in Marriage and Established Relationships 200 Divorce and After 202

SEXUALITY IN LATE ADULTHOOD 204 Developmental Concerns 204 Stereotypes of Aging 205 Sexuality and Aging 205

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Contents xiii

8 Love and Communication in Intimate Relationships 214

FRIENDSHIP AND LOVE 216

LOVE AND SEXUALITY 217 Men, Women, Sex, and Love 218 Love Without Sex: Celibacy and Asexuality 219

■ Think About It ARE GAY/LESBIAN COUPLES AND FAMILIES ANY DIFFERENT FROM HETEROSEXUAL ONES? 220

HOW DO I LOVE THEE? APPROACHES AND ATTITUDES RELATED TO LOVE 221

Styles of Love 221 The Triangular Theory of Love 222 Love as Attachment 225 Unrequited Love 227

■ Think About It THE SCIENCE OF LOVE 228

JEALOUSY 229 The Psychological Dimension 230 Managing Jealousy 230

■ Think About It THE PASSIONATE LOVE SCALE 231 Extradyadic Involvement 232 Rebound Sex 234

MAKING LOVE LAST: FROM PASSION TO INTIMACY 234

THE NATURE OF COMMUNICATION 235 The Cultural Context 235 The Social Context 236 The Psychological Context 237 Nonverbal Communication 237

SEXUAL COMMUNICATION 239 Sexual Communication in Beginning Relationships 239 Sexual Communication in Established Relationships 241

■ Think About It LET’S (NOT) TALK ABOUT SEX: AVOIDING THE DISCUSSION ABOUT PAST LOVERS 242

Initiating Sexual Activity 243

DEVELOPING COMMUNICATION SKILLS 243 Talking About Sex 244

■ Practically Speaking COMMUNICATION PATTERNS AND PARTNER SATISFACTION 245

CONFLICT AND INTIMACY 247 Sexual Conflicts 247

■ Practically Speaking LESSONS FROM THE LOVE LAB 248 Conflict Resolution 249

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xiv Contents

9 Sexual Expression 253 SEXUAL ATTRACTIVENESS 255 A Cross-Cultural Analysis 255 Evolutionary Mating Perspectives 258 Hooking Up and College Students 262 Sexual Desire 263

■ Think About It “HOOKING UP” AMONG COLLEGE STUDENTS: AS SIMPLE AS ONE MIGHT THINK? 264

SEXUAL SCRIPTS 266 Cultural Scripting 266 Intrapersonal Scripting 267 Interpersonal Scripting 267

AUTOEROTICISM 268 Sexual Fantasies and Dreams 269 Masturbation 271

■ Practically Speaking ASSESSING YOUR ATTITUDE TOWARD MASTURBATION 274

SEXUAL BEHAVIOR WITH OTHERS 277 Most Recent Partnered Sex 277

■ Think About It YOU WOULD SAY YOU “HAD SEX” IF YOU . . . 278 Couple Sexual Styles 279 Touching 281 Kissing 282

■ Think About It GIVING AND RECEIVING PLEASURABLE TOUCH: “GEARS OF CONNECTION” 283

Oral-Genital Sex 284 ■ Think About It THE FIRST KISS: A DEAL-BREAKER? 285

Sexual Intercourse 288 Anal Eroticism 291 Health Benefits of Sexual Activity 293

10 Variations in Sexual Behavior 296 SEXUAL VARIATIONS AND PARAPHILIC BEHAVIOR 297 What Are Sexual Variations? 297 What Is Paraphilia? 298

■ Think About It CLASSIFYING VARIANT SEXUAL BEHAVIORS AS PARAPHILIA: THE CHANGING VIEWS OF PSYCHOLOGY 300

TYPES OF PARAPHILIAS 301 Fetishism 301

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Contents xv

■ Think About It “SEXUAL ADDICTION”: REPRESSIVE MORALITY IN A NEW GUISE? 302 Transvestism 304 Zoophilia 306 Voyeurism 307

■ Think About It WOULD YOU WATCH? COLLEGE STUDENTS AND VOYEURISM 308 Exhibitionism 309 Telephone Scatologia 311 Frotteurism 311 Necrophilia 312 Pedophilia 313 BDSM, Sexual Masochism, and Sexual Sadism 314

ORIGINS AND TREATMENT OF PARAPHILIAS 318

11 Contraception and Abortion 322 RISK AND RESPONSIBILITY 323 Women, Men, and Birth Control: Who Is Responsible? 324 Navigating Reproductive Health 325

■ Think About It RISKY BUSINESS: WHY COUPLES FAIL TO USE CONTRACEPTION 326

METHODS OF CONTRACEPTION 328 Choosing a Method 328 Sexual Abstinence 330 Hormonal Methods 331 Barrier Methods 336

■ Practically Speaking TIPS FOR EFFECTIVE CONDOM USE 338 ■ Practically Speaking CORRECT CONDOM USE SELF-EFFICACY SCALE 339

Spermicides 342 Intrauterine Devices (IUDs) 343 Fertility Awareness–Based Methods 344 Lactational Amenorrhea Method (LAM) 346 Sterilization 346 Emergency Contraception (EC) 349

ABORTION 349 Methods of Abortion 350 Safety of Abortion 351 Women and Abortion 351 Men and Abortion 352 The Abortion Debate 353

RESEARCH ISSUES 355

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xvi Contents

12 Conception, Pregnancy, and Childbirth 359

FERTILIZATION AND FETAL DEVELOPMENT 360 The Fertilization Process 360 Development of the Conceptus 362

■ Think About It CHILD-FREE: A MATTER OF CHOICE 365

PREGNANCY 365 Preconception Care 366 Pregnancy Detection 366 Changes in Women During Pregnancy 367

■ Think About It SEXUAL BEHAVIOR DURING PREGNANCY 369 Complications of Pregnancy and Dangers to the Fetus 369 Diagnosing Fetal Abnormalities 374 Pregnancy Loss 375

INFERTILITY 376 Female Infertility 376 Male Infertility 377 Emotional Responses to Infertility 377 Infertility Treatment 377

GIVING BIRTH 380 Labor and Delivery 380 Choices in Childbirth 382

■ Think About It THE QUESTION OF MALE CIRCUMCISION 383 ■ Practically Speaking MAKING A BIRTH PLAN 385

Breastfeeding 387

BECOMING A PARENT 387 ■ Practically Speaking BREAST VERSUS BOTTLE: WHICH IS BETTER FOR

YOU AND YOUR CHILD? 388

13 The Sexual Body in Health and Illness 393

LIVING IN OUR BODIES: THE QUEST FOR PHYSICAL PERFECTION 395 Eating Disorders 395

■ Think About It BODY IMAGE AND SEXUALITY: ARE THEY ONE AND THE SAME? 396

ALCOHOL, DRUGS, AND SEXUALITY 398 Alcohol Use and Sexuality 398 Other Drug Use and Sexuality 399

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Contents xvii

SEXUALITY AND DISABILITY 402 Physical Limitations and Changing Expectations 402 Vision and Hearing Impairment 404 Chronic Illness 404 Developmental Disabilities 405 The Sexual Rights of People With Disabilities 406

SEXUALITY AND CANCER 407 Women and Cancer 407

■ Think About It FEMALE GENITAL CUTTING: MUTILATION OR IMPORTANT CUSTOM? 414

Men and Cancer 416 ■ Practically Speaking TESTICULAR SELF-EXAMINATION 419

Anal Cancer in Men and Women 422

ADDITIONAL SEXUAL HEALTH ISSUES 422 Toxic Shock Syndrome 422 Vulvodynia 423 Endometriosis 423 Prostatitis 424

SEXUAL ORIENTATION AND HEALTH 424

14 Sexual Function Difficulties, Dissatisfaction, Enhancement, and Therapy 429

SEXUAL FUNCTION DIFFICULTIES: DEFINITIONS, TYPES, AND PREVALENCE 431

Defining Sexual Function Difficulties: Different Perspectives 431 Prevalence and Cofactors 434 Disorders of Sexual Desire 439

■ Practically Speaking SEXUAL DESIRE: WHEN APPETITES DIFFER 444 ■ Think About It IS INTERCOURSE ENOUGH? THE BIG “O”

AND SEXUAL BEHAVIORS 446

Orgasmic Disorders 447 Sexual Pain Disorders 450 Substance/Medication-Induced Sexual Dysfunction 452 Other Disorders 452

PHYSICAL CAUSES OF SEXUAL FUNCTION DIFFICULTIES AND DISSATISFACTION 452

Physical Causes in Men 453 Physical Causes in Women 453

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xviii Contents

PSYCHOLOGICAL CAUSES OF SEXUAL FUNCTION DIFFICULTIES AND DISSATISFACTION 453

Immediate Causes 454 Conflict Within the Self 455 Relationship Causes 456

SEXUAL FUNCTION ENHANCEMENT 456 Developing Self-Awareness 456

■ Think About It “GOOD ENOUGH SEX”: THE WAY TO LIFETIME COUPLE SATISFACTION 458

Intensifying Erotic Pleasure 459 ■ Practically Speaking KEGEL EXERCISES FOR WOMEN AND MEN 460 ■ Think About It MY PARTNER COULD BE A BETTER LOVER IF . . . : WHAT MEN AND

WOMEN WANT FROM THEIR SEXUAL PARTNERS 462

Changing a Sexual Relationship and Managing Sexual Difficulties 463 ■ Think About It SEXUAL TURN-ONS AND TURN-OFFS: WHAT COLLEGE

STUDENTS REPORT 464

TREATING SEXUAL FUNCTION DIFFICULTIES 466 Masters and Johnson: A Cognitive-Behavioral Approach 466 Kaplan: Psychosexual Therapy 469 Other Nonmedical Approaches 469 Medical Approaches 470 Gay, Lesbian, and Bisexual Sex Therapy 472

■ Think About It THE MEDICALIZATION OF SEXUAL FUNCTION PROBLEMS 473 ■ Practically Speaking SEEKING PROFESSIONAL ASSISTANCE 474

15 Sexually Transmitted Infections 479

THE STI EPIDEMIC 481 STIs: The Most Common Reportable Infectious Diseases 481 Who Is Affected: Disparities Among Groups 481 Factors Contributing to the Spread of STIs 483

■ Practically Speaking PREVENTING STIs: THE ROLE OF MALE CONDOMS AND FEMALE CONDOMS 487

■ Practically Speaking STI ATTITUDE SCALE 490 Consequences of STIs 491

PRINCIPAL BACTERIAL STIs 491 Chlamydia 491 Gonorrhea 494 Urinary Tract Infections 495 Syphilis 496

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Contents xix

PRINCIPAL VIRAL STIs 497 HIV and AIDS 497

■ Think About It THE TUSKEGEE SYPHILIS STUDY: A TRAGEDY OF RACE AND MEDICINE 498

Genital Herpes 499 Genital Human Papillomavirus Infection 500 Viral Hepatitis 503

VAGINAL INFECTIONS 504 Bacterial Vaginosis 504 Genital Candidiasis 505 Trichomoniasis 505

OTHER STIs 506

ECTOPARASITIC INFESTATIONS 506 Scabies 506 Pubic Lice 507

STIs AND WOMEN 507 Pelvic Inflammatory Disease (PID) 508 Cervicitis 508 Cystitis 509

PREVENTING STIs 509 Avoiding STIs 509 Treating STIs 511

■ Practically Speaking SAFER AND UNSAFE SEX PRACTICES 512

16 HIV and AIDS 516 WHAT IS AIDS? 518 Conditions Associated With AIDS 518

■ Think About It THE STIGMATIZATION OF HIV AND OTHER STIs 519 Symptoms of HIV Infection and AIDS 520 Understanding AIDS: The Immune System and HIV 520 The Virus 521 AIDS Pathogenesis: How the Disease Progresses 522

THE EPIDEMIOLOGY AND TRANSMISSION OF HIV 524 The Epidemiology of HIV/AIDS in the United States 525 Myths and Modes of Transmission 528 Sexual Transmission 529 Injection Drug and Substance Use 530 Mother-to-Child Transmission 531 Factors Contributing to Infection 532

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xx Contents

AIDS DEMOGRAPHICS 532 Minority Races/Ethnicities and HIV 532 The Gay Community 535 Women and HIV/AIDS 537 Transgender People and HIV 538 Children and HIV/AIDS 539 HIV/AIDS Among Youth 539 Older Adults and HIV/AIDS 541 Geographic Region and HIV 541

■ Practically Speaking HEALTH PROTECTIVE SEXUAL COMMUNICATION SCALE 542

PREVENTION AND TREATMENT 543 Protecting Ourselves 543 Saving Lives Through Prevention 545

■ Think About It “DO YOU KNOW WHAT YOU ARE DOING?” COMMON CONDOM- USE MISTAKES AMONG COLLEGE STUDENTS 546

HIV Testing 547 Treatments 550

LIVING WITH HIV OR AIDS 552 If You Are HIV-Positive 552

17 Sexual Coercion 557 SEXUAL HARASSMENT 558 What Is Sexual Harassment? 559 Flirtation Versus Harassment 561 Harassment in School and College 563 Harassment in the Workplace 565 Harassment in Public Spaces 566

HARASSMENT AND DISCRIMINATION AGAINST GAY, LESBIAN, BISEXUAL, AND TRANSGENDER PEOPLE 568

Heterosexual Bias 568 Prejudice, Discrimination, and Violence 568 Ending Anti-Gay Prejudice and Enactment of Antidiscrimination Laws 570

SEXUAL VIOLENCE 572 Campus Sexual Violence 574 The Nature and Incidence of Rape 575 Myths About Rape 576

■ Practically Speaking PREVENTING SEXUAL ASSAULT 577

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Contents xxi

Forms of Rape 579 ■ Think About It DATE/ACQUAINTANCE RAPE DRUGS: AN INCREASING THREAT 581 ■ Think About It CAN MEN AND WOMEN ACCURATELY JUDGE A PARTNER’S

WILLINGNESS TO HAVE CASUAL SEX? 583

■ Think About It HOW COLLEGE STUDENTS INDICATE AND INTERPRET CONSENT TO HAVE SEX 585

Motivations for Rape 589 The Aftermath of Rape 590

■ Practically Speaking SUPPORTING SOMEONE WHO HAS BEEN RAPED 592

CHILD SEXUAL ABUSE 593 Effects of Child Sexual Abuse 595 Treatment Programs 596 Preventing Child Sexual Abuse 596

18 Sexually Explicit Materials, Prostitution, and Sex Laws 601

SEXUALLY EXPLICIT MATERIAL IN CONTEMPORARY AMERICA 602 Pornography or Erotica: Which Is It? 603 Sexually Explicit Material and Popular Culture 603 The Consumption of Sexually Explicit Materials 604 Themes, Content, and Actors of Sexually Explicit Videos 605

■ Think About It COLLEGE STUDENTS AND THE VIEWING OF SEXUALLY EXPLICIT MATERIALS 606

The Effects of Sexually Explicit Material 609 ■ Think About It SEXUALLY EXPLICIT MATERIAL USE IN ROMANTIC COUPLES:

BENEFICIAL OR HARMFUL? 612

Censorship, Sexually Explicit Material, and the Law 615

PROSTITUTION 618 Females Working in Prostitution 619

■ Think About It SEX TRAFFICKING: A MODERN-DAY SLAVERY 620 Males Working in Prostitution 625 Prostitution and the Law 627 The Impact of HIV/AIDS and Other STIs on Prostitution 628

SEXUALITY AND THE LAW 628 Legalizing Private, Consensual Sexual Behavior 629 Same-Sex Marriage 630 Advocating Sexual Rights 630

GLOSSARY G-1

REFERENCES R-1

NAME INDEX NI-1

SUBJECT INDEX SI-1

® McGraw-Hill Education Psychology’s APA Documentation Style Guide

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xxii

Since the first edition, Human Sexuality: Diversity in Contemporary America has presented students with a nonjudgmental view of human sexuality while encouraging them to become proactive about their own sexual well-being and identity. This sex-positive approach, combined with an integrated exploration of cultural diversity and contemporary research, continues today and includes an emphasis on the importance of affirming and supporting intimacy, pleasuring, and mutual satisfaction in sexual expression. Yarber and Sayad encourage stu- dents to critically assess their own values and modes of sexual expression while connecting them to research.

The new edition integrates SmartBook, a personalized learning program, offering students the insight they need to study smarter and improve classroom results.

Better Data, Smarter Revision, Improved Results Students helped inform the revision strategy:

STEP 1. Over the course of three years, data points showing concepts that caused students the most difficulty were anonymously collected from McGraw-Hill Education Connect for Human Sexuality’s LearnSmart® adaptive learning system.

STEP 2. The authors were provided with data from LearnSmart that graphically illustrated “hot spots” in the text impacting student learning (see following image).

STEP 3. The authors used the heat map data to refine content and reinforce student comprehension in the new edition. Additional quiz questions and assign- able activities were created for use in Connect for Human Sexuality to further support student success.

RESULT: With empirically based feedback at the paragraph and even sentence level, the authors developed the new edition using precise student data to pinpoint concepts that caused students to struggle.

Preface

Celebrating Sexual Diversity in Contemporary America

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Preface xxiii

LearnSmart is an adaptive learning program designed to help students learn faster, study smarter, and retain more knowledge for greater success. Distin- guishing what students know from what they don’t, and focusing on concepts they are most likely to forget, LearnSmart continuously adapts to each student’s needs by building an individual learning path. Millions of students have answered over a billion questions in LearnSmart since 2009, making it the most widely used and intelligent adaptive study tool that’s proven to strengthen memory recall, keep students in class, and boost grades.

Fueled by LearnSmart, SmartBook is the first and only adaptive reading experience currently available.

Make It Effective. SmartBook creates a personalized reading experience by highlighting the most impactful concepts a student needs to learn at that moment in time. This ensures that every minute spent with SmartBook is returned to the student as the most value-added minute possible.

Make It Informed. Real-time reports quickly identify the concepts that require more attention from individual students—or the entire class.

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xxiv Preface

Personalized Grading, on the Go, Made Easier Connect Insight® is a one-of-kind visual analytics dashboard—now available for both instructors and students—that provides at-a-glance information regarding student performance.

Designed for mobile devices, Connect Insight empowers students and helps instructors improve class performance.

■ Make it intuitive. Instructors receive instant, at-a-glance views of student per- formance matched with student activity. Students receive at-a-glance views of their own performance and how they are doing compared to the rest of the class.

■ Make it dynamic. Connect Insight puts real-time analytics in instructors’ and students’ hands, so they can take action early and keep struggling students from falling behind.

■ Make it mobile. Connect Insight is available on-demand wherever, and whenever, it’s needed.

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Preface xxv

Experience the Course You Want to Teach The Instructor Resources have been updated to reflect changes to the new edition; these can be accessed by faculty through Connect Psychology. Resources include the test bank, instructor’s manual, PowerPoint presentation, and image gallery.

Easily rearrange chapters, combine material, and quickly upload content you have written, such as your course syllabus or teaching notes, using McGraw- Hill Education Create. Find the content you need by searching through thou- sands of leading McGraw-Hill Education textbooks. Arrange your book to fit your teaching style. Create even allows you to personalize your book’s appear- ance by selecting the cover and adding your name, school, and course informa- tion. Order a Create book, and you will receive a complimentary print review copy in three to five business days or a complimentary electronic review copy via e-mail in about an hour. Experience how McGraw-Hill Education empowers you to teach your students your way: http://create.mheducation.com

Capture lessons and lectures in a searchable format for use in traditional, hybrid, “flipped classes” and online courses by using Tegrity (http://www .tegrity.com). Its personalized learning features make study time efficient, and its affordability brings this benefit to every student on campus. Patented search technology and real-time Learning Management System (LMS) integrations make Tegrity the market-leading solution and service.

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Annual Editions: Human Sexualities This volume offers diverse topics on sex and sexuality with regard to the human experience. Learning Outcomes, Critical Thinking questions, and Internet Refer- ences accompany each article to further enhance learning. Customize this title via McGraw-Hill Create at http://create.mheducation.com.

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xxvi

Chapter-by-Chapter Changes

The research on sexuality is ever increasing, thereby providing the material to allow this new edition to be current and relevant. This new edition is based on the trends, data, and laws from 2012–2015, including the U.S. Supreme Court’s ruling that legalized same-sex marriage in all 50 states, the role of media in singlehood, dating, and partnerships, expanding definitions and meanings of gender and gender identity; increased focus on sexual desire, pleasure, and sat- isfaction; and how the DSM-5 has reframed paraphilic behavior and sexual func- tion difficulties. Human Sexuality: Diversity in Contemporary America addresses these and many other important changes in the field.

Chapter 1: Perspectives on Human Sexuality ■ Updated and expanded material on media use and its impact on teens ■ New data on social networking ■ New Think About It box: “Before Pressing ‘Send’: Trends and Concerns

About Texting, Sexting, and Dating” ■ New data on online dating sites ■ Updated language used to describe gender and gender identity ■ Updated Declaration of Sexual Rights

Chapter 2: Studying Human Sexuality ■ New Think About It box: “Does Sex Have an Inherent Meaning?” ■ Expanded discussion of computer-based technology and the Internet for the

collection of sexuality-related research data ■ Expanded presentation of the Kinsey Heterosexual-Homosexual Rating

Scale ■ Findings of the latest Centers for Disease Control Youth Risk Behavior Survey ■ Findings of the latest American College Health Association research on

college student sexual behavior ■ Expanded discussion of African American sexuality

Chapter 3: Female Sexual Anatomy, Physiology, and Response ■ Continued discussion and research on the G-spot ■ New research on sexual fluidity

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Chapter-by-Chapter Changes xxvii

■ Expanded discussion about the role of female desire ■ New Think About It box: “ ‘Did You Come?’ What College Students Think

About Women’s Orgasms During Heterosexual Sex”

Chapter 4: Male Sexual Anatomy, Physiology, and Response ■ Increased discussion about men’s hormone cycles ■ Updated and new to Chapter 4 Think About It box: “ ‘Oh to Be Bigger’:

Breast and Penis Enhancement” with added discussion on the significance of a man’s penis size

■ Discussion of the biological differences between men’s and women’s orgasms ■ Update on the sexual health of men

Chapter 5: Gender and Gender Roles ■ Changing terminology and laws related to gender ■ New steps that college campuses can take to address sexual violence ■ Added emphasis about the ways in which contemporary sexual scripts can

influence attitudes and behaviors ■ New “Tips for Allies of Transgender People” ■ New DSM-5 diagnosis and explanation of gender dysphoria ■ New material on disorders of sex development ■ Updated and re-titled Think About It box: “A Cautious Approach to

Addressing Disorders of Sexual Development (DSD) in Children” ■ Expanded discussion of transgender ■ Updated and re-titled Think About It box: “Psychological and Medical

Treatment of Gender Dysphoria”

Chapter 6: Sexuality in Childhood and Adolescence ■ Review of literature on early adolescence and precocious puberty and its

impact on boys and girls ■ Expanded discussion on the harassment of GLBT adolescents and its

impact on behavior ■ Updated data on teen sexuality and research about what predisposes teens

to sexual behavior ■ New discussion about first intercourse and the varied cultural and personal

meanings young people give to it ■ Introduction to the President’s Teen Pregnancy Prevention Initiative, which

replaces abstinence-only programs ■ New Think About It box: “Healthy Teen Sexuality”

Chapter 7: Sexuality in Adulthood ■ New discussion of Centers for Disease Control’s data related to sexual

orientation and its impact on government funding and research decisions ■ Expanded discussion about bisexuality ■ Updated discussion on the motivations for college students to have sex

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xxviii Chapter-by-Chapter Changes

■ New material on men having sex with men and racial and ethnic identity ■ New data on rates of cohabitation, same-sex marriage, and parenthood

Chapter 8: Love and Communication in Intimate Relationships ■ New Think About It box: “Let’s (Not) Talk About Sex: Avoiding the Dis-

cussion About Past Lovers” ■ Expanded discussion on the health of children raised by gay and lesbian

parents ■ Updates in the Think About It box: “The Science of Love” ■ New data on extradyadic relationships and the motivations for nonexclu-

siveness ■ Added discussion about and motivations for “rebound sex” ■ Expanded scale in the Practically Speaking box: “Communication Patterns

and Partner Satisfaction” ■ New discussion on argumentation and the resolution of conflicts

Chapter 9: Sexual Expression ■ Expanded discussion on factors that influence sexual attractiveness ■ New material on the similarities and differences in sexual desire and

desired traits of a potential sexual partner of same-sex and mixed-sex individuals

■ New summary of the results of studies related to the Sexual Strategies Theory

■ Expanded discussion and new research on the prevalence, sexual behaviors, and outcomes of hooking up among college students

■ Updated and re-titled Think About It box: “Hooking Up Among College Students: As Simple As One Might Think?”

■ New research on sexual scripts among college students ■ Expanded discussion of the sexual repertoires of same-sex and opposite-sex

couples ■ New research on the meaning of the first kiss with a possible new romantic

partner and the role of kissing in exclusive relationships ■ New data on college women’s attitudes toward and experiences with

cunnilingus

Chapter 10: Variations in Sexual Behavior ■ Updated discussion of sexual paraphilias based on the American Psychiatric

Association (APA) Diagnostic and Statistical Manual of Mental Disorders— 5th Edition (DSM-5)

■ New discussion of the distinction between APA paraphilias (relatively harmless variant sexual behavior) and APA paraphilic disorders (relatively harmful variant sexual behavior)

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■ Discussion of the changes in the DSM-5 description of paraphilias compared to DSM-IV-TR description

■ New Think About It box: “Classifying Variant Sexual Behaviors as Paraphilia: The Changing Medical Views of Psychology”

■ Expanded and updated discussion of sex addiction in the Think About It box: “ ‘Sexual Addiction’: Repressive Morality in a New Guise?”

Chapter 11: Contraception and Abortion ■ Updated material about navigating reproductive health, including a brief

history of contraception, Title X, and Affordable Health Care ■ Added discussion on long-acting reversible contraceptive methods (LARCs) ■ Complete review and update of contraceptive methods ■ New information about breastfeeding and hormonal methods of birth control ■ New data on the rates of abortion

Chapter 12: Conception, Pregnancy, and Childbirth ■ Updated data on pregnancies, by race and ethnicity, and marital status ■ Increased focus on preconception and prenatal care ■ Expanded discussion on maternal obesity ■ Updates on male and female infertility and assisted reproductive technologies ■ Revised Think About It box: “The Question of Male Circumcision” ■ Updated and expanded discussion on breastfeeding

Chapter 13: The Sexual Body in Health and Illness ■ New Think About It box: “Body Image and Sexuality: Are They One and

the Same?” ■ New focus on myths about disability and sexuality ■ Thorough revision of statistics, research, and new and controversial guide-

lines for the detection of breast cancer ■ Discussion of sexual adjustment following breast cancer treatment ■ New screening recommendations for cervical cancer and prostate cancer ■ New material on sexual orientation and health, especially as they relate to

disparities and discrimination

Chapter 14: Sexual Function Difficulties, Dissatisfaction, Enhancement, and Therapy ■ Updated Think About It box: “Is Intercourse Enough? The Big ‘O’ and

Sexual Behaviors” ■ Updated discussion of sexual function difficulties based on the American

Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders—5th Edition (DSM-5)

■ Discussion of the changes in the DSM-5 description of sexual dysfunctions compared to the DSM-IV-TR description

Chapter-by-Chapter Changes xxix

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■ New data on sexual function difficulties among men and women with same-sex or opposite-sex partners and lesbian and heterosexual women

■ Discussion of a new DSM-5 category: substance/medication-induced sexual dysfunction

■ New discussion of the hierarchy of sexual behaviors ■ New Think About It box: “My Partner Could Be a Better Lover If . . . :

What Men and Women Want From Their Sexual Partners” ■ New material on strategies to cope with sexual difficulties ■ Updated Think About It box: “The Medicalization of Sexual Function

Problems”

Chapter 15: Sexually Transmitted Infections ■ Updated information on the prevalence and incidence of major STIs ■ Updated medical information on the major STIs ■ Expanded discussion on the role of male and female condoms in STI

prevention ■ New stances of the Centers for Disease Control and Prevention American

Academy of Pediatrics on the impact of male circumcision in stopping the spread of HIV infection and other STIs

■ Information on a new HPV vaccination ■ Expanded discussion of the impact of HPV vaccination on sexual behavior ■ Added discussion of the role of STI testing in preventing STIs

Chapter 16: HIV and AIDS ■ Updated information on the prevalence and incidence of HIV/AIDS in the

United States and worldwide ■ New discussion on the worldwide progress in reducing new HIV infections,

the recent decrease in annual HIV diagnoses, and stability of new HIV infections in the United States

■ Updated biological information on HIV/AIDS ■ Expanded discussion on the impact of HIV stigma ■ Expanded discussion of myths and modes of HIV transmission and esti-

mated lifetime risk for HIV diagnosis ■ Updated and expanded discussion of HIV/AIDS among minority races/

ethnicities and sexual minorities ■ New and expanded discussion of pre-exposure prophylaxis and new mate-

rial on post-exposure prophylaxis ■ Updated information on HIV testing and treatment

Chapter 17: Sexual Coercion ■ New and expanded information on stalking and sexual harassment in the

military and public places ■ Updated information on sexual harassment, discrimination, legal equality,

and rejection of GLBT persons

xxx Chapter-by-Chapter Changes

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■ New material on the lifetime prevalence of men and women who have experienced sexual violence

■ Updated and expanded information on preventing sexual assault ■ New material on campus sexual violence, including sexual coercion strate-

gies of both men and women ■ New Think About It box: “Can Men and Women Accurately Judge a Partner’s

Willingness to Have Casual Sex?” ■ New Think About It box: “How College Students Indicate and Interpret

Consent to Have Sex” ■ New material on strategies men and women employ to obtain sexual

contact with unwilling partners ■ New information on the mental health and sexual functioning of persons

who experience sexual violence

Chapter 18: Sexually Explicit Materials, Prostitution, and Sex Laws ■ New material on the 2015 U.S. Supreme Court’s ruling that legalized

same-sex marriage in all 50 states ■ New material on the consumption of sexually explicit materials, including

men’s and women’s preferences for various types of visual sexual stimuli ■ New research on the content of sexually explicit videos and the character-

istics of “porn stars” ■ New Think About It box: “Sexually Explicit Material Use in Romantic

Couples: Beneficial or Harmful?” ■ Expanded discussion on viewing sexually explicit videos and college stu-

dents, including its relationship with hooking up ■ New material on whether the label “porn addiction” is accepted among

mental health professionals ■ Expanded and updated discussion on research to determine any influence

of pornography consumption on sexual aggression ■ Expanded and updated information on female and male prostitution, why

individuals become prostitutes, and the characteristics of clients who pay for sex with male escorts

■ Updated and re-titled Think About It box: “Sex Trafficking: A Modern-Day Slavery”

Chapter-by-Chapter Changes xxxi

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• Acknowledgments In addition to student user feedback through McGraw-Hill Education’s Learn- Smart, feedback from instructor reviews were instrumental in guiding this revi- sion. Special thanks to the following:

Daria A. Bakina, SUNY Oswego Coreen Haym, University of Nevada at Las Vegas Nancy King, Western Michigan University Jennifer Mewes, Pima Community College Elizabeth Morgan, Springfield College Jonathan Moss, William Paterson University Helen J. Powell, Wayne State University Mary E. Ramey, University of Illinois at Urbana-Champaign Marie Wallace, Pima Community College, Northwest Campus Anthony D. Yankowski, Bergen Community College

We would also like to thank our team at McGraw-Hill Education: Nancy Welcher, Senior Brand Manager, Lead Product Developer Dawn Groundwater, Senior Product Developer Sarah Colwell, Product Developer Joni Fraser, Senior Marketing Managers AJ Laferrera, Ann Helgerson, and Christina Yu, Content Production Manager Sandy Wille, Content Licensing Specialists Beth Thole (text), Keri Johnson and Melissa Homer (photo), and Matt Diamond Designer. Additional thanks go out to: Alijah Marquez personal assistant and input editor, Angie Sigwarth and Christopher Greene, freelance proofreaders, and David Tietz, freelance photo researcher.

xxxii Chapter-by-Chapter Changes

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xxxiii

“Sex is like dynamite. . . . It can be the cement of a relationship, but it can be the level that breaks people apart.”

—Joseph Fletcher (1905–1991)

When students first enter a human sexuality class, they may feel excited, ner- vous, and uncomfortable, all at the same time. These feelings are common. This is because the more an area of life is judged “off limits” to public and private discussion the less likely it is to be understood and embraced. Yet, sex surrounds us and impacts our lives every day from the provocative billboard ad on the highway, to the steamy social media images of the body, to men’s and women’s fashions, and to prime-time television dramas. People want to learn about the role and meaning of human sexuality in their lives and how to live healthy psychologically and physically, yet they often do not know whom to ask or what sources to trust. In our quest for knowledge and understanding, we need to maintain an intellectual curiosity. Author William Arthur Ward observes, “Curi- osity is the wick in the candle of learning.”

Students begin studying sexuality for many reasons: to gain insights into their sexuality and relationships, to become more comfortable with their sexuality, to learn how to enhance sexual pleasure for themselves and their partners, to explore personal sexual issues, to dispel anxieties and doubts, to validate their sexual identity, to avoid and resolve traumatic sexual experiences, and to learn how to avoid STIs and unintended pregnancies. Many students find the study of human sexuality empowering; they develop the ability to make intelligent sexual choices based on reputable information and their own needs, desires, and values rather than on stereotypical, haphazard, unreliable, incomplete, or unre- alistic information; oppressive cultural dictums; or guilt, fear, or conformity. They learn to differentiate between what they have been told about their own sexuality and what they truly believe; that is, they begin to own their sexuality. Those studying this subject often report that they feel more appreciative and less apologetic, defensive, or shameful about their sexual feelings, attractions, and desires.

Particularly in a country as diverse as the United States, the study of human sexuality calls for us to be open-minded: to be receptive to new ideas and to various perspectives; to respect those with different experiences, values, orienta- tions, ages, abilities, and ethnicities; to seek to understand what we have not understood before; to reexamine old assumptions, ideas, and beliefs; and to embrace and accept the humanness and uniqueness in each of us.

Letter From the Authors

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Sexuality can be a source of great pleasure and, yes, the “cement” of a relationship. Through it, we can reveal ourselves, connect with others on the most intimate levels, create strong bonds, and bring new life into the world. Paradoxically, though, sexuality can also be a source of guilt and confusion, anger and disappointment, a pathway to infection, and a means of exploitation and aggression. We hope that by examining the multiple aspects of human sexuality presented in this book, you will come to understand, embrace, and appreciate your own sexuality and the unique individuality of sexuality among others, to learn how to make healthy sexual choices for yourself, to integrate and balance your sexuality into your life as a natural health-enhancing compo- nent, and to express your sexuality with partners in sharing, nonexploitive, and nurturing ways.

William L. Yarber Barbara W. Sayad

xxxiv Letter From the Authors

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xxxv

WILLIAM L. YARBER is professor of applied health science and affiliated faculty member in gender studies at Indiana University, Bloomington. He is also a senior research fellow at The Kinsey Institute for Research in Sex, Gender, and Reproduction and the senior director of the Rural Center for AIDS/STD Prevention at Indiana University.

Dr. Yarber, who received his doctorate from Indiana University, has authored or co-authored numerous scientific reports on sexual risk behavior and AIDS/STI pre- vention in professional journals and has received federal and state grants to support his research and prevention activities. He is a member of The Kinsey Institute Condom Use Research Team (CURT), comprised of researchers from Indiana University, University of Kentucky, University of Guelph (Canada), and University of Southampton (United Kingdom). For over 15 years, with federal and institutional research support, CURT has investigated male condom use errors and problems and has developed behav- ioral interventions designed to improve correct and consistent condom use.

At the request of the U.S. federal government, Dr. Yarber authored the country’s first secondary school AIDS prevention education curriculum, AIDS: What Young Peo- ple Should Know (1987). He also co-edited the Handbook of Sexuality-Related Mea- sures, third edition (2011). Dr. Yarber and Dr. Sayad’s textbook Human Sexuality: Diversity in Contemporary America (McGraw-Hill), which is used in colleges and uni- versities throughout the United States, was published in 2012 by the Beijing World Publishing Company as the most up-to-date text on human sexuality published in China in the past half century. Also in 2012, the text was published in Korea.

Dr. Yarber chaired the National Guidelines Task Force, which developed the Guide- lines for Comprehensive Sexuality Education: Kindergarten–12th Grade (1991, 1996, 2004), published by the Sexuality Information and Education Council of the United States (SIECUS) and adapted in six countries worldwide. Dr. Yarber is past president of The Society for the Scientific Study of Sexuality (SSSS) and a past chair of the SIECUS board of directors. His awards include the SSSS Distinguished Scientific Achievement Award; the Professional Standard of Excellence Award from the American Association of Sex Educators, Counselors, and Therapists; the Indiana University Pres- ident’s Award for Distinguished Teaching; and the inaugural Graduate Student Out- standing Faculty Mentor Award at Indiana University.

Dr. Yarber has been a consultant to the World Health Organization Global Program on AIDS as well as sexuality-related organizations in Brazil, China, Jamaica, Poland, Portugal, and Taiwan. He regularly teaches undergraduate and graduate courses in human sexuality. He was previously a faculty member at Purdue University and the University of Minnesota, as well as a public high school health science and biology teacher. Dr. Yarber endowed at Indiana University, for perpetuity, the world’s first professorship in sexual health, the William L. Yarber Professorship in Sexual Health.

About the Authors

William L. Yarber

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xxxvi About the Authors

BARBARA WERNER SAYAD is a consummate teacher, trainer, writer, and consul- tant. As a recently retired faculty member from California State University, Monterey Bay, Dr. Sayad has taught a wide variety of courses, including human sexuality, women’s health, community health education, multi-cultural health education and promotion, and senior capstone. Her work in the classroom has earned her several nominations for outstanding faculty member and she has and continues to serve as a McNair Scholars mentor. Additionally, she has chaired a number of university committees, spoken at dozens of university-related events, and trained and collaborated with other faculty mem- bers in areas related to public health and personal well-being.

Dr. Sayad has presented her work at a variety of institutions, most significant of which is focused on comprehensive sexuality education programming. One that she is most proud of is her alliance with Aibai, the largest GLBT organization in China, where she traveled with her co-author, Dr. Yarber, to present to the Asian Conference on Sexual Education. There she also provided training for American delegates and Chinese scholars at the U.S. Embassy, U.S. State Department, and UNESCO and was invited to speak at Xixi, the equivalent of a TED Talk, in Shanghai.

The vast majority of Dr. Sayad’s 34-year career has been connected to issues of social justice: women’s reproductive rights, GLBT education and advocacy, and health access. As a result of this focus coupled with her global travels, she has contributed to a variety of health-related texts, curricular guides, and publications and has facili- tated a wide array of training programs, presented at professional conferences, and worked as a trainer and curriculum specialist.

Dr. Sayad holds a Bachelor of Science degree in Foods and Nutrition, a Masters degree in Public Health, and a PhD in health services.

Dr. Sayad is most proud of her three children, new grandchild, and extended family and is eternally grateful to be married for 33 years to Dr. Robert Sayad.

Barbara Werner Sayad

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1 Perspectives on Human Sexuality chapter

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C H A P T E R O U T L I N E Studying Human Sexuality

Sexuality, Popular Culture, and the Media

Sexuality Across Cultures and Times

Societal Norms and Sexuality

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2 Chapter 1 Perspectives on Human Sexuality

“The media, especially magazines and televi- sion, has had an influ- ence on shaping my sexual identity. Ever since I was a little girl, I have watched the

women on TV and hoped I would grow up to look sexy and beautiful like them. I feel that because of the constant bar- rage of images of beautiful women on TV and in magazines young girls like me grow up with unrealistic expectations of what beauty is and are doomed to feel they have not met this exaggerated standard.”

—21-year-old female

“The phone, television, and Internet became my best friends. I never missed an episode of any of the latest shows, and I knew all the words to every new song. And when Facebook entered my life, I finally felt connected. At school, we would talk about status updates: whom we thought was cute, relationship status, and outrageous pho- tos. All of the things we saw were all of the things we fanta- sized about. These are the things we would talk about.”

—23-year-old female

“Though I firmly believe that we are our own harshest critics, I also believe that the media have a large role in

influencing how we think of ourselves. I felt like ripping my hair out every time I saw a skinny model whose stom- ach was as hard and flat as a board, with their flawless skin and perfectly coifed hair. I cringed when I realized that my legs seemed to have an extra ‘wiggle-jiggle’ when I walked. All I could do was watch the television and feel abashed at the differences in their bodies com- pared to mine. When magazines and films tell me that for my age I should weigh no more than a hundred pounds, I feel like saying, ‘Well, gee, it’s no wonder I finally turned to laxatives with all these pressures to be thin surround- ing me.’ I ached to be model-thin and pretty. This fixation to be as beautiful and coveted as these models so preoc- cupied me that I had no time to even think about anyone or anything else.”

—18-year-old female

“I am aware that I may be lacking in certain areas of my sexual self-esteem, but I am cognizant of my shortcomings and am willing to work on them. A person’s sexual self- esteem isn’t something that is detached from his or her daily life. It is intertwined in every aspect of life and how one views his or her self: emotionally, physically, and men- tally. For my own sake, as well as my daughter’s, I feel it is important for me to develop and model a healthy sexual self-esteem.”

—28-year-old male

Sexuality was once hidden from view in our culture: Fig leaves covered the “private parts” of nudes; poultry breasts were renamed “white meat”; censors prohibited the publication of the works of D. H. Lawrence, James Joyce, and Henry Miller; and homosexuality was called “the love that dares not speak its name.” But over the past few generations, sexuality has become more open. In recent years, popular culture and the media have transformed what we “know” about sexuality. Not only is sexuality not hidden from view; it often seems to surround and embed itself into all aspects of our lives.

In this chapter, we discuss why we study human sexuality and examine pop- ular culture and the media to see how they shape our ideas about sexuality. Then we look at how sexuality has been conceptualized in different cultures and at different times in history. Finally, we examine how society defines various aspects of our sexuality as natural or normal.

• Studying Human Sexuality The study of human sexuality differs from the study of accounting, plant biol- ogy, and medieval history, for example, because human sexuality is surrounded by a vast array of taboos, fears, prejudices, and hypocrisy. For many, sexuality

Voices Student

Nature is to be reverenced, not blushed at.

—Tertullian (c. 155 ce–c. 220 ce)

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Studying Human Sexuality 3

creates ambivalent feelings. It is linked not only with intimacy and pleasure but also with shame, guilt, and discomfort. As a result, you may find yourself con- fronted with society’s mixed feelings about sexuality as you study it. You may find, for example, that others perceive you as somehow “unique” or “different” for taking this course. Some may feel threatened in a vague, undefined way. Parents, partners, or spouses (or your own children, if you are a parent) may wonder why you want to take a “sex class”; they may want to know why you don’t take something more “serious”—as if sexuality were not one of the most important issues we face as individuals and as a society. Sometimes this uneas- iness manifests itself in humor, one of the ways in which we deal with ambiv- alent feelings: “You mean you have to take a class on sex?” “Are there labs?” “Why don’t you let me show you?”

Ironically, despite societal ambivalence, you may quickly find that your human sexuality text or ebook becomes the most popular book in your dormi- tory or apartment. “I can never find my textbook when I need it,” one of our students complained. “My roommates are always reading it. And they’re not even taking the course!” Another student observed: “My friends used to kid me about taking the class, but now the first thing they ask when they see me is what we discussed in class.” “People borrow my book so often without asking,” writes one student, “that I hide it now.”

As you study human sexuality, you will find yourself exploring topics not ordinarily discussed in other classes. Sometimes they are rarely talked about even among friends. They may be prohibited by family, religious, or cultural teaching. For this reason, behaviors such as masturbation and sexual fantasizing are often the source of considerable guilt and shame. But in your human sexu- ality course, these topics will be examined objectively. You may be surprised to discover, in fact, that part of your learning involves unlearning myths, factual errors, distortions, biases, and prejudices you learned previously.

Sexuality may be the most taboo subject you study as an undergraduate, but your comfort level in class will probably increase as you recognize that you and your fellow students have a common purpose in learning about sexuality. Your sense of ease may also increase as you and your classmates get to know one another and discuss sexuality, both inside and outside the class. You may find that, as you become accustomed to using the accepted sexual vocabulary, you are more comfortable discussing various topics. For example, your communication with a partner may improve, which will strengthen your relationship and increase sexual satisfaction for both of you. You may never before have used the word masturbation, clitoris, or penis in a class setting or any kind of setting, for that matter. But after a while, using these and other terms may become second nature to you. You may discover that discussing sexuality academically becomes as easy as discussing computer science, astronomy, or literature. You may even find yourself, as many students do, discussing with your friends what you learned in class while on a bus or in a restaurant, as other passengers or diners gasp in surprise or lean toward you to hear better!

Studying sexuality requires respect for your fellow students. You’ll discover that the experiences and values of your classmates vary greatly. Some have little sexual experience, while others have a lot of experience; some students hold progressive sexual values, while others hold conservative ones. Some students are gay, lesbian, queer, bisexual, or asexual individuals, while the majority are heterosexual people. Most students are young, others middle-aged, some

Educating the mind without educating the heart is no

education at all.

—Aristotle (384 B.C.–322 B.C.)

Taking a course in human sexuality is like no other college experience. It requires that students examine their sexual beliefs and behaviors in the context of a wide variety of social and cultural factors and incorporate this new perspective into their sexual lives and well-being. © Andersen Ross/Getty Images

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4 Chapter 1 Perspectives on Human Sexuality

older—each in a different stage of life and with different developmental tasks before them. Furthermore, the presence of students from any of the numerous ethnic groups in the United States reminds us that there is no single behavior, attitude, value, or sexual norm that encompasses sexuality in contemporary America. Finally, as your sexuality evolves you will find that you will become more accepting of yourself as a sexual human being. From this, you will truly “own” your sexuality.

• Sexuality, Popular Culture, and the Media Much of sexuality is influenced and shaped by popular culture, especially the mass media. Popular culture presents us with myriad images of what it means to be sexual. But what kinds of sexuality do the media portray for our consumption?

Media Portrayals of Sexuality What messages do the media send about sexuality to children, adolescents, adults, and older people? To men and women and to those of varied races, ethnicities, and sexual orientations? Perhaps as important as what the media portray sexually is what is not portrayed—masturbation, condom use, and older adults’ sexuality, for example.

The media are among the most powerful forces in people’s lives today. Adults ages 18 and over spend more time engaging with the media than in any other activity—an average of 12 hours per day, 7 days per week (see Figure 1). Watch- ing TV, playing video games, texting, listening to music, and searching the Internet provide a constant stream of messages, images, expectations, and values about which few (if any) of us can resist. Whether and how this exposure is related to sexual outcomes is complex and debatable, depending on the popula- tion studied. However, the data that are available may provide an impetus for policymakers who are forming media policies, parents who are trying to support their children’s identity and learning, and educators and advocates who are con- cerned about the impact of media on youth and who wish to underscore the

One picture is worth more than a thousand words.

—Chinese proverb

Images of sexuality permeate our society, sexualizing our environment. Think about the sexual images you see or hear in a 24-hour period. What messages do they communicate about sexuality?

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Sexuality, Popular Culture, and the Media 5

potential impact of media in individuals’ lives. For those concerned about pro- moting sexual health and well-being, understanding media’s prominence and role in people’s lives is essential.

Mass-media depictions of sexuality are meant to entertain and exploit, not to inform. As a result, the media do not present us with “real” depictions of sexu- ality. Sexual activities, for example, are usually not explicitly acted out or described in mainstream media, nor is interracial dating often portrayed. The social and cultural taboos that are still part of mainstream U.S. culture remain embedded in the media. Thus, the various media present the social context of sexuality; that is, the programs, plots, movies, stories, articles, newscasts, and vignettes tell us what behaviors are appropriate (e.g., kissing, sexual intercourse), with whom they are appropriate (e.g., girlfriend/boyfriend, partner, heterosexual), and why they are appropriate (e.g., attraction, love, to avoid loneliness).

Probably nothing has revolutionized sexuality the way that access to the Internet has. A click on a website link provides sex on demand. The Internet’s contributions to the availability and commercialization of sex include live images and chats, personalized pages and ads, and links to potential or virtual sex partners. The spread of the web has made it easy to obtain information, solidify social ties, and provide sexual gratification.

The music industry is awash with sexual images too. Contemporary pop music, from rock ’n’ roll to rap, is filled with lyrics about sexuality mixed with messages about love, rejection, violence, and loneliness. With the average young

12:05Total

Other 0:45

0:20Magazines

0:30Newspapers

Print** 0:32

Radio 1:26

TV 4:31

0:36Other

2:21Mobile (nonvoice)

2:19Online*

5:16Digital

Note: Ages 18+; time spent with each medium includes all time spent with that medium, regardless of multitasking; for example, 1 hour of multitasking online while watching TV is counted as 1 hour for TV and 1 hour for online; *includes all Internet activities on desktop and laptop computers; **ofine reading only.

1 2 3 4 5 6 7 8 9 10 11 12 13 Hr/Min

• FIGURE 1 Average Time Spent per Day in the United States with Media, Aged 18+ and Over, 2013. Includes all time spent with medium, regardless of multitasking.

(Source: www.eMarketer.com [July 2013].)

Would you like to come back to my place and do what I’m going to tell

my friends we did anyway?

—Spanky

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www.eMarketer.com

6 Chapter 1 Perspectives on Human Sexuality

person consuming approximately 2.5 hours of music each day (Roberts, Foehr, & Rideout, 2010), some research has found that increased exposure to sexualized music lyrics has the potential to negatively impact the development of healthy and equitable sexual attitudes of adolescent males and females (Hall, West, & Hill, 2011). Because of censorship issues, the most overtly sexual music is not played on the radio but can easily be streamed through the Internet, which we now recognize is available to nearly everyone.

Magazines, tabloids, and books contribute to the sexualization of our society as well. For example, popular romance novels and self-help books disseminate ideas and values about sexuality and body image. Men’s magazines have been singled out for their sexual emphasis. Playboy, Men’s Health, and Maxim, with their Playmates of the Month, sex tips, and other advice, are among the most popular magazines in the world. Sports Illustrated’s annual swimsuit edition, which is now a $1 billion empire, excites millions of readers who await the once-a-year feature (Spector, 2013). But it would be a mistake to think that only male-oriented magazines focus on sex.

Women’s magazines such as Cosmopolitan and Glamour have their own sexual content. These magazines feature romantic photographs of lovers to illustrate stories with such titles as “Sizzling Sex Secrets of the World’s Sexiest Women,” “Making Love Last: If Your Partner Is a Premature Ejacula- tor,” and “Turn on Your Man with Your Breasts (Even If They Are Small).” Preadolescents and young teens are not exempt from sexual images and arti- cles in magazines such as Seventeen and YM. In fact, of the top four teen magazines aimed at girls, 44% of the articles focused on dating and 37% on appearance ( American Academy of Pediatrics, 2014.1a). Given this heavy emphasis on looks, it’s not surprising that for those who read a lot of women- focused magazines, they are more likely to have internalized the thin ideal, have negative views of their appearance, and engage in restricted eating and bulimic behaviors (Northrup, 2013). Some of the men’s health magazines have followed the lead of women’s magazines, featuring sexuality-related issues as a way to sell more copies.

Advertising in all media uses the sexual sell, promising sex, romance, popularity, and fulfillment if the consumer will only purchase the right soap, perfume, cigarettes, alcohol, toothpaste, jeans, or automobile. In reality, not only does one not become “sexy” or popular by consuming a certain product, but the product may actually be detrimental to one’s sexual well-being, as in the case of cigarettes or alcohol.

Media images of sexuality permeate a variety of areas in people’s lives. They can produce sexual arousal and emotional reactions, provide social con- nection, entertain, increase sexual behaviors, and be a source of sex informa- tion. On the other hand, unmonitored Internet access among youth raises significant concerns about its risks (Federal Bureau of Investigation, 2014). Given the fact that 91% of 12- to 13-year-old girls have Internet access and 72% have mobile access via smartphones, tablets, and other devices, it’s clear that media consumption and exposure explode between the early and later tween years (Jones, 2014).

Studies examining the impact of exposure to sexual content in media have found a modest but significant association between adolescents’ sexual beliefs and early sexual initiation. When studies collectively examine adolescents’ online exposure to pornography, they suggest that youth may develop unrealis- tic sexual values and beliefs (Owens, Behun, Manning, & Reid, 2012).

Women’s magazines such as Cosmopolitan, Women’s Health, and Glamour use sex to sell their publications. How do these magazines differ from men’s magazines such as Men’s Health, Playboy, and Maxim in their treatment of sexuality? © Consumer Trends/Alamy

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Sexuality, Popular Culture, and the Media 7

Gender differences in self-concept have also been noted in adolescents’ use of pornography, with girls reporting feelings of physical inferiority, while boys fear they may not be as virile or able to perform compared to those in these media (Lofgren-Martenson & Mansson, 2010). As such, it isn’t surprising that self-objectification, choosing to evaluate ourselves based on appearance, has received some scrutiny from the American Psychological Association (2007), which warns that young people “may internalize an observer’s perspective on their physical selves and learn to treat themselves as objects to be looked at and evaluated for their appearance” (p. 18).

Television and Digital Media Among all types of media, television and digital (online and mobile) have been the most prevalent, pervasive, and vexing icons, saturating every corner of public and private space, shaping consciousness, defining reality, and enter- taining the masses. Between ages 12 and 17, the average youth spends over 100 hours a month watching TV and online videos (see Figure 2). By the time an American teenager finishes high school, he or she will have spent more time in front of a television or mobile device screen than in the class- room or sleeping. At the same time, most of the consumption of media leaves the majority of young people outside the purview of adult comment and with few messages or images that demonstrate the risks and responsibilities that accompany sexuality.

While the frequency of TV and digital viewing has been increasing, so has been the number of sexual references in programs. Television and digital video viewing are major sources of information about sex for teenagers, contributing to many aspects of young people’s sexual knowledge, beliefs, and behavior. Reporting on the health effects of media on children and adolescents, Stras- burger and colleagues (2010) state that “virtually every Western country makes birth control available to adolescents, including allowing birth control advertise- ments in the media, but the major U.S. television networks balk at airing ads for contraception” (p. 760).

In the accumulated volume of media research, media content does not reflect the realities of the social world; rather, the media images of women and men reflect and reproduce a set of stereotypical and unequal but changing gender roles. For example, women wearing skimpy clothing and expressing their sex- uality to attract attention underscores the objectification of women seen in

Reality shows, such as The Bachelorette, frequently highlight idealized and sexual themes. What are some of the most popular reality shows? Do they differ according to ethnicity? © Raymond Hall/GC Images/Getty Images

• FIGURE 2 Adolescents’ and Young Adults’ Monthly Video Viewing Time by Type of Device, 2012.

Source: The teen transition: Adolescents of today, adults of tomorrow (2013). New York: The Nielsen Company.

12- to 17-year-olds

8 mobile hours

5 online hours

99 TV hours

7 mobile hours

18- to 24-year-olds

15 online hours

111 TV hours

25- to 34-year-olds

5 mobile hours

11 online hours

136 TV hours

112 video hours per month

133 video hours per month

152 video hours per month

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8 Chapter 1 Perspectives on Human Sexuality

many genres of media. And men’s messages are equally unilateral, which is that they should accumulate sexual experience with women by any means pos- sible. Sexist advertising and stereotypical roles in comedy series and dramas may take subtle (or not so subtle) forms that, over time, may have an effect on the way some women and men view themselves. For example, studies exam- ining the effects of television have shown a positive connection between tele- vision viewing and poor self-image and self-esteem, particularly among girls and young women (Tiggemann, 2005). Girls who regularly watch reality tele- vision, for example, are significantly more likely to believe that a girl’s looks are the most important thing about her and are more likely to say they would rather people recognize them for their outer beauty than what’s inside (Girl Scout Research Institute, 2011). While it is apparent that exposure to television does not affect all people in the same way, it is clear that the sexual double standard that does exist taps into our national ambivalence about sex, equality, morality, and violence. In spite of this, television is making strides to educate teens and young adults about sexuality and parenting. Programs such as Teen Mom 2 and 3, Parenthood, East Los High, The Mindy Project, and The Fosters have consulted with organizations such as The National Campaign to Prevent Teen and Unplanned Pregnancy to help educate viewers. This type of alliance is good for all of us.

Unlike the film industry, which uses a single ratings board to regulate all American releases, television has been governed by an informal consensus. In 1997, networks began to rely on watchdog standards and practices departments to rate their shows; however, these divisions have few, if any, hard-and-fast rules. While the Federal Communication Commission (FCC) does not offer clear guidelines about what is and is not permissible on the airwaves, the agency does permit looser interpretations of its decency standards for broadcasts between 10 p.m. and 6 a.m. Additionally, in 2006, the television industry launched a large campaign to educate parents about TV ratings and the V-chip, technology that allows the blocking of programs based on their rating category.

Music and Game Videos MTV, MTV2, VH1, BET, and music Internet programs are very popular among adolescents and young adults. Unlike audio-recorded music, music videos play to the ear and the eye. At the same time, young female artists such as Alicia Keys and Rihanna have brought energy, sexuality, and individualism to the young music audience. Music videos have also objectified and degraded women by stripping them of any sense of power and individualism and focusing strictly on their sexuality. Male artists such as Justin Timberlake, Robin Thicke, and Jay-Z provide young audiences with a steady dose of sexuality, power, and rhythm.

Video games that promote sexist and violent attitudes toward women have filled the aisles of stores across the country. Pushing the line between obscenity and amusement, games often provide images of unrealistically shaped and sub- missive women mouthing sexy dialogues in degrading scenes. Men, in contrast, are often revealed as unrealistic, violent figures whose primary purpose is to destroy and conquer. Though many of these video games are rated “M” (mature) by the Entertainment Software Ratings Board, they are both popular with and accessible to young people.

Watching female icons such as Miley Cyrus twerk, or dance in a provocative manner, has become mainstream in most music videos. © Andrew H. Walker/WireImage/Getty Images

The vast wasteland of TV is not inter- ested in producing a better mouse-

trap but in producing a worse mouse.

—Laurence Coughlin

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Sexuality, Popular Culture, and the Media 9

Feature-Length Films From their very inception, motion pictures have dealt with sexuality. In 1896, a film titled The Kiss outraged moral guardians when it showed a couple stealing a quick kiss. “Absolutely disgusting,” complained one critic. “The performance comes near being indecent in its emphasized indecency. Such things call for police action” (quoted in Webb, 1983). Today, in contrast, film critics use “sexy,” a word indepen- dent of artistic value, to praise a film. “Sexy” films are movies in which the requi- site “sex scenes” are sufficiently titillating to overcome their lack of aesthetic merit. What is clear is that movies are not that dissimilar from television in their portrayal of the consequences of unprotected sex, such as unplanned pregnancies or sexually transmitted infections (STIs), including HIV/AIDS.

While one might argue that it is unwise to confuse entertainment with education, media use is not without its consequences on health. Studies find that high levels of media use are associated with academic problems, sleep deprivation, unhealthy eating, and more (Office of Adolescent Health, 2013). The American Academy of Pediatrics (AAP) (2010) recommends that adolescents have less than 2 hours of screen time per day in part because of its increasing association with childhood obesity. While health professionals can use media to promote people’s health, it’s going to take a lot more commitment and resources to achieve this goal.

Gay Men, Lesbian Women, and Bisexual and Transgender People in Film and Television

Gay men, lesbian women, and bisexual and transgender individuals are slowly being integrated into mainstream films and television. However, when gay men and lesbian women do appear, they are frequently defined in terms of their sexual orientation, as if there were nothing more to their lives than sexuality. Though the situation is changing, gay men are generally stereotyped as effemi- nate, flighty, or “arty,” or they may be closeted. Lesbian women are often stereotyped as either super-feminine or supermasculine.

Mainstream movies, such as Dallas Buyers Club, have presented their gay, lesbian, and transgender characters as fully realized human beings. © Photos 12/Alamy

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10 Chapter 1 Perspectives on Human Sexuality

“Coming out” stories are now the standard for television programs that deal with gay characters. However, what has recently changed is that the age of these characters has become younger. Teen coming-out stories seem relevant in that they reflect the identity issues of being gay, transsexual, queer, questioning, or unsure about their sexual identity and expose the vulnerability most young peo- ple in junior high and high school feel about being bullied. Different from stories in which gay people are marginalized and stereotyped, the messages in many of the shows for younger audiences are quite consistent: that you will be accepted for who you are. Still, television and mainstream media have a long way to go in terms of normalizing healthy sexual relationships between gay and queer people. The biggest hurdle remains in showing adults, particularly two males, kissing on screen as their heterosexual counterparts would. While teen shows may have somewhat overcome this barrier, most “adult” programs have not.

Online Social Networks Surfing the web is a major recreational activity that has altered the ways in which individuals communicate and carry on interpersonal relationships. Though social theorists have long been concerned with the alienating effects of technology, the Internet appears quite different from other communication technologies. Its effi- cacy, power, and influence, along with the anonymity and depersonalization that accompany its use, have made it possible for users to more easily obtain and distribute sexual materials and information, as well as to interact sexually in different ways.

It is apparent that social networking sites, like Facebook, Instagram, and Twitter, are well integrated into the daily lives of most people in the United

For anyone with a computer, social networks provide readily accessible friends and potential partners, help to maintain friendships, and shape sexual culture. © Dean Mitchell/Getty Images

Writers in television and film are finally giving gay characters prominence beyond their sexuality. These include Cameron Monaghan (“Shameless”), Andrew Rannells (“Girls”), Naya Rivera (“Glee”), and Sarah Paulson (“American Horror Story: Asylum”). © Matteo Prandoni/BFAnyc/Sipa USA/ Newscom

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Sexuality, Popular Culture, and the Media 11

States. Their popularity cannot be underestimated: Facebook alone reports to have over 1 billion global users (Social, Digital and Mobile Around the World, 2014). Add this to the additional 2 billion users with other or supplemental platforms and it’s obvious that the digital landscape is highly populated.

Social networking sites provide an opportunity for many to display their identities: religious, political, ideological, work-related, and sexual orientation. While doing so, individuals can also gain feedback from peers and strengthen their bonds of friendship. At the same time, social networking can be a place of “relationship drama” (Pew Research Internet Project, 2013). By posting details or pictures from a date on a social networking site, younger adults in particular are more likely to live out their relationships through these sites. While many who acknowledge that they use the Internet to flirt with others have largely positive opinions and experiences, significant numbers of others have negative ones. Over 25% of social networking users report having unfriended or blocked someone who was flirting in a way that made them feel uncomfortable, and 22% have unfriended or blocked someone they are no longer dating. Many have also used these sites to check up on someone they dated in the past or to research potential romantic partners. Not surprising, many realize that these sites can serve as an unwanted reminder that relationships have ended and, maybe even worse, that their previous beloved one is now dating someone else.

Like other forms of media, the Internet does not simply provide sexual culture; it also shapes sexual culture. With the widespread use of online dating sites, the medium has become an accepted means by which numerous individuals meet new partners for dating, matchmaking, and/or sex (see the “Think About It” box “Before Pressing ‘Send’ ”). For the isolated, underrepresented, and disenfranchised whose sexual identities up until now have been hidden, Internet communications may be a lifeline. The use of the Internet also provides a means of avoiding the pitfalls inherent in relying solely on real-world meetings and experiences. Thus, it’s probably not surprising that someone you know has found a long-term partner or spouse via an online dating site. With more positive attitudes toward online dating and social network sites playing a prominent role in navigating romantic relationships, it has been reported that 1 in 10 Americans have used an online dating site or mobile dating app (Pew Research Internet Project, 2013). Though people in nearly every major demographic group—old and young, straight and gay, urbanites and rural dwellers, and college graduates—are likely to know someone who uses online dating, the most common users are those in their mid-20s through mid-40s.

Even as online daters themselves give the experience high marks, many have had negative experiences. Half (54%) of online daters have felt that someone seriously misrepresented him- or herself, while over 28% have been contacted by someone in a way that made them feel harassed or uncomfortable (Pew Research Internet Project, 2013). Women are much more likely than men to have experienced this.

With thousands of sexual health sites maintained online, new forms of media are also powerful tools for learning. When credible sources are located, these media have become convenient avenues by which people can get important sexual health information. There are, however, two significant concerns associ- ated with using new media to learn about sexuality and sexual health: the pos- sibility that the information is inaccurate or misleading and that those who turn to the media may turn away from real people in their lives. Given that only a small number of new media interventions have been systematically evaluated, it is still unclear about their impact on health and well-being.

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12 Chapter 1 Perspectives on Human Sexuality

think about it

The popularity and accessibility of digital media and technology, including Internet social networking sites (SNS), have allowed individuals to present themselves publically in ways and means that were previously never possible. In fact, they have become what the Pew Research Internet Project (2014) describes as “key actors” in the lives of most Americans. Social media facilitate communication and support, play a prominent role in nav- igating and documenting romantic relationships, and, for many, provide an outlet for sexual exploration and expression. Individuals use technology throughout the day; they negotiate over when, with whom, and how to use it. What has drastically changed the culture of inter- personal communication is what is now commonly called sexting—the creating, sharing, and forwarding of sexually suggestive images. It’s what others have referred to in the past as “phone sex.” Unlike phone sex, however, sexting leaves little to the imagination. For many, sexting may be a means for those who are curious about sex and sexuality. The wide array of media available provides the opportunity for choosing different purposes for send- ing and receiving sexts, including sexual self-expression, experimentation, self-definition, and education. At the

same time, it can have serious consequences, including shame and guilt. In most states, teens caught with sex- ting photos can be charged with possession of child porn, even if they are under 18 and if the images are of themselves.

As can be seen in Figure 3, sexting is not reserved to teens and young adults. When looking at the relationship status of those who send and receive sexts, the land- scape becomes more varied than one may imagine. For example, it’s clear that relationship status does not nec- essarily play a significant role in who sends and receives sexts. Three common scenarios for sexting are to make congruent with the rest of the book: (1) the exchange of images solely between two romantic partners, (2) exchanges between a partner and someone outside the relationship, and (3) exchanges between people who are not yet in a relationship but at least one person hopes to be.

All of this invites concern, especially for tweens, those between the ages 8 and 14, who share provocative or sexual imagery of themselves. A recent survey of 12- to 13-year-olds found that 93% had access to the Internet, 71% had mobile access to the Internet (e.g., cell phone and tablet), and 16% had

Before Pressing “Send”: Trends and Concerns About Texting, Sexting, and Dating

• FIGURE 3 Percentage of Those Who Sext Monthly, By Age

Source: Adapted from Pew Research Internet Project, 2013.

6 15

11 22

22 34

<1 <1

18–24

25–34

35–44

45–54

55+

Receive sexts Send sexts Forward sexts

0 10 20 30 40 50 Percent

A g

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Sexuality, Popular Culture, and the Media 13

For most users, the Internet provides a fascinating venue for experiencing sex. For some users, however, porn consumption gets them in trouble: maxed-out credit cards, neglected responsibility, and overlooked loved ones. There are both online and community resources for those who desire counseling. While search- ing for such sources, however, consumers and professionals must be aware of the differences between therapy, consultation, and entertainment. Additionally, because entrepreneurs can make more money from hype and misinformation than from high-quality therapy and education, consumers must remain vigilant in assessing the background of the therapist and the source of the information.

Because of the high volume of sexual discussions and material available on the Internet, there is an increasing demand for government regulation. In 1996, Congress passed the Communications Decency Act, which made it illegal to use computer networks to transmit “obscene” materials or place “indecent” words or images where children might read or see them. However, courts have declared this legislation a violation of freedom of speech.

access to the Internet mostly on a cell phone (Lenhart, 2014). Additionally, texting is the most common form of daily communication used by teenagers (more than phones or face-to-face), with a median of 60 texts sent per day (Lenhart, 2012). What’s concerning about this is that even though young people may be technologically savvy, many lack the maturity to be aware of the consequences that can accompany unrestricted access to the media. This may be particularly true for those who are considered emotionally or behaviorally at-risk. Recent evidence underscored this concern when, among a group of at-risk seventh graders, it was found that sexting was associated with higher rates of engaging in a variety of sexual behaviors, including touching genitals over clothes and oral and vaginal sex (Rice et al., 2014). This study also found that those who sexted were more likely to perceive approval of sexual behavior from others, including peers, parents, and the media; demonstrated higher intensions to engage in sexual behavior; and exhibited lower emotional awareness and self-esteem. The authors reported: “Sexual text messaging behavior of any kind, with or without pictures, was associated with a greater likelihood of engaging in sexual behaviors, including touching genitals, having a ‘friend with benefits,’ oral sex, or vaginal sex” (p. 279). This higher prevalence of sexual behaviors and lower personal insight underscore the concern that many parents, teachers, and others have about the awareness and emotional competence of many youth who have unrestricted access to the media.

The altered social environment of today’s youth can no longer be left to chance. It’s clear that young users need to be taught how to resist the temptation and pressure to engage in sexting and to find and assess media sources that promote healthy sexual behavior. Parents need to monitor cell phone and computer use, limit unrestricted access, and use electronic communi- cation as opportunities to discuss relationship health.

The National Campaign to Prevent Teen and Unplanned Pregnancy (2009) suggests “Five Things to Think About Before Pressing ‘Send’”:

1. Don’t assume anything you send or post is going to remain private.

2. There is no changing your mind in cyberspace— anything you send or post will never truly go away.

3. Don’t give in to the pressure to do something that makes you uncomfortable, even in cyberspace.

4. Consider the recipient’s reaction. Just because the message is meant to be fun doesn’t mean the person who gets it will see it that way. Whatever you write, post, or send does contribute to the real-life impres- sion you’re making.

5. Nothing is truly anonymous. It is important to remem- ber that even if individuals know you only by screen name, online profile, phone number, or e-mail address, they can probably find you if they try hard enough.

Think Critically 1. Would you consider participating in or have

you participated in sexting? If so, what kind of image did you or might you send? Under what circumstances? If you would not consider par- ticipating in this activity, what prevents you from doing so?

2. Do you believe that Internet sites and their use should be censored? Why or why not?

3. Which of the “Five Things to Think About Before Pressing ‘Send’” is most concerning to you? Why? How does this influence your thoughts around sexting?

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14 Chapter 1 Perspectives on Human Sexuality

• Sexuality Across Cultures and Times What we see as “natural” in our culture may be viewed as unnatural in other cultures. Few Americans would disagree about the erotic potential of kissing. But other cultures perceive kissing as merely the exchange of saliva. To the Mehinaku of the Amazon rain forest, for example, kissing is a disgusting sexual abnormality; no Mehinaku engages in it (Gregor, 1985). The fact that others press their lips against each other, salivate, and become sexually excited merely confirms their “strangeness” to the Mehinaku.

Culture takes our sexual interests—our incitements or inclinations to act sexually—and molds and shapes them, sometimes celebrating sexuality and other times condemning it. Sexuality can be viewed as a means of spiritual enlightenment, as in the Hindu tradition, in which the gods themselves engage in sexual activities; it can also be at war with the divine, as in the Judeo- Christian tradition, in which the flesh is the snare of the devil (Parrinder, 1980).

Among the variety of factors that shape how we feel and behave sexually, culture is possibly the most powerful. A brief exploration of sexual themes across cultures and times will give you a sense of the diverse shapes and mean- ings humans have given to sexuality.

Sexual Interests All cultures assume that adults have the potential for becoming sexually aroused and for engaging in sexual intercourse for the purpose of reproduction. But cul- tures differ considerably in terms of how strong they believe sexual interests are. These beliefs, in turn, affect the level of desire expressed in each culture.

The Mangaia Among the Mangaia of Polynesia, both sexes, beginning in early adolescence, experience high levels of sexual desire (Marshall, 1971). Around age 13 or 14, following a circumcision ritual, boys are given instruction in the ways of pleasing a girl: erotic kissing, cunnilingus, breast fondling and sucking, and techniques for bringing her to multiple orgasms. After 2 weeks, an older, sexually experienced woman has sexual intercourse with the boy to instruct him further on how to sexually satisfy a woman. Girls the same age are instructed by older women on how to be orgasmic: how to thrust their hips and rhythmically tighten their vagina in order to experience repeated orgasms. A girl finally learns to be orgasmic through the efforts of a “good man.” If the woman’s partner fails to satisfy her, she is likely to leave him; she may also ruin his reputation with other women by denouncing his lack of skill. Young men and women are expected to have many sexual experiences prior to marriage.

This adolescent paradise, however, does not last forever. The Mangaia believe that sexuality is strongest during adolescence. As a result, when the Mangaia leave young adulthood, they experience a rapid decline in sexual desire and activity, and they cease to be aroused as passionately as they once were. They attribute this swift decline to the workings of nature and settle into a sexually contented adulthood.

The Dani In contrast to the Mangaia, the New Guinean Dani show little inter- est in sexuality (Schwimmer, 1997). To them, sex is a relatively unimportant aspect of life. The Dani express no concern about improving sexual techniques or enhancing erotic pleasure. Extrarelational sex and jealousy are rare. As their only sexual concern is reproduction, sexual intercourse is performed quickly,

The sensual movements of Latin American dancing have become mainstream in American culture, as can be seen in the popularity of Dancing With the Stars. © Ethan Miller/AEG Live/Getty Images

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Sexuality Across Cultures and Times 15

ending with male ejaculation. Female orgasm appears to be unknown to them. Following childbirth, both mothers and fathers go through 5 years of sexual abstinence. The Dani are an extreme example of a case in which culture, rather than biology, shapes sexual attractions.

Victorian Americans In the nineteenth century, White middle-class Americans believed that women had little sexual desire. If they experienced desire at all, it was “reproductive desire,” the wish to have children. Reproduction entailed the unfortunate “necessity” of engaging in sexual intercourse. A leading reformer wrote that in her “natural state” a woman never makes advances based on sexual desires, for the “very plain reason that she does not feel them” (Alcott, 1868). Those women who did feel desire were “a few exceptions amounting in all probability to diseased cases.” Such women were classified by a prominent phy- sician as suffering from “Nymphomania, or Furor Uterinus” (Bostwick, 1860).

Whereas women were viewed as asexual, men were believed to have raging sexual appetites. Men, driven by lust, sought to satisfy their desires by ravaging innocent women. Both men and women believed that male sexuality was dan- gerous, uncontrolled, and animal-like. It was part of a woman’s duty to tame unruly male sexual impulses.

The polar beliefs about the nature of male and female sexuality created destructive antagonisms between “angelic” women and “demonic” men. These beliefs provided the rationale for a “war between the sexes.” They also led to the separation of sex from love. Intimacy and love had nothing to do with male sexuality. In fact, male lust always lingered in the background of married life, threatening to destroy love by its overbearing demands.

The Sexual Revolution Between the 1960s and the mid-1970s, significant challenges to the ways that society viewed traditional codes of behavior took place in the United States. Dubbed the “sexual revolution,” or “sexual liberation,”

Similar to beliefs about sexuality, ideals about body image and what women are willing to do to achieve it change over time. (first) © History Archives/Alamy; (second) © Mirrorpix/Newscom

Sex is hardly ever just about sex.

—Shirley MacLaine (1934– )

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16 Chapter 1 Perspectives on Human Sexuality

this period of rapid and complex changes invited individuals and society to confront the sexually repressive Victorian era and begin to recognize a separa- tion and autonomy in what was thought to be unexamined decisions and regula- tions. This counterculture movement questioned previously established rules, regulations, and decisions in these areas:

■ Individual self-expression and autonomy. Previously structured around the collective good of the family and community, the counterculture found meaning and purpose in supporting the individual rights of men and women, including the right to sexual expression.

■ Women’s rights. The traditional, stereotypical role of the man being breadwinner and of the woman being the homemaker were challenged by roles whereby individuals could choose according to their needs. It became acceptable for women to express their inherent sexuality and for men to be their emotional and authentic selves. It was during this period that abortion became legal and widespread accessibility and dissemination of birth control became available.

■ Relationship status. No longer was marriage the only context within which couples could express their sexuality, love, and commitment for one another. A new philosophy of sex, referred to as “free love,” allowed individuals to broaden and act on their sexual desires without marriage, judgment, or contempt.

■ Sexual orientation. Overriding previous dogma from church and state, there has been a broader acceptance of homosexuality. This was reinforced in 1973 when the American Psychiatric Association removed homosexuality from its list of diagnosable mental disorders. More recently in 2015, the U.S. Supreme Court ruled same-sex marriage legal in all states.

■ Sexuality education. Though a handful of sexuality education programs had been introduced prior to the 1960s, few were uniformly embraced or included in school curriculums until the Sexuality Information and Education Council of the United States (SIECUS) became a vocal force in educational and policy circles.

Although a significant amount of time has passed since the end of the Victorian era and the counterculture’s attempt to shift values and attitudes about sexuality, many traditional sexual beliefs and attitudes continue to influence us. These include the belief that men are “naturally” sexually aggressive and women sexually passive, the sexual double standard, and the value placed on women being sexually inexperienced. While the media continue to push boundaries about what is acceptable and desirable in sexual expression, so do most Americans continue to adapt their thinking about what is acceptable, desirable, normal, and tolerable.

Sexual Orientation Sexual orientation is the pattern of sexual and emotional attraction based on the gender of one’s partner. Heterosexuality refers to emotional and sexual attraction between men and women; homosexuality, more commonly referred to as gay, refers to emotional and sexual attraction between persons of the same sex; bisexuality is an emotional and sexual attraction to both males and females. There is significant debate about whether asexuality, a state of having no sexual

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Sexuality Across Cultures and Times 17

attraction to anyone or low or absent interest in sexual activity, is a sexual ori- entation. Now that same-sex marriage has been legalized in all states, full social legitimacy and dignity have been granted to all people. This view of marriage is currently shared by 21 other countries.

Ancient Greece In ancient Greece, the birthplace of European culture, the Greeks accepted same-sex relationships as naturally as Americans today accept heterosexuality. For the Greeks, same-sex relationships between men represented the highest form of love.

The male-male relationship was based on love and reciprocity; sexuality was only one component of it. In this relationship, the code of conduct called for the older man to initiate the relationship. The youth initially resisted; only after the older man courted the young man with gifts and words of love would he reciprocate. The two men formed a close emotional bond. The older man was the youth’s mentor as well as his lover. He introduced the youth to men who would be useful for his advancement later; he assisted him in learning his duties as a citizen. As the youth entered adulthood, the erotic bond between the two evolved into a deep friendship. After the youth became an adult, he married a woman and later initiated a relationship with an adolescent boy.

Greek male-male relationships, however, were not substitutes for male-female marriage. The Greeks discouraged exclusive male-male relationships because marriage and children were required to continue the family and society. Men regarded their wives primarily as domestics and as bearers of children (Keuls, 1985). (The Greek word for woman, gyne, translates literally as “child- bearer.”) Husbands turned for sexual pleasure not to their wives but to hetaerae (hi-TIR-ee), highly regarded courtesans who were usually educated slaves.

In ancient Greece, the highest form of love was that expressed between males. Digital image courtesy of the Getty’s Open Content Program

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18 Chapter 1 Perspectives on Human Sexuality

The Sambians Among Sambian males of New Guinea, sexual orientation is very malleable (Herdt & McClintock, 2000). Young boys begin with sexual activities with older boys, move to sexual activities with both sexes during ado- lescence, and engage in exclusively male-female activities in adulthood. Sambi- ans believe that a boy can grow into a man only by the ingestion of semen, which is, they say, like mother’s milk. At age 7 or 8, boys begin their sexual activities with older boys; as they get older, they seek multiple partners to accel- erate their growth into manhood. At adolescence, their role changes, and they must provide semen to boys to enable them to develop. At first, they worry about their own loss of semen, but they are taught to drink tree sap, which they believe magically replenishes their supply. During adolescence, boys are betrothed to preadolescent girls, with whom they engage in sexual activities. When the girls mature, the boys give up their sexual involvement with other males. They become fully involved with adult women, losing their desire for men.

Gender Although sexual interests and orientation may be influenced by culture, it may be difficult for some people to imagine that culture has anything to do with gender, the socially constructed roles, behaviors, activities, and attributes that a society considers appropriate for men and women. Other terms used to describe gender are gender normative and cisgender, people whose sex assignment at birth corresponds to their gender identity and expression.

For those who do not ascribe to gender normative behaviors or expression, the umbrella term of transgender is used. This broad term describes those whose gender expression or identity is not congruent with the sex assigned at birth and whose gender is not validated by the dominant culture. Transgender is inclusive of transsexuality, a phenomenon in which a person is intent to live through actions, dress, hormone therapy, and/or surgery as a gender other than that which he or she was assigned at birth, and transvestism, the wearing of clothes of or passing as a member of the other sex.

Our sex appears solidly rooted in our biological nature. But is being male or female really biological? The answer is yes and no. Having male or female geni- tals is anatomical. But the possession of a penis does not always make a person a man, nor does the possession of a clitoris and vagina always make a person a

woman. Men who consider themselves women, “women with penises,” are accepted or honored in many cultures throughout the world (Bullough, 1991). Thus, culture and a host of other factors help to shape masculinity and femininity, while biology defines men and women. But this is not the case in all regions of the world.

Two-Spirited People A Native American tradition involving the existence of cross-gender roles, the male-female, the female- male is what is called the two-spirit person (Laframboise & Anhorn, 2008). These individuals often expressed their gender through dress and work roles; however, they were celibate and so did not convey it through their sexual practices. Two-spirit people were often visionaries, healers, medicine people, nannies of orphans, and caregivers. They were respected as fundamental components of the Native American culture and societies. However, since European colonization and persecution by the church to eradicate these individuals, the two-spirit community is now often

Transgendered people reside in many cultures, crossing age, religion, and social status. © Maciej Dakowicz/Alamy

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Societal Norms and Sexuality 19

viewed as perverted, untraditional, or untrustworthy. As such, two-spirit people have lost their place in society and their dignity.

In South Asian society, the third gender is known as the hijra. Regarded as sacred, they perform as dancers or musicians at weddings and religious ceremonies, as well as providing blessings for health, prosperity, and fertility (Nanda, 1990). It is almost always men who become two-spirits, although there are a few cases of women assuming male roles in a similar fashion (Blackwood, 1984). Two-spirits are often considered shamans, individuals who possess great spiritual power.

Among the Zuni of New Mexico, two-spirits are considered a third gender (Roscoe, 1991). Despite the existence of transsexual people and those born with disorders of sexual development (e.g., two testes or two ovaries but an ambigu- ous genital appearance), Westerners tend to view gender as biological, an incor- rect assumption. The Zuni, in contrast, believe that gender is socially acquired.

American Indian two-spirits were suppressed by missionaries and the U.S. government and were considered “unnatural” or “perverted.” As a result of cul- tural genocide and other factors, some of Native American communities now regard homophobia and sexism as common. This relatively new and unfortunate set of beliefs makes some who identify as Native American and queer feel both isolated and unsupported (Laframboise & Anhorn, 2008).

• Societal Norms and Sexuality The immense diversity of sexual behaviors across cultures and times immedi- ately calls into question the appropriateness of labeling these behaviors as inherently natural or unnatural, normal or abnormal. Too often, we give such labels to sexual behaviors without thinking about the basis on which we make those judgments. Such categories discourage knowledge and understanding because they are value judgments, evaluations of right and wrong. As such, they are not objective descriptions about behaviors but statements of how we feel about those behaviors.

Natural Sexual Behavior How do we decide if a sexual behavior is natural or unnatural? To make this decision, we must have some standard of nature against which to compare the behavior. But what is “nature”? On the abstract level, nature is the essence of all things in the universe. Or, personified as nature, it is the force regulating the universe. These definitions, however, do not help us much in trying to establish what is natural or unnatural.

When we asked our students to identify their criteria for determining which sexual behaviors they considered “natural” or “unnatural,” we received a variety of responses, including the following:

■ “If a person feels something instinctive, I believe it is a natural feeling.” ■ “Natural and unnatural have to do with the laws of nature. What these

parts were intended for.” ■ “I decide by my gut instincts.” ■ “I think all sexual activity is natural as long as it doesn’t hurt you or

anyone else.” ■ “Everything possible is natural. Everything natural is normal. If it is natu-

ral and normal, it is moral.”

In some cultures, men who dress or identify as women are considered shamans. We’wha was a Zuni two-spirit who lived in the nineteenth century. © History Archives/Alamy

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20 Chapter 1 Perspectives on Human Sexuality

think about it

Am I Normal?

The question “Am I normal?” seems to haunt many people. For some, it causes a great deal of unnecessary fear, guilt, and anxiety. For others, it provides the motiva- tion to study the literature, consult with a trusted friend or therapist, or take a course in sexuality.

What is normal? We commonly use several criteria in deciding whether to label different sexual behavior “normal” or “abnormal.” According to professor and psy- chologist Leonore Tiefer (2004), these criteria are subjec- tive, statistical, idealistic, cultural, and clinical. Regardless of what criteria we use, they ultimately reflect societal norms.

■ Subjectively “normal” behavior. According to this defi- nition, normalcy is any behavior that is similar to one’s own. Though most of us use this definition, few of us will acknowledge it.

■ Statistically “normal” behavior. According to this defi- nition, whatever behaviors are more common are nor- mal; less common ones are abnormal. However, the fact that a behavior is not widely practiced does not make it abnormal except in a statistical sense. Fellatio (fel-AY-she-o) (oral stimulation of the penis) and cun- nilingus (cun-i-LIN-gus) (oral stimulation of the female genitals), for example, are widely practiced today because they have become “acceptable” behaviors. But years ago, oral sex was tabooed as something “dirty” or “shameful.”

■ Idealistically “normal” behavior. Taking an ideal for a norm, individuals who use this approach measure all deviations against perfection. They may try to model their behavior after Christ or Gandhi, for example. Using idealized behavior as a norm can easily lead to feelings of guilt, shame, and anxiety.

■ Culturally “normal” behavior. This is probably the stan- dard most of us use most of the time: We accept as normal what our culture defines as normal. This mea- sure explains why our notions of normalcy do not always agree with those of people from other coun- tries, religions, communities, and historical periods. Men who kiss in public may be considered normal in one place but abnormal in another. It is common for deviant behavior to be perceived as dangerous and frightening in a culture that rejects it.

■ Clinically “normal” behavior. The clinical standard uses scientific data about health and illness to make judg- ments. For example, the presence of the syphilis bacte- rium in body tissues or blood is considered abnormal because it indicates that a person has a sexually trans- mitted infection. Regardless of time or place, clinical definitions should stand the test of time. The four crite- ria mentioned previously are all somewhat arbitrary— that is, they depend on individual or group opinion—but the clinical criterion has more objectivity.

These five criteria form the basis of what we usually consider normal behavior. Often, the different definitions and interpretations of “normal” conflict with one another. How does a person determine whether he or she is nor- mal if subjectively “normal” behavior—what that person actually does—is inconsistent with his or her ideals? How could our ideas about what we consider to be “normal” sexual functioning be altered if we knew that diversity, not homogeneity, was more characteristic of real-life sex- ual behavior (van Lankveld, 2013)? Such dilemmas are commonplace and lead many people to question their normalcy. However, they should not question their nor- malcy as much as their concept of normalcy.

Think Critically 1. How do you define normal sexual behavior?

What criteria did you use to create this definition? 2. How do your sexual attitudes, values, and

behaviors compare to what you believe are “normal” sexual behaviors? If they are different, how do you reconcile these? If they are similar, how do you feel about others who may not share them?

3. In Nepal, young women are isolated for one week during their first menses, whereas in Brazil, it is common to see men embrace or kiss in public. What are your thoughts about how other cultures define normality?

source: Tiefer, L. (2004). Sex is not a natural act and other essays (2nd ed.). Boulder, CO: Westview Press.

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Societal Norms and Sexuality 21

When we label sexual behavior as “natural” or “unnatural,” we are typically indicating whether the behavior conforms to our culture’s sexual norms. Our sexual norms appear natural because we have internalized them since infancy. These norms are part of the cultural air we breathe, and, like the air, they are invisible. We have learned our culture’s rules so well that they have become a “natural” part of our personality, a “second nature” to us. They seem “instinctive.”

Normal Sexual Behavior Closely related to the idea that sexual behavior is natural or unnatural is the belief that sexuality is either normal or abnormal. More often than not, describ- ing behavior as “normal” or “abnormal” is merely another way of making value judgments in the ways in which people perceive and appraise sexuality. Psychologist Sandra Pertot (2007) quips, “Normal today means that a person should have a regular and persistent physical sex drive, easy arousal, strong erections and good control over ejaculation for males, powerful orgasms, and a desire for a variety and experimentation [for women]” (p. 13). Normal has often been used to imply “healthy” or “moral” behavior. Normal sexual behavior is behavior that conforms to a group’s average, or median, patterns of behavior. Normality has nothing to do with moral or psychological deviance. Rather, the term is often used when one is critical of one’s partner and wants to “wheel in the heavy artillery of ‘you’re not normal. I’m normal’ ” (Klein, 2012).

Ironically, although we may feel pressure to behave like the average person (the statistical norm), most of us don’t actually know how others behave sexually. People don’t ordinarily reveal much about their sexual activities. If they do, they generally reveal only their most conformist sexual behaviors, such as sexual intercourse. They rarely disclose their masturbatory activities, sexual fantasies, or anxieties or feelings of guilt. All that most people present of themselves—unless we know them well—is the conventional self that masks their actual sexual feelings, attitudes, and behaviors.

The guidelines most of us have for determining our normality are given to us by our friends, partners, and parents (who usually present conventional sexual images of themselves) through stereotypes, media images, religious teachings, cus- toms, and cultural norms. None of these, however, tell us much about how people actually behave. Because we don’t know how people really behave, it is easy for us to imagine that we are abnormal if we differ from our cultural norms and ste- reotypes. We wonder if our desires, fantasies, and activities are normal: Is it normal to fantasize? To masturbate? To enjoy erotica? To be attracted to someone of the same sex? Some of us believe that everyone else is “normal” and that only we are “sick” or “abnormal” (or vice-versa). The challenge, of course, is to put aside our cultural indoctrination and try to understand sexual behaviors objectively.

Because culture determines what is normal, there is a vast range of normal behaviors across different cultures. What is considered the normal sexual urge for the Dani would send most of us into therapy for treatment of low sexual desire. And the idea of teaching sexual skills to early adolescents, as the Man- gaia do, would horrify most American parents.

Are there behaviors, however, that are considered essential to sexual function- ing and consequently universally labeled as normal? Not surprisingly, reproduction, or the biological process by which individuals are produced, is probably one shared view of normal sexual behavior that most cultures would agree upon. All other beliefs about sexual expression and behavior develop from social context.

The greatest pleasure in life is doing what people say you

cannot do.

—Walter Bagehot (1826–1877)

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22 Chapter 1 Perspectives on Human Sexuality

Kissing is “natural” and “normal” in our culture. It is an expression of intimacy, love, and passion for young and old, and persons of all sexual orientations. (first) © Thinkstock; (second) © Ronnie Kaufman/Blend Images LLC; (third) © McGraw-Hill Education/Christopher Kerrigan, photographer; (fourth) © Stockbyte/Punchstock

Sexual Behavior and Variations Sex researchers have generally rejected the traditional sexual dichotomies of natural/unnatural, normal/abnormal, moral/immoral, and good/bad. Regarding the word “abnormal,” sociologist Ira Reiss (1989) writes:

We need to be aware that people will use those labels to put distance between themselves and others they dislike. In doing so, these people are not making a scientific diagnosis but are simply affirming their support of certain shared concepts of proper sexuality.

Instead of classifying behavior into what are essentially moralistic normal/abnor- mal and natural/unnatural categories, researchers view human sexuality as characterized by sexual variation—that is, sexual variety and diversity. As humans, we vary enormously in terms of our sexual orientation, our desires, our fantasies, our attitudes, and our behaviors. Alfred Kinsey and his colleagues (1948) suc- cinctly stated the matter: “The world is not to be divided into sheep and goats.”

Researchers believe that the best way to understand our sexual diversity is to view our activities as existing on a continuum. On this continuum, the frequency with which individuals engage in different sexual activities (e.g., sexual intercourse, masturbation, and oral sex) ranges from never to always. Significantly, there is no point on the continuum that marks normal or abnormal behavior. In fact, the difference between one individual and the next on the continuum is minimal ( Kinsey,

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Societal Norms and Sexuality 23

think about it

Declaration of Sexual Rights

Sexuality is an integral part of the personality of every human being. Since health is a fundamental human right, so must sexual health be recognized, promoted, respected, and defended by all societies and through all means. Sexual health is the result of an environment that recognizes, respects, and exercises these rights.

1. The right to equality and nondiscrimination. Every- one is entitled to enjoy all sexual rights set forth in this Declaration without distinction of any kind.

2. The right to life, liberty, and security of the person. This right cannot be arbitrarily threatened, limited, or taken away for reasons related to sexuality. These include: sexual orientation, consensual sexual behav- ior and practices, gender identity and expression, or because of accessing or providing services related to sexual and reproductive health.

3. The right to autonomy and bodily integrity. Everyone has the right to control and decide freely on matters related to their sexuality and their body. This includes the choice of sexual behaviors, practices, partners, and relationships with due regard to the rights of others.

4. The right to be free from torture and cruel, inhumane, or degrading treatment or punishment. This right includes traditional practices, forced sterilization, contraception, or abortion; and other forms of torture, cruel, inhumane, or degrading treatment perpetrated for any reason.

5. The right to be free from all forms of violence and coercion. This right includes rape, sexual abuse, sexual harassment, bullying, sexual exploitation and slavery, trafficking for purposes of sexual exploitation, virginity testing, and violence.

6. The right to privacy. Everyone has the right to privacy related to sexuality, sexual life, and choices regarding their own body and consensual sexual relations and practices without arbitrary interference and intrusion.

7. The right to the highest attainable standard of health, including sexual health; with the possibility of pleasurable, satisfying, and safe sexual experi- ences. This requires the accessibility to quality health services and access to the conditions that influence health including sexual health.

8. The right to enjoy the benefits of scientific progress and its application. This right is inclusive of sexuality and sexual health.

9. The right to information. Everyone shall have access to scientifically accurate and understandable informa- tion related to sexuality, sexual health, and sexual rights through diverse sources.

10. The right to education and the right to comprehen- sive sexuality education. Comprehensive sexuality education must be age appropriate, scientifically accurate, culturally competent, and grounded in human rights, gender equality, and a positive approach to sexuality and pleasure.

11. The right to enter, form, and dissolve marriage and other similar types of relationships based on equal- ity and full and free consent. All persons are entitled to equal rights entering into, during, and at dissolution of marriage, partnership, and other similar relation- ships without discrimination or exclusion of any kind.

12. The right to decide whether to have children, the number and spacing of children, and to have the information and means to do so. To exercise this right requires access to the conditions that influence and determine health and wellbeing.

13. The right to freedom of thought, opinion, and expression. Everyone has the right to express their own sexuality with due respect to the rights of others.

14. The right to freedom of association and peaceful assembly. Everyone has the right to peacefully dem- onstrate and advocate including about sexuality, sex- ual health, and sexual rights.

15. The right to participation in public and political life. Everyone is entitled to an environment that enables active, free, and meaningful participation in all aspects of human life.

16. The right to access to justice, remedies, and redress. This right requires effective, adequate, accessible, and appropriate educative, legislative, judicial, and other measures.

Think Critically 1. What are your reactions to the “Declaration of

Sexual Rights”? For whom should these rights, be promoted? Would you delete, edit, or add rights to this list?

2. Why do you suppose such a declaration is nec- essary and important?

3. What (if any) consequences should there be for governments, cultures, or individuals who do not follow these rights?

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http://www.worldsexology.org

24 Chapter 1 Perspectives on Human Sexuality

Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). The most that can be said of a person is that his or her behaviors are more or less typical or atypical of the group average, whatever that group may be. Furthermore, nothing can be inferred about an individual whose behavior differs significantly from the group average other than his or her behavior is atypical. Except for engaging in sexually atypical behavior, one person may be indistinguishable from any other.

Many activities that are usually thought of as “deviant” or “abnormal” sexual behavior—activities diverging from the norm, such as exhibitionism, voyeurism, and fetishism—are engaged in by most of us to some degree. We may delight in displaying our bodies on the beach (exhibitionism) or in “twerking” in crowded clubs. We may like watching ourselves having sex, viewing erotic scenes, or see- ing our partner undress (voyeurism). Or we may enjoy kissing our lover’s photo- graph, keeping a lock of his or her hair, or sleeping with an article of his or her clothing (fetishism). Most of the time, these feelings or activities are only one aspect of our sexual selves; they are not especially significant in our overall sexu- ality. Such atypical behaviors represent nothing more than sexual nonconformity when they occur between mutually consenting adults and do not cause distress.

The rejection of natural/unnatural, normal/abnormal, and moral/immoral cat- egories by sex researchers does not mean that standards for evaluating sexual behavior do not exist. There are many sexual behaviors that are harmful to oneself (e.g., masturbatory asphyxia—suffocating or hanging oneself during masturbation to increase sexual arousal) and to others (e.g., rape, child molesta- tion, and obscene phone calls). Current psychological standards for determining the harmfulness of sexual behaviors center around the issues of coercion, poten- tial harm to oneself or others, and personal distress.

We, the authors, believe that the basic standard for judging various sexual activities is whether they are between consenting adults and are expressed in shar- ing, enhancing, and nonexploitive ways. Understanding diverse sexual attitudes, motives, behaviors, and values will help deepen our own value systems and help us understand, accept, and appreciate our own sexuality and that of others.

Imagination is more important than knowledge.

—Albert Einstein (1879–1955)

Sexuality can be a source of great pleasure and profound satisfaction as well as a source of guilt and means of exploitation. Popular culture both encourages and dis- courages sexuality. It promotes stereotypical sexual interactions but fails to touch on the deeper significance sexuality holds for us or the risks and responsibilities that accompany it. Love and sexuality in a committed relationship are infrequently depicted, in contrast to casual sex. The media often ignore or disparage the wide array of sexual behaviors and choices—from masturbation to gay, lesbian, bisexual, and transgender relationships—that are significant in many people’s lives. They dis- courage the linking of sex and intimacy, contraceptive responsibility and the acknowl- edgment of the risk of contracting sexually transmitted infections.

What is clear from examining other cultures is that sexual behaviors and norms vary from culture to culture and, within our own society, from one time to another. The variety of sexual behaviors even within our own culture testifies to diversity not only between cultures but within cultures as well. Understanding diversity allows us to acknowledge that there is no such thing as inherently “normal” or “natural” sexual behavior. Rather, sexual behavior is strongly influenced by culture—including our own.

Final Thoughts

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Summary 25

Summary Studying Human Sexuality

■ Students study sexuality for a variety of rea- sons. Examining the multiple aspects of this fascinating topic can help students understand, accept, and appreciate their own sexuality and that of others.

Sexuality, Popular Culture, and the Media

■ The media are among the most powerful forces in people’s lives today. Mass-media depictions of sex- uality are meant primarily to entertain and exploit, not to inform.

■ The Internet’s contributions to the availability and commercialization of sex and sexuality information have made it easy for individuals to obtain infor- mation, strengthen social ties, and provide sexual gratification.

■ Television and digital media are the most prevalent and pervasive media. At the same time, the risks and responsibilities that accompany this program- ming remain disproportionate to the sexual images that are portrayed.

Sexuality Across Cultures and Times

■ One of the most powerful forces shaping human sexuality is culture. Culture molds and shapes our sexual interests.

■ The Mangaia of Polynesia and the Dani of New Guinea represent cultures at the opposite ends of a continuum, with the Mangaia having an elaborate social and cultural framework for instructing ado- lescents in sexual technique and the Dani down- playing the importance of sex.

■ Middle-class Americans in the nineteenth century believed that men had strong sexual drives but that women had little sexual desire. Because sexuality was considered animalistic, the Victorians separated sex and love. The sexual revolution brought significant changes to previous assumptions about sexuality.

■ Sexual orientation is the pattern of sexual and emotional attraction based on the sex of one’s partner. In contemporary America, heterosexuality, or attraction between men and women, is the only sexual orientation that receives full societal and legal legitimacy. Homosexuality refers to same-sex

attractions, bisexuality involves attraction to both males and females, and asexuality is a state of having no sexual attraction to anyone, or low or absent sexual activity.

■ In ancient Greece, same-sex relationships between men represented the highest form of love. Among the Sambians of New Guinea, boys have sexual contact with older boys, believing that the ingestion of semen is required for growth. When the girls to whom they are betrothed reach puberty, adolescent boys cease these same-sex sexual relations.

■ The socially constructed roles, behaviors, activities, and attributes that a society considers appropriate for men and women are otherwise called gender. While culture helps to shape masculinity or femi- ninity, biology defines men and women.

■ A two-spirit is a person of one sex who identi- fies with the other sex; in some communities, such as the Zuni, a two-spirit is considered a third gender and is believed to possess great spiritual power.

Societal Norms and Sexuality

■ Sexuality tends to be evaluated according to cate- gories of natural/unnatural, normal/abnormal, and moral/immoral. These terms are value judgments, reflecting social norms rather than any quality inherent in the behavior itself.

■ There is no commonly accepted definition of natu- ral sexual behavior. Normal sexual behavior is what a culture defines as normal. We commonly use five criteria to categorize sexual behavior as normal or abnormal: subjectively normal, statisti- cally normal, idealistically normal, culturally nor- mal, and clinically normal.

■ Human sexuality is characterized by sexual variation. Researchers believe that the best way to examine sexual behavior is on a continuum. Many activities that are considered deviant sexual behavior exist in most of us to some degree. These include exhibitionism, voyeurism, and fetishism.

■ Behaviors are not abnormal or unnatural; rather, they are more or less typical or atypical of the group average. Many of those whose behaviors are atypical may be regarded as sexual nonconformists rather than as abnormal or perverse.

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26 Chapter 1 Perspectives on Human Sexuality

Sex and the Internet Sex and the Media With hundreds of millions of sexuality-related web- sites available, you might wonder about the issues and laws associated with access to cyberspace. Though the following sites each deal primarily with intellectual freedom, they also contain information and links to other sites that address issues of sex and the media. Select one of the following:

■ Electronic Frontier Foundation http://www.eff.org

■ Entertainment Software Rating Board http://www.esrb.org/index-js.jsp

■ National Coalition for Sexual Freedom http://www.ncsfreedom.org

■ Pew Research Internet Project http://www.pewinternet.org

Go to the site and answer the following questions:

■ What is the mission of the site—if any?

■ Who are its supporters and advocates?

■ Who is its target audience?

■ What is its predominant message?

■ What current issue is it highlighting?

Given what you have learned about this site, how do your feelings about sex and the Internet compare with those of the creators of this website?

Suggested Websites National Gay and Lesbian Task Force http://thetaskforce.org Helps to build the grassroots power of the LGBT community by training activists, organizing campaigns, and providing research and policy analysis to support equality.

Sexuality Information and Education Council of the United States (SIECUS) www.siecus.org Educates, advocates, and informs about sexuality and sexual and reproductive health.

World Association for Sexual Health http://www.worldsexology.org/ Promotes sexual health throughout the world by developing and supporting the field of human sexuality and sexual rights for all.

Suggested Reading Castaneda, L., & Campbell, S. B. (Eds.). (2005). News and

sexuality: Media portrayals of diversity. Thousand Oaks, CA: Sage. Provides an understanding of issues and perspec- tives on gender, race, ethnicity, and sexual orientation as addressed in the media.

Dines, G., & McMahon, J. M. (Eds.). (2015). Gender, race and class in media: A critical reader (4th ed.). Thousand Oaks, CA: Sage. An analysis of media entertainment culture.

Francoeur, R. T., & Noonan, R. (Eds.). (2004). The continuum complete international encyclopedia of sexuality. New York: Continuum. The foremost reference work on sexual behav- ior throughout the world.

Middleton, D. R. (2001). Exotics and erotics: Human culture and sexual diversity. Prospect Heights, IL: Waveland Press. Explores universal human sexuality in conjunction with its local manifestations in specific cultural contexts; topics include the body, patterns of sexuality, sexual behavior, romantic passion, marriage, and kinship.

Strasburger, V. C., Wilson, B. J., & Jordan, A. B. (2014). Children, adolescents, and the media (3rd ed.). Thousand Oaks, CA: Sage. Explores mass media, including the sexual messages the media convey and their impact on adolescents.

Tiefer, L. (2004). Sex is not a natural act and other essays (2nd ed.). Boulder, CO: Westview Press. A revised collec- tion of provocative essays on sex and its many meanings in our culture.

Questions for Discussion ■ At what age do you believe a young person

should be given a smartphone? What, if any, type of education should accompany it?

■ To what extent do you think your peers are influ- enced by the media? How does it affect you?

■ While growing up, what sexual behaviors did you consider to be normal? Abnormal? How have these views changed now that you are older?

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http://www.eff.org

http://www.esrb.org/index-js.jsp

http://www.ncsfreedom.org

http://www.pewinternet.org

http://thetaskforce.org

www.siecus.org

http://www.worldsexology.org/

2 Studying Human Sexuality chapter

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C H A P T E R O U T L I N E Sex, Advice Columnists, and Pop Psychology

Thinking Objectively About Sexuality

Sex Research Methods

The Sex Researchers

Contemporary Research Studies

Emerging Research Perspectives

Ethnicity and Sexuality

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28 Chapter 2 Studying Human Sexuality

“I’ve heard about those sex surveys, and I wonder how truthful they are. I mean, don’t you think that people who volunteer for

those studies only report behaviors which they deem socially acceptable? I just don’t think people who lose their virginity, for instance at age 12 or age 30, would actually report it. Besides, no sex study is going to tell me what I should do or whether I am normal.”

—21-year-old male

“I feel that sexual research is a benefit to our society. The human sexuality class I took my sophomore year in college taught me a lot. Without research, many of the topics we learned about would not have been so thoroughly dis- cussed due to lack of information. Sexual research and human sexuality classes help keep the topic of sex from being seen as such a faux pas by society.”

—20-year-old female

“I took a sex survey once, during my undergraduate years. I found that the survey was easy to take, and the process of answering the questions actually led me to ask myself more questions about my sexual self. The survey was detailed, and I was encouraged to answer truthfully. Ulti- mately, every answer I gave was accurate because I knew that the research would benefit science (and it was com- pletely anonymous).”

—22-year-old female

“I think sex research is great because it helps remove the taboo from the topic. Sex, in this country, is on TV, on the Internet, and in movies all the time, but people do not want to seriously discuss it, especially adults with children. Sex research, when made public, can help ease the tension of discussing sex—especially when it reveals that something considered abnormal actually is normal and that many people practice the specific behavior.”

—24-year-old male

“Anew university study finds that many college students lie to a new sexual partner about their sexual past . . . but first, a message from . . .” So begins a commercial lead-in on the news, reminding us that sex research is often part of both news and entertainment. In fact, most of us learn about the results of sex research from television, newspapers, the Internet, and magazines rather than from scholarly journals and books. After all, the mass media are more entertaining than most scholarly works. And unless we are studying human sex- uality, few of us have the time or interest to read the scholarly journals in which scientific research is regularly published.

But how accurate is what the mass media tell us about sex and sex research? In this chapter, we discuss the dissemination of sexuality-related information by the various media. Then we look at the critical-thinking skills that help us evaluate how we discuss and think about sexuality. When are we making objective statements? When are we reflecting biases or opinions? Next, we examine sex research methods because they are critical to the sci- entific study of human sexuality. Then we look at some of the leading sex researchers to see how they have influenced our understanding of sexuality. Next, we discuss five national studies as examples of important research that has been conducted. Finally, we examine feminist, gay, lesbian, bisexual, transgender, and ethnic sex research to see how they enrich our knowledge of sexuality.

Voices Student

Discovery consists of seeing what everybody has seen and thinking

what nobody has thought.

—Albert Szent-Györgyi (1893–1986)

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Sex, Advice Columnists, and Pop Psychology 29

•Sex, Advice Columnists, and Pop Psychology As we’ve seen, the mass media convey seemingly endless sexual images. Besides various television, film, Internet, and advertising genres, there is another genre, which we might call the sex information/advice genre, which transmits infor- mation and norms, rather than images, about sexuality to a mass audience to both inform and entertain in a simplified manner. For many college students, as well as others, the sex information/advice genre is a major source of their knowl- edge about sex. This genre is ostensibly concerned with transmitting information that is factual and accurate. In addition, on an increasing number of college campuses, sex columns in student-run newspapers have become popular and sometimes controversial, as some college administrators have been concerned that the information provided is too explicit.

Information and Advice as Entertainment Newspaper columns, Internet sites, syndicated radio shows, magazine articles, and TV programs share several features. First, their primary purpose is financial profit. This goal is in marked contrast to the primary purpose of scholarly research, which is to increase knowledge. Even the inclusion of survey question- naires in magazines asking readers about their sexual attitudes or behaviors is ultimately designed to promote sales. We fill out the questionnaires for fun, much as we would crossword puzzles or anagrams. Then we buy the subsequent issue or watch a later program to see how we compare to other respondents.

Second, the success of media personalities rests not so much on their exper- tise as on their ability to present information as entertainment. Because the genre seeks to entertain, sex information and advice must be simplified. Complex explanations and analyses must be avoided because they would interfere with the entertainment purpose. Furthermore, the genre relies on high-interest or bizarre material to attract readers, viewers, and listeners. Consequently, we are more likely to read, view, or hear stories about unusual sexual behaviors or ways to increase sexual attractiveness than stories about new research methods or the negative outcomes of sexual stereotyping.

Third, the genre focuses on how-to information or on morality. Sometimes it mixes information and normative judgments. How-to material tells us how to improve our sex lives. Advice columnists often give advice on issues of sexual morality: “Is it all right to have sex without commitment?” “Yes, if you love him/her” or “No, casual sex is empty” and so on. These columnists act as moral arbiters, much as ministers, priests, and rabbis do.

Fourth, the genre uses the trappings of social science and psychiatry without their substance. Writers and columnists interview social scientists and therapists to give an aura of scientific authority to their material. They rely especially heavily on therapists, whose background is clinical rather than academic. Because clinicians tend to deal with people with problems, they often see the problematic aspects of sexuality.

The line between media sex experts and advice columnists is often blurred. This line is especially obscure on the Internet, where websites dealing with sexuality have proliferated. Most of these sites are purely for entertainment rather than education, and it can be difficult to determine a site’s credibility. One way to assess the educational value of a website is to investigate its spon- sor. Reputable national organizations like the American Psychological

If you believe everything you read, don’t read.

—Chinese proverb

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30 Chapter 2 Studying Human Sexuality

think about it

Some people are afraid that if sex has no inherent meaning and they do not salute it, they won’t behave ethically.

—Marty Klein (2012, p. 158)

Renowned sex therapist and author Marty Klein addresses a commonly believed idea that sex has inherent meaning by provocatively stating that “sex has no inherent meaning” (Klein, 2012). He states that indi- viduals can make their sexual experiences meaningful but that sex is meaningless until and unless they give it meaning. Klein continues by noting that many people give sex too much meaning and often the wrong type of meaning. When sex has too much meaning, too much is riding on each sexual encounter, producing both pressure and anxiety that interferes with pleasurable and reward- ing sexual expression.

The meanings of sexuality are derived from the reli- gious, political, ethical, and legal interpretations of sexual- ity, reflecting how culture describes why we have sex. Some meanings or distinctive purposes of human sexual expression commonly held include:

■ What individuals do when they love each other

■ The ultimate expression of love

■ A divine gift to humans

■ A validation of our identities as a man or woman

■ A supreme gift to another person

■ A method of strengthening a relationship

■ A way of fulfilling desire

Historically, the naming and categorization of sexual behaviors have reflected efforts to “normalize” specific sexual behavior and to label unsanctioned behavior as abnormal, resulting in many persons being stigmatized. The variation of sexual expression was not recognized or endorsed. An example of efforts to attach meaning to sexuality is the “invention of heterosexuality” and heterosexual-homosexual dichotomization of sexual orientation.

In her book Straight: The Surprisingly Short History of Heterosexuality, author Hanne Blank (2012) states that the term “heterosexuality” first appeared in the medical literature in 1869, offering a way to validate and support

the religious priorities of heterosexual marriage and to be a synonym of “sexually normal.” Blank contends that nor- mal is not a mode of eternal truth but a mechanism to describe commonness and conformity to expectations. She continues by noting:

The original creation of “heterosexual” and “homosex- ual” had nothing to do with scientists or science at all. Nor did it have anything to do with biology or medicine. There is, biomedically speaking, nothing about what human beings do sexually that requires that something like what we now think of as “sexual orientation” exists. Virtually everyone alive today, especially in the devel- oped world, has lived their entire lives in a culture of sexuality that assumes that “heterosexual” and “homosexual” are objectively real elements of nature (pp. xiv–xvi).

As described in this chapter, Alfred C. Kinsey ordered individuals on a 0–6 scale instead of the binary heterosexual-homosexual model or triad model of homo- sexual, bisexual, and heterosexual. His scale shifted the perspective and conversation about the classification of sexual behavior toward a focus on multiple varieties and combinations of sexual desire, behavior, and fantasy, resulting in variation being more culturally, scientifically, and politically determined to be normal (Drucker, 2014). In speaking about the diversity of sexual orientation, Kinsey (Kinsey, Pomeroy, & Martin, 1948) said:

Males [similarly for females] do not represent two discrete populations, heterosexual and homosexual. The world is not to be divided into sheep and goats. Not all things are black and white. It is a fundamen- tal of taxonomy that nature rarely deals with dis- crete categories. Only the human mind invents categories and tries to force facts into separated pigeon-holes. The living world is a continuum in each and every one of its aspects. The sooner we learn this concerning human sexual behavior the sooner we shall reach a sound understanding of the realities of sex (p. 639).

Klein contends that when people believe that sex has inherent meaning they want to experience sex that

Does Sex Have an Inherent Meaning?

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Sex, Advice Columnists, and Pop Psychology 31

Association (http://www.apa.org) and the Sexuality Information and Education Council of the United States (http://www.siecus.org) provide reliable informa- tion and links to other, equally reputable, sites.

The Use and Abuse of Research Findings To reinforce their authority, the media often incorporate statistics from a study’s findings, which are key features of social science research. Further, the media may report the results of a study that are contradicted by subsequent research. It is common, particularly in the medical field, for the original results not to be replicated when continued research is conducted (Tanner, 2005). For example, a review of major studies published in three influential medical journals from 1990 to 2003 found that one third of the results do not hold up (Ionannidis, 2005). But, of course, changes in “current knowledge” also happen in behavioral research. For example, an assertion that is often presented in the media as definitive is that the consumption of alcohol always leads to risky sexual behav- iors. However, studies have found that among young people the relationship between alcohol use and risky sexual behaviors is complex and often the research findings are inconsistent or inconclusive (Cooper, 2006). An alternative explana- tion is that possibly a high proportion of young people take more risks than other young people in several areas such as cigarette use, drug use, alcohol use, driving, and sex. That is, there is a clustering of risk behaviors representing high sensation seeking, and alcohol use alone does not cause risky sex but both are part of the total risk behavior pattern (Coleman, 2001; Coleman & Cater, 2005).

The media frequently quote or describe social science research, but they may do so in an oversimplified or distorted manner. An excellent example of dis- torted representation of sex-related research was some of the media coverage of the research on ram sheep by Charles Roselli, a researcher at the Oregon Health and Science University. Roselli searched for physiological explanations of why 8% of rams exclusively seek sex with other rams instead of ewes. His research was funded by the National Institutes of Health and published in major scientific journals. Following media coverage of his research, animal-rights activists, gay advocates, and others criticized the studies. A New York Times article in January 2007 noted that his research drew outrage based on, according to Roselli and

fulfills the meaning, and if they don’t, they assume there is something wrong with them or their partner. Some worry that they are not fulfilling some duty to “honor” sex, such as avoiding having sex “like animals.” He pur- ports that we should not be serving sex but sex should be serving us: this perspective enables one to experi- ence a huge range of sexual feelings and meanings. Klein states:

If we think that sex has inherent meaning and that it’s our job to both find and conform to that meaning, we won’t be able to see sex freshly, we won’t be moti- vated to perceive or act counterintuitively, and we’ll accept arbitrary, outside limits on our erotic activities. If you want to give sex meaning, go ahead. At the same time, remember to enjoy the freedom of playful, amoral (not immoral, amoral) sex (p. 157).

Think Critically 1. Do you agree with Klein’s contention that sex

has no inherent meaning? Explain your rationale. 2. Does sex have an inherent meaning to you? If so,

what is that meaning and how did you learn it? 3. Can one believe that sex has no inherent

meaning yet express sex ethically?

sources: Blank, H. (2012). Straight: The Surprisingly Short History of Heterosexuality. Boston: Beacon Press; Drucker, D. J. (2014). The Classification of Sex: Alfred Kinsey and the Organization of Knowl- edge. Pittsburgh: University of Pittsburgh Press; Kinsey, A., Pomeroy, W., & Martin, C. Sexual Behavior in the Human Male. Philadelphia: Saunders; Klein, M. (2012). Sexual Intelligence: What We Really Want from Sex—and How to Get It. New York: Harper One.

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http://www.apa.org

http://www.siecus.org

32 Chapter 2 Studying Human Sexuality

his colleagues, “bizarre misinterpretation of what the work is about.” The researchers contended that discussion of possible human implications of their findings in their reports differed from intentions of carrying the work over to humans. Critics claimed that the research could lead to altering or controlling sexual orientation. According to the Times article, The Sunday Times in London asserted, incorrectly, that Dr. Roselli found a way to “cure” homosexual rams with hormone treatment, adding that critics feared the research “could pave the way for breeding out homosexuality in humans.” John Schwartz, author of the Times article, concluded that “the story of the gay sheep became a textbook example of the distortion and vituperation that can result when science meets the global news cycle” (Schwartz, 2007). As this example illustrates, scholars tend to qualify their findings as tentative or limited to a certain group, and they are very cautious about making generalizations. In contrast, the media tend to make results sound generalizable.

• Thinking Objectively About Sexuality Although each of us has our own perspective, values, and beliefs regarding sex- uality, as students, instructors, and researchers, we are committed to the scientific study of sexuality. Basic to any scientific study is a fundamental commitment to objectivity, or the observation of things as they exist in reality as opposed to our feelings or beliefs about them. Objectivity calls for us to suspend the beliefs, biases, or prejudices we have about a subject in order to understand it.

Objectivity in the study of sexuality is not always easy to achieve, for sexu- ality can be the focal point of powerful emotions and moral ambivalence. We experience sex very subjectively. But whether we find it easy or difficult to be objective, objectivity is the foundation for studying sexuality.

Most of us think about sex, but thinking about it critically requires us to be logical and objective. It also requires that we avoid making value judgments; put aside our opinions, biases, and stereotypes; and not fall prey to common fallacies such as egocentric and ethnocentric thinking.

Value Judgments Versus Objectivity For many of us, objectivity about sex is difficult because our culture has tradi- tionally viewed sexuality in moral terms: Sex is moral or immoral, right or wrong, good or bad, normal or abnormal. When examining sexuality, we tend, therefore, to make value judgments, evaluations based on moral or ethical standards rather than objective ones. Unfortunately, value judgments are often blinders to understanding. They do not tell us about what motivates people, how frequently they behave in a given way, or how they feel. Value judgments do not tell us anything about sexuality except how we ourselves feel. In studying human sexuality, then, we need to put aside value judgments as incompatible with the pursuit of knowledge.

How can we tell the difference between a value judgment and an objective statement? Examine the following two statements and determine which is a value judgment and which is an objective statement:

■ College students should be in a committed relationship before they have sex. ■ The majority of students have sexual intercourse sometime during their

college careers.

He who knows nothing doubts nothing.

—French proverb

Morality is simply the attitude we adopt towards people we person-

ally dislike.

—Oscar Wilde (1854–1900)

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Thinking Objectively About Sexuality 33

The first statement is a value judgment; the second is an objective statement. There is a simple rule of thumb for telling the difference between the two: Value judgments imply how a person ought to behave, whereas objective statements describe how people actually behave.

There is a second difference between value judgments and objective state- ments: Value judgments cannot be empirically validated, whereas objective statements can be. That is, the truth or accuracy of an objective statement can be measured and tested.

Opinions, Biases, and Stereotypes Value judgments obscure our search for understanding. Opinions, biases, and stereotypes also interfere with the pursuit of knowledge.

Opinions An opinion is an unsubstantiated belief or conclusion about what seems to be true according to our thoughts. Opinions are not based on accurate knowledge or concrete evidence. Because opinions are unsubstantiated, they often reflect our personal values or biases and rarely change unless we are open to verifiable facts.

Biases A bias is a personal leaning or inclination that reflects a prejudice in favor of or against a person, group, or thing in contrast to another. Biases lead us to select information that supports our views or beliefs while ignoring infor- mation that does not. We need not be victims, however, of our biases. We can make a concerted effort to discover what they are and overcome them. To avoid personal bias, scholars apply the objective methods of social science research.

Stereotypes A stereotype is a set of simplistic, rigidly held, overgeneralized beliefs about a particular type of individual or group of people, an idea, and so on. Stereotypical beliefs are resistant to change. Furthermore, stereotypes— especially sexual ones—are often negative.

Common sexual stereotypes include the following:

■ Men are always ready for sex. ■ “Nice” women are not interested in sex. ■ Women need a reason for sex; men need a place. ■ Virgins are uptight and asexual. ■ The relationships of gay men never last. ■ Lesbian women hate men. ■ African American men lust after White women. ■ Latino men are promiscuous.

Psychologists believe that stereotypes structure knowledge. They affect the ways in which we process information: what we see, what we notice, what we remember, and how we explain things. Or as humorist Ashleigh Brilliant said, “Seeing is believing. I wouldn’t have seen it if I hadn’t believed it.” A stereotype is a type of schema, a way in which we organize knowledge in our thought processes. Schemas help us channel or filter the mass of information we receive so that we can make sense of it. They determine what we will regard as important. Although these mental plans are useful, they can also create blind spots. With stereotypes, we see what we expect to see and ignore what we don’t expect or want to see.

Facts do not cease to exist because they are ignored.

—Aldous Huxley (1894–1963)

The human understanding when it has once adopted an opinion . . .

draws all things else to support and agree with it.

—Francis Bacon (1561–1626)

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34 Chapter 2 Studying Human Sexuality

Sociologists point out that sexual stereotyping is often used to justify dis- crimination. Targets of stereotypes are usually members of subordinate social groups or individuals with limited economic resources. As we will see, sexual stereotyping is especially powerful in stigmatizing African Americans, Latinos, Asian Americans, gay men, lesbian women, and bisexual and transgender individuals.

We all have opinions and biases, and most of us to varying degrees think stereotypically. But the commitment to objectivity requires us to become aware of our opinions, biases, and stereotypes and to put them aside in the pursuit of knowledge.

Common Fallacies: Egocentric and Ethnocentric Thinking A fallacy is an error in reasoning that affects our understanding of a subject. Fallacies distort our thinking, leading us to false or erroneous conclusions. In the field of sexuality, egocentric and ethnocentric fallacies are common.

The Egocentric Fallacy The egocentric fallacy is the mistaken belief that our own personal experience and values generally are held by others. On the basis of our belief in this false consensus, we use our own beliefs and values to explain the attitudes, motivations, and behaviors of others. Of course, our own experi- ences and values are important; they are the source of personal strength and knowledge, and they can give us insight into the experiences and values of others. But we cannot necessarily generalize from our own experience to that of others. Our own personal experiences are limited and may be unrepresentative. Some- times, our generalizations are merely opinions or disguised value judgments.

The Ethnocentric Fallacy The ethnocentric fallacy, also known as ethno- centrism, is the belief that our own ethnic group, nation, or culture is innately superior to others. Ethnocentrism is reinforced by opinions, biases, and stereo- types about other groups and cultures. As members of a group, we tend to share similar values and attitudes with other group members. But the mere fact that

we share these beliefs is not sufficient proof of their truth.

Ethnocentrism has been increasingly evi- dent as a reaction to the increased awareness of ethnicity, or ethnic affiliation or identity. For many Americans, a significant part of their sense of self comes from identification with their ethnic group. An ethnic group is a group of people distinct from other groups because of cultural characteristics, such as language, religion, and customs, that are transmitted from one generation to the next.

Although there was little research on ethnicity and sexuality until the 1980s, evi- dence suggests that there are significant ethnic variations in terms of sexual atti- tudes and behavior. When data are avail- able, the variations by ethnicity will be presented throughout this book.

Re-examine all that you have been told. Dismiss that which insults

your soul.

—Walt Whitman (1819–1892)

A great many people think they are thinking when they are merely

rearranging their prejudice.

—William James (1842–1910)

Ethnocentrism is the belief that one’s own culture or ethnic group is superior to others. Although child marriage is prohibited in our society, it is acceptable in many cultures throughout the world, including India. © STRDEL/AFP/Getty Images

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Sex Research Methods 35

Ethnocentrism results when we stereotype other cultures as “primitive,” “innocent,” “inferior,” or “not as advanced.” We may view the behavior of other peoples as strange, exotic, unusual, or bizarre, but to them it is normal. Their attitudes, behaviors, values, and beliefs form a unified sexual system that makes sense within their culture. In fact, we engage in many activities that appear peculiar to those outside our culture.

• Sex Research Methods One of the key factors that distinguish the findings of social science from beliefs, prejudice, bias, and pop psychology is the field’s commitment to the scientific method. The scientific method is the method by which a hypothesis is formed from impartially gathered data and tested empirically. The scientific method relies on induction—that is, drawing a general conclusion from specific facts. The scientific method seeks to describe the world rather than evaluate or judge it.

Although sex researchers, sometimes called sexologists, use the same meth- odology as other social scientists, they are constrained by ethical concerns and taboos that those in many other fields do not experience. Because of the taboos surrounding sexuality, some traditional research methods are inappropriate (Schick, Calabrese, & Herbenick, 2014).

Sex research, like most social science research, uses varied methodological approaches. These include clinical research, survey research (questionnaires and interviews), observational research, and experimental research. And as in many fields, no single research approach has emerged in sexual science (Weis, 2002).

Research Concerns Researchers face two general concerns in conducting their work: (1) ethical concerns centering on the use of human beings as subjects and (2) method- ological concerns regarding sampling techniques and their accuracy. Without a representative sample, the conclusions that can be drawn using these method- ologies are limited.

Ethical Issues A fundamental principle of research is informed consent. Informed consent means that people are free to decide, without coercion, whether to participate in a research study. This occurs following the full disclo- sure to an individual of the study purpose and the potential risks and the ben- efits of being a participant in the research project. Studies involving children and other minors typically require parental consent. Once a study begins, par- ticipants have the right to withdraw at any time without penalty.

Each research participant is entitled to protection from harm. Some sex research, such as the viewing of explicit films to measure physiological responses, may cause some people emotional distress. The identity of research subjects should be kept confidential. Because of the highly charged nature of sexuality, participants also need to be guaranteed anonymity.

All colleges and universities have review boards or human-subject commit- tees to make sure that researchers follow ethical guidelines. Proposed research is submitted to the committee for approval before the project begins.

All universal judgments are weak, loose, and dangerous.

—Michel de Montaigne (1533–1595)

Anything more than truth would be too much.

—Robert Frost (1874–1963)

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36 Chapter 2 Studying Human Sexuality

Sampling In each research approach, the choice of a sample—a portion of a larger group of people or population—is critical. To be most useful, a sample should be a random sample—that is, a sample collected in an unbiased way, with the selection of each member of the sam- ple based solely on chance. Furthermore, the sample should be a representative sample, with a small group representing the larger group in terms of age, sex, eth- nicity, socioeconomic status, sexual ori- entation, and so on. With a random sample, information gathered from a small group can be used to make infer- ences about the larger group. Samples

that are not representative of the larger group are known as biased samples (Crosby, DiClemente, & Salazar, 2006).

Using samples is important. It would be impossible, for example, to study the sexual behaviors of all college students in the United States. But we could select a representative sample of college students from various schools and infer from their behavior how other college students behave. Using the same sample to infer the sexual behavior of Americans in general, however, would mean using a biased sample. We cannot generalize the sexual activities of American college students to the larger population.

Most samples in sex research are limited for several reasons:

■ They depend on volunteers or clients. Because these samples are gener- ally self-selected, we cannot assume that they are representative of the population as a whole. Volunteers for sex research are often more likely to be male, sexually experienced, liberal, and less religious and to have more positive attitudes toward sexuality and less sex guilt and anxiety than those who do not choose to participate (Strassberg & Lowe, 1995; Wiederman, 1999).

■ Most sex research takes place in a university or college setting with stu- dent volunteers. Their sex-related attitudes, values, and behaviors may be very different from those of other adults.

■ Some ethnic groups are generally underrepresented. Representative sam- ples of African Americans, Latinos, American Indians, Middle Eastern Americans, and some Asian Americans, for example, are not easily found because these groups are underrepresented at the colleges and universities where subjects are generally recruited.

■ The study of gay men, lesbian women, and bisexual and transgender individuals presents unique sampling issues. Are gay men, lesbian women, and bisexual individuals who have come out—publicly identified themselves as gay, lesbian, or bisexual—different from those who have not? How do researchers find and recruit subjects who have not come out?

Because these factors limit most studies, we must be careful in making gener- alizations from studies.

A couple is being interviewed by a sex researcher. The face- to-face interview, one method of gathering data about sexuality, has both advantages and disadvantages. © sturti/iStock/Getty Images

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Sex Research Methods 37

Clinical Research Clinical research is the in-depth examination of an individual or group that goes to a psychiatrist, psychologist, or social worker for assistance with psychological or medical problems or disorders. Clinical research is descriptive; inferences of cause and effect cannot be drawn from it. The individual is interviewed and treated for a specific problem. At the same time the person is being treated, he or she is being studied. In their evaluations, clinicians attempt to determine what caused the disorder and how it may be treated. They may also try to infer from dysfunctional people how healthy people develop. Clinical research often focuses on atypical, unhealthy behaviors, problems related to sexuality (e.g., feeling trapped in the body of the wrong gender), and sexual function problems (e.g., lack of desire, early ejaculation, erectile difficulties, or lack of orgasm).

A major limitation of clinical research is its emphasis on pathological behavior, or unhealthy or diseased behavior. Such an emphasis makes clinical research dependent on cultural definitions of what is “unhealthy” or “patho- logical.” These definitions, however, change over time and in the context of the culture being studied. In the nineteenth century, for example, masturbation was considered pathological. Physicians and clinicians went to great lengths to root it out. In the case of women, surgeons sometimes removed the clitoris. Today, masturbation is viewed more positively.

Survey Research Survey research is a method that uses questionnaires or interviews to gather information. Questionnaires offer anonymity, can be completed fairly quickly, and are relatively inexpensive to administer; however, they usually do not allow an in-depth response. A person must respond with a short answer or select from a limited number of options. The limited-choices format provides a more objective assessment than the short-answer format and results in a total score. Interview techniques avoid some of the shortcomings of questionnaires, as inter- viewers are able to probe in greater depth and follow paths suggested by the participant.

Although surveys are important sources of information, the method has several limitations, as people may be poor reporters of their own sexual behavior:

■ Some people may exaggerate their number of sexual partners; others may minimize their casual encounters.

■ Respondents generally underreport experiences that might be culturally considered deviant or immoral, such as bondage and same-sex experiences.

■ Some respondents may feel uncomfortable about revealing information— such as about masturbation or fetishes—in a face-to-face interview.

■ The accuracy of one’s memory may fade as time passes, and providing an accurate estimation, such as how long sex lasted, may be difficult.

■ Some ethnic groups, because of their cultural values, may be reluctant to reveal sexual information about themselves.

■ Interviewers may allow their own preconceptions to influence the way in which they frame questions and to bias their interpretations of responses.

■ The interviewer’s sex, race, religion, or sexual orientation may also influ- ence how comfortable respondents are in disclosing information about themselves.

One of the great tragedies of life is the murder of a beautiful theory by

a gang of brutal facts.

—Benjamin Franklin (1705–1790)

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38 Chapter 2 Studying Human Sexuality

Interestingly, despite these limitations of self-reporting of sexual behavior, a recent review of seven population-based surveys of adults in the United States concluded that self-reported data may not be as unreliable as generally assumed. The study examined the consistency in the number of sexual partners reported in these seven national studies and found a remarkable level of consistency among the studies. The researchers concluded that the findings show promise for research that relies on self-reported number of sexual partners (Hamilton & Morris, 2010).

Some researchers use computers to improve interviewing techniques for sen- sitive topics. With the audio computer-assisted self-interviewing (audio-CASI) method, the respondent hears the questions over headphones or reads them on a computer screen and then enters his or her responses into the computer. Audio- CASI, an increasingly popular method of data collection, apparently increases feelings of confidentiality and accuracy of responses on sensitive topics such as sexual risk behaviors (Cooley et al., 2001; Des Jarlais et al., 1999; Potdar & Koenig, 2005). Even though the use of audio-CASI has advantages, research has found that the use of the audio part by respondents was limited and that gains in more candid responses from the audio component are modest relative to text-only CASI (Couper, Tourangeau, & Marvin, 2009).

Other types of computer-based technology being used for data collection include: (1) computer-assisted telephone interviewing, involving a telephone interviewer administering a scripted questionnaire and then entering the participant’s responses directly into the computer and (2) computer-assisted personal interviewing, during which a face-to-face interviewer administers a scripted questionnaire and enters the responses of the participant directly into the computer. Such technologies, including smart phones, have several advan- tages including convenient data entry and the ability to enter information about sexual-related variables (e.g., attitudes and behaviors) at a specified time such as soon after a sexual episode with a partner (McCallum & Peterson, 2012; Schick, Calabrese, & Herbenick, 2014).

Another technology technique is the use of the Internet to administer ques- tionnaires and conduct interviews. Since the mid-1990s, the use of the Internet has become a popular method of survey research, largely because of its ability to collect data quickly and to eliminate the costs of other methods such as travel expenses for interviews, office space for interviews, printing and mailing of written questionnaires, and the software for audio-CASI. The use of the Internet can also result in larger samples. For example, a British Internet study on sex- uality and gender had about 255,000 participants (Reimers, 2007). Because of the large number of Internet websites, social networks, and chat rooms that serve particular populations such as sexual minorities, the Internet facilitates access to hard-to-reach groups as well as geographically isolated persons. For example, stigmatized groups such as bisexual individuals may feel more comfortable par- ticipating via the Internet. While an advantage of the Internet is the perceived anonymity by the participant, it can be a disadvantage in that a researcher is not present to clarify survey instructions or questions or to verify that the par- ticipant is the person he or she claims to be (Schick et al., 2014).

Daily data collection, using a sexual diary, or personal notes of one’s sexual activity, can increase the accuracy of self-reported data and make possible the analysis of any specific sexual-related event (Crosby et al., 2006). Often, research participants make daily diary entries online or by phone, for example, about sexual variables such as interest, fantasies, and behavior. Or they may be requested to make entries only after a certain sexual activity has occurred, such

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Sex Research Methods 39

as intercourse. Research suggests that event-specific behaviors such as condom use during sex will be more accurately recalled in diaries than by retrospective methods such as self-report questionnaires and interviews (Fortenberry, Cecil, Zimet, & Orr, 1997; Gilmore et al., 2001; Graham & Bancroft, 1997; McAuliffe, DiFranceisco, & Reed, 2007).

Observational Research Observational research is a method by which a researcher unobtrusively observes and makes systematic notes about people’s behavior without trying to manipulate it. The observer does not want his or her presence to affect the subject’s behavior, although this is rarely possible. Because sexual behavior is regarded as significantly different from other behaviors, there are serious ethical issues involved in observing people’s sexual behavior without their knowledge and consent. Researchers cannot observe sexual behavior as they might observe, say, flirting at a party, dance, or bar, so such observations usually take place in a laboratory setting. In such instances, the setting is not a natural environment, and participants are aware that their behavior is under observation.

Participant observation, in which the researcher participates in the behav- iors he or she is studying, is an important method of observational research. For example, a researcher may study prostitution by becoming a customer or may study anonymous sex between men in public restrooms by posing as a lookout (Humphreys, 1975). There are several questions raised by such participant observation: How does the observer’s participation affect the interactions being studied? For example, does a prostitute respond differently to a researcher if he or she tries to obtain information? If the observer participates, how does this affect his or her objectivity? And what are the researcher’s ethical responsibili- ties regarding informing those he or she is studying?

Experimental Research Experimental research is the systematic manipulation of individuals or the environment to learn the effects of such manipulation on behavior. It enables researchers to isolate a single factor under controlled circumstances to determine its influence. Researchers are able to control their experiments by using variables, or aspects or factors that can be manipulated in experiments. There are two types of variables: independent and dependent. Independent

An increasing number of sex researchers are placing their questionnaires on the Internet so that persons at any location or at any time can participate in the study. © Studio Works/Alamy

Ignorance is like a delicate exotic fruit; touch it and the bloom is gone.

—Oscar Wilde (1854–1900)

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40 Chapter 2 Studying Human Sexuality

variables are factors that can be manip- ulated or changed by the experimenter; dependent variables are factors that are likely to be affected by changes in the independent variable.

Because it controls variables, experi- mental research differs from the previous methods we have examined. Clinical studies, surveys, and observational research are correlational in nature. Cor- relational studies measure two or more naturally occurring variables to determine their relationship to each other. Because these studies do not manipulate the vari- ables, they cannot tell us which variable causes the other to change. But experi-

mental studies manipulate the independent variables, so researchers can reason- ably determine what variables cause the other variables to change.

Much experimental research on sexuality depends on measuring physiological responses. These responses are usually measured by plethysmographs (pluh- THIZ-muh-grafs)—devices attached to the genitals to measure physiological response. Two of the most frequently used methods of penile plethysmograph assessment is the measurement of the penis circumference using a strain gauge (a device resembling a rubber band that fits around the penis) and the measurement of the volume of the penis using an airtight cylinder and cuff placed on the base of the penis. The device measures penile engorgement but not necessarily sexual desire or sexual arousal as we know that men can experience erections (e.g. awaken from sleep with an erection). The vaginal plethysmograph is about the size of a menstrual tampon and is inserted into the vagina like a tampon. The device mea- sures the amount of blood within the vaginal walls, which increases as a woman becomes sexually aroused (Chivers, Suschinsky, Timmers, & Bossio, 2014). The device may not be a good indicator of female sexual arousal as studies have shown poor correlations between women’s self-reported sexual desire and device readings (Chivers, Seto, Lalumière, Laan, & Grimbos, 2010).

Suppose researchers want to study the influence of alcohol on sexual response. They can use a plethysmograph to measure sexual response, the dependent vari- able. In this study, the independent variable is the level of alcohol consumption: no alcohol consumption, moderate alcohol consumption (1–3 drinks), and high alcohol consumption (3+ drinks). In such an experiment, subjects may view an erotic video. To get a baseline measurement, researchers measure the genitals’ physiological patterns in an unaroused state, before participants view the video or take a drink. Then they measure sexual arousal (dependent variable) in response to erotica as they increase the level of alcohol consumption (independent variable).

• The Sex Researchers It was not until the nineteenth century that Western sexuality began to be stud- ied using a scientific framework. Prior to that time, sexuality was the domain of religion rather than science; sex was the subject of moral rather than scientific scrutiny. From the earliest Christian era, treatises, canon law, and papal bulls,

Judge a man by his questions rather than by his answers.

—Voltaire (1694–1778)

Participant observation is an important means by which anthropologists gain information about other cultures. © Pascale Beroujon/Getty Images

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The Sex Researchers 41

as well as sermons and confessions, catalogued the sins of the flesh. Reflecting this Christian tradition, the early researchers of sexuality were concerned with the supposed excesses and deviances of sexuality rather than its healthy functioning. They were fascinated by what they considered the pathologies of sex, such as fetishism, sadism, masturbation, and homosexuality—the very behaviors that religion condemned as sinful. Alfred Kinsey ironically noted that nineteenth-century researchers created “scientific classifications . . . nearly iden- tical with theological classifications and with moral pronouncements . . . of the fifteenth century” (Kinsey, Pomeroy, & Martin, 1948).

As we will see, however, there has been a liberalizing trend in our thinking about sexuality. Both Richard von Krafft-Ebing and Sigmund Freud viewed sexuality as inherently dangerous and needing repression. But Havelock Ellis, Alfred Kinsey, William Masters and Virginia Johnson, and many other more recent researchers have viewed sexuality more positively; in fact, historian Paul Robinson (1976) regards these later researchers as modernists, or “sexual enthu- siasts.” Three themes are evident in the work of modernists: (1) They believe that sexual expression is essential to an individual’s well-being, (2) they seek to broaden the range of legitimate sexual activity, including homosexuality, and (3) they believe that female sexuality is the equal of male sexuality.

As much as possible, sex researchers attempt to examine sexuality objec- tively. But, as with all of us, many of their views are intertwined with the beliefs and values of their times. This is especially apparent among the early sex researchers, some of the most important of whom are described here.

Richard von Krafft-Ebing Richard von Krafft-Ebing (1840–1902), a Viennese professor of psychiatry, was probably the most influential of the early researchers. In 1886 he published his most famous work, Psychopathia Sexualis, a collection of case histories of fetishists, sadists, masochists, and homosexuals. (He invented the words “sado- masochism” and “transvestite.”)

Krafft-Ebing traced variations in Victorian sexuality to “hereditary taint,” to “moral degeneracy,” and, in particular, to masturbation. He intermingled descrip- tions of fetishists who became sexually excited by certain items of clothing with those of sadists who disemboweled their victims. For Krafft-Ebing, the origins of fetishism and murderous sadism, as well as most variations, lay in masturba- tion, the prime sexual sin of the nineteenth century. Despite his misguided focus on masturbation, Krafft-Ebing’s Psychopathia Sexualis brought to public atten- tion and discussion an immense range of sexual behaviors that had never before been documented in a dispassionate, if erroneous, manner. A darkened region of sexual behavior was brought into the open for public examination.

Sigmund Freud Few people have had as dramatic an impact on the way we think about the world as the Viennese physician Sigmund Freud (1856–1939). In his attempt to under- stand the neuroses, or psychological disorders characterized by anxiety or ten- sion, plaguing his patients, Freud explored the unknown territory of the unconscious. If unconscious motives were brought to consciousness, Freud believed, a person could change his or her behavior. But, he suggested, repres- sion, a psychological mechanism that kept people from becoming aware of hid- den memories and motives because they aroused guilt, prevents such knowledge.

Richard von Krafft-Ebing (1840–1902) viewed most sexual behavior other than marital coitus as a sign of pathology. © Imagno/Getty Images

Sigmund Freud (1856–1939) was the founder of psychoanalysis and one of the most influential European thinkers of the first half of the twentieth century. Freud viewed sexuality with suspicion. © Ingram Publishing

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42 Chapter 2 Studying Human Sexuality

To explore the unconscious, Freud used various techniques; in particular, he analyzed dreams to discover their meaning. His journeys into the mind led to the development of psychoanalysis, a psychological system that ascribes behav- ior to unconscious desires. He fled Vienna when Hitler annexed Austria in 1938 and died a year later in England.

Freud believed that sexuality begins at birth, a belief that set him apart from other researchers. Freud described five stages in psychosexual development. The first stage is the oral stage, lasting from birth to age 1. During this time, the infant’s eroticism is focused on the mouth; thumb sucking produces an erotic pleasure. Freud believed that the “most striking character of this sexual activity . . . is that the child gratifies himself on his own body; . . . he is autoerotic” (Freud, 1938). The second stage, between ages 1 and 3, is the anal stage. Children’s sexual activ- ities continue to be autoerotic, but the region of pleasure shifts to the anus. From age 3 through 5, children are in the phallic stage, in which they exhibit interest in the genitals. At age 6, children enter a latency stage, in which their sexual impulses are no longer active. At puberty, they enter the genital stage, at which point they become interested in genital sexual activities, especially sexual intercourse.

The phallic stage is the critical stage in both male and female development. The boy develops sexual desires for his mother, leading to an Oedipal complex. He simultaneously desires his mother and fears his father. This fear leads to cas- tration anxiety, the boy’s belief that his penis will be cut off by his father because of jealousy. Girls follow a more complex developmental path, according to Freud. A girl develops an Electra complex, desiring her father while fearing her mother. Upon discovering that she does not have a penis, she feels deprived and develops penis envy. By age 6, boys and girls have resolved their Oedipal and Electra complexes by relinquishing their desires for the parent of the other sex and iden- tifying with their same-sex parent. In this manner, they develop their masculine and feminine identities. But because girls never acquire their “lost penis,” Freud believed, they fail to develop an independent character like that of boys.

In many ways, such as in his commitment to science and his explorations of the unconscious, Freud seems the embodiment of twentieth-century thought. But in recent times, his influence among American sex researchers has dwindled. Two of the most important reasons are his lack of empiricism and his inadequate description of female development.

Because of its limitations, Freud’s work has become mostly of historical interest to mainstream sex researchers. It continues to exert influence in some fields of psychology but has been greatly modified by other fields. Even among contemporary psychoanalysts, Freud’s work has been radically revised.

Havelock Ellis English physician and psychologist Havelock Ellis (1859–1939) was the earliest important modern sexual theorist and scholar. His Studies in the Psychology of Sex (the first six volumes of which were published between 1897 and 1910) consisted of case studies, autobiographies, and personal letters. One of his most important contributions was pointing out the relativity of sexual values. In the nineteenth century, Americans and Europeans alike believed that their society’s dominant sexual beliefs were the only morally and naturally correct standards. But Ellis demonstrated not only that Western sexual standards were hardly the only moral standards but also that they were not necessarily rooted in nature. In doing so, he was among the first researchers to appeal to studies in animal behavior, anthropology, and history.

Havelock Ellis (1859–1939) argued that many behaviors previously labeled as abnormal were actually normal, including masturbation and female sexuality. For example, he found no evidence that masturbation leads to mental disorders, and he documented that women have sexual drives no less intense than those of men. © Hulton-Deutsch Collection/Corbis

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The Sex Researchers 43

Ellis also challenged the view that masturbation was abnormal. He argued that masturbation was widespread and that there was no evidence linking it with any serious mental or physical problems. He recorded countless men and women who masturbated without ill effect. In fact, he argued, masturbation had a pos- itive function: It relieved tension.

In the nineteenth century, women were viewed as essentially “pure beings” who possessed reproductive rather than sexual desires. Men, in contrast, were driven by such strong sexual passions that their sexuality had to be severely controlled and repressed. In countless case studies, Ellis documented that women possessed sexual desires no less intense than those of men.

Ellis asserted that a wide range of behaviors was normal, including much behavior that the Victorians considered abnormal. He argued that both masturba- tion and female sexuality were normal behaviors and that even the so-called abnormal elements of sexual behavior were simply exaggerations of the normal.

He also reevaluated homosexuality. In the nineteenth century, homosexuality was viewed as the essence of sin and perversion. It was dangerous, lurid, and criminal. Ellis insisted that it was not a disease or a vice but a congenital con- dition: A person was born homosexual; one did not become homosexual. By insisting that homosexuality was congenital, Ellis denied that it could be con- sidered a vice or a form of moral degeneracy, because a person did not choose it. If homosexuality were both congenital and harmless, then, Ellis reasoned, it should not be considered immoral or criminal.

Alfred Kinsey Alfred C. Kinsey (1894–1956), a biologist at Indiana University and America’s leading authority on gall wasps, destroyed forever the belief in American sexual innocence and virtue. He accomplished this through two books, Sexual Behavior in the Human Male (Kinsey, Pomeroy, & Martin, 1948) and Sexual Behavior in the Human Female (Kinsey, Pomeroy, Martin, & Gebhard, 1953). These two volumes statistically documented the actual sexual behavior of Americans. In massive detail, they demonstrated the great discrepancy between public stan- dards of sexual behavior and actual sexual behavior. Kinsey believed that sex was as legitimate a subject for study as any other and that the study of sex should be treated as a scientific discipline involving compiling and examining data and drawing conclusions without moralizing. He challenged the traditional medical field’s dominance of sexual research, leading to the field becoming open to many more disciplines (Bullough, 1994).

In the firestorm that accompanied the publication of Kinsey’s books (popu- larly known as the Kinsey Reports), many Americans protested the destruction of their cherished ideals and illusions. Kinsey was highly criticized for his work—and that criticism continues even today. Many people believed that his findings were responsible for a moral breakdown in the United States. Eminent sex researcher Vern Bullough (2004) stated that

few scholars or scientists have lived under the intense firestorm of publicity and criticism that he did but even as the attacks on him increased and as his health failed, he continued to gather his data, and fight for what he believed. He changed sex for all of us.

Sexual Diversity and Variation What Kinsey discovered in his research was an extraordinary diversity in sexual behaviors. He declared that all types of sexual behavior—even those that occur infrequently—are simply variants on the complex

Alfred C. Kinsey (1894–1956) photographed by William Dellenback, 1953. Kinsey shocked Americans by revealing how they actually behaved sexually. His scientific efforts led to the termination of his research funding because of political pressure. © Arthur Siegel/The LIFE Images Collection/ Getty Images

We are the recorders and reporters of facts—not judges of the behavior

we describe.

—Alfred C. Kinsey (1894–1956)

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44 Chapter 2 Studying Human Sexuality

continuum of human behavior. A fundamental tenet of Kinsey was his commitment to be objective in research, refraining from traditional and religious judgments and from suggesting that persons participating in variant behavior should change their behavior (Drucker, 2014). Among men, he found individuals who had orgasms daily and others who went months without orgasms. Among women, he found individuals who had never had orgasms and others who had them several times a day. He discovered one male who had ejaculated only once in 30 years and another who ejaculated 30 times a week on average. “This is the order of variation,” he commented dryly, “which may occur between two individuals who live in the same town and who are neighbors, meeting in the same place of business and coming together in common social activities” (Kinsey, Pomeroy, & Martin, 1948).

A Reevaluation of Masturbation Kinsey’s work aimed at a reevaluation of the role of masturbation in a person’s sexual adjustment. Kinsey made three points about masturbation: (1) It is harmless, (2) it is not a substitute for sexual intercourse but a distinct form of sexual behavior that provides sexual pleasure, and (3) it plays an important role in women’s sexuality because it is a more reliable source of orgasm than heterosexual intercourse and because its practice seems to facilitate women’s ability to become orgasmic during intercourse. Indeed, Kinsey believed that masturbation is the best way to measure a woman’s inherent sexual responsiveness because it does not rely on another person.

Sexual Orientation Prior to Kinsey’s work, an individual was identified as homo- sexual if he or she had ever engaged in any sexual behavior with a person of the same sex. Kinsey found, however, that many people had sexual experiences with persons of both sexes. He reported that 50% of the men and 28% of the women in his studies had had same-sex experiences and that 38% of the men and 13% of the women had had orgasms during these experiences (Kinsey, Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). Furthermore, he discovered that sexual attractions could change over the course of a person’s lifetime. Kinsey’s research led him to conclude that it was erroneous to classify people as either heterosexual or homosexual. A person’s sexuality was significantly more complex and fluid.

Kinsey wanted to eliminate the concept of heterosexual and homosexual identities. He did not believe that homosexuality, any more than heterosexuality, existed as a fixed psychological identity. Instead, he argued, there were only sexual behaviors, and behaviors alone did not make a person gay, lesbian, bisex- ual, or heterosexual. It was more important to determine what proportion of behaviors were same-sex and other-sex than to label a person as gay, lesbian, or heterosexual.

He devised the Kinsey Heterosexual-Homosexual Rating Scale to represent the proportion of an individual’s sexual behaviors and psychosexual reactions with the same or other sex (see Figure 1). The scale charts sexual behavior and psychosexual reactions exclusively directed toward either persons of the same or the other sex and along a continuum of both sexes. Kinsey’s scale radicalized the categorization of human sexual expression and represents his signature the- oretical model of human sexuality (Drucker, 2014; McWhirter, 1990).

Rejection of Normal/Abnormal Dichotomy As a result of his research, Kinsey insisted that the distinction between normal and abnormal was meaning- less. Like Ellis, he argued that sexual differences were a matter of degree, not kind. Almost any sexual behavior could be placed alongside another that differed

You shall know the truth and the truth shall make you mad.

—Aldous Huxley (1894–1963)

I don’t see much of Alfred anymore since he got so interested in sex.

—Clara Kinsey (1898–1982)

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The Sex Researchers 45

from it only slightly. His observations led him to be a leading advocate of the acceptance of sexual diversity.

William Masters and Virginia Johnson In the 1950s, William Masters (1915–2001), a St. Louis physician, became inter- ested in treating sexual function difficulties—such problems as early ejaculation and erection difficulties in men and lack of orgasm in women. As a physician, he felt that a systematic study of the human sexual response was necessary, but none existed. To fill this void, he decided to conduct his own research. Masters was joined several years later by Virginia Johnson (1925–2013).

Masters and Johnson detailed the sexual response cycles of 382 men and 312 women during more than 10,000 episodes of sexual behavior, including masturbation and sexual intercourse. The researchers combined observation with direct measurement of changes in male and female genitals using elec- tronic devices. (Their four-phase sexual response cycle will be discussed in chapters 3 and 4.)

Human Sexual Response (1966), their first book, became an immediate success among both researchers and the public. What made their work sig- nificant was not only their detailed descriptions of physiological responses but also the articulation of several key ideas. First, Masters and Johnson discovered that, physiologically, male and female sexual responses are very similar. Second, they demonstrated that women experience orgasm primarily through clitoral stimulation. Penetration of the vagina is not needed for orgasm to occur. By demonstrating the primacy of the clitoris, Masters and Johnson destroyed once and for all the Freudian distinction between vaginal and clitoral orgasm. (Freud believed that an orgasm a woman experienced through masturbation was somehow physically and psychologically inferior to one experienced through sexual intercourse. He made no such distinction for men.) By destroying the myth of the vaginal orgasm, Masters and Johnson legitimized female masturbation.

Exclusively heterosexual with no homosexual

Based on other-sex and/or same-sex sexual behaviors and psychosexual reactions such as sex dreams and fantasies in the person's sexual history, individuals rate as follows:

Predominately heterosexual, only incidentally homosexual

Predominately heterosexual, but more than incidentally homosexual

Equally heterosexual and homosexual

3 4

Predominately homosexual, but incidentally heterosexual

Exclusively homosexual

H et

er o

se xu

H o

m o

se xu

Predominately homosexual, but more than incidentally heterosexual

• FIGURE 1 The Kinsey Heterosexual-Homosexual Rating Scale. This scale illustrates the continuum of sexual expression.

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46 Chapter 2 Studying Human Sexuality

In 1970, Masters and Johnson published Human Sexual Inadequacy, which revolu- tionized sex therapy by treating sexual problems simply as difficulties that could be treated using behavioral therapy. They argued that sexual problems were not the result of underlying neuroses or personality disorders. More often than not, problems resulted from a lack of information, poor communication between partners, or mari- tal conflict. Their behavioral approach, which included “homework” exercises such as clitoral or penile stimulation, led to an astounding increase in the rate of successful treatment of sexual problems. Their work made them pioneers in modern sex therapy.

•Contemporary Research Studies Several large, national sexuality-related studies have been conducted in recent years. We briefly describe five national surveys here to illustrate research on the general population of men and women, adolescents, and college students. These studies, largely directed to determine the prevalence of certain behaviors, give little or no attention to factors that help explain the findings. Further, they represent only the tip of the sexuality-related research pertinent to the topics covered in this text- book. Sex research continues to be an emerging field of study. Most studies are not national projects but are smaller ones dealing with special populations or issues and focus on examining factors that are related to or influence sexual behavior. Even though these studies may be smaller in scope, they provide valuable informa- tion for furthering our understanding of human sexual expression. Throughout the book, we cite numerous studies to provide empirical information about the topic.

Before describing these studies, it is important to note that, just as in the days of Alfred Kinsey, these are difficult times in which to conduct sex research. For example, members of Congress and some conservative groups are attacking the value of certain sex research topics, even those related to HIV prevention. The result has been a chilling effect on sex research. Funding for sex research has become more limited, and sexuality-related grant applications to the National Institutes of Health that have been approved by peer review have been ques- tioned. Sex research is a relatively young area of study when compared to longer and better-established fields such as psychology, and the number of researchers specializing in sexuality-related study is small. Hopefully, these efforts to limit and discredit sex research will not discourage the next generation of researchers from becoming sex researchers. (To read a brief discussion about the controversy surrounding sex research, see the “Think About It” box “Sex Research: A Ben- efit to Individuals and Society or a Threat to Morality?”)

The National Health and Social Life Survey In 1994, new figures from the first nationally representative survey of Ameri- cans’ sexual behavior were released, showing us to be in a different place than when Kinsey did his research a half century earlier. Researchers from

The profoundest of all our sensuali- ties is the sense of truth.

—D. H. Lawrence (1885–1930)

William Masters (1915–2001) and Virginia Johnson (1925–2013) detailed the sexual response cycle in the 1960s and revolutionized sex therapy in the 1970s. © Bettmann/Corbis

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Contemporary Research Studies 47

the University of Chicago published two titles—the popular trade book Sex in America: A Definitive Survey (Michael, Gagnon, Laumann, & Kolata, 1994) and a more detailed and scholarly version, The Social Organization of Sexuality (Laumann, Gagnon, Michael, & Michaels, 1994). The survey contradicted many previous findings and beliefs about sex in America.

The study, titled the National Health and Social Life Survey (NHSLS), involved 3,432 randomly selected Americans aged 18–59, interviewed face-to- face. Even though this study was conducted over two decades ago (1992) and had some sampling limitations, sexual scientists regard it as one of the most methodologically sound studies; hence, we highlight major findings here and in subsequent chapters of this text.

Released as the first study to explore the social context of sexuality, the NHSLS revealed the following:

■ Americans are largely exclusive. The median number of sexual partners since age 18 for men was six and for women two.

■ On average, Americans have sex about once a week. Nearly 30% had sex with a partner only a few times a year or not at all, 35% had sex once or several times a month, and about 35% had sex two or more times a week.

■ Extramarital sex is the exception, not the rule. Among those who were married, 75% of men and 85% of women said they had been sexually exclusive with their spouse.

■ Most Americans have fairly traditional sexual behaviors. When respon- dents were asked to name their preferences from a long list of sexual behaviors, vaginal intercourse was considered “very appealing” by most of those interviewed. Ranking second, but far behind, was watching a partner undress. Oral sex ranked third.

■ Homosexuality is not as prevalent as originally believed. Among men, 2.8% described themselves as homosexual or bisexual; among women, 1.4% did so.

■ Orgasms appear to be the rule for men and the exception for women. Seventy-five percent of men claimed to have orgasms consistently with their partners, whereas only 29% of women did. Married women were most likely to report that they always or usually had orgasms.

■ Forced sex and the misperception of it remain critical problems. Twenty- two percent of women said they had been forced to do sexual things they didn’t want to do, usually by a loved one. Only 3% of men reported ever forcing themselves on women.

■ Three percent of adult Americans claim never to have had sex.

The National Survey of Family Growth Periodically, the National Center for Health Statistics (NCHS) conducts the National Survey of Family Growth (NSFG) to collect data on marriage, divorce, contraception, infertility, and the health of women and infants in the United States. In 2011, the NCHS published Sexual Behavior, Sexual Attraction, and Sexual Identity in the United States: Data from the 2006–2008 National Survey of Family Growth, which presents national estimates of several measures of sexual behavior, sexual attraction, and sexual identity among males and females 15–44 years of age in the United States. In-person, face-to-face interviews and

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48 Chapter 2 Studying Human Sexuality

think about it

Socrates said, “There is only one good, knowledge, and one evil, ignorance.” This philosophy has been a core tenet in the growth of humankind and cultures since it was first written sometime between 469 BCE and 399 BCE. But in one area of life, human sexuality, some espouse that there is one good, ignorance, and one evil, knowledge. In our culture, the value of sexual knowledge is debated. One way this ambivalence manifests itself is through criticism and barriers to research on human sex- uality (Yarber, 1992; Yarber & Sayad, 2010).

Sex research faces many issues that other areas of scientific inquiry do not, largely because human sexuality in our culture is too often surrounded by fear and denial, and its expression is often accompanied by shame, guilt, and embarrassment. These discomforts, particularly the fear of sexual knowledge, have fueled efforts to refute sex research. Some opposed to sex research believe that it has little value, and the research may be discredited. As such, the researchers may face public scorn, as Alfred Kinsey did. In fact, because of public outcry, Alfred Kinsey lost foundation funding for his research following the publication of his first book on male sexuality. The National Health and Social Life Survey (Laumann, Gagnon, Michael, & Michaels, 1994) conducted in the 1990s had to seek funding from foundations and private donors after a large federal grant was withdrawn following political pres- sure. Even today, federal government funding of sexuality- related areas is limited primarily to the study of HIV/STI risk behavior and prevention, which means researchers must search for nongovernment funding sources for top- ics outside this area. For example, a study of relation- ships between masturbation and mental health among older adults who no longer have a partner would most likely not be federally funded. The National Survey of Sexual Health and Behavior (Herbenick et al., 2010.2a), a national study of Americans’ sexual behavior conducted in 2010, was funded by a condom manufacturer.

A major test of academic freedom within the univer- sity occurred over 60 years ago when Alfred Kinsey’s research was heavily criticized and outside pressure was exerted upon Indiana University to end Kinsey’s work (Capshew, 2012). Herman B. Wells, president of IU then, defended Alfred Kinsey by declaring that the search for truth is an important function of a university and that a fundamental university tenet and core value is that a fac- ulty member is free to conduct research on any subject in which the person has competence. Wells (1980)

unequivocally articulated the tenet that “. . . a university that bows to the wishes of a person, group, or segment of society is not free.’’ Wells’s support of Alfred Kinsey’s research is considered a landmark victory for academic freedom and helped pave the way for sex research at other universities (Clark, 1977). William Masters stated that without Kinsey’s work and the support it received from IU, he and Virginia Johnson would not have been able to conduct their observational research on sexual response and dysfunction (Maier, 2009).

In the face of criticism, sex research has shown value—many individuals and society have benefited in so many ways from the deeper understanding of human sexual expression that research brings. But not all persons agree. Here are just three examples of the cultural ambi- guity surrounding sex research and sexual knowledge:

■ Some persons believed that Kinsey’s research was destructive, leading to the sexual revolution of the 1960s and the breakdown of traditional mores. How- ever, renowned sexologists consider Kinsey’s scientific findings profound, making it possible for individuals, couples, and the public to talk about sex as well as freeing many persons from the stigma of abnormality (Bullough, 2004; Gagnon, 1975).

■ Some persons were outraged upon learning that Mas- ters and Johnson actually observed persons having sex, believing that such research had gone too far. However, Masters and Johnson’s laboratory observa- tion and measurement of the sexual responses of men and women led to the development of effec- tive behavioral therapy for sexual function problems that have benefited many individuals and couples (Masters & Johnson, 1970).

■ Some individuals and evangelical religious groups support abstinence-only education and contend that sexuality education that discusses methods of preventing HIV/STIs and pregnancy other than absti- nence leads to sexual behavior among young per- sons outside of marriage. However, research has shown that abstinence-only sexuality education is largely ineffective in delaying the onset of sex and that comprehensive approaches, which included infor- mation about HIV/STIs and pregnancy prevention methods, postponed the initiation of first vaginal inter- course and increased condom and contraception use (Grossman, Tracy, Charmaraman, Ceder, & Erkut, 2014; Kirby, 2007, 2008; Stanger-Hall & Hall, 2011).

Sex Research: A Benefit to Individuals and Society or a Threat to Morality?

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Contemporary Research Studies 49

audio-CASI were used with a nationally representative sample of 13,495 males and females in the household population of the United States. Important findings for this sample include the following:

■ Sexual behaviors among males and females aged 15–44, based on the 2006–2008 NSFG, were generally the same as those reported in a similar report of 2002.

■ Among adults aged 25–44, about 98% of females and 97% of males ever had sexual intercourse, 89% of females and 90% of males ever had oral sex with an other-sex partner, and 36% of females and 44% of males ever had anal sex with an other-sex partner.

■ For men aged 15–44, the mean number of lifetime female partners was 5.1 and for women 3.2 lifetime male partners.

■ For ages 15–44, 21% of men and 8% of women reported 15 or more lifetime sexual partners.

■ For ages 15–44, 12.5% of women and 5.2% of men reported any same- sex contact in their lifetimes, and 9.3% of women and 5% of men reported oral sex with a same-sex partner.

■ For ages 15–44, for sexual identity, 92.8%, 1.0%, and 3.5% of women self- identified as heterosexual (straight), homosexual (gay or lesbian), and bisexual, respectively. For men, 95.0%, 1.6%, and 1.1% self-identified as heterosexual (straight), homosexual (gay or lesbian), and bisexual, respectively.

■ Of sexually active people aged 15–24, 63% of females and 64% of males had oral sex, down from 69% in 2002.

■ Among teenagers aged 15–19, 7% of females and 9% of males had oral sex with an other-sex partner, but no vaginal intercourse.

For a full copy of the report, see the National Center for Health Statistics web- site: http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdf.

The Youth Risk Behavior Survey The Youth Risk Behavior Survey (YRBS), conducted biannually by the Centers for Disease Control and Prevention (CDC), measures the prevalence of six cat- egories of health risk behaviors among youths through representative national,

Supporters of sex research contend that we all suffer and the public loses when sex research is hampered. They believe that a fundamental principle of a democracy is at stake: the individual right to know. One way of mak- ing it possible for people to learn more about sexuality is through sex research’s goals to increase people’s knowl- edge about sexuality and its various components and to show them the positive impact that a rewarding and health-enhancing sexuality can have. But many oppo- nents believe that sex research is harmful to society and should be limited or even eliminated. So, what do you think? For human sexuality, was Socrates right or wrong when he said, “There is one good, knowledge, and one evil, ignorance”?

Think Critically 1. Do you believe that sex research benefits

individuals and society or that it leads to moral decay? Explain.

2. Should researchers at colleges and universities have the academic freedom to conduct any type of sex research? Defend your answer.

3. Given that the vast majority of federal government–funded sexuality-related research deals with HIV/STI risk behavior, do you think that other areas of human sexuality should be funded? If so, what areas? If not, why?

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state, and local surveys using a self-report questionnaire. Sexual behaviors that contribute to unintended pregnancy and sexually transmitted infections, including HIV, are among those assessed. The 2013 YRBS includes a national school-based survey of 13,583 students in grades 9–12, from 148 public and private schools in 42 states, and 21 local surveys, revealing the following (CDC, 2014.2b):

■ Forty-seven percent of students (46% of females and 48% of males) reported ever having had sexual intercourse.

■ Fifteen percent of students (13% of females and 17% of males) reported having had sexual intercourse with four or more partners during their life.

■ Six percent of students (3% of females and 8% of males) reported having had sexual intercourse for the first time before age 13.

■ Thirty-four percent of students (35% of females and 33% of males) reported having had sexual intercourse with at least one person during the 3 months before the survey.

■ Sixty percent of students (53% of females and 66% of males) who reported being currently sexually active (34%) also reported using a con- dom during their most recent sexual intercourse.

■ Nineteen percent of students (23% of females and 15% of males) who reported being currently sexually active (34%) also reported that either they or their partner had used birth control pills before their most recent sexual intercourse.

■ Fourteen percent of students (16% of females and 12% of males) did not use any method of contraception to prevent pregnancy during their last intercourse.

■ Twenty-two percent of students (19% of females and 26% of males) who reported being currently sexually active (34%) also reported using alcohol or drugs prior to their most recent sexual intercourse.

■ Seven percent of students (11% of females and 4% of males) reported ever being forced to have sexual intercourse.

■ Among the 74% of students who dated or went out with someone during the 12 months prior the survey, 10% of students (14% of females and 6% of males) had been kissed, touched, or physically forced to have sexual intercourse when they did not want to by someone they were dating or going out with one or more times during the 12 months before the survey.

■ Thirteen percent of students (17% of females and 11% of males) reported having been tested for HIV (not counting being done while donating blood).

See http://www.cdc.gov/mmwr/pdf/ss/ss6304.pdf for more information on the 2013 YRBS.

The National College Health Assessment Since year 2000, every fall and spring term the American College Health Asso- ciation has conducted research at colleges and universities throughout the United States to assess students’ health behaviors and their perceptions of the prevalence of these behaviors among their peers. Areas covered are general health; disease and injury prevention; academic impacts; violence, abusive relationships, and personal safety; alcohol, tobacco, and other drug use; sexual behavior; nutrition and exercise; mental health; and sleep. The data reported below is for the 66,887

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Contemporary Research Studies 51

undergraduate students at 140 U.S. campuses (American College Health Association, 2014). Findings from the sexual health questions include

■ Within the last school year, 70% of college men and 69% of college women had at least one sexual partner. Most had one sexual partner—39% of men and 43% of women—although 14% of men and 9% of women had four or more partners. (See Figure 2 for the percentage reporting having oral, vaginal, and anal intercourse in the past 30 days and the percentage who used protection during these behaviors.)

■ Among sexually active students, birth control pills and male condoms were the most common (between 6 and 7 of 10 students for each method) birth control methods used to prevent pregnancy by the students or their partner the last time they had vaginal intercourse.

■ Sixty-seven percent and 51% reported receiving the vaccination against hepatitis B and against human papillomavirus, respectively.

■ Within the last 12 months, students reported sexual touch without their consent (10% of females and 4% of males), sexual penetration attempt without their consent (4% of females and 1% of males), and sexual pen- etration without their consent (3% of females and 1% of males).

■ Among sexually active students, 16% reported using (or reported their partner used) emergency contraception (“morning-after pill”) within the last school year.

A copy of the report can be found at the American College Health Association website: http://www.acha-ncha.org/docs/ACHA-NCHA-II_ReferenceGroup_ DataReport_Spring2014.pdf.

The National Survey of Sexual Health and Behavior The most expansive nationally representative study of sexual and sexual-health behaviors, the National Survey of Sexual Health and Behavior (NSSHB), was published in 2010, 16 years following the first nationally representative study, the 1994 National Health and Social Life Survey, described earlier. The NSSHB, a study based on Internet reports from 5,865 American adolescents and adults aged 14–94, provides a needed and valuable updated overview of Americans’

Oral sex in past 30 days

aPercentage reporting the behavior.

bPercentage of sexually active students reporting using a condom or other protective barrier during the speci�c sexual behavior within the past 30 days.

Vaginal sex in past 30 days

Anal intercourse in past 30 days

P er

ce nt

ag e

100

46%a

(5%)b 45%a

(4%)b 45%a

(57%)b

50%a

(51%)b

7%a

(36%)b 4%a

(23%)b

Male Female

• FIGURE 2 Percentage of Undergraduate College Students Who Reported Having Oral Sex, Vaginal Sex, and Anal Intercourse in the Past 30 Days and the Percentage Reporting Using a Condom or Other Protective Barrier, Spring 2014.

(Source: American College Health Associa- tion National College Health Assessment II: Undergraduate Students Reference Group Executive Summary, Spring 2014.)

The good thing about science is that it’s true whether you believe it

or not.

—Neil deGrasse Tyson (1958– )

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52 Chapter 2 Studying Human Sexuality

sexual behavior and reveals an increase in sexual diversity since the NHSLS. A major strength of the NSSHB is its larger range of ages—spanning 80 years— in contrast to other studies that had narrow age ranges. The study was conducted and led by researchers from the Indiana University Center for Sexual Health Promotion with collaboration from researchers from The Kinsey Institute for Research in Sex, Gender, and Reproduction and the Indiana University School of Medicine. The first reports of the NSSHB findings were published in 2010 in nine articles as a special issue of the Journal of Sexual Medicine. (The NSSHB was funded by Church & Dwight, makers of Trojan condoms.)

The NSSHB provides data on masturbation (solo and partnered), oral sex (given and received), vaginal intercourse, and anal intercourse, categorized by 10 age ranges. These new data will be highlighted throughout the textbook. Major gener- alized NSSHB findings include the following (Dodge et al., 2010; Herbenick et al., 2010.2a, 2010.2b, 2010.2c; Reece et al., 2010.2a, 2010.2b; Sanders et al., 2010):

■ A large variability of sexual repertoires of adults was found, with numerous combinations of sexual behaviors described at adults’ most recent sexual event.

■ Men and women participated in diverse solo and partnered behaviors throughout their life course, yet in spite of lower frequency of these behaviors among older adults, many reported active, pleasurable sex lives.

■ Masturbation was more common among all age groups but more common among men than women and individuals aged 25–29.

■ Vaginal intercourse occurred more frequently than other sexual behaviors from early to late adulthood.

■ Partnered noncoital behaviors—oral sex and anal intercourse—were well- established components of couple sexual behavior and were reported in greater numbers than in the NHSLS.

■ Among adults, many sexual episodes included partnered masturbation and oral sex, but not intercourse.

■ Fewer than 1 in 10 men and women self-identified as a gay man, lesbian woman, or bisexual person, but the proportion of study participants hav- ing same-gender interactions sometime in their lives was higher.

■ Masturbation, oral sex, and vaginal intercourse were prevalent among all ethnic groups and among men and women throughout the life course.

■ During a single sexual event, orgasm among men was facilitated by vagi- nal intercourse with a relationship partner, whereas women’s orgasm was facilitated by varied sexual behaviors.

■ Higher rates of condom use during most recent vaginal intercourse were found compared to other recent studies, and condoms were used more frequently with casual partners than relationship partners.

• Emerging Research Perspectives Although sex research continues to explore diverse aspects of human sexuality, some scholars feel that their particular interests have been given insufficient attention. Feminist, gay, lesbian, bisexual, and transgender research has focused on issues that mainstream research has largely ignored. And ethnic research, only recently undertaken, points to the lack of knowledge about the sexuality of some ethnic groups, such as African Americans, Latinos, Asian

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Emerging Research Perspectives 53

Americans, Middle Eastern Americans, and American Indians. These emerging research perspectives enrich our knowledge of sexuality.

Feminist Scholarship The initial feminist research generated an immense amount of groundbreaking work on women in almost every field of the social sciences and humanities. Feminists made gender and gender-related issues significant research questions in a multitude of academic disciplines, with the goal of producing useful knowl- edge that can be valuable to individual and societal change (Harding and Norberg, 2005; Letherby, 2003). In the field of sexuality, feminists expanded the scope of research to include the subjective experience and meaning of sex- uality for women; sexual pleasure; sex and power; erotic material; risky sexual behavior; and issues of female victimization, such as rape, the sexual abuse of children, and sexual harassment.

There is no single feminist perspective; instead, there are several. For our pur- poses, feminism is “a movement that involves women and men working together for equality” (McCormick, 1996). Feminism centers on understanding female experience in cultural and historical context—that is, the social construction of gender asymmetry. Social construction is the development of social categories, such as masculinity, femininity, heterosexuality, and homosexuality, by society.

Feminists believe in these basic principles:

■ Gender is significant in all aspects of social life. Like socioeconomic status and ethnicity, gender influences a person’s position in society.

■ The female experience of sex has been devalued. By emphasizing genital sex, frequency of sexual intercourse, and number of orgasms, both researchers and society ignore other important aspects of sexuality, such as kissing, caressing, love, commitment, and communication. Sexuality in lesbian women’s relationships is even more devalued. Until the 1980s, most research on homosexuality centered on gay men, making lesbian women invisible.

■ Power is a critical element in male-female relationships. Because women are often subordinated to men as a result of our society’s beliefs about gender, women generally have less power than men. As a result, feminists believe that men have defined female sexuality to benefit themselves. Not only do men typically decide when to initiate sex, but the man’s orgasm often takes precedence over the woman’s. The most brutal form of the male expression of sexual power is rape.

■ Ethnic diversity must be addressed. Women of color, feminists point out, face a double stigma: being female and being from a minority group. Although an inadequate number of studies exist on ethnicity and sexual- ity, feminists are committed to examining the role of ethnicity in female sexuality (Amaro, Raj, & Reed, 2001).

Despite its contributions, feminist research and the feminist approach have often been marginalized. However, the feminist perspective in sex research has expanded in recent years, and many more women are making important contri- butions to the advancement of sexual science. As one consequence, the research literature has increased, resulting in an expansion of our understanding of female as well as male sexuality. For example, renowned sex researcher Charlene

It is better to debate a question without settling it than to settle a

question without debating it.

—Joseph Joubert (1754–1824)

One of the greatest pains to human nature is the pain of a new idea.

—Walter Bagehot (1826–1877)

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54 Chapter 2 Studying Human Sexuality

Muehlenhard of the University of Kansas has developed a body of research that has defined the field of women’s experiences with sexual coercion. She has addressed controversial issues such as token sexual resistance and has challenged researchers to clarify their conceptualizations of wanted and unwanted sex, par- ticularly among young women (Muehlenhard & Peterson, 2005; Peterson & Muehlenhard, 2007; Muehlenhard, 2011).

Gay, Lesbian, Bisexual, and Transgender Research During the nineteenth century, sexuality became increasingly perceived as the domain of science, especially medicine. Physicians competed with ministers, priests, and rabbis in defining what was “correct” sexual behavior. However, as noted previously, medicine’s so-called scientific conclusions were not scientific; rather, they were morality disguised as science. “Scientific” definitions of healthy sex closely resembled religious definitions of moral sex. In studying sexual activities between men, medical researchers “invented” and popularized the distinction between heterosexuality and homosexuality (Blank, 2012; Gay, 1986; Gray & Garcia, 2013; Weeks, 1986).

Early Researchers and Reformers Although most physician-moralists con- demned same-sex relationships as not only immoral but also pathological, a few individuals stand out in their attempt to understand same-sex sexuality.

Karl Heinrich Ulrichs Karl Ulrichs (1825–1895) was a German poet and political activist who in the 1860s developed the first scientific theory about homosexuality (Kennedy, 1988). As a rationalist, he believed reason was supe- rior to religious belief and therefore rejected religion as superstition. He argued from logic and inference and collected case studies from numerous men to reinforce his beliefs. Ulrichs maintained that men who were attracted to other men represented a third sex, whom he called “Urnings.” Urnings were born as Urnings; their sexuality was not the result of immorality or pathology. Ulrichs believed that Urnings had a distinctive feminine quality about them that distin- guished them from men who desired women. He fought for Urning rights and the liberalization of sex laws.

Karl Maria Kertbeny Karl Kertbeny (1824–1882), a Hungarian physician, created the terms “heterosexuality” and “homosexuality” in his attempt to under- stand same-sex relationships (Feray & Herzer, 1990). Kertbeny believed that “homosexualists” were as “manly” as “heterosexualists.” For this reason, he broke with Ulrichs’s conceptualization of Urnings as inherently “feminine” (Herzer, 1985). Kertbeny argued that homosexuality was inborn and thus not immoral. He also maintained “the rights of man” (quoted in Herzer, 1985):

The rights of man begin . . . with man himself. And that which is most immediate to man is his own body, with which he can undertake fully and freely, to his advantage or disadvantage, that which he pleases, insofar as in so doing he does not disturb the rights of others.

Magnus Hirschfeld In the first few decades of the twentieth century, there was a great ferment of reform in England and other parts of Europe. While Havelock Ellis was the leading reformer in England, Magnus Hirschfeld (1868–1935) was the leading crusader in Germany, especially for homosexual rights.

Magnus Hirschfeld (1868–1935) was a leading European sex reformer who championed homosexual rights. He founded the first institute for the study of sexuality, which was burned when the Nazis took power in Germany. Hirschfeld fled for his life. © Keystone-France/Gamma-Keystone via Getty Images

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Emerging Research Perspectives 55

Hirschfeld was a gay man and possibly a transvestite (a person who wears clothing of the other sex). He eloquently presented the case for the humanity of transvestites (Hirschfeld, 1991). And in defense of homosexual rights, he argued that homosexuality was not a perversion but rather the result of the hormonal development of inborn traits. His defense of homosexuality led to the populariza- tion of the word “homosexual.” Hirschfeld’s importance, however, lies not so much in his theory of homosexuality as in his sexual reform efforts. In Berlin in 1897, he helped found the first organization for homosexual rights. In addition, he founded the first journal devoted to the study of sexuality and the first Insti- tute of Sexual Science, where he gathered a library of more than 20,000 volumes.

Evelyn Hooker As a result of Kinsey’s research, Americans learned that same-sex sexual relationships were widespread among both men and women. A few years later, psychologist Evelyn Hooker (1907–1996) startled her col- leagues by demonstrating that homosexuality in itself was not a psychological disorder. She found that “typical” gay men did not differ significantly in per- sonality characteristics from “typical” heterosexual men (Hooker, 1957). The reverberations of her work continue to this day.

Earlier studies had erroneously reported psychopathology among gay men and lesbian women for two reasons. First, because most researchers were clini- cians, their samples consisted mainly of gay men and lesbian women who were seeking treatment. The researchers failed to compare their results against a con- trol group of similar heterosexual individuals. (A control group is a group that is not being treated or experimented on; it controls for any variables that are introduced from outside the experiment, such as a major media report related to the topic of the experiment.) Second, researchers were predisposed to believe that homosexuality was in itself a sickness, reflecting traditional beliefs about homosexuality. Consequently, emotional problems were automatically attributed to the client’s homosexuality rather than to other sources.

Later Contributions: Michel Foucault One of the most influential social theorists in the twentieth century was the French thinker Michel Foucault (1926–1984). A cultural historian and philosopher, Foucault explored how society creates social ideas and how these ideas operate to further the established order. His most important work on sexuality was The History of Sexuality, Volume I (1978), a book that gave fresh impetus to scholars interested in the social con- struction of sex, especially those involved in gender and gay and lesbian studies.

Foucault challenged the belief that our sexuality is rooted in nature. Instead, he argued, it is rooted in society. Society “constructs” sexuality, including homo- sexuality and heterosexuality. Foucault’s critics contend, however, that he under- estimated the biological basis of sexual impulses and the role individuals play in creating their own sexuality.

Contemporary Gay, Lesbian, Bisexual, and Transgender Research In 1973, the American Psychiatric Association (APA) removed homosexuality from its list of psychological disorders in its Diagnostic and Statistical Manual of Mental Disorders (DSM-II). The APA decision was reinforced by similar resolutions by the American Psychological Association and the American Sociological Association. In 1997 at its annual meeting, the American Psychological Association overwhelmingly passed a resolution stating that there is no sound scientific evidence on the efficacy of reparative therapies for gay

Michel Foucault (1926–1984) of France was one of the most important thinkers who influenced our understanding of how society “constructs” human sexuality. © AFP/Getty Images

Never underestimate the difficulty of changing false beliefs by fact.

—Henry Rosovsky (1927– )

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56 Chapter 2 Studying Human Sexuality

men and lesbian women. This statement reinforced the association’s earlier stand that, because there is nothing “wrong” with homosexuality, there is no reason to try to change sexual orientation through therapy. In 1998, the APA issued a statement opposing reparative therapy, thus joining the American Psychological Association, the American Academy of Pediatrics, the American Medical Association, the American Counseling Association, and the National Association of Social Workers.

As a result of the rejection of the psychopathological model, social and behav- ioral research on gay men, lesbian women, and bisexual individuals has moved in a new direction. Research no longer focuses primarily on the causes and cures of homosexuality, and most of the contemporary research approaches homo- sexuality in a neutral manner.

Directions for Future Research Historically, sex research has focused on preventive health, which “prioritizes sexuality as a social problem and behavioral risk” (di Mauro, 1995). In light of the HIV/AIDS pandemic and other social problems, this emphasis is important, but it fails to examine the full spectrum of individuals’ behaviors or the social and cultural factors that drive those behaviors. If sex research is to expand our understanding of human sexual expression, it should examine the numerous components of a broader definition of sexuality.

Sex research, globally, faces several challenges. Few sex researchers and sex research centers exist worldwide, particularly in developing countries. Only a few Western countries have comprehensive statistics, and most of them are about fertility or sexually transmitted infections rather than sexual behaviors of various groups. There is no international depository for sex data.

• Ethnicity and Sexuality Researchers have begun to recognize the significance of ethnicity in various aspects of American life, including sexuality. Although there have been modest increases in ethnic diversity of research samples, important questions must still be addressed (CDC, 2011.2a). These include the differences that socioeconomic status and environment play in sexual behaviors, the way in which questions are posed in research studies, the research methods that are used, and research- ers’ preconceived notions regarding ethnic differences. Diversity-related bias can be so ingrained in the way research is conducted that it is difficult to detect. Although limited research is available, this section attempts to provide some background to enhance an understanding of sexuality and ethnicity.

African Americans Several factors must be considered when studying African American sexuality, including sexual stereotypes, racism, socioeconomic status, and Black subculture.

Sexual stereotypes greatly distort our understanding of Black sexuality. One of the most common stereotypes, strongly rooted in American history, culture, and religion, is the image of Blacks as hypersexual beings (Scott, 2010; Staples, 2006). This stereotype, which dates back to the fifteenth century, continues to hold considerable strength among non-Blacks. Family sociologist Robert Staples (1991) writes: “Black men are saddled with a number of stereotypes that label

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Ethnicity and Sexuality 57

them as irresponsible, criminalistic, hypersexual, and lacking in masculine traits.” Evelyn Higginbotham (1992), a leading authority on the African American experience, discusses the racialized constructions of African American women’s sexuality as primitive, animal-like and promiscuous, and nonvirtuous. During the days of slavery, this representation of Black sexuality rationalized sexual exploitation of Black women by White masters (Nagel, 2003). The belief that Black women were “promiscuous” by nature was perpetuated by a variety of media, such as theater, art, the press, and literature. From this, historian Darlene Hine (1989) notes that silence arose among women: a “culture of dissemblance.” To protect the sanctity of inner aspects of their lives and to combat pervasive negative images and stereotypes about them, Black women (particularly the middle class) began to represent their sexuality through silence, secrecy, and invisibility. For example, they would dress very modestly to remain invisible— hence, not drawing attention that might lead to being sexually assaulted. Efforts to adhere to Victorian ideology and represent pure morality were deemed by Black women to be necessary for protection and upward mobility and to attain respect and justice. These representations continue today for many older African American women (Rose, 2004). For some younger, African American women, however, the opposite is happening: being more visible and less reserved about their sexuality. These younger women feel more self-assured about themselves and their sexuality. The emphasis on sexuality of the younger African American woman is often depicted, for example, in advertising and rap music videos, particularly Gangsta rap. Unfortunately, much Gangsta rap is explicit about both sex and violence and rarely illustrates the long-term consequences of sexual risk behaviors; research has shown that these videos lead to increased sexual risk behavior among African American adolescents ( Wingood et al., 2002).

Socioeconomic status is a person’s ranking in society based on a combina- tion of occupational, educational, and income levels. It is an important element

In the rich cultural history of African Americans, family life is very important. © BananaStock/PunchStock

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in African American sexual values and behaviors (CDC, 2014.2a; Staples, 2006; Staples & Johnson, 1993). For example, a study of White and African Ameri- can women and Latinas who voluntarily sought HIV counseling and testing found that socioeconomic status, not race, was directly related to HIV risk behavior. Women with lower incomes had riskier (e.g., drug-injecting) sexual partners and higher levels of stress, factors related to risky sexual behaviors (Ickovics et al., 2002). Values and behaviors are shaped by culture and social class. The subculture of Blacks of low socioeconomic status is deeply influ- enced by poverty, discrimination, and structural subordination.

Although there has been a significant increase in African American research, much still needs to be done. For example, researchers need to (1) explore the sexual attitudes and behaviors of the general African American population, not merely adolescents, (2) examine Black sexuality from an African American cul- tural viewpoint, (3) utilize a cultural equivalency perspective that rejects differ- ences between Blacks and Whites as signs of inherent deviance, and (4) assess confusion about race-based stereotypes and historical health disparities and mis- trust. The cultural equivalency perspective is the view that the attitudes, values, and behaviors of one ethnic group are similar to those of another ethnic group. Research focused on furthering our understanding of Black sexuality will facilitate the development of effective behavioral interventions that address sexual health within the context of African American life (Wyatt, Williams, & Myers, 2008).

Latinos Latinos are the fastest-growing ethnic group in the United States. There is very little research, however, about Latino sexuality.

Two common stereotypes depict Latinos as sexually permissive and Latino males as pathologically macho. Like African Americans, Latino males are often stereotyped as being “promiscuous,” engaging in excessive and indiscriminate sexual activities. No research, however, validates this stereotype.

The macho stereotype paints Latino males as hypermasculine—swaggering and domineering. But the stereotype of machismo distorts its cultural meaning

among Latinos. (The Spanish word “machismo” was originally incorporated into English in the 1960s as a slang term to describe any male who was sexist.) Within its cultural context, however, machismo is a positive concept, celebrating the values of courage, strength, generosity, polite- ness, and respect for others. This is particularly true for the younger generation of Latino males who are acculturated into American life. And in day-to-day functioning, relations between Latino men and women are significantly more egalitarian than the macho stereotype suggests. This is especially true among Latinos who are more acculturated (Sanchez, 1997). Accultura- tion is the process of adaptation of an ethnic group to the values, attitudes, and behaviors of the dominant culture.

Another trait of Latino life is familismo, a commitment to family and family members.

In studying Latino sexuality, it is important to remember that Latinos come from diverse ethnic groups, including Mexican American, Cuban American, and Puerto Rican, each with its own unique background and set of cultural values. © JGI/Blend Images LLC

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Ethnicity and Sexuality 59

Researcher Rafael Diaz (1998) notes that familismo can be a strong factor in helping heterosexual Latinos reduce rates of unprotected sex with casual part- ners outside of primary relationships. He warns, however, that for many Latino men who have sex with men, familismo and homophobia can create conflict because families may perceive homosexuality as wrong.

Rebellion against the native culture may be expressed through sexual behav- ior (Gonzalez-Lopez & Vival-Ortiz, 2008; Sanchez, 1997). Traditional Latinos tend to place a high value on female virginity while encouraging males, begin- ning in adolescence, to be sexually active. Females are viewed according to a virgin/whore dichotomy—“good” girls are virgins and “bad” girls are sexual. Females are taught to put the needs of others, especially males, before their own. Among traditional Latinos, fears about American “sexual immorality” pro- duce their own stereotypes of Anglos. Adolescent boys learn about masturbation from peers; girls rarely learn about it because of its tabooed nature. There is little acceptance of gay men and lesbian women, whose relationships are often regarded as “unnatural” or sinful (Bonilla & Porter, 1990; Raffaelli & Ontai, 2004). In traditional Latino culture, Catholicism plays an important role, espe- cially in the realm of sexuality. The Church advocates premarital virginity and prohibits both contraception and abortion.

Three important factors must be considered when Latino sexuality is studied: (1) diversity of ethnic groups, (2) significance of socioeconomic status, and (3) acculturation. Latinos comprise numerous ethnic subgroups, such as Mexi- can American, Cuban American, and Puerto Rican. Each group has its own unique background and set of cultural traditions that affect sexual attitudes and behaviors.

Given the high rate of immigration of Latinos into the United States, par- ticular research attention has been given to examining the impact of accultura- tion. For example, studies have addressed the relationship between acculturation and sexual risk behavior. Research has examined the personal and family conflict caused by the traditional Latino values and the progressive sexual values in the United States, and whether acculturation results in liberality among Latinos. For example, one study of college students found that Latinos who had greater iden- tification with mainstream culture had more liberal sexual attitudes than those who had less identification with mainstream culture (Ahrold & Meston, 2010).

Asian Americans and Pacific Islanders Asian Americans and Pacific Islanders represent one of the fastest-growing and most diverse populations in the United States. Significant differences in attitudes, values, and practices in this population make it difficult to generalize about these groups without stereotyping and oversimplifying. Given this caveat, we can say that many Asian Americans are less individualistic and more relationship ori- ented than members of other cultures. Individuals are seen as the products of their relationships to nature and other people. Asian Americans are less verbal and expressive in their interactions and often rely on indirection and nonverbal communication, such as silence and avoidance of eye contact as signs of respect.

In traditional Chinese culture, the in-laws of a married woman were respon- sible for safeguarding her chastity and keeping her under the ultimate control of her spouse. Where extended families worked and lived in close quarters for extended periods, many spouses found it difficult to experience intimacy with each other. As in other Asian American populations, the rate of cross-cultural marriage

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60 Chapter 2 Studying Human Sexuality

among younger Chinese Americans is higher than in their parents’ and grandparents’ generations. Still, Confucian principles, which teach women to be obedient to their spouse’s wishes and attentive to their needs and to be sexually loyal, play a part in maintaining exclusivity and holding down the divorce rate among traditional Chinese families (Ishii-Kuntz, 1997). In contrast, men are expected to be sexually expe- rienced, and their engagement in nonmarital sex is frequently accepted.

For more than a century, Japanese Americans have maintained a significant presence in the United States. Japanese cultural values of loyalty and harmony are strongly embedded in Confucianism and feudalism (loyalty to the ruler), yet Japanese lives are not strongly influenced by religion (Ishii-Kuntz, 1997). Like Chinese Americans born in the United States, Japanese Americans born in the United States base partner selection more on love and individual compatibil- ity than on family concerns (Nakano, 1990).

Traditional Japanese values allowed sexual freedom for men but not for women. Japanese women were expected to remain pure; sexual permissiveness or nonexclusiveness on the part of women was considered socially disruptive and threatening (Ishii-Kuntz, 1997). Over time, attitudes and conditions related to sexuality have changed so that sexual activity is no longer considered solely procreational,

and there is increased use of contraceptives. As with other groups, the degree of acculturation may be the most important

factor affecting sexual attitudes and behaviors of Asian Americans. Compared with those who were raised in the United States, those who were born and raised in their original homeland tend to adhere more closely to their culture’s norms, customs, and values. Further, a research study of Asian women attending a large Canadian university found that those who maintained affiliation with traditional Asian heritage became less acculturated with the more liberal, Western sexuality– related attitudes (Brotto, Chik, Ryder, Gorzalka, & Seal, 2005). This finding was verified in a study at a southern U.S. university in which students with less identification with their heritage culture had sexual attitudes similar to those of Euro-Americans (Ahrold & Meston, 2010).

Researcher and psychologist Sumie Okazaki (2002) reviewed the scientific literature concerning several aspects of Asian Americans’ sexuality: sexual knowledge, attitudes, norms, and behavior. Okazaki reports that she found nota- ble differences in several sexuality-related areas between Asian Americans and other ethnic groups:

For example, relative to other U.S. ethnic group cohorts, Asian American adolescents and young adults tend to show more sexually conservative attitudes and behavior and initiate intercourse at a later age. There are indications that as Asian Americans become more acculturated to the mainstream American culture, their attitudes and behavior become more consistent with the White American norm. Consistent with their more sexually conservative tendencies in normative sexual behavior, Asian American women also appear more reluctant to obtain sexual and reproductive health care, which in turn places them at greater risk for delay in treatment for breast and cervical cancer as well as other gynecological problems.

As in other areas of social science, there are gaps in the research concerning the sexuality of Asian Americans and other racial and ethnic groups. Obviously, more empirical work is needed.

Men do not seek truth. It is the truth that pursues men who run

away and will not look around.

—Lincoln Steffens (1866–1936)

Among Asian Americans (as with other ethnic groups), attitudes toward relationships, family, and sexuality are related to the degree of acculturation. © Dex Image/PunchStock

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Ethnicity and Sexuality 61

Middle Eastern Americans There is a scarcity of research on the sexuality of Middle Eastern Americans, especially as it concerns women who have migrated from parts of the Middle East (Rashidian, 2010). Furthermore, other than in the context of heterosexual relationships, research is almost nonexistent in the areas of sexual expression and sexual orientation. Wide historical contexts—cultural and ideological—of gender and gender bias suggest that the patriarchal system in place helps per- petuate some of the struggles that many Middle Eastern women face when they arrive here (Ebadi & Moaveni, 2006). At the same time, it is known that many Middle Eastern immigrants have a poor understanding about sexuality-related topics (Khan & Khanum, 2000). For example, given that traditional beliefs dic- tate that women should not learn about sexual relationships until marriage, more often than not their primary source of sexuality information, besides the media, is married friends.

In the case of Iranian American women, culture has been a major factor in the construction of their sexual self, gender role, gender identity, and knowledge about sex. However, many of the messages received regarding their roles as women have been confusing and have resulted in a sense of self-worthlessness (Rashidian, 2010). Gender, birth order, family honor, religion, and traditional cultural values are all highly regarded and are often associated with lower status of women, male dominance, and discrimination against women. Obedience and fear of reprisal often help sustain many of the related practices.

With increasing numbers of immigrants moving from other countries to the United States, it is important that American professionals be knowledgeable about the significance of culture and gender role in the immigrant community. Research, sexuality education, and counseling need to take into consideration an awareness of individuals’ sexual beliefs; attempt to understand their current view of themselves as individuals, their values, and the presence and types of interpersonal relationships that exist in their lives; and ascertain their level of communication skills related to sexual topics (Rashidian, 2010).

Popular culture surrounds us with sexual images, disseminated through adver- tising, music, television, film, video games, and the Internet, that form a back- drop to our daily living. Much of what is conveyed is simplified, overgeneralized, stereotypical, shallow, sometimes misinterpreted—and entertaining. Studying sexuality enables us to understand how research is conducted and to be aware of its strengths and its limitations. Traditional sex research has been expanded in recent years by feminist, gay, lesbian, bisexual, and transgender research, which provides fresh insights and perspectives. Although the study of sexuality and ethnicity has yet to reach its full potential, it promises to enlarge our under- standing of the diversity of attitudes, behaviors, and values in contemporary America.

Final Thoughts

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62 Chapter 2 Studying Human Sexuality

Summary Sex, Advice Columnists, and Pop Psychology

■ The sex information/advice genre transmits infor- mation to both entertain and inform; the informa- tion is generally oversimplified and sometimes distorted so that it does not interfere with the genre’s primary purpose, entertainment. Much of the information or advice conveys dominant social norms.

Thinking Objectively About Sexuality

■ Objective statements are based on observations of things as they exist in themselves. Value judgments are evaluations based on moral or ethical standards. Opinions are unsubstantiated beliefs based on an individual’s personal thoughts. Biases are personal leanings or inclinations. Stereotypes—rigidly held beliefs about the personal characteristics of a group of people—are a type of schema, which is the organization of knowledge in our thought processes.

■ Fallacies are errors in reasoning. The egocentric fallacy is the belief that others necessarily share one’s own values, beliefs, and attitudes. The ethno- centric fallacy is the belief that one’s own ethnic group, nation, or culture is inherently superior to any other.

Sex Research Methods

■ Ethical issues are important concerns in sex research. The most important issues are informed consent, protection from harm, and confidentiality.

■ In sex research, sampling is a particularly acute problem. To be meaningful, samples should be rep- resentative of the larger group from which they are drawn. But most samples are limited by volunteer bias and dependence on college students.

■ The most important methods in sex research are clinical, survey, observational, and experimental. Clinical research relies on in-depth examinations of individuals or groups who go to the clinician seeking treatment for psychological or medical problems. Survey research uses questionnaires, interviews, or diaries, for example, to gather infor- mation from a representative sample of people. Observational research requires the researcher to observe interactions carefully in as unobtrusive a

manner as possible. Experimental research presents subjects with various stimuli under controlled conditions in which their responses can be measured.

■ Experiments are controlled through the use of inde- pendent variables (which can be changed by the experimenter) and dependent variables (which change in relation to changes in the independent variable). Clinical, survey, and observational research efforts, in contrast, are correlational studies that reveal relationships between variables without manipulating them. In experimental research, physi- ological responses are often measured by a plethys- mograph, often measured by a plethysmograph.

The Sex Researchers

■ Richard von Krafft-Ebing was one of the earliest sex researchers. His work emphasized the patho- logical aspects of sexuality.

■ Sigmund Freud was one of the most influential thinkers in Western civilization. Freud believed there were five stages in psychosexual develop- ment: the oral stage, anal stage, phallic stage, latency stage, and genital stage.

■ Havelock Ellis was the first modern sexual theorist and scholar. His ideas included the relativity of sexual values, the normality of masturbation, a belief in the sexual equality of men and women, the redefinition of “normal,” and a reevaluation of homosexuality.

■ Alfred Kinsey’s work documented enormous diver- sity in sexual behavior, emphasized the role of masturbation in sexual development, and argued that the distinction between normal and abnormal behavior was meaningless. The Kinsey scale charts sexual behaviors and psychosexual reactions along a continuum ranging from exclusively other-sex behaviors to exclusively same-sex behaviors.

■ William Masters and Virginia Johnson detailed the physiology of the human sexual response cycle. Their physiological studies revealed the similarity between male and female sexual responses and demonstrated that women experience orgasm through clitoral stimulation. Their work on sexual inadequacy revolutionized sex therapy through the use of behavioral techniques.

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Questions for Discussion 63

Contemporary Research Studies

■ The National Health and Social Life Survey (NHSLS) in 1994 was the first nationally represen- tative survey of Americans’ sexual behavior, and its findings contradicted many prior findings and beliefs about sex in America.

■ The National Survey of Family Growth (NSFG) is a periodic survey that collects data related to mar- riage, divorce, contraception, infertility, and the health of women and infants in the United States. A 2011 NSFG is one of the most recent compre- hensive surveys of the prevalence of certain sexual behaviors in the general population.

■ The Youth Risk Behavior Study (YRBS), con- ducted biennially since 1991, is a large, national, school-based study of the health behaviors of ado- lescents. Behaviors related to sexuality and risk taking are assessed.

■ The American College Health Association’s National College Health Assessment has conducted research on campuses throughout the United States since 2000 to determine students’ health and sexual behaviors.

■ The National Survey of Sexual Health and Behavior (NSSHB), conducted in 2010, was a nationally representative Internet study of adoles- cents and adults aged 14–95, an age range much greater than in other studies. The NSSHB provided an update on Americans’ sexual behavior, show- ing an increase in sexual diversity since the NHSLS.

Emerging Research Perspectives

■ There is no single feminist perspective in sex research.

■ Most feminist research focuses on gender issues, assumes that the female experience of sex has been devalued, believes that power is a critical element in female-male relationships, and explores ethnic diversity.

■ Research on homosexuality has rejected the moralistic-pathological approach. Researchers in gay and lesbian issues include Karl Ulrichs, Karl Kertbeny, Magnus Hirschfeld, Evelyn Hooker, and Michel Foucault.

■ Contemporary gay, lesbian, bisexual, and transgen- der research focuses on the psychological and social experience of being other than heterosexual.

Ethnicity and Sexuality

■ The role of ethnicity in human sexuality has been largely overlooked until recently.

■ Socioeconomic status is important in the study of African American sexuality. Other factors to con- sider include the stereotype of Blacks as hypersex- ual and “promiscuous” and racism.

■ Two common stereotypes about Latinos are that they are sexually permissive and that Latino males are pathologically macho. Factors to consider in studying Latino sexuality include the diversity of national groups, the role of socioeconomic status, and the degree of acculturation.

■ Significant differences in attitudes, values, and practices make it difficult to generalize about Asian Americans and Pacific Islanders. Degree of accul- turation and adherence to traditional Asian heritage are important factors affecting sexual attitudes and behaviors. Religious and cultural values still play an important role in the lives of many Asian Amer- icans and Pacific Islanders. Little research has been conducted on the sexuality of Middle Eastern Americans, yet it is known that many immigrants from the Middle East have a poor understanding of sexuality-related topics.

Questions for Discussion ■ Is sex research valuable or necessary? If you

feel that it is, what areas of sexuality do you think need special attention? Which, if any, areas of sexuality should be prohibited from being researched?

■ Alfred Kinsey was, and continues to be, criti- cized for his research. Some people even believe that he was responsible for eroding sexual morality. Do you think his research was valuable, or that it led to the sexual rev- olution in the United States, as many people claim?

■ Would you volunteer for a sex research study? Why or why not? If so, what kind of study?

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64 Chapter 2 Studying Human Sexuality

Suggested Websites Advocates for Youth http://www.advocatesforyouth.org Focuses on teen sexual health; provides valuable data on issues related to teen sexual health.

Centers for Disease Control and Prevention http://www.cdc.gov A valuable source of research information about sexual behavior and related health issues in the United States.

Gallup Poll http://www.gallup.com Provides results of current surveys, including those dealing with sexuality-related issues.

International Academy of Sex Research http://www.iasr.org A scientific society that promotes research in sexual behavior; provides announcements of IASR conferences and abstracts of its journal’s recent articles.

Kinsey Confidential http://kinseyconfidential.org A sexuality information service designed by The Kinsey Institute for Research in Sex, Gender, and Reproduction to meet the sex- ual health information needs of college-age adults.

Society for the Scientific Study of Sexuality http://www.sexscience.org A nonprofit organization dedicated to the advancement of knowl- edge about sexuality; provides announcements of the SSSS con- ferences and other meetings.

Suggested Reading Bancroft, J. (Ed.). (1997). Researching sexual behavior. Bloom-

ington: Indiana University Press. A discussion of the meth- odological issues of large-scale survey research in studying human sexuality.

Bullough, V. L. (1994). Science in the bedroom: A history of sex research. New York: Basic Books. A comprehensive his- tory of sex research of the twentieth century.

Drucker, D. J. (2014). The classification of sex: Alfred Kinsey and the organization of knowledge. Pittsburgh: University of Pittsburgh Press. A detailed description of Alfred Kinsey’s early research of the gall wasp, which provided the scien- tific foundation for this assembling, analysis, and publica- tion of the research of over 18,000 personal sexual behavior histories.

Garton, S. (2004). Histories of sexuality: Antiquity to sexual revolution. New York: Routledge. A comprehensive histori- cal review of major figures, from Havelock Ellis to Alfred Kinsey, and an exploration of such topics as the “invention” of homosexuality in the nineteenth century and the rise of sexual sciences in the twentieth century.

Maier, T. (2009). Masters of sex. New York: Basic Books. An unprecedented look at Masters and Johnson and their pio- neering work together that highlights interviews with both.

Meezen, W., & Martin, J. I. (Eds.). (2006). Research methods with gay, lesbian, bisexual and transgendered populations. New York: Harrington Park Press. Discusses the unique issues in sexuality-related research among gay, lesbian, bisexual, and transgender populations and provides sugges- tions for doing this research.

Staples, R. (2006). Exploring Black sexuality. Boulder, CO: Rowman & Littlefield. A distinguished Black sexologist explores the sexual mores, folkways, and values among African Americans.

Wiederman, M., & Whitley, B., Jr. (2002). Handbook for con- ducting research on human sexuality. Mahwah, NJ: Erl- baum. A reference tool for researchers and students interested in research in human sexuality from a variety of disciplines; examines the specific methodological issues inherent in conducting human sexuality research.

Wyatt, G. (1997). Stolen women: Reclaiming our sexuality and taking back our lives. New York: Wiley. Discusses sociocul- tural influences, such as slavery and institutionalized racism, on the expression of sexuality among African American women.

Sex and the Internet The Kinsey Institute for Research in Sex, Gender, and Reproduction Few centers that conduct research exclusively on sexuality exist in the world. One of the most respected and well-known centers is The Kinsey Insti- tute for Research in Sex, Gender, and Reproduction (KI) at Indiana University, Bloomington. The institute bears the name of its founder, Alfred C. Kinsey, whose research was described earlier in this chapter. Visit the institute’s website (http://www.kinseyinstitute .org) and find out information about the following:

■ The mission and history of KI

■ A chronology of events and landmark publications

■ The KI research staff and their publications

■ KI’s current research projects

■ KI’s exhibitions, services, and events

■ KI’s library and special collections

■ Graduate education in human sexuality at KI and Indiana University

■ Links to related sites in sexuality research

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http://www.advocatesforyouth.org

http://www.cdc.gov

http://www.gallup.com

http://www.iasr.org

http://kinseyconfidential.org

http://www.sexscience.org

http://www.kinseyinstitute.org

3 Female Sexual Anatomy, Physiology, and Response chapter

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C H A P T E R O U T L I N E Female Sex Organs: What Are They For?

Female Sexual Physiology

Human Sexual Response

Female Sexual Response

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66 Chapter 3 Female Sexual Anatomy, Physiology, and Response

“I identify with the pas- sion [of women], the strength, the calmness, and the flexibility of being a woman. To me being a woman is like being the ocean.

The ocean is a powerful thing, even at its calmest moments. It is a beauty that commands respect. It can challenge even the stron- gest men, and it gives birth to the smallest creatures. It is a pro- vider, and an inspiration; this is a woman and this is what I am.”

—20-year-old female

“The more I think about things that annoy me about being a woman, the more I realize that those annoyances are what make it so special. When I get my period, it isn’t just a ‘monthly curse’; it is a reminder that I can have children.”

—19-year-old female

“When I started my period, my father kept a bit of a dis- tance. How could I forget [that day]? The entire family was at my aunt’s house, and no one had pads. You would think among 67 or so people one female would have a pad. I remember crying and my grandmother asking me what was wrong. After I told her, she began to laugh and said it was a natural cycle. I knew this from sixth-grade sexuality edu- cation class, but I still didn’t want it. I was finally a woman.”

—19-year-old female

“I think I am a good sexual partner and enjoy pleasing a woman. I especially love the foreplay that occurs between two people because it gets the body more excited than just going at it. I can go on forever with foreplay because I get to explore my partner’s body, whether it is with my hands, lips, or tongue.”

—25-year-old male

Although women and men are similar in many more ways than they are different, we tend to focus on the differences rather than the similarities. Various cultures hold diverse ideas about exactly what it means to be female or male, but virtually the only differences that are consistent are actual physical differences, most of which relate to sexual structure and function. In this chap- ter and the following one, we discuss both the similarities and the differences in the anatomy (body structures), physiology (body functions), and sexual response of females and males. This chapter introduces the sexual structures and functions of women’s bodies, including hormones and the menstrual cycle. We also look at models of sexual arousal and response, the relationship of these to women’s experiences of sex, and the role of orgasm.

• Female Sex Organs: What Are They For? Anatomically speaking, all embryos are female when their reproductive structures begin to develop (see Figure 1). If it does not receive certain genetic and hormonal signals, the fetus will continue to develop as a female. In humans and most other mammals, the female, in addition to providing half the genetic instructions for the offspring, provides the environment in which it can develop until it becomes capable of surviving as a separate entity. She also nourishes the offspring, both during gestation (the period of carrying the young in the uterus) via the placenta and following birth via the breasts through lactation (milk production).

In spite of what we do know, we haven’t yet mapped all of the basic body parts of women, especially as they relate to the microprocesses of sexual response. Such issues as the function of the G-spot, the role of orgasm, and the placement of the many nerves that spider through the pelvic cavity still are not completely understood. Add to these puzzles the types, causes, and treatments of sexual function problems and one can quickly see that the science of sexual response is still emerging.

Voices Student

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Female Sex Organs: What Are They For? 67

Clearly, the female sex organs serve a reproductive function. But they perform other functions as well. Significant to nearly all women are the sexual parts that bring them pleasure; they may also attract potential sexual partners. Because of the mutual pleasure partners give each other, we can see that sexual structures also serve an important role in human relationships. People demonstrate their affection for one another by sharing sexual pleasure and form enduring partner- ships at least partially on the basis of mutual sexual sharing. Let’s look at the features of human female anatomy and physiology that provide pleasure to women and their partners and that enable women to conceive and give birth.

External Structures (the Vulva) The sexual and reproductive organs of both men and women are usually called genitals, or genitalia, from the Latin genere, “to beget.” The external female genitals are the mons pubis, the clitoris, the labia majora, and the labia minora, collectively known as the vulva (see Figures 2 and 3). (People often use the word “vagina” when they are actually referring to the vulva. The vagina is an internal structure.)

• FIGURE 1 Embryonic-Fetal Differentiation of the External Reproductive Organs. Female and male reproductive organs are formed from the same embryonic tissues. An embryo’s external genitals are female in appearance until certain genetic and hormonal instructions signal the development of male organs. Without such instructions, the genitals continue to develop as female.

Genital tubercle

Labioscrotal swelling

Anus Urogenital fold Genital groove

Undifferentiated Stage Prior to 6th Week

Inner labial fold

Urogenital fold

Anus

Glans (penis)

Urethral groove

Scrotal swelling

Male7th–8th Week

Clitoris

Labia majora

Labia minora

Opening of vagina

Opening of urethra

Female 12th Week

Penis

Urethral closure

Scrotum

Male

Glans (clitoris)

Vulval groove

Labial swelling

Anus

Female

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68 Chapter 3 Female Sexual Anatomy, Physiology, and Response

The Mons Pubis The mons pubis (pubic mound), or mons veneris (mound of Venus), is a pad of fatty tissue that covers the area of the pubic bone about 6 inches below the navel. Beginning in puberty, the mons is covered with pubic hair. Because there is a rich supply of nerve endings in the mons, caressing it can produce pleasure in most women.

• FIGURE 2 External Structures of the Female Genitals

Clitoral hoodMons pubisGlans of clitoris

Urethral opening

Vestibule

Vaginal opening

Ducts for Bartholin’s glands

Labia minora

Anus

Labia majora

Perineum

• FIGURE 3 Internal Structures of the Female Genitalia

Ischiocavernosus muscle

Remnants of hymen

External urethral opening

Clitoral hood

Corpora cavernosa of clitoris

Vestibule of vaginaExternal anal sphincter muscle

Anus

Bartholin's gland and its duct

Vestibular bulb

Vaginal opening

Labia minora (inner lips)

Crura of clitoris

Glans clitoris

Symphysis pubis Suspensory ligament of clitoris

People will insist on treating the mons veneris as though it were

Mount Everest.

—Aldous Huxley (1894–1963)

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Female Sex Organs: What Are They For? 69

The current practice of trimming and shaving pubic hair has become one barom- eter of fashion. Over the past few years, it has become commonplace in both sexes and for similar reasons: aesthetic and psychosexual. Its acceptance and practice among women expresses itself in a diverse range of pubic hair–grooming practices that have become an important component of sexual expression and participation in sexual activity (Herbenick, Schick, Reece, Sanders, & Fortenberry, 2010.3a). Find- ings revealed that pubic hair styles are diverse and that it is more common than not for women to have at least some pubic hair on their genitals. The study found that women’s total removal of their pubic hair was associated with being young, being partnered, having looked closely at one’s own genitals, cunnilingus, positive genital self-image, and sexual function. At the same time, the growing trend of male pubic hair removal, or what some call “manscaping,” also contributes to the male’s feel- ings of sexiness and cleanliness (Gale & Pettypiece, 2013).

Implicated in the shift in cultural attitudes regarding pubic hair is Internet- based pornography, where hair removal has become the “norm.” In fact, more than 80% of male and female college students in the United States remove all or some of their pubic hair (Smolak & Murnen, 2011). This practice, however, is not new; many societies have for centuries decorated and sculpted their pubic hair, while others have removed the hair to avoid body lice. Many anecdotal reports on the removal of pubic hair highlight increased genital sensitivity and increased partner satisfaction. From a public health perspective, body hair removal may be a risk factor for folliculitis (infection in the hair follicle). On the other hand, a significant drop has been found in the number of cases of pubic lice (Armstrong & Wilson, 2006). If people choose to shave, wax, or tweeze, they should use only clean tools and exercise caution, since this is obviously a sensitive area.

The Clitoris The clitoris (KLIH-tuh-rus) is considered the center of sexual arousal. It contains a high concentration of sensory nerve endings and is exqui- sitely sensitive to stimulation, especially at the tip of its shaft, the glans clitoris. A fold of skin called the clitoral hood covers the glans when the clitoris is not engorged. Although the clitoris is structurally analogous to the penis (it is formed from the same embryonic tissue), its sole function is sexual arousal. (The penis serves the additional functions of urine excretion and semen ejaculation.) The clitoris is a far more extensive structure than its visible part, the glans, would suggest (Bancroft, 2009). The shaft of the clitoris is both an external and an inter- nal structure. The external portion is about 1 inch long and a quarter inch wide. Internally, the shaft is divided into two branches called crura (KROO-ra; singular, crus), each of which is about 3.5 inches long, which are the tips of erectile tissue that attach to the pelvic bones. The crura contain two corpora cavernosa (KOR- por-a kav-er-NO-sa), hollow chambers that fill with blood and swell during arousal. The hidden erectile tissue of the clitoris plus the surrounding muscle tissue all contribute to muscle spasms associated with orgasm. When stimulated, the clitoris enlarges initially and then retracts beneath the hood just before and during orgasm. With repeated orgasms, it follows the same pattern of engorgement and retraction, although its swellings may not be as pronounced after the initial orgasm. The role of the clitoris in producing an orgasm is discussed later in the chapter.

The Labia Majora and Labia Minora The labia majora (LAY-be-a maJOR- a) (outer lips) are two folds of spongy flesh extending from the mons pubis and enclosing the labia minora, clitoris, urethral opening, and vaginal entrance. The labia minora (inner lips) are smaller folds within the labia majora that meet above the clitoris to form the clitoral hood. The labia minora also enclose the

Really that little dealybob is too far away from the hole. It should be

built right in.

—Loretta Lynn (1935– )

Artwork often imitates anatomy, as can be seen in this painting titled Black Iris (Georgia O’Keeffe, 1887–1986). © Tomas Abad/AGE Fotostock

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70 Chapter 3 Female Sexual Anatomy, Physiology, and Response

urethral and vaginal openings. They are smooth and hairless and vary quite a bit in appearance from woman to woman. Another rich source of sexual sensation, the labia are sensitive to the touch and swell during sexual arousal, doubling or tripling in size and changing in color from flesh-toned to a deep wine-red hue. The area enclosed by the labia minora is referred to as the vestibule. During sexual arousal, the clitoris becomes erect, the labia minora widen, and the ves- tibule (vaginal opening) becomes visible. Within the vestibule, on either side of the vaginal opening, are two small ducts from the Bartholin’s glands, which secrete a small amount of moisture during sexual arousal.

Internal Structures The internal female sexual anatomy and reproductive organs include the vagina; the uterus and its lower opening, the cervix; the ovaries; and the fallopian tubes. (Figure 4 provides illustrations of the front and side views of the female inter- nal sexual anatomy.)• FIGURE 4

Internal Female Sexual Structures

Fallopian tube

Ovary

Uterus

Bladder

Pubic bone

Urethra

Crura Clitoris (glans)

Urethral opening

Labia majora

Fimbriae

Cervix

Rectum

Vagina

Approximate location of the G-spot

Anus

Vaginal opening (introitus)

Hymen

Labia minora

EndometriumUterus

Cervix

Os Vagina

Fimbriae

Fallopian tubes

Ovaries

(a) Side view

(b) Front view

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Female Sex Organs: What Are They For? 71

The Vagina The vagina (va-JI-na), from the Latin word for “sheath,” is a flexible, muscular structure that extends 3–5 inches back and upward from the vaginal opening. It is the birth canal through which an infant is born, allows menstrual flow to pass from the uterus, and encompasses the penis or other object during sexual expression. In the unaroused state, the walls of the vagina are relaxed and collapsed together, but during sexual arousal, the inner two thirds of the vagina expand while pressure from engorgement causes the many small blood vessels that lie in the vaginal wall to produce lubrication. In response to sexual stimulation, lubrication can occur within 10–30 sec- onds. The majority of sensory nerve endings are concentrated in the introitus (in-TROY-tus), or vaginal opening. This part of the vagina is the most sensi- tive to erotic pressure and touch. In contrast, the inner two thirds of the vagina has virtually no nerve endings, which make it likely that a woman cannot feel a tampon when it is inserted deep in the vagina. Although the vaginal walls are generally moist, the wetness of a woman’s vagina can vary by woman, by the stage of her menstrual cycle, and after childbirth or at menopause. Lubrication also increases substantially with sexual excitement. This lubrication serves several purposes. First, it increases the possibility of conception by alkalinizing the normally acidic chemical balance in the vagina, thus making it more hospitable to sperm, which die faster in acid environ- ments. Second, it can make penetration more pleasurable by reducing friction in the vaginal walls. Third, the lubrication helps prevent small tears in the vagina, which, if they occur, can make the vagina more vulnerable to con- tracting HIV (the virus that causes AIDS) and some other STIs.

Prior to first intercourse or other form of penetration, the introitus is par- tially covered by a thin membrane containing a relatively large number of blood vessels, the hymen (named for the Roman god of marriage). The hymen typically has one or several perforations, allowing menstrual blood and mucous secretions to flow out of the vagina (and generally allowing for tampon inser- tion). In many cultures, it is (or was) important for a woman’s hymen to be intact on her wedding day. Blood on the nuptial bedsheets is taken as proof of her virginity. The stretching or tearing of the hymen may produce some

The external female genitalia (vulva) can assume many different colors, shapes, and structures. (a) © Daniel Sambraus/Science Source; (b) © H.S. Photos/Alamy; (c) © Custom Medical Stock Photo

Clitoral hood

Labia minora

Labia majora

Introitus

(a) (b) (c)

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72 Chapter 3 Female Sexual Anatomy, Physiology, and Response

pain or discomfort and possibly some bleeding. Usually, the partner has little trouble inserting the penis or other object through the hymen if he or she is gentle and there is adequate lubrication. Prior to first intercourse, the hymen may be stretched or ruptured by tampon insertion, by the woman’s self- manipulation, by a partner during noncoital sexual activity, by accident, or by a health care provider conducting a routine pelvic examination. Hymenoplasty, a controversial procedure that re-attaches the hymen to the vagina, is now sought by some women, particularly in Muslim countries where traditionalists place a high value on a woman’s virginity, to create the illusion that they are still virgins. Hymen repair, also referred to as “revirgination,” may also be performed for women who have been abused or those from cultures who risk a violent reaction from their partners. In spite of its availability, the American College of Obstetricians and Gynecologists has issued strong warnings to women that there is no evidence cosmetic genital surgery is safe or effective (ACOG, 2007).

An area inside the body, surrounding the urethra, is what many women report to be an erotically sensitive area, the Grafenberg spot, or G-spot. The name is derived from Ernest Grafenberg, a gynecologist, who first discussed its erotic significance. Located on the front wall of the vagina midway between the pubic bone and the cervix on the vaginal side of the urethra (see Figure 5), this area varies in size from a small bean to a half walnut. It can be located by pressing one or two fingers and about two knuckles deep into the front wall of a wom- an’s vagina. Coital positions such as rear entry, in which the penis makes con- tact with the spot, may also produce intense erotic pleasure (Ladas, Whipple, & Perry, 1982; Whipple & Komisaruk, 1999). A variety of responses have been reported by women who first locate this spot. Initially, a woman may experience a slight feeling of discomfort or the need to urinate, but shortly thereafter, the tissue may swell and a pleasurable feeling may occur. Women who report orgasms as a result of stimulation of the G-spot describe them as intense and

• FIGURE 5 The Grafenberg Spot (G-Spot). To locate the Grafenberg spot, insert two fingers into the vagina and press deeply into its anterior wall.

Urethral opening (exit point for emission)

Pubic bone

G-spot

Emptied bladder

Uterus

Anterior vaginal wall

Anus

Cervix

Urethra

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Female Sex Organs: What Are They For? 73

extremely pleasurable (Perry & Whipple, 1981; Whipple, 2002). Though an exact gland or site has not been found in all women, nor do all women experi- ence pleasure when the area is massaged (Kilchevsky, Vardi, Lowenstein, Gruenwald, 2012), it has been suggested that the orgasm occurring in the area called the G-spot could be caused by the contact and connection of the richly innervated internal clitoris and the anterior vaginal wall (Foldes & Buisson, 2009). More specifically, by using special instruments and photography that measure changes in the vagina, it was found that the displacement of the ante- rior vaginal wall that occurs with pressure of the finger on this site, along with movement of the engorged and enlarged clitoris that occurs during sexual arousal, could provide close contact between the internal root of the clitoris and the anterior vaginal wall and thereby lead to what is known as a G-spot orgasm, sometimes with accompanying emission of fluid, which spurts out of the urethra (not vagina). This fluid, referred to as the “female ejaculate,” has the appearance of skim milk and is chemically similar to seminal fluid, but different from urine (Komisaruk, Whipple, Nasserzadeh, & Beyer-Flores, 2010). It has been sug- gested that the emitted fluid comes from the para-urethral glands, also called the Skene’s glands, better known as the “female prostate gland.”

Despite the controversy that still exists around the presence of the G-spot, most women would agree that having more than one area of erotic arousal is sexually liberating and, as such, expands sexual enjoyment beyond the clitoris. In fact, some women who are concerned about their lack of ability to experience orgasm during vaginal intercourse have sought out G-spot amplification, in which collagen is injected into the vicinity of the G-spot to increase its size and sensitivity (Lehmiller, 2014). Still, reliable reports and anecdotal testimonials of the existence of this highly sensitive area will continue to raise the question about whether sufficient research has been done to verify the existence of the G-spot and, even more so, whether it is safe and effective to enhance it.

The Uterus and Cervix The uterus (YU-te-rus), or womb, is a hollow, thick- walled, muscular organ held in the pelvic cavity by a number of flexible ligaments and supported by several muscles. It is pear-shaped, with the tapered end, the cervix, extending down and opening into the vagina. If a woman has not given birth, the uterus is about 3 inches long and 3 inches wide at the top; it is somewhat larger in women who have given birth. The uterus expands dur- ing pregnancy to the size of a volleyball or larger, to accommodate the develop- ing fetus. The inner lining of the uterine walls, the endometrium (en-doe-MEE-tree-um), is filled with tiny blood vessels. As hormonal changes occur during the monthly menstrual cycle, this tissue is built up and then shed and expelled through the cervical os (opening), unless fertilization has occurred. In the event of pregnancy, the pre-embryo is embedded in the nourishing endo- metrium.

In addition to the more or less monthly menstrual discharge, mucous secre- tions from the cervix also flow out through the vagina. These secretions tend to be somewhat white, thick, and sticky following menstruation, becoming thinner as ovulation approaches. At ovulation, the mucous flow tends to increase and to be clear, slippery, and stretchy, somewhat like egg white.

The Ovaries On each side of the uterus, held in place by several ligaments, is one of a pair of ovaries. The ovary is a gonad, an organ that produces gam- etes (GA-meets), the sex cells containing the genetic material necessary for

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74 Chapter 3 Female Sexual Anatomy, Physiology, and Response

While reading this material, some females may wish to examine their own genitals and discover their unique features. In a space that is comfortable for you, take time to look at your vulva, or outer genitals, using a mirror and a good light. The large, soft folds of skin with hair on them are the outer lips, or labia majora. The color, tex- ture, and pattern of this hair vary widely among women. Inside the outer lips are the inner lips, or labia minora. These have no hair and vary in size from small to large and protruding. They extend from below the vagina up toward the pubic bone, where they form a hood over the clitoris. The glans may not be visible under the clitoral hood, but it can be seen if a woman separates the labia minora and retracts the hood. The size and shape of the clitoris, as well as the hood, also vary widely among women. These variations have nothing to do with a wom- an’s ability to respond sexually. You may also find some cheesy white matter under the hood. This is called smegma and is normal.

Below the clitoris is a smooth area and then a small hole. This is the urethral opening. Below the urethral opening is the vaginal opening, which is surrounded by rings of tissue. One of these, which you may or may not be able to see, is the hymen. Just inside the vagina, on both sides, are the Bartholin’s glands. These may secrete a small amount of mucus during sexual excitement, but little else of their function is known. If they are infected, they will be swollen, but otherwise you won’t notice them. The smooth area between your vagina and anus is called the perineum.

You can also examine your inner genitals, using a speculum, flashlight, and mirror. A speculum is an instru- ment used to hold the vaginal walls apart, allowing a clear view of the vagina and cervix. You should be able to obtain a speculum and information about doing an internal exam from a clinic that specializes in women’s health or family planning.

It is a good idea to observe and become aware of what your normal vaginal discharges look and feel like. Colors vary from white to gray, and secretions change in

consistency from thick to thin and clear (similar to egg white that can be stretched between the fingers) over the course of the menstrual cycle. Distinct changes or odors, along with burning, bleeding between menstrual cycles, pain in the pelvic region, itching, or rashes, should be reported to a health care provider.

By inserting one or two fingers into the vagina and reaching deep into the canal, it is possible to feel the cer- vix, or tip of the uterus. In contrast to the soft vaginal walls, the cervix feels like the end of a nose: firm and round.

In doing a vaginal self-exam, you may initially experi- ence some fear or uneasiness about touching your body. In the long run, however, your patience and persistence will pay off in increased body awareness and a height- ened sense of personal health.

Once you’re familiar with the normal appearance of your outer genitals, you can check for any changes, especially unusual rashes, soreness, warts, or parasites, such as pubic lice, or “crabs.”

practically speaking Performing a Gynecological

Self-Examination

Examining your genitals can be an enlightening and useful practice that can provide you with information about the health of your body. © H.S. Photos/Alamy

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Female Sex Organs: What Are They For? 75

reproduction. Female gametes are called oocytes (OH-uh-sites), from the Greek words for “egg” and “cell.” Oocytes are commonly referred to as eggs or ova [singular, ovum]. Technically, however, the cell does not become an egg until it completes its final stages of division following fertilization. The ovaries are the size and shape of large almonds. In addition to producing oocytes, they serve the important function of producing hormones such as estrogen, progesterone, and testosterone. (These hormones are discussed later in this chapter.)

At birth, the female’s ovaries contain about half a million oocytes. During childhood, many of these degenerate; then, beginning in puberty and ending after menopause, a total of about 400 oocytes mature and are released during a woman’s reproductive years. The release of an oocyte is called ovulation. The immature oocytes are embedded in saclike structures called ovarian follicles. The fully ripened follicle is called a vesicular or Graffian follicle. At maturation, the follicle ruptures, releasing the oocyte. After the oocyte emerges, the ruptured follicle becomes the corpus luteum (KOR-pus LOO-tee-um) (from the Latin for “yellow body”), a producer of important hormones; it eventually degener- ates. The egg is viable for about 24 hours.

The Fallopian Tubes At the top of the uterus are two tubes, one on each side, known as fallopian tubes, uterine tubes, or oviducts. The tubes are about 4 inches long. They extend toward the ovaries but are not attached to them. Instead, the funnel-shaped end of each tube (the infundibulum) fans out into fingerlike fimbriae (fim-BREE-ah), which drape over the ovary but may not actually touch it. Tiny, hairlike cilia on the fimbriae become active during ovulation. Their waving motion, along with contractions of the walls of the tube, transports the oocyte that has been released from the ovary into the fallopian tube. (The process of ovulation and the events leading to fertilization are discussed later in this chapter.)

Other Structures There are several other important anatomical structures in the genital areas of both men and women. Although they may not serve reproductive functions, they may be involved in sexual activities. Some of these areas may also be affected by sexually transmitted infections. In women, these structures include the ure- thra, anus, and perineum. The urethra (yu-REE-thra) is the tube through which urine passes; the urethral opening is located between the clitoris and the vag- inal opening. Between the vagina and the anus—the opening of the rectum, through which excrement passes—is a diamond-shaped region called the perineum (per-e-NEE-um). This area of soft tissue covers the muscles and ligaments of the pelvic floor, the underside of the pelvic area extending from the top of the pubic bone (above the clitoris) to the anus.

The anus consists of two sphincters, which are circular muscles that open and close like valves. The anus contains a dense supply of nerve endings that, along with the tender rings at the opening, can respond erotically. In sex play or intercourse involving the anus or rectum, care must be taken not to rupture the delicate tissues. This may occur because of the lack of adequate lubrication or very rough anal sex play. Anal sex, which involves insertion of the penis or other object into the rectum, is potentially unsafe, as is vaginal sex, because abrasions of the tissue provide easy passage for pathogens, such as HIV, to the

Girls got balls. They’re just a little higher up, that’s all.

Joan Jett (1960– )

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76 Chapter 3 Female Sexual Anatomy, Physiology, and Response

bloodstream. To practice safer sex, partners who engage in anal intercourse should use a latex condom with a water-based lubricant.

The Breasts With the surge of sex hormones that occurs during adolescence, the female breasts begin to develop and enlarge (see Figure 6). The reproductive function of the breasts is to nourish offspring through lactation, or milk production. A mature female breast, also known as a mammary gland, is composed of fatty tissue and 15–25 lobes that radiate around a central protruding nipple. Around the nipple is a ring of darkened skin called the areola (a-REE-o-la). Tiny mus- cles at the base of the nipple cause it to become erect in response to touch, cold, or sexual arousal.

When a woman is pregnant, the structures within the breast undergo further development. Directly following childbirth, in response to hormonal signals, small glands within the lobes called alveoli (al-VEE-a-lee) begin producing

milk. The milk passes into ducts, each of which has a dilated region for storage; the ducts open to the outside at the nipple. During lactation, a woman’s breasts increase in size from enlarged glandular tissues and stored milk. Because there is little variation in the amount of glandular tissue among women, the amount of milk produced does not vary with breast size. In women who are not lactating, breast size depends mainly on fat content, which is deter- mined by hereditary factors.

In the Western culture, women’s breasts capture a sig- nificant amount of attention and serve an erotic function. Many, but not all, women find breast stimulation intensely pleasurable, whether it occurs during breastfeeding or sex- ual contact. Partners tend to be aroused by both the sight and the touch of women’s breasts. Although there is no basis in reality, some believe that large breasts denote greater sexual responsiveness than small breasts. (Table 1 provides a summary of female sexual anatomy.)

Uncorsetted, her friendly bust gives promise of pneumatic bliss.

—T. S. Eliot (1888–1965)

• FIGURE 6 The Female Breast. Front and cross- sectional views.

Areola

Nipple

Milk ducts

Fat

Suspensory ligaments

Chest wall

Ribs

Mammary glands

Alveoli

Western culture tends to be ambivalent about breasts and nudity. Most people, however, are comfortable with artistic portrayals of the nude female body. © Anthony Saint James/Getty Images

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Female Sex Organs: What Are They For? 77

TABLE 1 ● Summary Table of Female Sexual Anatomy

External Structures

Mons pubis (mons veneris) Fatty tissue that covers the area of the pubic bone

Clitoris Center of sexual arousal

Clitoral hood Covers the glans clitoris when the clitoris is not engorged

Crura (singular, crus) Tips of erectile tissue that attach to the pelvic bones

Corpora cavernosa Hollow chambers that fill with blood and swell during sexual arousal

Labia majora (outer lips) Two folds of spongy flesh that extend from the mons pubis and run downward along the sides of the vulva

Labia minora (inner lips) Smaller, hairless folds within the labia majora that meet above the clitoris to form the clitoral hood

Vestibule (vaginal opening) Area enclosed by the labia minora

Bartholin’s glands Glands that secrete a small amount of moisture during sexual arousal

Internal Structures

Vagina (birth canal) Flexible, muscular structure in which menstrual flow and babies pass

Introitus Vaginal opening

Hymen Thin membrane that partially covers the introitus and contains a relatively large number of blood vessels

Grafenberg spot (G-spot) Located on the upper front wall of the vagina, an erotically sensitive area that may produce intense erotic pleasure and a fluid emission in some women

Uterus (womb) Hollow, thick-walled muscular organ in which a fertilized ovum implants and develops until birth

Cervix Lower end of the uterus that extends down and opens to the vagina

Endometrium Inner lining of the uterine wall to which the fertilized egg attaches; partly discharged (if pregnancy does not occur) with the menstrual flow

Os Opening to the cervix

Ovary (gonad) Organ that produces gametes (see below)

Gametes Sex cells containing the genetic material necessary for reproduction; also referred to as oocytes, eggs, ova (singular, ovum)

Ovarian follicles Saclike structures that contain the immature oocytes

Corpus luteum Tissue formed from a ruptured ovarian follicle that produces important hormones after the oocyte emerges

Fallopian tubes (oviducts) Uterine tubes that transport the oocyte from the ovary to the uterus

Infundibulum Funnel-shaped end of each fallopian tube

Fimbriae Fingerlike projections that drape over the ovary and help transport the oocyte from the ovary into the fallopian tube

Cilia Tiny, hairlike structures that provide waving motion to help transport the oocyte within the fallopian tube to the ovary

Ampulla Widened part of the fallopian tube in which fertilization normally occurs

Other Structures

Urethra Tube through which urine passes

Urethral opening Opening in the urethra, through which urine is expelled

Anus Opening in the rectum, through which excrement passes

Perineum Area that lies between the vaginal opening and the anus

Pelvic floor Underside of the pelvic area, extending from the top of the pubic bone (above the clitoris) to the anus

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78 Chapter 3 Female Sexual Anatomy, Physiology, and Response

• Female Sexual Physiology Just how do the various structures of the female anatomy function to produce the menstrual cycle? The female reproductive cycle can be viewed as having two components (although, of course, multiple biological processes are involved): (1) the ovarian cycle, in which eggs develop, and (2) the menstrual, or uterine cycle, in which the womb is prepared for pregnancy. These cycles repeat approx- imately every month for about 35 or 40 years. The task of directing these processes belongs to a class of chemicals called hormones.

During ovulation, the ovarian follicle swells and ruptures, releasing the mature oocyte to begin its journey through the fallopian tube. © Petit Format/Science Source

TABLE 2 ● Female Sex Hormones

Hormone Where Produced Functions

Estrogen (including estradiol, estrone, estriol)

Ovaries, adrenal glands, placenta (during pregnancy)

Promotes maturation of reproductive organs, development of secondary sex characteristics, and growth spurt at puberty; regulates menstrual cycle; sustains pregnancy; maintains libido

Progesterone Ovaries, adrenal glands, placenta

Promotes breast development, maintains uterine lining, regulates menstrual cycle, sustains pregnancy

Gonadotropin-releasing hormone (GnRH)

Hypothalamus Promotes maturation of gonads, regulates menstrual cycle

Follicle-stimulating hormone (FSH)

Pituitary Regulates ovarian function and maturation of ovarian follicles

Luteinizing hormone (LH) Pituitary Assists in production of estrogen and progesterone, regulates maturation of ovarian follicles, triggers ovulation

Human chorionic gonadotropin (HCG)

Embryo and placenta Helps sustain pregnancy

Testosterone Adrenal glands and ovaries Helps stimulate sexual desire

Oxytocin Hypothalamus Stimulates uterine contractions during childbirth and possibly during orgasm, promotes milk let-down

Prolactin Pituitary Stimulates milk production

Prostaglandins All body cells Mediates hormone response, stimulates muscle contractions

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Female Sexual Physiology 79

• FIGURE 7 Oogenesis. This diagram charts the development of an ovum, beginning with embryonic development of the oogonium and ending with fertilization of the secondary oocyte, which then becomes the diploid zygote. Primary oocytes are present in a female at birth; at puberty, hormones stimulate the oocyte to undergo meiosis.

Mitosis

Meiosis I

Meiosis II

meiosis

meiosismeiosis

ovulation

mitosis

Polar bodies degenerating

Second polar body

First polar body

Oogonium (46 chromosomes)

Many oogonia

Primary oocyte (46 chromosomes)

Secondary oocyte (23 chromosomes)

Sperm (23 chromosomes)

Fertilization

Diploid zygote

growth and differentiation

before birth

after birth

sexual maturity

Reproductive Hormones Hormones are chemical substances that serve as messengers, traveling within the body through the bloodstream. Most hormones are composed of either amino acids (building blocks of proteins) or steroids (derived from cholesterol). They are produced by the ovaries and the endocrine glands—the adrenals, pituitary, and hypothalamus. Hormones assist in a variety of tasks, including development of the reproductive organs and secondary sex characteristics during puberty, regula- tion of the menstrual cycle, maintenance of pregnancy, initiation and regulation of childbirth, initiation of lactation, and, to some degree, the regulation of libido (li-BEE-doh; sex drive or interest). Hormones that act directly on the gonads are known as gonadotropins (go-nad-a-TRO-pins). Among the most important of the female hormones are the estrogens, which affect the maturation of the repro- ductive organs, menstruation, and pregnancy, and progesterone, which helps maintain the uterine lining until menstruation occurs. (The principal hormones involved in a woman’s reproductive and sexual life and their functions are described in Table 2.) (Testosterone is discussed later in this chapter.)

The Ovarian Cycle The development of female gametes is a complex process that begins even before a woman is born. In infancy and childhood, the cells develop into ova (eggs). During puberty, hormones trigger the completion of the process of oogenesis (oh-uh-JEN-uh-sis), literally, “egg beginning” (see Figure 7). The oocyte, otherwise referred to as germ cell or immature ovum, marks the start of mitosis, the process by which a cell divides, creating two daughter cells. Oogenesis results in the formation of both primary oocytes, before birth, and

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80 Chapter 3 Female Sexual Anatomy, Physiology, and Response

as secondary oocytes after it and as part of ovulation. This process, called the ovarian cycle, continues until a woman reaches menopause.

The ovarian cycle averages 28 days in length, although there is considerable variation among women, ranging from 21 to 40 days. In their own particular cycle length after puberty, however, most women experience little variation. Gen- erally, ovulation occurs in only one ovary each month, with only a 50-50 chance of releasing an egg from the opposite ovary as the month before. If a single ovary is removed, the remaining one begins to ovulate every month. The ovarian cycle has four phases: menstrual, follicular (fo-LIK-u-lar), ovulatory (ov-UL-a- toree), and luteal (LOO-tee-ul) (see Figure 8). As an ovary undergoes its changes, corresponding shifts occur in the uterus. Menstruation marks the end of this sequence of hormonal and physical changes in the ovaries and uterus.

The Follicular Phase On the first day of the cycle, gonadotropin-releasing hormone (GnRH) is released from the hypothalamus. GnRH begins to

• FIGURE 8 Ovarian Cycle. The ovarian cycle consists of the activities within the ovaries and the development of oocytes; it includes the menstrual, follicular, ovulatory, and luteal phases.

Fallopian tube

Ovary

Fimbriae

Uterine lining sloughs off and passes out of the body through the cervix and vagina

Vagina

Cervix

Uterus

Uterine lining

Oocyte disintegrates

(Menstruation)

Uterine lining renews

Maturing oocyte in follicle

Immature oocytes

(Follicle development)

Uterine lining thickens

Oocyte is released (ovulation)

Oocyte travels through tube

Ruptured follicle becomes the corpus luteum

Lining continues to thicken

Menstrual Phase Follicular Phase

Ovulatory Phase Luteal Phase

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Female Sexual Physiology 81

stimulate the pituitary to release follicle-stimulating hormone (FSH) and luteinizing hormone (LH), initiating the follicular phase. During the first 10 days, 10–20 ovarian follicles begin to grow, stimulated by FSH and LH. In 98–99% of cases, only one of the follicles will mature completely during this period. (The maturation of more than one oocyte is one factor in multiple births.) All the developing follicles begin secreting estrogen. Under the influence of FSH and estrogen, the oocyte matures, bulging from the surface of the ovary. This may also be referred to as the proliferative phase.

Ovulatory Phase The ovulatory phase begins at about day 11 of the cycle and culminates with ovulation at about day 14. An exact day of ovulation cannot be predicted. Stimulated by an increase of LH from the pituitary, the primary oocyte undergoes cell division and becomes ready for ovulation. The ballooning follicle wall thins and ruptures, and the oocyte enters the abdominal cavity near the beckon- ing fimbriae. Ovulation is now complete. Some women experience a sharp twinge, called Mittelschmerz, on one side of the lower abdomen during ovulation. A very slight bloody discharge from the vagina may also occur. Occasionally, more than one ovum is released. If two ova are fertilized, nonidentical twins will result. If one egg is fertilized and divides into two separate zygotes, identical twins will develop.

The Luteal Phase Following ovulation, estrogen levels drop rapidly, and the ruptured follicle, still under the influence of increased LH, becomes a corpus luteum, which secretes progesterone and small amounts of estrogen. Increasing levels of these hormones inhibit pituitary release of FSH and LH. Unless fertilization has occurred, the corpus luteum deteriorates. In the event of preg- nancy, the corpus luteum maintains its hormonal output, helping sustain the pregnancy. The hormone human chorionic gonadotropin (HCG)—similar to LH—is secreted by the embryo and signals the corpus luteum to continue until the placenta has developed sufficiently to take over hormone production.

The luteal phase starts on ovulation day and can occur anytime from day 7 to 22, depending on the length of the menstrual cycle. Even when cycles are more or less than 28 days, the duration of the luteal phase remains the same; the time between ovulation and the beginning of menstruation, an average 14 days. At this point, the ovarian hormone levels are at their lowest, GnRH is released, and FSH and LH levels begin to rise.

Menstrual Phase As hormone levels decrease following the degeneration of the corpus luteum, the uterine lining (endometrium) is shed because it will not be needed to help sustain the fertilized ovum. The shedding of endometrial tissue and the bleeding that accompanies it are known as the menstrual phase, a monthly event in the lives of women from puberty through menopause. Cultural and religious attitudes, as well as personal experience, influence our feelings about this phenomenon.

The Menstrual Cycle Most American women who menstruate use sanitary pads, panty liners, or tam- pons to help absorb the flow of menstrual blood. While pads and panty liners are used outside the body, tampons are placed inside the vagina. For a wide variety of reasons, including environmental concerns, comfort, chemical resi- dues, and toxic shock syndrome (TSS) (a bacterial infection that can occur in menstruating women and cause a person to go into shock), women are turning to alternative means for catching menstrual flow.

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82 Chapter 3 Female Sexual Anatomy, Physiology, and Response

While some Americans may question the use of alternative products, across time and cultures a wide variety of methods have been used to absorb the flow of blood. Cloth menstrual pads, for example, are reusable, washable, and quite comfortable.

For those desiring to wear something internally, reusable, or disposable, menstrual cups are another alternative to tam- pons. The cup is inserted inside the vagina a few inches below the cervix and is held in place by the muscles of the lower vagina. If put into place properly, the cup should not be felt. About 10 brands of menstrual cups are available on the market today, including The Keeper, The Keeper Moon- cup, and The DivaCup. These cups are made of rubber or medical-grade silicon, making them easy to fold and insert. The cups come in two sizes; the larger size is recommended for women who have delivered a baby vaginally. Reusable menstrual cups can be worn about 6–12 hours, depending on the amount of blood flow. When it’s time to change the cup, it is removed, emptied into a drain, rinsed, and rein- serted (this can be awkward in public restrooms). Menstrual cups are not linked to TSS because they only collect the blood, rather than absorb it. They also do not protect against pregnancy or sexually transmitted infections (“Ins and Outs of Menstrual Cups,” 2012). Some women have used the dia- phragm or cervical cap in a similar manner.

Reusable sea sponges can work like tampons in absorb- ing blood. Boiling the sponge before use and between uses can help to rid it of possible ocean pollutants and help to keep it sanitary. Sewing or tying a piece of cotton string on the sponge for easy retrieval is suggested. Most likely,

the majority of American women will continue to rely on more widely available and advertised commercial tampons or sanitary pads; however, alternatives pro- vide women with an opportunity to take charge of how they respond to their menstrual flow and the environmental impacts of that decision.

The menstrual cycle (uterine cycle), is divided into three phases: menstrual, proliferative, and secretory. What occurs within the uterus is inextricably related to what is happening in the ovaries, but only in their final phases do the two cycles actually coincide (see Figure 9).

Menstruation With hormone levels low because of the degeneration of the corpus luteum, the outer layer of the endometrium becomes detached from the uterine wall. The shedding of the endometrium marks the beginning of the menstrual phase. This endometrial tissue, along with mucus, other cervical and vaginal secretions, and a small amount of blood (2–5 ounces per cycle), is expelled through the vagina. The menstrual flow, or menses (MEN-seez), gen- erally occurs over a period of 3–5 days. FSH and LH begin increasing around day 5, marking the end of this phase. A girl’s first menstruation is known as menarche (MEH-nar-kee).

The Proliferative Phase The proliferative phase lasts about 9 days. During this time, the endometrium thickens in response to increased estrogen. The mucous membranes of the cervix secrete a clear, thin mucus with a crystalline structure that facilitates the passage of sperm. The proliferative phase ends with ovulation.

An array of choices that collect and absorb menstrual flow are now available to women. (a) © Editorial Image, LLC/Alamy; (b) © Editorial Image, LLC/Alamy

(a)

(b)

Follicle Corpus luteum degenerates

Ovum

Menstrual cycle

Ovarian cycle

Ovarian hormone levels in bloodstream

Pituitary hormone levels in bloodstream

For many, highest intimacy and sex drive

FSH

Estrogen

Progesterone

Testosterone/androgen

Menstrual �ow

Endometrium Menstrual �ow

Day 1 Day 14 Day 28

Menses OvulationProliferative phase

Secretory phase Menses

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Female Sexual Physiology 83

The Secretory Phase During the first part of the secretory phase, with the help of progesterone, the endometrium begins to prepare for the arrival of a fertilized ovum. Glands within the uterus enlarge and begin secreting glycogen, a cell nutrient. The cervical mucus thickens and starts forming a plug to seal off the uterus in the event of pregnancy. If fertilization does not occur, the cor- pus luteum begins to degenerate, as LH levels decline. Progesterone levels then fall, and the endometrial cells begin to die. The secretory phase lasts approxi- mately 14 days, corresponding with the luteal phase of the ovarian cycle. It ends with the shedding of the endometrium.

Menstrual Synchrony Women who live or work together sometimes report developing similarly timed menstrual cycles (Cutler, 1999). Termed menstrual synchrony, this phenomenon appears to be related to the sense of smell—more specifically, a response to pheromones, chemical substances secreted into the air. Though there is considerable controversy among researchers as to whether

• FIGURE 9 The Menstrual Cycle, Ovarian Cycle, and Hormone Levels. This chart compares the activities of the ovaries and uterus and shows the relationship of blood hormone levels to these activities.

Follicle Corpus luteum degenerates

Ovum

Menstrual cycle

Ovarian cycle

Ovarian hormone levels in bloodstream

Pituitary hormone levels in bloodstream

For many, highest intimacy and sex drive

FSH

Estrogen

Progesterone

Testosterone/androgen

Menstrual �ow

Endometrium Menstrual �ow

Day 1 Day 14 Day 28

Menses OvulationProliferative phase

Secretory phase Menses

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84 Chapter 3 Female Sexual Anatomy, Physiology, and Response

the phenomenon actually exists, if it does, there could be implications for birth control, sexual attraction, and other aspects of women’s lives. (Pheromones are discussed later in the chapter.)

Menstrual Effects American women have divergent attitudes toward men- struation. For some women, menstruation is a problem; for others, it is simply a fact of life that creates little disruption. For individual women, the problems associated with their menstrual period may be physiological, emotional, or prac- tical. The vast majority of menstruating women notice at least one emotional, physical, or behavioral change in the week or so prior to menstruation. Most women describe the changes negatively: breast tenderness and swelling, abdom- inal bloating, irritability, cramping, depression, or fatigue. Some women also report positive changes such as increased energy, heightened sexual arousal, or a general feeling of well-being. For most women, changes during the menstrual cycle are usually mild to moderate; they appear to have little impact on their lives. The most common problems associated with menstruation are discussed in the following paragraphs.

Premenstrual Syndrome A collection of physical, emotional, and psycho- logical changes that may occur 7–14 days before a woman’s menstrual period is known as premenstrual syndrome (PMS). These symptoms disappear soon after the start of menstrual bleeding. Though no one knows for sure what causes PMS, it seems to be linked to alterations in the levels of sex hormones and brain chemicals, or neurotransmitters.

Controversy exists over the difference between premenstrual discomfort and true PMS. Premenstrual discomfort is a common occurrence, affecting about 75% of all menstruating women (IntelHealth, 2013). Fewer than 1 in 10 women have symptoms that are severe enough to be labeled PMS. Even less common is pre- menstrual dysphoric disorder, a condition that affects approximately 3–8% of all women sufficiently enough to impair their ability to function normally (“Pre- menstrual dysphoric disorder,” 2012). Symptoms of PMS fall into two categories: (1) physical symptoms, which may include bloating, breast tenderness, swelling and weight gain, headaches, cramping, migraine headaches, and food cravings and (2) psychological and emotional symptoms, which include fatigue, depression, irritability, crying, and decrease in libido. For many, symptoms may be worse some months and better other ones. It may also be comforting to know that in most women, PMS symptoms begin to subside after the age of 35 and at menopause.

Menorrhagia At some point in her menstrual life, nearly every woman expe- riences heavy or prolonged bleeding during her menstrual cycle, also known as menorrhagia. Although heavy menstrual bleeding is common among most women, only a few experience blood loss severe enough for it to be defined as menorrhagia. Signs and symptoms may include a menstrual flow that soaks through one or more sanitary pads or tampons every hour for several consecutive hours, the need to use double sanitary protection throughout the menstrual flow, menstrual flow that includes large blood clots, and/or heavy menstrual flow that interferes with the regular lifestyle. Though the cause of heavy menstrual bleed- ing is unknown, a number of conditions may cause menorrhagia, including hormonal imbalances, uterine fibroids, having an IUD, cancer, or certain medi- cations. The combined effect of hormonal imbalances and uterine fibroids accounts for 80% of all cases of menorrhagia. Excessive or prolonged menstrual

Menstrual Period Slang that time of the month monthlies the curse female troubles a visit from my friend a visit from Aunt Flo a visit from George on the rag on a losing streak falling off the roof

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Female Sexual Physiology 85

bleeding can lead to iron deficiency anemia and other medical conditions; thus, it is advisable for women with this problem to seek medical care and treatment.

Dysmenorrhea While menstrual cramps are experienced by some women before or during their periods, a more persistent, aching, and serious pain suf- ficient to limit a woman’s activities is called dysmenorrhea. There are two types of dysmenorrhea. Primary dysmenorrhea is not associated with any diag- nosable pelvic condition. It is characterized by pain that begins with (or just before) uterine bleeding when there is an absence of pain at other times in the cycle. It can be very severe and may be accompanied by nausea, weakness, or other physical symptoms. In secondary dysmenorrhea, the symptoms may be the same, but there is an underlying condition or disease causing them; pain may not be limited to the menstrual phase alone. Secondary dysmenorrhea may be caused by pelvic inflammatory disease (PID), endometriosis, endometrial cancer, or other conditions that should be treated.

The effects of dysmenorrhea can totally incapacitate a woman for several hours or even days. Once believed to be a psychological condition, primary dysmenorrhea is now known to be caused by high levels of prostaglandins (pros-ta-GLAN-dins), natural substances made by cells in the endometrium and other parts of the body. When excessive amounts are produced, the woman may have extreme pain with her menstrual cycle along with headaches, nausea, vomiting, and diarrhea. Prostaglandin production can be decreased with over-the-counter drugs such as aspirin or ibuprofen. Birth control pills or Depo-Provera can also be used to prevent ovulation and thus decrease the thickness of the endometrium, where the prostaglandins are produced.

Amenorrhea When women do not menstruate for reasons other than aging, the condition is called amenorrhea (ay-meh-neh-REE-a). Principal causes of amenorrhea are pregnancy and breastfeeding. Lack of menstruation, if not a result of pregnancy or nursing, is categorized as either primary or secondary amenorrhea. Women who have passed the age of 16 and never menstruated are diagnosed as having primary amenorrhea. It may be that they have not yet reached their critical weight, when an increased ratio of body fat triggers men- strual cycle–inducing hormones, or that they are hereditarily late maturers. But it can also signal hormonal deficiencies, abnormal body structure, or an intersex condition or other genital anomaly that makes menstruation impossible. Most primary amenorrhea can be treated with hormone therapy.

Secondary amenorrhea exists when a previously menstruating woman stops menstruating for several months. If it is not due to pregnancy, breastfeeding, or the use of hormonal contraceptives, the source of secondary amenorrhea may be found in stress, lowered body fat, heavy physical training, cysts or tumors, disease, or hormonal irregularities. Anorexia is a frequent cause of amenorrhea. If a woman is not pregnant, is not breastfeeding, and can rule out hormonal contraceptives as a cause, she should see her health care practitioner if she has gone 3 months without menstruating.

Lifestyle changes or treatment of the underlying condition can almost always correct amenorrhea, unless it is caused by a congenital anomaly. Because there is no known harm associated with amenorrhea, the condition is corrected when an underlying problem presents itself or it causes a woman psychological distress.

Sexuality and the Menstrual Cycle Although studies have tried to deter- mine whether there is a biologically based cycle of sexual interest and activity

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86 Chapter 3 Female Sexual Anatomy, Physiology, and Response

Vaginal and Menstrual Health Care

Many factors can influence the way we experience the changes that occur over the course of the men- strual cycle. While the vast majority of women feel few and minor changes, others experience changes that are uncomfortable and debilitating. The variations can be sig- nificant in any one woman and from month to month. For women, recognizing their menstrual patterns, learning about their bodies, and recognizing and dealing with existing difficulties can be useful in heading off or easing potential problems. Different remedies work for different women. We suggest that you try varying combinations of them and keep a record of your response to each. Following are some common changes that occur dur- ing the menstrual cycle and self-help means to address them.

For Vaginal Changes

The mucous membranes lining the walls of the vagina normally produce clear, white, or pale yellow secretions. These secretions pass from the cervix through the vagina and vary in color, consistency, odor, and quantity, depending on the phase of the menstrual cycle, the woman’s health, and her unique physical characteristics. It is important for you to observe your secretions periodi- cally and note any changes, especially if symptoms accompany them. Because self-diagnosis of unusual dis- charges is inaccurate over half the time, it is wise to go ahead with self-treatment only after a diagnosis is made by a health care practitioner. Call a health professional if you feel uncertain or suspicious and/or think you may have been exposed to a sexually transmitted infection.

Here are some simple guidelines that may help a woman avoid getting vaginal infections (vaginitis):

1. Avoid douching and vaginal deodorants, especially deodorant suppositories or deodorant tampons. The vagina is a clean environment and does not need to be washed. Douching upsets the natural chemical balance of the vagina.

2. Maintain good genital hygiene by washing the labia and clitoris regularly (about once a day) with mild soap.

3. After a bowel movement, wipe the anus from front to back, away from the vagina, to prevent contamination with fecal bacteria.

4. Wear cotton underpants with a cotton crotch. Nylon does not “breathe,” and it allows heat and moisture to build up, creating an ideal environment for infectious organisms to reproduce.

5. If you use a vaginal lubricant, be sure it is water- soluble. Oil-based lubricants such as Vaseline encour- age bacterial growth.

6. Socialize with others or go to a support group to help reduce the stress that may cause or exacerbate the infection.

For Premenstrual Changes

1. Consume a well-balanced diet, with plenty of whole- grain cereals, fruits, and vegetables.

2. Moderate your intake of alcohol, avoid tobacco, and get sufficient sleep.

3. Exercise at least 30–45 minutes a day. Aerobic exercise brings oxygen to body tissues and stimulates the production of endorphins, chemical substances that help promote feelings of well-being.

For Cramps

1. Relax and apply heat by using a heating pad or hot- water bottle (or, in a pinch, a cat) applied to the abdominal area may help relieve cramps; a warm bath may also help.

2. Get a lower-back or other form of massage, such as acupressure, or Shiatsu.

3. Take prostaglandin inhibitors, such as aspirin and ibuprofen, to reduce cramping of the uterine and abdominal muscles. Aspirin increases menstrual flow slightly, whereas ibuprofen reduces it. Stronger anti- prostaglandins may be prescribed by your health care practitioner.

4. Having an orgasm (with or without a partner) is reported by some women to relieve menstrual conges- tion and cramping.

When symptoms are severe, further medical evaluation is needed.

practically speaking

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Human Sexual Response 87

in women that correlates with the menstrual cycle (such as higher interest around ovulation), the results have been varied. There is also variation in how people feel about sexual activity during different phases of the menstrual cycle.

There has been a general taboo in our culture, as in many others, against sexual intercourse during menstruation. This taboo may be based on religious or cultural beliefs. Among Orthodox Jews, for example, women are required to refrain from intercourse for 7 days following the end of menstruation. They may then resume sexual activity after a ritual bath, the mikvah. Contact with blood may make some people squeamish. Some women, especially at the beginning of their period, feel bloated or uncomfortable; they may experience breast ten- derness or a general feeling of not wanting to be touched. Others may find that sexual activity helps relieve menstrual discomfort.

For some couples, merely having to deal with the logistics of bloodstains, bathing, and laundry may be enough to discourage them from intercourse at this time. For many people, however, menstrual blood holds no special con- notation. In a study of 108 women aged 18–23, females described their experi- ences with sexuality during menstruation. Nearly one half, most of whom were in committed relationships, stated they had sexual activity during their men- strual cycle (Allen & Goldberg, 2009). Young adults who were comfortable with menstrual sex saw it as just another part of a committed intimate relationship. It is important to note that although it is unusual, conception can occur during menstruation. Some women find that a diaphragm or menstrual cup can collect the menstrual flow. Menstrual cups, however, are not a contraceptive. It is not recommended that women engage in intercourse while a tampon is inserted because of possible injury to the cervix. And inventive lovers can, of course, find many ways to give each other pleasure that do not require putting the penis into the vagina.

•Human Sexual Response The ways in which individuals respond to sexual arousal are highly varied. Women’s sexuality, though typically thought of as personal and individual, is significantly influenced by the social groups to which women belong. Sociocul- tural variables include gender, religious preference, class, educational attain- ment, age, marital status, race, and ethnicity. For many women, gender—the social and cultural characteristics associated with being male or female—is probably the most influential variable in shaping their sexual desires, behaviors, and partnerships. Because gender is largely defined by cultural expectations, women’s sexual experiences must be understood in terms of cultural, political, and relational forces. Research into the anatomy and physiology of sexuality has helped us increase our understanding of orgasm, the climax of sexual sen- sation that involves rhythmic contractions in the genital area and intensely plea- surable sensations. By looking beyond the genitals to the central nervous system, where electrical impulses travel from the brain to the spinal cord, researchers are examining nerves and pathways to better understand the biology of the orgasm. What is probably most critical to all of these functions are the ways we interpret sexual cues.

Though scientific research has contributed much to our understanding of sexual arousal and response, there is still much to be learned. One way in which researchers investigate and describe phenomena is through the creation of

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88 Chapter 3 Female Sexual Anatomy, Physiology, and Response

think about it Sexual Fluidity: Women’s Variable

Sexual Attractions

When the media report stories about same-sex lov- ers, such as actress Anne Heche leaving Ellen DeGe- neres for a man, Cynthia Nixon (from Sex and the City) leaving her male partner of 15 years for a woman, and Julie Cypher leaving a heterosexual marriage for Melissa Etheridge then later leaving her for a man, what are your responses? Are these incidents simply flukes? Are the women confused? Bisexual? None of these, according to Lisa Diamond, professor of psychol- ogy and gender studies at the University of Utah. Rather, she has coined the term “sexual fluidity” to describe sex- ual desires and attractions as situation- dependent in sex- ual responsiveness (Diamond, 2008).

Based on her own research and analysis of animal mat- ing and women’s sexuality coupled with reviews of others’, Diamond suggests that female desire may be dictated by both intimacy and emotional connection. She came to this conclusion after 10 years following the erotic attractions of nearly 100 young women who, at the start of her work, identified themselves as lesbian or bisexual or refused a label. From her analysis of their shifts between sexual iden- tities and descriptions of their erotic lives, Diamond sug- gests that for her participants and possibly for women on the whole, desire is malleable, embedded in the nature of female desire, and cannot be captured by asking women to categorize their attractions. Among the women in her study who called themselves lesbian, one third reported attraction solely to women, while the other two thirds revealed peri- odic and genuine desire and attraction to men. When dis- cussing sexual orientation, Diamond sees significance in the fact that many of her subjects agreed with the statement “I am the kind of person who becomes physically attracted to the person rather than their gender.”

Thus it is, in the cases of Diamond’s subjects, that emotional closeness overrode predominant orientation, resulting in attraction and desire. This concept seems to violate the core underlying assumption of our model of sexuality: that sexual orientation is defined by sexual behavior. Not long ago, the sexualities—heterosexuality, homosexuality, and even bisexuality—were categorical. Sexual attraction and desire, sexual behavior, and sexual identity were assumed to be congruent; same-gender sexual attraction/behavior assumed a gay, lesbian, or bisexual identity; and other sexual attraction/behavior assumed a heterosexual identity (Schecter, 2009). Now, Diamond’s work, along with others’, reveals this may be true for some women but not true for all. In fact, desire/ behavior and orientation/identity do not always match up.

The more scholars learn about sexual desire, the more it becomes apparent that it involves a complex interplay

among biological, environmental, psychological, cultural, and interpersonal factors. Evidence points to three charac- teristics about desire: (1) It is both hormonally and situation- ally driven, (2) individuals are often unaware of the full range of their desires, and (3) women’s sexual desires show more variability than do men’s. Probably the largest review of all the published data on the subject around the variability of women’s sexual desires was published by Roy Baumeister (2000), professor of psychology at Florida State University. The study found that women show greater variability than men in a wide range of sexual behaviors, including desired frequency of sex, preferred contexts for sexual behavior, types and frequency of fan- tasy, and desirable partner characteristics. Baumeister cited this phenomenon as “erotic plasticity.” Newer research concerning the connection between sexual orientation and fluidity has shown that though heterosexuality was the most stable identity for men and women, among women, sexual fluidity was a pattern that applied more to bisexual and homosexual women than those who identified as het- erosexual. Among men, those who identified as bisexual were more sexually fluid (Mock & Eiback, 2012). Neverthe- less, sex researchers still do not understand the mecha- nisms that underlie sexual fluidity (Diamond, 2013).

While tremendous strides have been made to foster greater acceptance of a diversity of sexual expression, sexual minorities as a whole still remain isolated and unsupported. Textbooks, media, and culture continue to assume that there is a fixed model of same-sex sexuality, in spite of the fact that many individuals know differently. Although the notion of sexual fluidity may be confusing, frightening, or threatening to some, it does offer one more variable to the broad spectrum of sexual expres- sion of which humans are capable and can celebrate.

Think Critically 1. Is sexual orientation innate and/or fixed? As a

result of the research described, is your under- standing of sexual orientation changing?

2. Have you experienced sexual fluidity? If so, what were your reactions?

3. What would you do if your same-sex or other- sex best friend told you that he or she was romantically interested in you?

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Human Sexual Response 89

models, hypothetical descriptions used to study or explain something. Although models are useful for promoting general understanding or for assisting in the treatment of specific clinical problems, we should remember that they are only models. It may be helpful to think of sexual functioning as interconnected, link- ing desire, arousal, orgasm, and satisfaction. Turbulence or distraction at any one point affects the functioning of the others.

Sexual Response Models A number of sexologists have attempted to outline the various physiological changes that both men and women undergo when they are sexually stimulated and aroused. Three important models are described here. The sequence of changes and patterns that take place in the body during sexual arousal is referred to as the sexual response cycle. Masters and Johnson’s four-phase model of sexual response identifies the significant stages of response as excitement, plateau, orgasm, and resolution (see Figure 10). Helen Singer Kaplan (1979) collapses the excitement and plateau phases into one, elimi- nates the resolution phase, and adds a phase to the beginning of the process. Kaplan’s tri-phasic model of sexual response consists of desire, excitement, and orgasm phases. Though Masters and Johnson’s and Kaplan’s are the most widely cited models used to describe the phases of the sexual response cycle, they do little to acknowledge the affective parts of human response. A third but much less known pattern is Loulan’s sexual response model, which incorporates both the biological and affective components into a six-stage cycle. Beyond any questions of similarities and differences in the female and male sexual response cycle is the more significant issue of variation in how individuals experience each phase. The diversity of experiences can be described only by the individual. (These models are described and compared in Table 3.)

To help organize our thinking about the complexities of human behavior, the dual control model provides a theoretical perspective of sexual response that is based on brain function and the interaction between sexual excitation (respond- ing with arousal to sexual stimuli) and sexual inhibition (inhibiting sexual arousal) (Bancroft, Graham, Janssen, & Sanders, 2009). The authors of this model argue that though much research has been dedicated to understanding sexual excitation, little research has been conducted on the inhibitory brain mechanisms that provide an equally significant role in sexual arousal and response. They purport that the adaptive role the inhibitory mechanism produces is relevant to our understanding of “normal” sexuality, individual variability, and problematic sexuality. The functions of the inhibitory response can be found in the following circumstances: (1) When sexual activity in a specific situation is potentially risky (as when you or your partner suspects an unintended pregnancy could result); (2) when a nonsexual challenge occurs and sex needs to be sup- pressed (as when a child calls out for help); (3) when excessive involvement in the pursuit of sexual pleasure distracts from other important functions (as when someone is late for work because he or she is distracted by viewing sexually explicit materials); (4) when social or environmental pressure results in suppres- sion of reproductive behavior (as when someone is so stressed during finals week he or she doesn’t feel like having sex); and (5) when the consequences of continued excessive sexual behavior potentially reduces possible conception (as when repeated ejaculations can result in lower sperm count).

Passion, though a bad regulator, is a powerful spring.

—Ralph Waldo Emerson (1803–1882)

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90 Chapter 3 Female Sexual Anatomy, Physiology, and Response

• FIGURE 10 Masters and Johnson’s Stages of Female Sexual Response (internal, left; and external, right)Resolution

Pubic bone

Uterus elevates

Clitoral hood

Urethra Labia minora

Labia majora

Anus

Clitoral shaft and glans swell; glans retracts beneath hood

Clitoris remains retracted under hood

Orgasmic platform contracts

Anal sphincter contracts

Labia minora deepen in color and enlarge

Bartholin’s glands may secrete a small amount of �uid

Uterus elevates further

Upper part of vagina expands

Vaginal wall forms orgasmic platform

Color of labia deepens

Rectal sphincter contracts

Rhythmic contractions in vagina

Contractions in uterus

Vaginal lubrication appears

Clitoris engorges with blood

Labia majora swell

Labia minora swell

Bladder

Excitement

Plateau

Orgasm

Unaroused

Excitement

Orgasm

Clitoris withdraws under clitoral hood

Clitoris remains retracted under hood

Labia majora separate from the vaginal opening

Clitoris

Uterus lowers

Vagina returns to normal

Orgasmic platform disappears

Seminal pool

Clitoris returns to unaroused position

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Human Sexual Response 91

Resolution

Pubic bone

Uterus elevates

Clitoral hood

Urethra Labia minora

Labia majora

Anus

Clitoral shaft and glans swell; glans retracts beneath hood

Clitoris remains retracted under hood

Orgasmic platform contracts

Anal sphincter contracts

Labia minora deepen in color and enlarge

Bartholin’s glands may secrete a small amount of �uid

Uterus elevates further

Upper part of vagina expands

Vaginal wall forms orgasmic platform

Color of labia deepens

Rectal sphincter contracts

Rhythmic contractions in vagina

Contractions in uterus

Vaginal lubrication appears

Clitoris engorges with blood

Labia majora swell

Labia minora swell

Bladder

Excitement

Plateau

Orgasm

Unaroused

Excitement

Orgasm

Clitoris withdraws under clitoral hood

Clitoris remains retracted under hood

Labia majora separate from the vaginal opening

Clitoris

Uterus lowers

Vagina returns to normal

Orgasmic platform disappears

Seminal pool

Clitoris returns to unaroused position

A major finding of the dual control model is that it views excitation and sexual inhibition as separate systems, as opposed to other models that view these as two ends of a single dimension. Additional findings from this model include the following:

■ Though most people fall in the moderate range on propensities toward sexual excitation and sexual inhibition, there is great variability from one person to the next.

■ Men, on average, score higher on excitation and lower on inhibition than women.

■ Gay men, on average, score higher on excitation and lower on inhibition than straight men.

■ Bisexual women, on average, score higher on excitation than lesbian and straight women.

TABLE 3 ● Models of the Sexual Response Cycle

Psychological/Physiological Process Name of Phase

People make a conscious decision to have sex even if there might not be emotional or physical desire.

Willingness (Loulan)

Some form of thought, fantasy, or erotic feeling causes individuals to seek sexual gratification. (An inability to become sexually aroused may be due to a lack of desire, although some people have reported that they acquire sexual desire after being sexually aroused.)

Desire (Kaplan, Loulan)

Physical and/or psychological stimulation produces characteristic physical changes. In men, increased amounts of blood flow to the genitals produce erection of the penis; the scrotal skin begins to smooth out, and the testicles draw up toward the body. Later in this phase, the testes increase slightly in size. In women, vaginal lubrication begins, the upper vagina expands, the uterus is pulled upward, and the clitoris becomes engorged. In both women and men, the breasts enlarge slightly, and the nipples may become erect. Both men and women experience increasing muscular contractions.

Excitement (Masters/Johnson, Loulan)

Excitement (Kaplan)

Sexual tension levels off. In men, the testes swell and continue to elevate. The head of the penis swells slightly and may deepen in color. In women, the outer third of the vagina swells, lubrication may slow down, and the clitoris pulls back. Coloring and swelling of the labia increase. In both men and women, muscular tension, breathing, and heart rate increase.

Plateau (Masters/Johnson)

Engorgement (Loulan)

Increased tension peaks and discharges, affecting the whole body. Rhythmic muscular contractions affect the uterus and outer vagina in women. In men, there are contractions of the glands and tubes that produce and carry semen, the prostate gland, and the urethral bulb, resulting in the expulsion of semen (ejaculation).

Orgasm (Masters/Johnson, Kaplan, Loulan)

The body returns to its unaroused state. In some women, this does not occur until after repeated orgasms.

Resolution (Masters/Johnson)

Pleasure (Loulan)

Pleasure is one purpose of sexuality and can be defined only by the individual. One can experience pleasure during all or only some of the above stages, or one can leave out any of the stages and still have pleasure.

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92 Chapter 3 Female Sexual Anatomy, Physiology, and Response

■ Excitation lessens with age for men and women; however, inhibition is not age-related in women but is somewhat age-related in men.

■ The relation between negative mood and sexuality is best predicted by inhibition scores in men, but by excitation scores in women.

The dual control model suggests that individuals who have a low propensity for sexual excitation or a high propensity for sexual inhibition are more likely to experience difficulties related to sexual response or sexual interest. Furthermore, those who have a high propensity for sexual excitation or low propensity for sex- ual inhibition are more likely to engage in problematic sexuality such as high-risk sexual behaviors, for example, not using a condom. Because the focus is on sexual arousal, there remain questions about if and how this model might apply to orgasm.

Desire and Arousal: Mind or Matter? Desire is the psychological component of sexual arousal. Although we can expe- rience desire without becoming aroused, and in some cases become aroused without feeling desire, some form of erotic thought or feeling is usually involved in our sexual behavior.

The physical manifestations of sexual arousal involve a complex interaction of thoughts and feelings, sensory organs, neural responses, and hormonal reac- tions. These involve various parts of the body, including the nucleus accumbens, cerebellum, and hypothalamus of the brain, the nervous system, the circulatory system, and the endocrine glands—as well as the genitals.

In a comprehensive review of women’s sexual desire, it was clear how little is understood about what women desire (Meana, 2010). The author pointed to the distinction between “desire to be desired,” which does not necessarily lead to sexual interaction (as being desired may be rewarding in itself) and “desire to have sex.” Qualitative data indicated that many women report that feeling desired enhances their arousal. It’s these kinds of issues that contribute to our still limited understanding of the fundamental aspects of women’s sexuality (Bancroft & Graham, 2011).

A meta-study, which combined the results of several studies, of men’s and women’s sexual arousal patterns found that in women, lubrication was only one of the physiological changes that occurred when they were sexually aroused, and not a necessary condition for women to report that they were sexually aroused (Chivers, Seto, Lalumière, & Grimbos, 2010). Much of the science behind sexuality was designed around a very linear model: First, there’s desire; then there’s arousal, followed by orgasms, then snuggling. For most women, this process is more circular, whereby sexuality is about intimacy, relationships, and wanting to cuddle first and feel close to someone. It’s also about how women feel about themselves. If they do not feel desirable or comfortable with their bodies, it’s likely that they will not be able to relax and enjoy the sexual interchange (Wortman & van den Brink, 2012).

Among men who have trouble getting erect, genital engorgement is aided by drugs such as Viagra because the pills target genital capillaries. Thus, the med- ications may enhance male desire by granting men a feeling of power and control, but not medically increasing desire or want. For some men, desire is not an issue. However, for women, there still are uncertainties about what is common female sexuality in its various forms (Bancroft & Graham, 2011). The roles of androgens and estrogens are unclear, though we know that there is a testosterone- dependent component of women’s sexuality that is more important for some than

Some desire is necessary to keep life in motion.

—Samuel Johnson (1709–1784)

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Human Sexual Response 93

others. Until we learn more about women’s sexuality, our ability to effectively treat women’s sexual difficulties remains somewhat elusive.

The Neural System and Sexual Stimuli The brain is crucial to sexual response and is currently a focus of research to understanding how we respond to sexual stimulation. Through the neural system, the brain receives stimuli from the five senses plus one: sight, smell, touch, hearing, taste, and the imagination.

The Brain The brain, of course, plays a major role in all of our body’s func- tions. Nowhere is its role more apparent than in our sexual functioning. The relationship between our thoughts and feelings and our actual behavior is not well understood (and what is known would require a course in neurophysiology to satisfactorily explain it). Relational factors and cultural influences, as well as expectations, fantasies, hopes, and fears, combine with sensory inputs and neu- rotransmitters (chemicals that transmit messages in the nervous system) to bring us to where we are ready, willing, and able to be sexual. Even then, potentially erotic messages may be short-circuited by the brain itself, which can inhibit as well as incite sexual responses. It is not known how the inhibitory mechanism works, but negative conditioning and emotions will prevent the brain from sending messages to the genitals. In fact, the reason moderate amounts of alcohol and marijuana appear to enhance sexuality is that they reduce the control mech- anisms of the brain that act as inhibitors. Conversely, women who feel persistent sexual arousal and no relief from orgasm reveal unusually high activation in regions of the brain that respond to genital stimulation (Komisaruk et al., 2010).

Anatomically speaking, the part of the body that appears to be involved most in sexual behaviors of both men and women is the vast highway of nerves called the vagus nerve network, which stretches to all the major organs, including the brain. Using MRI scans to map the brain, researchers have found increases in brain activity during sexual arousal (Holstege et al., 2003; Komisaruk et al., 2010). Since specific parts of the brain send their sensory signals via specific nerves, the different quality of orgasms that result from clitoral or anal stimula- tion, for example, is divided among the different genital sensory nerves.

As many of us know, the early stages of a new romantic relationship are characterized by intense feelings of euphoria, well-being, and preoccupation with the romantic partner. This was observed in one study in which college students were shown photos of their beloved intermixed with photos of an equally attrac- tive acquaintance (Younger, Aron, Parke, Chatterjee, & Mackey, 2010). Induced with pain during the experiment, students reported their pain was less severe when they were looking at photos of their new love. The test results suggest the chemicals the body releases in the early stages of love— otherwise referred to as endogenous opioids—work on the spinal cord to block the pain message from getting to the brain. MRI scans showed that, indeed, the areas of the brain acti- vated by intense love are the same areas targeted by pain-relieving drugs.

The Senses An attractive person (sight), a body fragrance or odor (smell), a lick or kiss (taste), a loving caress (touch), and erotic whispers (hearing) are all capable of sending sexual signals to the brain. Preferences for each of these sensory inputs are both biological and learned and are very individualized. Many of the connections we experience between sensory data and emotional responses are probably products of the limbic system, or those structures of the brain that are associated with emotions and feelings and involved in sexual arousal. Some sensory inputs may evoke sexual arousal without a lot of conscious thought or

Women might be able to fake orgasms. But men can fake whole

relationships.

—Sharon Stone (1958– )

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94 Chapter 3 Female Sexual Anatomy, Physiology, and Response

emotion. Certain areas of the skin, called erogenous zones, are highly sensitive to touch. These areas may include the genitals, breasts, mouth, ears, neck, inner thighs, and buttocks; erotic associations with these areas vary from culture to culture and from individual to individual. Our olfactory sense (smell) may bring us sexual messages below the level of our conscious awareness. Scientists have isolated chemical substances, called pheromones, that are secreted into the air by many kinds of animals, including humans, ants, moths, pigs, deer, dogs, and monkeys. One function of pheromones, in animals at least, appears to be to arouse the libido.

Hormones The libido in both men and women is biologically influenced by the hormone testosterone. In men, testosterone is produced mainly in the testes; in women, it is produced in the adrenal glands and the ovaries. Growing evi- dence suggests that testosterone may play an important role in the maintenance of women’s bodies (Davis, Davison, Donath, & Bell, 2005). Although it does not play a large part in a woman’s hormonal makeup, it is present in the blood vessels, brain, skin, bone, and vagina. Testosterone is believed to contribute to bone density, blood flow, hair growth, energy and strength, and libido.

Although women produce much less testosterone than men, this does not mean that they have less sexual interest; apparently, women are much more sensitive than men to testosterone’s effects. Though testosterone decreases in women as they age, the ovaries manufacture it throughout life. Symptoms produced by the decrease of testosterone can be similar to those related to estrogen loss, including fatigue, vaginal dryness, and bone loss. Signs specific to testosterone deficiency are asso- ciated with reduced sexual interest and responsiveness in men. It is believed that for some women, very low levels may contribute to reduced libido and weaker orgasmic responses (North American Menopause Society, 2014). In spite of wide- spread claims of testosterone’s effect in treating low sex desire in women, in December 2004, the Food and Drug Administration voted against approval of a testosterone patch, citing concerns about the safety of long-term use of the patch and use by groups that have not been adequately studied. Though research has shown that testosterone delivered via a skin patch increases sexual desire and frequency of satisfying sex among some menopausal women with low desire, common side effects of supplemental testosterone range from acne and increased facial and body hair to rare but sometimes seen liver problems and declines in good cholesterol (North American Menopause Society, 2014). Until long-term safety data are submitted, prescribed use of testosterone to treat difficulties in sexual functioning among women remains illegal in the United States and Canada.

It’s important to remember that although sexual problems, including low libido and/or sexual dissatisfaction, may have a physiological link, they can also be caused, for example, by relationship issues, work fatigue, past experiences, or financial problems. Thus, it is necessary to look beyond medical solutions when assisting women who have the desire to confront their sexual dissatisfaction.

Estrogen also plays a role in sexual functioning, though its effects on sexual desire are not completely understood. In addition to protecting the bones and heart, in women estrogen helps maintain the vaginal lining and lubrication, which can make sex more pleasurable. Men also produce small amounts of estrogen, which facilitates the maturation of sperm and maintains bone density. Too much estrogen, however, can cause erection difficulties. Like testosterone replacement, some doc- tors are also promoting estrogens and bioidentical, or natural, estrogen supplements to treat conditions caused by estrogen deficiency. The most significant push is aimed at menopausal women. Because no risk-free hormone has ever been identified,

Sensory inputs, such as the sight, touch, or smell of someone we love or the sound of his or her voice, may evoke desire and sexual arousal. © Design Pics/Darren Greenwood

The age of a woman doesn’t mean a thing. The best tunes are played

on the oldest fiddles.

—Ralph Waldo Emerson (1803–1882)

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Female Sexual Response 95

claims that human estrogens will protect against cardiovascular effects and other maladies are misleading. While a number of estrogens are effective treatments for hot flashes and vaginal dryness, any health-promotion claims for these drugs are clearly misguided. Nevertheless, over-the-counter lubricants and/or long-acting vaginal moisturizers may be helpful for women who have insufficient lubrication.

Oxytocin is a hormone more commonly associated with contractions during labor and with breastfeeding. It is also increased by nipple stimulation in men and women. This neurotransmitter, which has also been linked to bonding, is released in variable amounts in men and women during orgasm and remains raised for at least 5 minutes after orgasm. This is why oxytocin is sometimes referred to as the “cuddle hormone” (Gray & Garcia, 2013). It helps us feel connected and promotes touch, affection, and relaxation. Interestingly, oxytocin is important in stimulating the release of all the other sex hormones and, since it peaks during orgasm, it may be responsible for the desire to touch or cuddle after orgasm occurs (Chia & Abrams, 2005).

In spite of what we do know about the importance of biological influences on sexual desire and performance, when biological determinants or evolutionary accounts are given undue weight and psychosocial forces are ignored or mini- mized, a medical model that negates the significance of culture, relationships, and equality can emerge.

Experiencing Sexual Arousal For both males and females, physiological changes during sexual excitement depend on two processes: vasocongestion and myotonia. Vasocongestion is the concentration of blood in body tissues. For example, blood fills the genital regions of both males and females, causing the penis to become erect and the clitoris to swell. Myotonia is increased muscle tension accompanying the approach of orgasm; upon orgasm, the body undergoes involuntary muscle con- tractions and then relaxes. The sexual response pattern remains the same for all forms of sexual behavior, whether autoerotic or sex with a partner, heterosexual or homosexual. Nevertheless, approximately 30% of women report problems related to arousal (Chivers et al., 2010).

• Female Sexual Response Sexual Excitement Many women do not separate sexual desire from arousal (Tiefer, 2004). Addition- ally, many seem to care less about physical arousal but rather place more empha- sis on the relational and emotional aspects of intimacy. In any case, for women, one of the first signs of sexual excitement is the seeping of moisture through the vaginal walls through a process called vaginal transudation or sweating. Some women also report “tingling” in the genital area. Blood causes lymphatic fluids to push by the vaginal walls, engorging them, lubricating the vagina, and enabling it to encompass the penis or other object. The upper two thirds of the vagina expands in a process called tenting; the vagina expands about an inch in length and doubles its width. The labia minora begin to protrude outside the labia majora during sexual excitement, and breathing and heart rate increase. These signs do not occur on a specific timetable; each woman has her own pattern of arousal, which may vary under different conditions, with different partners, and so on.

Contractions raise the uterus, but the clitoris remains virtually unchanged during this early phase. Although the clitoris responds more slowly than the penis to

Those who restrain desire do so because theirs is weak enough to

be restrained.

—William Blake (1757–1827)

The reason so many women fake orgasms is that so many men fake

foreplay.

—Graffito

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96 Chapter 3 Female Sexual Anatomy, Physiology, and Response

think about it “Did You Come?” What College Students

Think About Women’s Orgasms During Heterosexual Sex

la petite mort (French) “The little death” —the human orgasm

While nearly all men report that they usually or always experience orgasm during heterosexual intercourse, the majority of women report that they do not always orgasm (Dawood et al., 2005; Lloyd, 2005; Wade, Kremer, & Brown, 2005). Given this major gap, psychologists Claire Salisbury and William Fisher (2014) at Western University in Ontario, Canada, conducted a study focusing on gen- der differences in the experiences, beliefs, and concerns surrounding the lack of female orgasm during penile- vaginal intercourse.

A total of 24 female and 21 male undergraduates (mean age 5 19) from an Ontario university participated in focus group discussions. One female reported never hav- ing had sexual intercourse, and one female reported never having had an orgasm. All of the men had experienced both sexual intercourse and orgasm. From the analysis of the focus group discussions, six themes emerged from the females, and seven themes emerged from the males. Fol- lowing are the themes and a summary the major concerns.

Female Discussion Group Themes

Males are responsible for the physical stimulation of females to orgasm.

The women viewed men as responsible for giving them orgasms and themselves as responsible for being psychologically ready to receive the orgasm.

Female orgasm is not necessary for women’s sexual sat- isfaction during partnered interactions.

Female sexual satisfaction was viewed as not being dependent on having an orgasm. Instead, the women viewed female orgasm as a “bonus” and not the goal of sexual interaction.

Female orgasm is more important for the male partner than the female partner.

The importance of female orgasm rested not with increasing the female’s sexual satisfaction and pleasure

but centered around the male partner’s ego and sense of himself as a competent lover capable of “giving” her an orgasm. Some women faked orgasms to avoid nega- tive partner reaction.

Reliance on working assumptions and lack of communication.

The women assumed that men highly valued them having an orgasm and judged themselves harshly if she did not experience one. However, there was little direct communication between partners about the absence of female orgasm or the woman’s assumption about its importance.

Superiority of male concerns over female physical pleasure.

Concern for the male partner’s feelings, ego, and judgments inhibited the women from acting on their own desires. Even if desired, women tended to avoid requesting for clitoral stimulation or engaging in clitoral stimulation during intercourse or other sexual activity, fearing the male partner would feel incompetent or would judge them.

Orgasm beliefs and concerns differ by relationship status.

In a casual sexual encounter, the women thought that female orgasm was not very important to men and that faking orgasm was more acceptable. However, for com- mitted romantic relationships, the women thought that female orgasm was very important to the male partner and that faking was not acceptable. Communication was considered easier but still difficult in the committed relationship.

Male Discussion Group Themes

Male coital orgasm is very important for men. For men, the occurrence of their own orgasm during sexual intercourse is very important and expected to be a common occurrence.

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Female Sexual Response 97

Females are perceived to have a strong desire for orgasm during intercourse.

Given the sexual pleasure from experiencing orgasm, the men assumed that orgasm during intercourse was also very important to women, particularly when they were in casual encounters.

Female orgasm is extremely satisfying and important to men.

The occurrence of female orgasm was viewed by men as extremely satisfying and extremely important. Most men listed the occurrence of female orgasm as one of the most satisfying sexual experiences a man could have. The men concurred with the women, believ- ing that it was their physical responsibility to “give” their female partner orgasms and that is was the psychologi- cal responsibility of the women to be prepared to receive the orgasm.

Lack of female orgasm is very distressing for men. The female partner not experiencing an orgasm

during sexual interactions brought negative reactions to the men, especially within a relationship context. The most common concern was self-focused in worrying about his skills as a sexual partner. Secondly, they worried that the female partner would not experience the pleasure she could have had if she had an orgasm. Men indicated that they were highly motivated to make their partner orgasm in the future and that a repeated lack of female orgasm has a negative impact on the relationship.

Positive and encouraging view of (manual) clitoral stimulation:

The men were highly motivated to increase the female partner’s sexual pleasure, expressing positive reactions to: (1) stimulating their female partner’s clitoris during intercourse, (2) the female stimulating her clitoris during intercourse, and (3) the female partner asking for additional clitoral stimulation. These views were most positive from manual clitoral stimulation, however these extremely positive reactions disappeared when a vibrator was used as the source of stimulation.

Importance of female communication on lack of orgasm occurrence:

Men reported the need for communication about female orgasm so they could employ different techniques to give their partners orgasm. However, they generally preferred their partner to directly bring up this topic her- self. Men in relationships preferred that the woman not fake an orgasm but directly communicate the truth about the lack of an orgasm.

Orgasm beliefs and concerns differ between casual ver- sus relationship sexual interactions.

The men reported that in casual relationships their focus was on themselves; however of great importance was the attainment of orgasm by both partners. In commit- ted relationships, the men’s goals of both his and his female partner’s experiencing orgasm were very important.

As you see, the men and women in the focus groups agreed on two main things: the man’s responsibility to physically produce female orgasm and the importance of the male ego relative to female orgasm. The most fre- quent concern of both sexes was on the male partner’s judgment of himself as a lover and the impact on his self- esteem if the female did or did not attain orgasm. Salis- bury and Fisher concluded by stating that:

By not actively engaging in clitoral self-stimulation during sexual interactions (particularly intercourse), those women who desire more frequent orgasms during partnered sex are limiting the extent of sexual pleasure they can obtain. Perceived male responsibility for producing female orgasms may therefore be an obstacle to sexual gratification for both partners, and perceived female responsibility for protecting the male ego may be a burden for women (pp. 12–13).

While these results cannot be extended to all college students, they can provide a barometer and (hopefully) an impetus for increased communication about sexual behaviors between college students of both sexes.

Think Critically 1. Which of the findings of this study surprise you

and/or confirm the norms at your college or university? Explain.

2. What does the study imply about female orgasms during sexual intercourse? In your opinion, are intercourse orgasms inherently more important than orgasms from other sexual behaviors such as oral sex or masturbation?

3. What do the findings suggest about gender roles of men and women related to female orgasm during heterosexual sexual activities? What, if anything, should change?

sources: Dawood, K., Kirk, K. M., Bailey, J. M., Andrews, P. W., & Martin, N. G. (2005). Genetic and environmental influences on the frequency of female orgasm. Twin Research and Human Genetics, 8, 27–33; Lloyd, E. A. (2005). The case of female orgasm: The bias in the science of evolution. Cambridge, MA: Harvard University Press; Salisbury, C.M.A., & Fisher, W. A. (2014). “Did you come?” A qualitative exploration of gender differences in beliefs, experiences, and concerns regarding female orgasm occurrence during heterosexual sexual interactions. Journal of Sex Research, 51(6), 616–631.

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98 Chapter 3 Female Sexual Anatomy, Physiology, and Response

What is the earth? What are the body and soul without satisfaction?

—Walt Whitman (1819–1892)

vasocongestion, it is still affected. The initial changes, however, are minor. Clitoral tumescence (swelling) occurs simultaneously with engorgement of the labia minora. During masturbation and oral sex, the clitoris is generally stimulated directly. Dur- ing intercourse, clitoral stimulation is mostly indirect, caused by the clitoral hood being pulled over the clitoris or by pressure in the general clitoral area. At the same time that these changes are occurring in the genitals, the breasts are also respond- ing. The nipples become erect, and the breasts may enlarge somewhat because of the engorgement of blood vessels; the areolae may also enlarge. Many women (and men) experience a sex flush, a darkening of the skin or rash that temporarily appears as a result of blood rushing to the skin’s surface during sexual excitement.

As excitement increases, the clitoris retracts beneath the clitoral hood and virtu- ally disappears. The labia minora become progressively larger until they double or triple in size. They deepen in color, becoming pink, bright red, or a deep wine-red color, depending on the woman’s skin color. This intense coloring is sometimes referred to as the “sex skin.” When it appears, orgasm is imminent. Meanwhile, the vaginal opening and lower third of the vagina decrease in size as they become more congested with blood. This thickening of the walls, which occurs in the plateau stage of the sexual response cycle, is known as the orgasmic platform. The upper two thirds of the vagina continues to expand, but lubrication decreases or may even stop. The uterus becomes fully elevated through muscular contractions.

Changes in the breasts continue. The areolae become larger even as the nipples decrease in relative size. If the woman has not breastfed, her breasts may increase by up to 25% of their unaroused size; women who have breastfed may have little change in size.

Orgasm Continued stimulation brings orgasm, a peak sensation of intense pleasure that cre- ates an altered state of consciousness and is accompanied by involuntary, rhythmic uterine and anal contractions, myotonia, and a state of well-being and contentment. The upper two thirds of the vagina does not contract; instead, it continues its tenting effect. The labia do not change during orgasm, nor do the breasts. Heart and respi- ratory rates and blood pressure reach their peak during orgasm.

After orgasm, the orgasmic platform rapidly subsides. The clitoris reemerges from beneath the clitoral hood. Orgasm helps the blood flow out of the genital tissue quickly. If a woman does not have an orgasm once she is sexually aroused, the clitoris may remain engorged for up to an hour. This unresolved vasoconges- tion sometimes leads to a feeling of frustration, analogous to what men call “blue balls.” The labia slowly return to their unaroused state, and the sex flush gradu- ally disappears. About 30–40% of women perspire as the body begins to cool.

Interestingly, when women and men are asked to use adjectives to describe their experience of orgasm, data suggest that beyond the awareness of ejaculation that men report, their sensations bear more similarities than differences (Mah & Binik, 2002).

Prolactin levels double immediately following orgasm and remain elevated for about 1 hour (Meston & Buss, 2009). This prolactin is thought to be respon- sible for the refractory period, in which men are unable to ejaculate again. In contrast, women are often physiologically able to be orgasmic immediately fol- lowing the previous orgasm. As a result, women can have repeated orgasms, also called multiple orgasms, if they continue to be stimulated. Though findings vary on the percentage of women who experience multiple orgasms (estimates range from 14% to 40%), what is clear is that wide variability exists among women and within any one woman from one time to another.

Most women experience orgasm through clitoral stimulation rather than through vaginal penetration. Masturbation can be an important step in learning how to be orgasmic. © Chris Rout/Alamy

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Summary 99

Another chapter will discuss the anatomical features and physiological functions that characterize men’s sexuality and sexual response. The information in these two chapters should serve as a comprehensive basis for understanding the material that follows.

Summary Female Sex Organs: What Are They For?

■ All embryos appear as female at first. Genetic and hormonal signals trigger the development of male organs in those embryos destined to be male.

■ Sex organs serve a reproductive purpose, but they per- form other functions also: giving pleasure, attracting sex partners, and bonding in relationships.

■ The external female genitals are known collectively as the vulva. The mons pubis is a pad of fatty tissue that covers the area of the pubic bone. The clitoris is the center of sexual arousal. The labia majora are two folds of spongy flesh extending from the mons pubis and enclosing the other external geni- tals. The labia minora are smooth, hairless folds within the labia majora that meet above the clitoris.

■ The internal female sexual structures and reproduc- tive organs include the vagina, the uterus, the cer- vix, the ovaries, and the fallopian tubes. The vagina is a flexible, muscular organ that encom- passes the penis or other object during sexual expression and is the birth canal through which an infant is born. The opening of the vagina, the introitus, is partially covered by a thin, perforated membrane, the hymen, prior to first intercourse or other intrusion.

■ Many women report the existence of an erotically sensitive area, the Grafenberg spot (G-spot), on the upper front wall of the vagina midway between the introitus and the cervix.

■ The uterus, or womb, is a hollow, thick-walled, muscular organ; the tapered end, the cervix, extends downward and opens into the vagina. The lining of the uterine walls, the endometrium, is built up and then shed and expelled through the cervical os (opening) during menstruation. In the event of pregnancy, the pre-embryo is embedded in the

nourishing endometrium. On each side of the uterus is one of a pair of ovaries, the female gonads (organs that produce gametes, sex cells containing the genetic material necessary for reproduction). At the top of the uterus are the fallopian tubes, or uterine tubes. They extend toward the ovaries but are not attached to them. The funnel-shaped end of each tube (the infundibulum) fans out into fingerlike fimbriae, which drape over the ovary. Hairlike cilia on the fimbriae transport the ovulated oocyte (egg) into the fallopian tube. The ampulla is the widened part of the tube in which fertilization normally occurs. Other important structures in the area of the genitals include the urethra, anus, and perineum.

■ The reproductive function of the female breasts, or mammary glands, is to nourish the offspring through lactation, or milk production. A breast is composed of fatty tissue and 15–25 lobes that radi- ate around a central protruding nipple. Alveoli within the lobes produce milk. Around the nipple is a ring of darkened skin called the areola.

Female Sexual Physiology

■ Hormones are chemical substances that serve as messengers, traveling through the bloodstream. Important hormones that act directly on the gonads (gonadotropins) are follicle-stimulating hormone (FSH) and luteinizing hormone (LH). Hormones produced in the ovaries are estrogen, which helps regulate the menstrual cycle, and progesterone, which helps maintain the uterine lining, until men- struation occurs.

■ At birth, the human female’s ovaries contain approx- imately half a million oocytes, or female gametes. During childhood, many of these degenerate. In a woman’s lifetime, about 400 oocytes will mature

Final Thoughts

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100 Chapter 3 Female Sexual Anatomy, Physiology, and Response

changes during sexual excitement depend on two processes: vasocongestion, the concentration of blood in body tissues, and myotonia, increased muscle tension with approaching orgasm.

Female Sexual Response

■ For women, an early sign of sexual excitement is the moistening, or vaginal transudation or sweat- ing, of the vaginal walls. The upper two thirds of the vagina expands in a process called tenting; the labia may enlarge or flatten and separate; the clito- ris swells. Breathing and heart rate increase. The nipples become erect, and the breasts may enlarge somewhat. The uterus elevates. As excitement increases, the clitoris retracts beneath the clitoral hood. The vaginal opening decreases by about one third, and its outer third becomes more congested, forming the orgasmic platform.

■ Continued stimulation brings orgasm, a peak sensa- tion of intense pleasure that creates an altered state of consciousness and is accompanied by contractions, myotonia, and a state of well-being and contentment. Women are often able to be orgasmic following a previous orgasm if they continue to enjoy giving and receiving sexual pleasure.

Questions for Discussion ■ Are changes in mood that may occur during a

woman’s menstrual cycle caused by biological factors, or are they learned? What evidence supports your response?

■ Given the choice between the environmentally friendly menstruation products and commercial products, which would you choose for yourself (or recommend to a woman), and why?

■ If another adult were to ask you “What is an orgasm?” how would you reply? If the person were to proceed to ask you how to induce one in a woman, what would you say?

■ What are your thoughts and reactions to learn- ing about the Grafenberg spot? Do you believe it is an invented erotic spot for some women or a genuine gland or erogenous zone?

■ How important is it to you that both you and your partner enjoy sexual pleasuring and pleasure?

and be released, beginning in puberty when hor- mones trigger the completion of oogenesis, the pro- duction of oocytes, commonly called eggs or ova.

■ The activities of the ovaries and the development of oocytes for ovulation, the expulsion of the oocyte, are described as the four-phase ovarian cycle, which is on average about 28 days long. The phases are menstrual, follicular (maturation of the oocyte), ovulatory (expulsion of the oocyte), and luteal (hormone production by the corpus luteum).

■ The menstrual cycle (uterine cycle), like the ovar- ian cycle, is divided into four phases. The shedding of the endometrium marks the beginning of the menstrual phase. The menstrual flow, or menses, generally occurs over a period of 3–5 days. Endo- metrial tissue builds up during the proliferative phase; it produces nutrients to sustain an embryo in the secretory phase.

■ Women who live or work together may develop similarly timed menstrual cycles, called menstrual synchrony.

■ The most severe menstrual problems have been attributed to premenstrual syndrome (PMS), a clus- ter of physical, psychological, and emotional symp- toms that may occur 7–14 days before the menstrual period. Some women experience very heavy bleeding (menorrhagia), while others have pelvic cramping and pain during the menstrual cycle (dysmenorrhea). When women do not men- struate for reasons other than aging, the condition is called amenorrhea. Principal causes of amenor- rhea are pregnancy and nursing.

Human Sexual Response

■ Masters and Johnson’s four-phase model of sexual response identifies the significant stages of response as excitement, plateau, orgasm, and reso- lution. Kaplan’s tri-phasic model of sexual response consists of three phases: desire, excite- ment, and orgasm. Loulan’s sexual response model includes both biological and affective components in a six-stage cycle. The dual control model helps explain the interaction between sexual excitation and sexual inhibition.

■ The physical manifestations of sexual arousal involve a complex interaction of thoughts and feel- ings, sensory perceptions, neural responses, and hormonal reactions occurring in many parts of the body. For both males and females, physiological

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Suggested Reading 321

Sex and the Internet Paraphilias The web is one resource for locating information about paraphilias. Go to the Google website (http:// www.google.com) and type “paraphilias” in the Google Search box. As you can see, there are a wide range of sites posted. Look over the posted sites and answer the following questions:

■ What types of websites are listed?

■ Are the sites primarily from medical and academic organizations, individuals, or commercial groups?

■ Are there sites for specific paraphilias?

■ Which sites provide the most valuable information to you? Why?

■ Did you learn anything new about paraphilias from the websites? If so, what?

■ Do you believe that any of the sites contain inaccurate or harmful information? Explain.

Suggested Websites AllPsych Online http://allpsych.com/disorders/paraphilias Offers information on numerous psychiatric disorders, including symptoms, etiology, treatment, and prognosis for paraphilias and sexual disorders.

American Psychiatric Association http://www.psych.org/home/search-results?k=paraphilias Provides information on the APA’s classification of paraphilias and paraphilic disorders with highlights of the changes in the latest version of the DSM.

WebMD http://www.webmd.com/sexual_conditions/paraphilias Describes common paraphilias and provides a search for paraphilia information.

Suggested Reading Frances, A. (2013). Saving normal: An insider’s revolt against

out-of-control psychiatric diagnosis, DSM-5, big pharma and the medicalization of ordinary life. New York: William Morrow. The author presents a history of medical illness and an account of an explosion of psychiatric disorder in the United States. He cautions the mislabeling and diagnosis of normal daily issues as mental illness.

Greenberg, G. (2013). The book of woe: The DSM and the unmaking of psychiatry. London, UK: Penguin Books. Psychotherapist Gary Greenberg details a critical historical analysis of the APA’s Diagnostic and Statistical Manual of Mental Disorders with interviews of persons on both sides of the treacheries and valuable strengths of the DSM.

Kleinplatz, P. J., & Moser, C. (2006). Sadomasochism: Power- ful pleasures. Binghamton: NY: Harrington Park Press. Arti- cles from leading experts discuss the results of research into practitioners’ behaviors and perspectives and stresses greater tolerance and understanding of S&M.

Laws, D. R., & O’Donohue, W. (Eds.). (2008). Sexual deviance: Theory, assessment and treatment (2nd ed.). New York: Guilford Press. A collection of papers that examine the theories, assessment procedures, and treatment tech- niques for a spectrum of sexually variant behaviors.

Money, J. (1989). Lovemaps. Buffalo, NY: Prometheus Books. A description of variant and paraphilic behavior.

Tyler, A., & Bussel, R. K. (Eds.). (2006). Caught looking: Erotic tales of voyeurs and exhibitionists. San Francisco: Cleis Press. A collection of 20 short fiction stories with the theme being voyeurism and exhibitionism.

Valdez, N. (2010). A little bit kinky: A couple’s guide to rediscovering the thrill of sex. New York: Broadway Books. This book, for both men and women, provides ideas for the “kinky” side of sex, from the little bit kinky to the kinkiest behaviors.

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http://www.google.com

http://allpsych.com/disorders/paraphilias

http://www.psych.org/home/search-results?k=paraphilias

http://www.webmd.com/sexual_conditions/paraphilias

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Risk and Responsibility

Methods of Contraception

Abortion

Research Issues

C H A P T E R O U T L I N E

Contraception and Abortion

chapter

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Risk and Responsibility 323

Today, more than ever before, we are aware of the impact of fertility on our own lives, as well as on the world. Reproduction, once considered strictly a personal matter, is now a subject of open debate and political action. Yet, regardless of our public views, we must each confront fertility on a personal level. In taking charge of our reproductive potential, we must be informed about the availability and effectiveness of birth control methods, as well as ways to protect ourselves against sexually transmitted infections (STIs). But information is only part of the picture. We also need to understand our own personal needs, values, and habits, so that we can choose methods we will use consistently, thereby minimizing our risks.

In this chapter, we begin by examining the psychology of risk taking and the role of individual responsibility in contraception. We then describe in detail the numerous contraceptive devices and techniques that are used today: methods of use, effectiveness rates, advantages, and possible problems. Finally, we look at abortion, its effect on individuals and society, and research issues.

•Risk and Responsibility A typical American woman who wants to have two children spends about 5 years pregnant, postpartum, or trying to become pregnant and 30 years trying to avoid pregnancy (Guttmacher Institute, 2015). Over the course of this time, her contraceptive needs will change; however, the most important factor in her choice of a method of contraception will often be its effectiveness.

In the United States, nearly half of all pregnancies and 82% of teen births each year are unintended and about 4 in 10 pregnancies are terminated by abortion (Guttmacher Institute, 2014.11a). Although on average a woman has only about a 2–4% chance of becoming pregnant during intercourse without contraception, age and timing affect the odds. For example, if intercourse occurs during ovulation, the chance of conception is about 25%. Over a period of a year, sexually active couples who do not use contraception have an 85% chance of conception.

“My parents and I never talked about sex until I had to ask them questions for one of my high school classes. They got so excited about the topic. I guess they were just waiting for me to ask. I remember my mom throwing a pack of condoms on the bed. She said, ‘Just in case!’ We just all laughed.”

—20-year-old male

“During the summer before my sophomore year, things started to change. My father came into my room much as he had done the first time. It was ‘The Talk, Part Two.’ He asked me if I knew what a condom was and told me about abstinence. I told him I wasn’t planning on having sex for a while, but I was lying; it was all I thought about. I felt awk- ward and embarrassed. Nevertheless, he made his point, and before he left he said, ‘I love you.’ ”

—20-year-old male

“Mom gave me an important sense that my body was mine, that it was my responsibility and under my control. Birth control was always discussed whenever sex was mentioned, but when it was, it was treated like a joke. The message was that sex can be a magical thing as long as you are being responsible—responsible for not getting yourself or anyone else pregnant. Back then, sexually transmitted infections were not discussed, so it was the pill or a diaphragm for me and condoms for my brothers.”

—26-year-old female

One year they asked me to be poster boy—for birth control.

—Rodney Dangerfield (1921–2004)

Voices Student

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324 Chapter 11 Contraception and Abortion

Because the gap between first sex and first birth is nearly 10 years (Guttmacher Institute, 2014.11b) and the potential for getting pregnant is so high for a sexually active, childbearing-age couple, it would seem reasonable that sexually active couples would use contraception to avoid unintended pregnancy. Unfortunately, all too often, this is not the case. In 2011–2013, approximately 62% of women aged 15–44 were using some type of contraceptive method, while 38% were sterile, pregnant, postpartum and breastfeeding, trying to become pregnant, or abstinent (Daniels, Daugherty, & Jones, 2014) (see Figure 1). Not surprisingly, the nonusers of contraception accounted for about half of unintended pregnancies;

those who used contraception reported that the method either failed or was not used correctly or consistently (see Figure 2).

Numerous studies have indicated that the most consistent users of contracep- tion are men and women who explicitly communicate about the subject. People at greatest risk for not using contraceptives are under age 20, are in casual dating relationships, and infrequently discuss contraception with their partners or others.

Women, Men, and Birth Control: Who Is Responsible? If oral contraceptives for men became available, how many women would trust their partner to use them? Because women bear children and have most of the responsibility for raising them, women often have a greater interest than their partners in controlling their fertility. Also, it is generally easier to keep one egg from being fertilized once a month than to stop millions of sperm during each episode of intercourse. For these and other reasons, birth control has traditionally been seen as the woman’s responsibility, but attitudes and practices are changing. The more education couples have, the more likely they

are to talk about and utilize family planning (Jones et al., 2012). Education appears to instill confidence in both partners to discuss intended family size and birth control methods. Regardless of the motive or level of education, society no longer views the responsibility for birth control to lie solely with women. Rather, the majority of men as well as women perceive that there is gender equality in sexual decision making and equal responsibility for decisions about contraception. Male methods account for approximately 20% of all reversible contraceptive use (Guttmacher Institute, 2014.11c). These methods, the most common of which are the male condom and withdrawal, may be effective when used correctly and consistently. As opposed to an irreversible method, such as a vasectomy, reversible methods of birth control can be changed or stopped at any time. In fact, male methods of contraception predominate among couples 25–39 in all industrialized countries of the world except the United States. Although withdrawal, a common method in most countries, is not considered a reliable method of birth control, the condom is quite effective when used consistently and correctly, especially in combination with a spermicide.

When a partner becomes pregnant unexpectedly, the reactions and expec- tations of college men are often complex and multifaceted: ranging from

Pregnant/postpartum, seeking to become

pregnant 9%

All other contraceptive

methods 18%

Condom 10%

Pill 17%

Female sterilization

17%

All other reasons

10% No sex ever in last 3 months

19%

• FIGURE 1 Percentage of Women Aged 15–44, By Whether They Are Using Contraception and By Reason and Methods Used: United States, 2006–2012.

(Source: Jones, Mosher, & Daniels, 2012.)

Intended 49%

Mistimed 31%

Unintended 20%

• FIGURE 2 Pregnancies, By Intention Status. Currently about half of the 6.6 million pregnancies in the United States each year are unintended. Most unintended pregnancies are attributable to nonuse, ambivalence, fear of side effects, inconsistent use, or incorrect use of contraceptives.

(Source: Guttmacher Institute, 2015.)

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Risk and Responsibility 325

ambivalent or avoidant to concerned and responsible. (Olmstead, Koon, Puhlman, Pasley, & Fincham, 2013). In a qualitative analysis, 148 college men were asked questions about an unplanned pregnancy, and three common responses emerged: They would expect to raise the child (87%), not raise the child (10%), or agree that their partner can decide (3%). Of those who expected to raise the child, most anticipated they would marry the child’s mother. This research has significant implications for sexually active college men, particularly since they have been shown to engage in heavier drinking, which is linked to lower levels of condom use and other sexually risky behaviors (Cooper, 2002).

In addition to using a condom, a man can take contraceptive responsibility by: (1) exploring ways of being sexual without intercourse; (2) helping pay doctor or clinic bills and sharing the cost of pills, injections, or other birth control methods; (3) checking on supplies, helping keep track of his partner’s menstrual cycle, and helping her with her part in the birth control routine; and (4) in certain circumstances like a long-term relationship, if no or no more children are planned, having a vasectomy.

Navigating Reproductive Health Reproductive health care reflects a deep commitment to supporting the family and makes a significant and necessary contribution to humankind. Margaret Sanger, widely regarded as the founder of the modern birth control movement, first acknowledged this when, in 1915, she opened an illegal clinic where women could obtain and learn to use the diaphragms she had shipped from Europe. Sanger believed that in order for women to lead healthier lives, they needed to be able to determine when to have children. Her advocacy also took the form of published birth control information, for which she was soon arraigned for violating the Comstock Laws, which made it a crime to sell or distribute materials that could be used for contraception or abortion. Later, in 1921, she founded the American Birth Control League, which we now know as Planned Parenthood Federation of America. It wasn’t, however, until 1960 that the first birth control pills entered the U.S. marketplace. Fertility control, rather than abstinence, proved to be a major shift in the way women and some men regarded their sexuality and sexual expression.

Currently, the backbone of the nation’s publicly funded family planning efforts is Title X, the Public Health Service Act, which makes effective contra- ceptive options accessible to all women, regardless of income. Clinical services for those who receive Title X support include a range of family planning and preventive health options that promote health and well-being among adolescents as well as adult men and women (see Figure 3 for recommended services).

The Title X package of care overlaps with services provided by the Affordable Care Act’s (ACA) preventive services by expanding eligibility for private and public programs and guaranteeing contraceptive coverage

When the history of our civilization is written, it will be a biological

history, and Margaret Sanger will be its heroine.

—H. G. Wells (1866–1946)

Related preventive health services

(e.g., screening for breast and cervical cancer)

Other preventive health services

(e.g., screening for lipid disorders)

• Contraceptive services • Pregnancy testing and counseling • Achieving pregnancy • Basic infertility services • Preconception health • Sexually transmitted infection services

Recommended family planning services

• FIGURE 3 Recommended Family Planning and Related Preventive Health Services.

(Source: Gavin, L., et al., 2014).

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326 Chapter 11 Contraception and Abortion

think about it Risky Business: Why Couples Fail

to Use Contraception

Most persons having sexual intercourse know they are taking a chance of getting pregnant when they don’t use contraception. But the more frequently a person takes chances with unprotected intercourse without resultant pregnancy, the more likely he or she is to do so again. Eventually, the woman or couple will feel almost magically invulnerable to pregnancy. Each time they are lucky, their risk taking is reinforced.

The consequences of an unintended pregnancy— economic hardships, adoption, or abortion—may be overwhelming. So why do people take chances in the first place? Part of the reason is faulty knowledge. People often underestimate how easy it is to get pregnant, or they may not know how to use a contraceptive method correctly. Additionally, talking about or using some types of birth control can be uncomfortable and can interrupt spontaneity. But so can an unintended pregnancy.

Perceived Costs of Contraceptive Planning

One reason people avoid taking steps to prevent pregnancy is that they don’t want to acknowledge their own sexuality. Acknowledging our sexuality is not necessarily easy, for it may be accompanied by feelings of guilt, conflict, and shame. The younger or less experienced we are, the more difficult it is for us to acknowledge our sexuality.

Planning contraception requires us to acknowledge not only that we are sexual but also that we plan to be sexually active. Without such planning, men and women can pretend that their sexual intercourse “just happens”— when a moment of passion occurs, when they have been drinking, or when there is a full moon—even though it may happen frequently.

Another reason people don’t use contraception is difficulty in obtaining it. It is often embarrassing for sexually inexperienced people to be seen in contexts that identify them as sexual beings. The cost of contraceptives is also a problem for some. Although free or low-cost contraceptives may be obtained through family planning clinics or other agencies, people may have transportation or work considerations that keep them away.

Because it is women who get pregnant, men may be unaware of their responsibility or downplay their role in conception, although with the popularity of the condom, responsibility may become more balanced especially if women insist on it. Nevertheless, males, especially ado- lescents, often lack the awareness that supports contra- ceptive planning.

Many people, especially women using the pill, practice birth control consistently and effectively within an ongoing

relationship but may give up their contraceptive practices if the relationship breaks up. They define themselves as sex- ual only within the context of a relationship. When men or women begin a new relationship, they may not use contra- ception because the relationship has not yet become established. They do not expect to have sexual intercourse or to have it often, so they are willing to take chances.

Using contraception such as a condom or spermicide may destroy the feeling of spontaneity in sex. For those who justify their sexual behavior by romantic impulsive- ness, using these devices seems cold and mechanical.

Anticipated Benefits of Pregnancy

Ambivalence about pregnancy is a powerful incentive not to use contraception. For many people, being pregnant proves that a woman is indeed feminine on the most fundamental biological level. Getting a woman pregnant provides similar proof of masculinity for some men.

Pregnancy also proves beyond any doubt that a person is fertile. Many men and women have lingering doubts about whether they can have children. This is especially true for partners who have used contraception for a long time, but it is also true for those who take chances.

Another anticipated benefit of pregnancy is that it requires the partners to define their relationship and level of commitment to each other. It is a form of testing, albeit often an unconscious one. Many men and women unconsciously expect their partners to be pleased, but this is not always the reaction they get.

Finally, pregnancy involves not only two partners but possibly their parents as well, especially the woman’s. Preg- nancy may force a young person’s parents to pay attention to and deal with him or her as an adult. Pregnancy may mean many things with regard to the parent-child relation- ship: a sign of rebellion, a form of punishment for a parental lack of caring, a plea for help and understanding, or an insistence on autonomy, independence, or adulthood.

Think Critically 1. If sexually active, do you take risks relative to

not adequately protecting yourself or your part- ner from conception? If so, what kinds? Why?

2. When do you believe a person is more inclined to take risks?

3. What would you say to a sexual partner who hesitates in using a condom because he or she doesn’t like the way it feels?

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Risk and Responsibility 327

without copays (Guttmacher Institute, 2013). Those who have insurance through the ACA are now covered for their contraceptive methods and counseling, as prescribed by a health care provider. These plans cover the services without charging a copayment or coinsurance when they are provided by an in-network provider (HealthCare.gov, 2014). It is interesting to note that, for every $1.00 invested in helping women avoid unintended pregnancies, $5.68 is saved in Medicaid expenditures (Guttmacher Institute, 2013.11a). Additionally, the health law requires that preventive care services be provided by health plans to customers without cost. These services include annual well woman visits, depression screening, intimate partner violence screening and counseling, education about STIs, including HIV, and vaccines for flu, hepatitis, and HPV. Excluded are plans sponsored by certain exempt religious employers whose religious convictions do not cover certain types of contraceptive methods and counseling.

The ability of minors to consent to a range of health care services, including sexual and reproductive health care, has expanded dramatically in the last 30 years, with 26 states and the District of Columbia allowing those aged 12 and older to consent to contraceptive, prenatal, and STI services without parental involvement (Guttmacher Institute, 2014.11b). This trend reflects the recognition that many minors will remain sexually active and not seek services if they have to tell their parents beforehand. School districts are among those opting to pro- vide birth control and condoms to their students. In spite of these efforts, many still need a place to go for contraceptive services, while others remain uninsured. Creative strategies aimed at both service providers and policymakers are needed to improve access to and use of contraceptives among women, especially those who are disadvantaged.

Adolescents and Contraception In the United States, 614,000 teens became pregnant in 2010, with the overwhelming majority (82%) of those pregnancies being unintended (Guttmacher Institute, 2014.11c). Among these teens, the most cited reason for not using contraception was “I didn’t think I could become pregnant” (Centers for Disease Control and Prevention, 2012). Eighteen percent of young men believed that having sex standing up helps prevent pregnancy (Kaye, Suellentrop, & Sloup, 2009). Despite the high levels of unplanned preg- nancies, the overall teen pregnancy rate has actually declined since 1990, with effective use of contraception accounting for the decline. The majority of sexu- ally experienced teens (78% of females and 85% of males) used contraceptives the first time they had sex, with condoms being their first method of choice (Martinez et al., 2011). Of the 2.7 million teenage women aged 15–19 who use contraceptives, 44% rely on the pill; 36% on the condom; 13% on other hor- monal methods, such as the implant, injectable, patch, and ring; and 5% on other methods (Jones et al., 2012).

In 2014, the American Academy of Pediatrics (AAP) recommended that pediatricians consider long-acting reversible contraceptive (LARC) methods, namely, intrauterine devices (IUDs) and hormonal implants as “first-line contraceptive choices for adolescents.” (Descriptions of these devices will follow in this chapter.) Also known as extended-use contraceptives, these options provide effective contraception for both adolescents and women for a prolonged period without requiring user action. As noted previously, the Affordable Care Act (ACA) provides funds for these and other contraceptives without out-of-pocket costs, which would otherwise be a critical barrier for use by teens.

The comedy The To Do List (2013), starring Aubrey Plaza, focuses on a set of teens who attempt to navigate their sexuality. © Film Fanatic/Alamy

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328 Chapter 11 Contraception and Abortion

•Methods of Contraception The methods we use to prevent pregnancy or its progress vary widely. Thus, the best method of contraception is one that will be used consistently and correctly. Hopefully, this method is also one that is available and in harmony with one’s preferences, fears, and expectations.

Contraception, or birth control, is the use of artificial methods or other techniques to prevent pregnancy. (Note that throughout this chapter we will be interchanging the terms “contraception” and “birth control.”) This is done in a variety of ways, includ- ing: (1) barrier methods, such as condoms and diaphragms, which place a physical barrier between the sperm and the egg; (2) spermicides, which kill the sperm before they can get to the egg; (3) hormonal methods, such as the pill, the shot, the patch, the implant, and the ring, which inhibit the release of the oocyte from the ovary; and (4) intrauterine devices, which prevent the sperm from fertilizing the egg.

Choosing a Method To be fully responsible in using birth control, individuals must know what options they have, how reliable these methods are, and what advantages and disadvantages including possible side effects each has. Thus, it is important to be aware of both personal health issues and the specifics of the methods them- selves. (Table 1 shows the failure rates of contraceptives.)

Most women who are not currently using contraception go to a clinic or doctor’s office knowing exactly what method they want. However, many of these women are not aware of other options available to them. In some instances, the method they think they want may not be medically appropriate or may not be one they will use correctly and consistently. Knowing the facts about the methods gives you a solid basis from which to make decisions, as well as more security once you reach a deci- sion. (See Figure 4 for percentages of all women aged 15–44 who use contraceptives.)

To help you make an informed decision about which method of birth control is medically appropriate and will be used every time, consider these questions (Hatcher et al., 2011):

■ Do you have any particular preferences or biases related to birth control? ■ Do you know the advantages and disadvantages of each of the contracep-

tive methods? ■ How convenient and easy is it to use this method? ■ If you or your partner is at risk, does this method protect against STIs,

including HIV? ■ What are the effects of this method on menses? ■ Is it important that you negotiate with your partner to help determine the method? ■ What other influences (e.g., religion, privacy, past experience, friends’

advice, and frequency of intercourse) might affect your decision? ■ Have you discussed potential methods with your health care practitioner?

Knowledge and familiarity about contraceptive methods are strong determinants of use among young adults. Among unmarried women aged 18–29, for each correct response on a contraceptive knowledge scale, the odds of currently using a hormonal or long-acting reversible method increased by 17% and of using no method decreased by 17%. Other factors that increase the usage of a contraceptive method include having a higher income, being married, being religious, and cohabiting. The proportion of at-risk women who are not using a method is

Planning contraception requires us to acknowledge our sexuality. One way a responsible couple can reduce the risk of unintended pregnancy is by visiting a family planning clinic—together. © B. Boissonnet/BSIP/AGE Fotostock

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Methods of Contraception 329

TABLE 1 ● Failure Rates and Relative Effectiveness of Contraceptives During First Year of Use

% of Women Experiencing an Unintended Pregnancy Within the First Year of Use

% of Women Continuing Use at 1 Year Relative EffectivenessMethod

Typical Use (%)a

Perfect Use (%)b

No method 85 85 Least effective: 18 or more pregnancies per 100 women in a year

Spermicides (foams, creams, gels, suppositories, and film) 28 18 42

Fertility awareness–based methods 24 12 47

Withdrawal 22 4 46

Sponge

Parous women (given birth) 24 20 36

Nulliparous women (never given birth) 12 9 —

Condom

Female 21 5 41

Male 18 2 43

Diaphragm 12 6 57 Effective: 6–12 pregnancies per 100 in a yearCombined pill and

progestin-only pill 9 0.3 67

Contraceptive patch 9 0.3 67

Contraceptive ring 9 0.3 67

DMPA contraceptive injection 6 0.2 56

IUD Most effective: less than 1 pregnancy per 100 in a year

ParaGard 0.8 0.6 78

Mirena and Skyla (Levonorgestrel) 0.2 0.2 80

Single-rod contraceptive implant 0.05 0.05 84

Female sterilization 0.5 0.5 100

Male sterilization 0.15 0.10 100

source: Adapted from Hatcher, R. A., et al. (2011). Contraceptive technology (20th rev. ed.). New York: Reprinted by permission of Ardent Media.

aThe percentage of typical users who become pregnant within 1 year while using the method. bThe percentage of women who become pregnant within 1 year using the method perfectly every time.

highest among 15- to 19-year-olds (Guttmacher Institute, 2014.11a). Still, the pill remains one of the most popular methods of birth control for women, along with female sterilization and condoms (Daniels et al., 2014) (see Figure 4). Among the two thirds of women aged 15–44 who used birth control between 2011 and 2013, approximately 16% used the pill. Long-acting reversible contraceptives are becoming more popular, with their use nearly doubling over the past 5 years.

In the following discussion of method effectiveness, “perfect use” refers to the percentage of women who become pregnant during their first year of use

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330 Chapter 11 Contraception and Abortion

when they use the method correctly and consistently. “Typical use” refers to the percentage of women who become pregnant during their first year of use; this number includes both couples who use the method correctly and consistently and those who do not (see Table 1). Thus, typical use is the more significant number to use when considering a method of contraception. Of those who use contraceptives consistently and correctly throughout the course of a year, only 5% become pregnant (Guttmacher Institute, 2014.11c).

Sexual Abstinence Before we begin our discussion of devices and techniques for preventing concep- tion, we must acknowledge the oldest and most reliable birth control method of all: abstinence. There is a wide variety of opinion about what constitutes sexual activity. However, from a family planning perspective, abstinence is the absence of genital contact that could lead to a pregnancy (i.e., penile penetration of the vagina). The term “celibacy” is sometimes used interchangeably with “abstinence.” We prefer “abstinence” because “celibacy” often implies the avoidance of all forms of sexual activity and, often, a commitment to not marry or to maintain a nonsexual life.

Individuals who choose not to have intercourse are still free to express affection and to give and receive sexual pleasure if they so desire in a variety of ways, includ- ing talking, hugging, massaging, kissing, petting, and manually and orally stimulat- ing the genitals. Those who choose abstinence from sexual intercourse as their method of birth control need to communicate this clearly to their partners. They should also be informed about other forms of contraception. And in the event that either partner experiences a change of mind, it can’t hurt to have a condom handy. An advantage of abstinence is that refraining from sexual intercourse in a new relationship may allow two people to get to know and trust each other more before experiencing greater intimacy and it is 100% effective at preventing pregnancy.

Female sterilization1

0.7

14.6

31.0

22.4

16.9

10.1 11.5

6.6 5.0

11.1

5.3

Male condom2Pill1

P er

ce nt

Long-acting reversible contraceptives3

8.7

1All percentages are signi�cantly different from each other across age groups. 2Percentages for age group 15–24 and 25–34 are signi�cantly different from age group 35–44. 3Percentages for age group 15–24 and 35–34 are signi�cantly different from age group 25–34.

NOTES: For women using more than one method, categorized by the most effective method they were using. Long-acting reversible contraceptives include contraceptive implants and intrauterine devices. Access data table at: http://www.cdc. gov/nchs/ data/databriefs/ db173_table.pdf#1.

15–24 25–34 35–44

• FIGURE 4 Percentage of All Women Aged 15–44 Who Were Using Female Sterilization, the Pill, the Male Condom, and Long-Acting Reversible Contraceptives, by Age: United States, 2011–2013. (Source: Daniels, K., Daugherty, J., & Jones, J., 2014).

The best contraceptive is the word no—repeated frequently.

—Margaret Smith

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http://www.cdc

Methods of Contraception 331

Hormonal Methods In addition to the tried-and-true birth control pill, several varieties of hormonal contraception are available. These include a pill that causes menstrual suppres- sion, a birth control shot, a patch, a vaginal ring, and an implant.

The Pill Oral contraceptives (OCs), popularly called “the pill,” are the most widely used form of reversible contraception in the United States, accounting for 17% of all contraceptives used (Guttmacher Institute, 2014.11c). The pill is actu- ally a series of pills (various numbers to a package) containing synthetic estrogen and/or progesterone that regulate egg production and the menstrual cycle. When taken for birth control, oral contraceptives accomplish some or all of the following:

■ Suppresses ovulation 90–95% of the time ■ Thickens cervical mucus thereby preventing sperm penetration into the

woman’s upper genital tract ■ Thins the lining of the uterus to inhibit implantation of the fertilized ovum ■ Slows the rate of ovum transport ■ Disrupts transport of the fertilized egg ■ Inhibits capacitation of the sperm, which limits the sperm’s ability to

fertilize the egg

The pill produces basically the same chemical conditions that would exist in a woman’s body if she were pregnant.

Types and Usage Oral contraceptives must be prescribed by a physician or family planning clinic. Most commonly prescribed are the combination pills, which contain a fairly standard amount of estrogen (usually about 35 micrograms) and different amounts of progestin, a synthetic form of progesterone, according to the pill type. In the triphasic pill, the amount of progestin is altered during the cycle, purportedly to approximate the normal hormonal pattern. Progestin-only pills (POPs), sometimes called “minipills,” contain the hormone progestin. The minipill is considered slightly less effective than the combination pill, and it must be taken with precise, unfailing regularity to be effective. Taken at the same time each day, with no hormone-free days, the minipill provides an alternative to those who can- not safely take estrogen. These include women who are breastfeeding, have had weight loss (bariatric) surgery, have liver disease, or have had breast cancer.

A woman can begin taking oral contraceptives on the same day as she receives her prescription, providing she is not pregnant and not in need of emergency contraception. Women may prefer this “quick start” practice because other approaches generally leave a time gap between the time the pills are prescribed and the time one starts taking them. If a woman starts taking the pill within 5 days after starting her period, she is protected against pregnancy right away.

The pill is considered among the most effective birth control methods available when used correctly. But the pill is not effective when taken inconsistently. It must be taken every day, as close as possible to the same time each day. If one pill is missed, it should be taken as soon as the woman remembers, and the next one taken on schedule. If two pills are missed, the method cannot be relied on, and an additional form of contraception should be used for the rest of the cycle.

A shift to extended-use oral contraceptives acknowledges a little known fact: Women don’t need to have monthly periods. Extended-cycle oral contraceptives

Although oral contraceptives are effective in preventing pregnancy, they do not provide protection against STIs, including HIV infection. © Don Farrall/Getty Images

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provide women with a safe, acceptable, and effective form of contraception (Planned Parenthood, 2014.11a). The use of these regimens provides women with more options and almost certainly improves the acceptability and efficacy of hormonal contraception.

Since none of the hormonal methods of birth control offer protection against STIs, women on the pill should consider the additional use of a condom, if she is not in a monogamous relationship or is unsure of her partner’s STI status.

Effectiveness Oral contraceptives are more than 99.7% effective if used cor- rectly. The typical-use rate is 91%.

Advantages The benefits of hormonal methods generally far outweigh any significant negative effects. Pills are easy to take. They are dependable. No applications or interruptions are necessary before or during intercourse. In fact, millions of women use the pill with moderate to high degrees of satisfaction. For many women, if personal health or family history does not contraindicate it, the pill is both effective and safe. Some women experience benefits such as more regular or reduced menstrual flow, less menstrual cramping, and some protection against pelvic inflammatory disease (PID) which often leads to infer- tility (Planned Parenthood, 2014.11b). The pill may offer some protection against bone thinning and ovarian and endometrial cancer, and may decrease the risk of benign breast conditions and iron deficiency anemia. In addition, evidence has revealed that women on the birth control pill are protected from ovarian cancer, even decades after they stop taking it.

Disadvantages There are many possible side effects, which may or may not prevent the user from taking the pill. Those most often reported are spotting, breast tenderness, nausea or vomiting, and bleeding between periods (most often with progestin-only pills). Depending on the woman, hormones in the pills may increase or decrease a woman’s sex drive.

These side effects can sometimes be eliminated by changing the prescription, but not always. Certain women react unfavorably to the pill because of existing health factors or extrasensitivity to female hormones. Women who are age 35 or over; have high cholesterol, certain inherited blood clotting disorders, or high blood pressure; need prolonged bed rest; smoke; or are prone to migraine head- aches are usually considered poor candidates for the pill. Women have a higher risk of blood clots if they are obese. Certain medications may react differently or unfavorably with the pill, either diminishing in their therapeutic effect or interfering with oral contraceptive effectiveness. Thus, it is important to check with a doctor before starting any new prescriptions if a woman is taking the pill.

The pill also creates certain health risks, but to what extent is a matter of controversy. Though the pill has been studied extensively and is very safe, in rare instances hormonal methods can lead to serious problems. Some of the warning signs to look for spell out the word “ACHES.” If a woman experiences any of these she needs to check with her clinician as soon as possible:

■ Abdominal pain (severe) ■ Chest pain ■ Headaches (severe) ■ Eye problems (including blurred vision, spots, or a change in shape of

the cornea) ■ Swelling and/or aching in the legs and thighs

Literature is mostly about sex and not much about having children

and life is the other way round.

—David Lodge (1921–2003)

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A woman should also consult with her clinician if she develops severe mood swings or depression, becomes jaundiced (yellow-colored skin), misses two periods, or has signs of pregnancy.

Several brands of pills that have caught the attention of the public via a U.S. Food and Drug Administration (FDA) safety alert are Yaz, Gianvi, Yasmin, Ocella, Syeda, and Zarah. Compared to older forms of oral contraceptives, the newer type of progestin hormone in these pills may carry a higher risk of caus- ing dangerous blood clots in the legs and lungs and other health problems (Planned Parenthood, 2014.11b).

The type of hormones and the stage of life when the pill is used may make them helpful at one point and harmful at another. The health risks for taking the pill are low for the young, but they increase with age. While no contraception is contraindicated based on age alone, estrogen-containing methods should be reserved for women without heart or blood-clotting risk factors (Baldwin & Jensen, 2013). The risk for side effects and complications also increase if a woman smokes, is overweight, has diabetes, or has high blood pressure. Pills are not recommended for those over the age of 35 and who smoke (Planned Parenthood, 2014.11b). Definite risks of cardiovascular complications and various forms of cancer exist because of the synergistic action of the ingredients in cigarettes and oral contraceptives. This caution should be separated from claims linking the pill to breast cancer. The most recent literature suggests that the pill has little, if any, effect on the risk of developing breast cancer (Planned Parenthood, 2014.11a).

Certain other factors may need to be taken into account in determining if oral contraceptives are appropriate for a woman. Since it is possible to get pregnant again shortly after a pregnancy or delivery, birth control needs to be considered. (For more information about birth control following delivery, see the section titled “Lactational Amenorrhea Method.”)

Once a woman stops taking the pill, her menstrual cycle will usually resume within 2 months, though it may take several more months before it becomes regular. If a woman wants to become pregnant, it is recommended that she change to another method of contraception for 2–3 months after she stops tak- ing the pill and then start efforts to conceive.

Birth Control Shot (Depo-Provera) The birth control shot, known by the brand name Depo-Provera (DMPA), is an injection of the hormone progestin that is used to prevent pregnancy for 12 weeks. The progestin works by stopping ovulation and thickening the cervical mucus, which keeps sperm from reaching the eggs (Planned Parenthood, 2014.11c). A woman should get her first injection of DMPA within 7 days of the start of her menstrual period. The drug is effective immediately. If the shot is given within 5 days after a miscarriage or an abortion, or within 3 weeks after giving birth, a women is protected from pregnancy immediately. Most women can use the birth control shot safely; however, risks and side effects are similar to those of the pill. Irregular bleeding is the most common side effect, especially in the first 6–12 months of use. Additionally, after 1 year, half of those using the shot will stop having periods completely. This side effect is very common and may cause some women who are not having periods to worry that they are pregnant. When the shot is used correctly, it is very effective. There is no way to stop the side effects of Depo-Provera; they may continue for 12–14 weeks after the shot. Because it can take anywhere from 6 to 10 months to become pregnant following the last shot, Depo-Provera is not a good birth control method for those desiring an immediate pregnancy.

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If a pregnancy does occur while a woman is on the shot, a rare occurrence, it is more likely to be an ectopic one, which can be life-threatening.

Effectiveness The perfect-use effectiveness rate is 99.8% while the typical- use rate is slightly less at 94%.

Advantages Because DMPA injections contain no estrogen, they do not appear to cause the rare but potentially serious problems associated with estro- gen. Additionally, DMPA is highly effective for 3 months, causes women to have very light or missed periods (women vary in their reactions to this), decreased menstrual symptoms, and less pain from endometriosis. DMPA can also be a good choice for women who are breastfeeding.

Disadvantages Menstrual cycle disturbances may occur, including unpre- dictable or prolonged episodes of bleeding or spotting and temporary and revers- ible decrease in bone density.

Serious health problems are rarely associated with DMPA use; however, if a woman develops very painful headaches, heavy bleeding, serious depression, severe lower abdominal pain (may be a sign of pregnancy), or pus or pain at the site of the injection, she should see her physician. Because Depo-Provera lowers estrogen levels, it may cause women to lose calcium stored in their bones. Women who use the shot may also have temporary bone thinning, which will abate once a woman stops taking the shot. A women can protect her bones by exercising regularly and getting extra calcium and vitamin D either through diet or supplements.

Birth Control Patch The birth control patch, generic name xulane, is a thin, beige, plastic transdermal reversible method of birth control that releases syn- thetic estrogen and progestin to protect against pregnancy for 1 month (Planned Parenthood, 2014.11d). Each week for 3 consecutive weeks, one patch is removed and a new one is placed on the lower abdomen, buttocks, upper arm, or upper torso (excluding the breast). This is followed by a patch-free week, when menstruation occurs. The combination of hormones works the same way that oral contraceptives do. The patch is most effective when it is changed on the same day of the week for 3 consecutive weeks. Pregnancy can happen if an error is made in using the patch, especially if it becomes loose for longer than 24 hours or falls off or if the same patch is left on for more than 1 week.

If the patch has partially or completely detached for less than 24 hours, the woman should try to reapply it; however, if it does not stick well, a replacement should be applied. If a woman applies the patch late during week 1, she should apply a new patch as soon as she remembers. This becomes her new patch “change day.” A backup method, such as a condom, should be used for 7 days after the patch is applied. If vaginal intercourse occurs without a backup method, emergency contraception should be used up to 5 days after unprotected intercourse.

Two groups of women that may need additional counseling about the use of the contraceptive patch are adolescents and women who are above 130% of ideal body weight. The latter group should be aware that they have a slightly increased risk of pregnancy due to lower levels of blood hormones.

Effectiveness Overall, contraceptive efficacy of the patch is similar to that of oral contraceptives; if used perfectly, the patch is more than 99% effective. Typical use results in a success rate of 91%.

The contraceptive patch, prescribed by a physician, protects against pregnancy for 1 month. © Michael Keller/Corbis

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Advantages Like those who take OCs, many women who use the patch report the same benefits, including more-regular, lighter, and shorter periods. Furthermore, a woman’s ability to become pregnant returns quickly when the patch is discon- tinued. The patch is safe, simple, and convenient, and it does not interfere with sex. Additionally, a woman does not have to remember to take a pill each day.

Disadvantages The most common side effects reported by users of the patch include mild skin reactions, breast tenderness usually in the first one or two men- strual cycles following its first application, headaches, and nausea. The risk of stroke or heart attack is similar to that of combined oral contraceptives. The patch may cause more long-lasting side effects, including changing a women’s sexual desire.

The Vaginal Ring (NuvaRing) A vaginal ring, commonly referred to as NuvaRing, is a form of reversible, hormonal birth control (Planned Parenthood, 2014.11f). It is a small, flexible ring inserted high into the vagina once every 28 days (see Figure 5). The ring is kept in place for 21 days and removed for a 7-day break to allow a withdrawal bleed. The ring releases synthetic estrogen and progestin, preventing ovulation in a manner similar to that of other combined hormonal contraceptives. The vaginal ring is prescribed by a doctor and provides protection against pregnancy if implanted during the first 5 days of a woman’s period.

Effectiveness Like the other methods of hormonal contraception, if used per- fectly, the vaginal ring is more than 99% effective. Typical use results in a success rate of 91%.

Advantages The ring protects against pregnancy for 1 month and is easy to use. Many women who use the ring have more-regular, lighter, and shorter peri- ods. A woman can stop using NuvaRing at any time, offering her more control over contraception than with some other hormonal methods of birth control. The

My best birth control now is to leave the lights on.

—Joan Rivers (1933–2014)

• FIGURE 5 The Vaginal Ring. Like a tampon, the ring can be placed anywhere in the vagina that is comfortable. There is no specific fit or need to check the position of the ring. If it causes pressure, the user may just push it farther into the vagina.

(first) © vario images GmbH & Co.KG/Alamy

(a) (b)

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ring provides a consistent release of hormones, does not usually cause weight gain, and can be removed for up to 3 hours without compromising effectiveness.

Disadvantages The side effects of the ring are similar to those associated with oral contraceptives. Additionally, there may be an increased risk of blood clots possibly due to the hormone desogesterel. Vaginal discharge, irritation, or infection; sensation of a foreign body; expulsion; and headaches may also occur. The ring should not be used by women who have weak pelvic floor muscles. Additionally, it may be less effective for women weighing more than 200 pounds. Regularly using oil-based medicines in the vagina for yeast infections while the ring is in place may increase the level of hormones released into the blood. This, however, will not reduce the effectiveness of the ring. The effect of using these types of yeast infection medications with long-term use of the vaginal ring is unknown.

Implants The birth control implant is a thin, flexible, plastic rod about the size of a cardboard matchstick that is inserted under the skin of the upper arm and protects against pregnancy for up to 3 years (Planned Parenthood, 2014.11g). The implant is available under the brand names Implanon and Nexplanon. Like several other progestin-containing methods of birth control, implants prevent ovulation and fertilization and thicken the cervical mucus to block sperm.

Questions about the difference between the more widely used Implanon and the newer Nexplanon and Implanon NXT may arise. The later two implants are essentially identical to Implanon but have a small amount of a substance added to their core, so they are detectable by X-ray, which makes it easier to ensure they are in place. The newer implants also have a pre-loaded applicator for easier insertion.

Implants are among the most effective of the available contraceptives, simi- lar in effectiveness to intrauterine devices (IUDs) and sterilization (see Table 1). Currently, there is no distinction between the implant and other progestin-only methods with respect to increased risk of blood clots. An implant requires a doctor to insert and remove it, along with the use of local anesthesia. If a woman desires to become pregnant within the 3 years following insertion, the device can be removed.

Advantages The device is highly effective, easy to insert, and discrete; does not interrupt sex or require maintenance; has no estrogen-related side effects; is easily reversible; and may provide relief for pelvic pain due to endometriosis or other causes. It can also be used while breast feeding.

Disadvantages Like all progestin-only methods, implants may cause unpre- dictable bleeding, particularly in the first 6–12 months of use, and weight gain; they may have insertion complications; and they may increase the risk of blood clots. The implant is also clinician-dependent, so once it is inserted, women have little control over their side effects or outcomes.

Barrier Methods Barrier methods are designed to keep sperm and egg from uniting. The barrier device used by men is the condom. Barrier methods available to women include the diaphragm, the female condom, the contraceptive sponge, and the cervical cap. These methods of birth control have become increasingly popular because, in addition to preventing conception, they can reduce the risk of STIs. The

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effectiveness of all barrier methods is increased by use with spermicides, which are discussed later in this chapter.

The Condom A condom (male condom) is a thin, soft, flexible sheath of latex rubber, polyurethane, or processed animal tissue that fits over the erect penis to help prevent semen from being transmitted. Condoms prevent infections by covering the portals of entry and exit for many STI organisms (Planned Parenthood, 2014.11h).

Condoms are the third most widely used form of birth control in the United States after sterilization and the pill. Their use has increased significantly since the late 1980s, due in large part to their effectiveness in helping prevent the spread of STIs, including HIV, when they are used prop- erly. Condoms are available in a wide variety of shapes, sizes, and colors. Some are dry, while others are lubricated.

A small proportion of condoms are made of polyurethane or other synthetic materials. These condoms are more resistant to deterioration than latex con- doms, have a longer shelf life, and can provide an alternative if a person is allergic to latex. Unlike latex condoms, oil-based lubricants can be used with condoms made from synthetic materials.

Most condoms are very thin (but also strong), conduct heat well, and allow quite a bit of sensation to be experienced. While picking out condoms can be a fun experience, if a person needs them for protection, be sure to read the label to see if they are FDA-approved for use against unplanned pregnancy and STIs. Latex condoms should be used with water-based lubricants (like K-Y Jelly) or glycerine only because oil-based lubricants such as Vaseline can weaken the rubber. If a condom breaks, slips, or leaks, there are some things a person can do (see the section “Emergency Contraception” later in the chapter).

Women and Condom Use Today, a vast number of male condoms are pur- chased by women, and condom advertising and packaging increasingly reflect this trend. Several key points are relevant to the issue of women and condom use:

■ Women experience more health consequences than men from STIs, including permanent infertility, for example. Condoms when used consistently and correctly are an effective means of reducing the risk of STI transmission and acquisition.

■ Since women are far more likely to contract an STI from intercourse with a male partner than vice versa, it is in the woman’s best interest to use or have her partner use a condom.

■ Condoms help protect women against unplanned pregnancy, ectopic pregnancy, bacterial infections such as vaginitis and pelvic inflammatory disease (PID), viral infections such as herpes and HIV, cervical cancer, and infections that may harm a fetus or an infant during delivery.

■ A woman can protect herself by insisting on condom use. Even if a woman regularly uses another form of birth control, such as the pill or an intrauterine device (IUD), she may want to have the added protection provided by a condom.

Male condoms come in a variety of sizes, colors, and textures; some are lubricated, and many have a reservoir tip designed to collect semen. © Image Source/AP Images

Condom machines are often placed in bathrooms, subway stations, airports, and schools as a public health measure to promote safer sex. Rarely do these vending machines dispense female condoms. © Sonda Dawes/The Image Works

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Tips for Effective Condom Use

Condoms can be very effective contraceptive devices when used properly. They also can reduce the risk of STIs, including HIV. Here are some tips for their use:

1. Use condoms every time you have vaginal, anal, or oral sex.

2. Check the expiration date on the package and press the container to make sure there is an air pocket.

3. Carefully open the condom package—teeth or finger- nails can tear the condom.

4. If the penis is uncircumcised, pull back the foreskin before putting on the condom.

5. Use of a condom lubricated with nonoxynol-9 (N-9) is not recommended for vaginal or anal intercourse.

6. Put on the condom before it touches any part of a partner’s body.

7. If you accidentally put the condom on wrong-side up, discard the condom and use another.

8. Leave about a half inch of space at the condom tip, and roll the condom all the way down the erect penis to the base. Push out any air bubbles.

9. Withdraw the penis soon after ejaculation. Make sure the male or his partner holds the base of the condom firmly against the penis as it is withdrawn.

10. After use, check the condom for possible tears. If you find a tear or hole, consider the use of emergency contraception (see the section “Emergency Contraception” later in the chapter). If torn condoms are a persistent problem, use a water-based lubricant such as K-Y Jelly.

11. Do not reuse a condom.

12. Keep condoms in a cool, dry, and convenient place.

13. To help protect against HIV and other STIs, always use a latex rubber or polyurethane condom, not one made of animal tissue.

14. Don’t forget to incorporate sensual ways of placing the condom on the penis.

(a) Place the rolled condom on the erect penis, leaving about a half inch of space at the tip (first, squeeze any air out of the condom tip). (b) Roll the condom down, smoothing out any air bubbles. (c) Roll the condom to the base of the penis. (d) After ejaculation, hold the condom base while withdrawing the penis. (a) © H.S. Photos/Alamy; (b) © H.S. Photos/Alamy; (c) © H.S. Photos/Alamy; (d) © H.S. Photos/Alamy

practically speaking

(a) (b)

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Effectiveness With perfect use, condoms are 98% effective in preventing con- ception, but user effectiveness is about 88%. Failures sometimes occur from using the condom incorrectly, but they are usually the result of not putting it on until after some semen has leaked into the vagina or simply not putting it on at all. When used in anal sex, a male condom is more likely to break and slip than when used for vaginal sex if adequate lubrication is not used.

Advantages Condoms are easy to obtain and do not cause harmful side effects. They are simple to carry and are inexpensive or even free. Latex con- doms help protect against STIs, including HIV infection, and lower the risk of unplanned pregnancy. Some men appreciate the slightly reduced sensitivity they experience when using a condom because it may help delay ejaculation.

Correct Condom Use Self-Efficacy Scale

Correct and consistent condom use is one of the most effective methods for preventing the transmis- sion of HIV, reducing the risk of other STIs, and lower- ing the risk of unplanned pregnancy. It is also known that young people aged 15–24 account for half of all STIs, even though they represent just 25% of the sexu- ally active population (CDC, 2013.11a). Just what prevents individuals from making a decision to use condoms? The Condom Use Self-Efficacy Scale (CUSES) is designed to measure an individual’s perception of the ease or difficult with which he or she can correctly apply and use a male condom. It measures an individu- al’s perception of his or her ability to purchase con- doms, apply and remove them, and negotiate their use with partners.

Directions

Circle the number that represents how easy or difficult it would be to do what each question asks.

1. How easy or difficult would it be for you to find con- doms that fit you properly?