Sexual Psychology – Reproductive Cosmetic Procedures – Due Fri 11/5

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The Psychology of Human Sexuality, Second Edition. Justin J. Lehmiller. © 2018 John Wiley & Sons, Ltd. Published 2018 by John Wiley & Sons, Ltd. Companion Website: www.wiley.com\go\lehmiller2e

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©Jeff Thrower, 2013. Used under license from Shutterstock.com.

CHAPTER OUTLINE

Introduction, 55 Male Sexual Anatomy, 55

A Historical and Cultural Overview of the Penis, 55 External Anatomy, 56 Internal Anatomy, 60 Psychology of the Penis: Male Genital Concerns, 63 Male Genital Health Issues, 65

Female Sexual Anatomy, 66 A Historical and Cultural Overview of the Vulva, 66 External Anatomy, 67 Internal Anatomy, 72 Breasts, 74 Psychology of the Breasts and Vulva: Female Bodily Concerns, 75 Female Breast and Genital Health Issues, 78

Conclusions, 81

Human Sexual Anatomy

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Introduction

“What's the average penis size?” “Can a woman have an orgasm without clitoral stimulation?” “Does penis size really matter?” “Is female ejaculation real?”

The above questions were asked by college students taking my human sexuality course, but not just once—these and many other such questions have come up semester after semester. As a result, I have come to realize that most students taking this course never learned the things they really want and need to know about their bodies and their sexuality. The goal of the cur- rent chapter is to address this fundamental need.

You may be wondering why you are reading an entire chapter about human anatomy in a psychology textbook, but I can assure you that there are several good reasons for it. For one thing, many people are unfamiliar with the exact names and locations of certain portions of their genitalia. To the extent that this lack of information prevents you from knowing what is and is not normal, that can create a number of problems. For instance, if you do not know how things are supposed to look or function, you will be unable to identify potential health threats. Likewise, lacking knowledge about your own physique can cause unnecessary anxiety about body image, which can feed into sexual dysfunction and relationship problems. Lacking knowledge about a partner’s body can lead to similar issues by reducing sexual satisfaction for the both of you. As we will see in chapter 13, one of the first steps involved in many forms of sex therapy is giving the client(s) specific information, often consisting of the anatomy lesson you will get in this chapter. This alone is enough to solve many sexual problems. Thus, learn- ing about anatomy has definite psychological importance because it can help you to feel better about yourself, enhance the quality of your sex life, and potentially prevent future problems from developing in your sexual relationships.

We will begin by covering genital anatomy in men, followed by women. However, as we dis- cuss anatomy, please keep in mind that not everyone who has a penis necessarily identifies as a man and not everyone with a vulva necessarily identifies as a woman. One’s gender identity does not always match one’s genital anatomy. Also, keep in mind that not every person has a penis or a vulva. For example, intersexed individuals may have genitals that appear to be a mix of male and female genital structures. We will return to these points in chapter 5 when we dis- cuss gender issues in more detail. For the time being, however, we will describe genital anatomy in terms of how things typically appear and function in most biological men and women.

Male Sexual Anatomy

A Historical and Cultural Overview of the Penis

Humans have been obsessed with the penis for thousands of years. However, the nature of phallic attitudes has varied considerably. At times, the penis has been celebrated and openly displayed as a symbol of fertility. This view was perhaps best exemplified by the ancient Romans, who surrounded themselves with artistic representations of penises in everyday life. For instance, it was once considered a sign of prestige for Roman boys to wear a tiny replica of an erect penis around their neck known as a fascinum (on a side note, the word “fascinating” is derived from fascinum. Thus, when we say that something is “fascinating,” we are actually lik- ening it to the wonders and intrigue of nothing other than the penis!) At other times, however,

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the penis has been seen as vulgar, and every effort has been made to hide it from view. This has been the case throughout much of recent history. The penis has little place in the modern media (e.g., when was the last time you saw a penis on primetime TV?), and it makes only infrequent appearances in the world of art. In fact, it is not uncommon to see artistic repre- sentations of the penis painted over in pictures or broken off of sculptures so as to keep any semblance of the penis out of public view.

Given that much of the modern world is anti-penis, most of us know relatively little about it, including how it works and how it is “supposed” to look. This has led to a lot of penile mis- conceptions and misinformation. For instance, many people think that the penis consists of muscles and/or bone, when in reality it is composed mostly of fibrous tissue and blood vessels. Thus, despite the fact that an erection is often referred to as a “boner,” there are no bones in the human penis. In contrast, some other species, such as chipmunks and dogs, do have a penis bone (known as the baculum), which assists during sexual intercourse. Another thing people frequently get wrong when it comes to the human penis is that they assume it is supposed to be extremely large, like the ones they may have seen in porn videos. Many people also assume that bigger is better when it comes to penises, such that men who are more well-endowed are more sexually satisfied and better able to please their partners. However, as we will see later in this chapter, this is not necessarily the case.

External Anatomy

With the preceding in mind, let us begin our discussion of the external sexual anatomy of biological men. The penis consists of three parts: the root, shaft, and glans. The root is the completely internal portion of the penis that serves to anchor it to the pubic bones. The shaft and glans are the external portions of the penis that are visible to the naked eye. The shaft (in its non-aroused state) is loose and pendulous, and is usually covered with hair at the base.

Figure 3.1 In recent history, the penis has largely been seen as vulgar and makes infrequent appearances even in artistic depictions of the male body. ©Karashaev under Shutterstock.com.

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The glans (head) sits at the end of the shaft and contains the urethral opening (meatus). The glans is the most sensitive portion of the penis, containing the largest concentration of nerve endings.

At the base of the glans is the corona (“crown”), which is the distinctive ridge encircling the head. The flared shape of the glans and the surrounding corona is theorized to have evolved that way as a potential “semen displacement device” (Gallup et al., 2003). That is, the unique shape of the penis combined with the thrusting action of intercourse may exist to enable men to remove any semen deposited in the female reproductive tract by other men before deposit- ing their own. In fact, research by Dr. Gordon Gallup and colleagues in which they simulated intercourse with artificial penises, ejaculate, and vaginas found that just one thrust of their mock penis was enough to displace more than 90% of any previously deposited “ejaculate.” They tested a variety of alternative “penises” that did not have the same features (i.e., penises without a flared glans and corona), but found that they were far less effective at semen dis- placement. Of course, we cannot say for sure why the head of the penis has the shape that it does, and Gallup’s theory has been disputed by others. For example, Bowman (2013) argues that because sperm travel into the uterus very quickly, and any sperm remaining outside the uterus will not live long in the acidity of the vagina anyway, semen displacement is unlikely to have significant effects on conception likelihood. Bowman’s argument is that the penile glans is instead optimized for absorption of chemicals in the vaginal secretions, such as oxytocin (see chapter  4), which helps facilitate bonding between partners. Some scientists think that such bonding is adaptive in that it helps facilitate the survival of any offspring produced.

Covering the corona and glans is the foreskin (prepuce), a loose and retractable layer of skin that can be thought of as a sheath for the head of the penis. Not all men have foreskin because it is sometimes removed during infancy in a procedure known as circumcision. For men who retain their foreskin into adulthood, it requires proper care and attention. Specifically, it is important for the foreskin to be gently pulled back and cleansed with some regularity to pre- vent the buildup of smegma, a smelly, cheese-like substance that consists of an accumulation of glandular secretions and dead skin cells.

In the United States, just over half of all male infants today are circumcised, although the per- centage of parents opting for this procedure has decreased dramatically in recent years (Cent- ers for Disease Control and Prevention, 2011). Circumcision rates in other countries around the world vary, with the highest rates in the Middle East and the lowest rates in Europe. There are vast differences in opinion on this procedure, which has made it a subject of hot debate. See the Digging Deeper 3.1 box for a discussion of some of the oft cited pros and cons of male circumcision. It is also worth pointing out that foreskin cutting may take other forms in differ- ent cultures. For instance, in some Polynesian cultures, a procedure known as a superincision (sometimes called a dorsal slit) is performed, in which a lengthwise slit is made in the upper portion of the foreskin (Diamond, 2004). This reveals the glans of the penis without necessarily removing the foreskin.

Removal or cutting of foreskin is obviously one major factor that affects the external appear- ance of the penis. However, penises also vary substantially in terms of several other features, including the presence or absence of pubic hair, degree of curvature, and overall length. First, pubic hair naturally varies from man to man in terms of density, color, and coarseness. Of course, some men opt to trim and, in some cases, completely shave off their pubic hair for a variety of reasons (e.g., some men prefer the sensation of no hair, while others think it makes their genitals look larger). Male pubic hair removal is becoming increasingly common, with survey studies finding that most men under 50 have done it at least once before, with gay men being some- what more likely to report having removed their pubic hair than heterosexual men (Martins,

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Digging Deeper 3.1 Should Men be Circumcised?

Circumcision used to be performed on virtually all infant boys in the United States. However, this practice has become increasingly controversial and the number of US parents opting to sub- ject their male children to it has dropped to 55–57% (Centers for Disease Control and Preven- tion, 2011). Many parents have asked me whether circumcision is a good idea. Although there are strong arguments for and against it, no scientific consensus exists.

One argument in favor of circumcision is that it serves religious and cultural purposes. For instance, this procedure is commonplace in the Jewish religion, where it has a basis in scrip- ture and is performed during a bris eight days after birth. Circumcision is frequently practiced in Islamic cultures as well, although it is typically performed at puberty as a rite of passage instead of during infancy. The other major argument on this side is that circumcision provides hygienic and health benefits. For example, circumcision is a medical treatment for a condition known as phiotsis, in which one’s foreskin is too tight and is not easily retracted, thereby creating painful erections. In addition, circumcision is linked to a reduced risk of contracting sexually transmitted infections, including HIV. The thought here is that the foreskin contains certain cells that are highly susceptible to infection, and by removing them, it may cut off that route to disease transmission. A clinical trial in Africa in which adult men were either circumcised or not (voluntarily, of course) had to be called off because the observed rate of contracting HIV was so much lower among newly circumcised men that ethical concerns were raised about withholding circumcision from men who still had their foreskin (Roehr,  2007). Other studies have shown that circumcision is linked to a reduced risk of contracting the human papilloma virus (HPV; Larke, Thomas, Dos San- tos Silva, & Weiss, 2011a) and syphilis (Weiss, Thomas, Munabi, & Hayes, 2006), as well as a lower likelihood of developing penile cancer (Larke, Thomas, Dos Santos Silva, & Weiss, 2011b). There is no evidence that circumcision necessarily harms sexual functioning either. A meta-analysis of the research in this area found that circumcision was not related to negative effects on genital sensation, sensitivity, or sexual satisfaction (Morris & Krieger, 2013). This research, combined with a low rate of side effects, has resulted in significant support for circumcision within the medical community.

On the other hand, however, circumcision research has been critiqued by those who argue that any STI-preventative benefits of circumcision are culturally relative and that we cannot generalize research on circumcision in Africa to the rest of the world. If circumcision were really so beneficial, they argue, we would expect to see that rates of HIV and other STIs are lower in the United States (where most men are circumcised) than they are in Europe (where most men are uncircumcised); however, we see precisely the opposite pattern (more on this in chap- ter 12)! In other words, there’s not a lot of evidence that high rates of circumcision in the United States are improving American men’s sexual health. Others have argued that circumcision should never be performed unless there is a true medical need and that routine circumcision amounts to nothing more than male genital cutting/mutilation. They believe that everyone has the right to an intact body, and that extends to the sexual organs (Hammond, 1999). As a result, some see it as cruel to irreversibly modify another person’s body, especially when they cannot consent to the procedure themselves. Likewise, others have focused on the pain and trauma that circumcision is likely to cause to male infants, given that anesthetics are not always used (particularly when the procedure occurs as part of a religious ritual). Some have argued against the religious practice of circumcision, suggesting that it is an affront to try and improve upon God’s creation. Yet one additional argument is that if delaying circumcision until adulthood can still yield potential health benefits, such as reducing HIV risk (Roehr,  2007), why not let men decide whether they want the procedure when they become adults and can evaluate the pros and cons themselves?

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Tiggemann, & Churchett,  2008). Second, with respect to curvature, it is normal for penises to not be perfectly straight and instead curve slightly to one side or the other. In cases where there is a severe curvature (known as Peyronie’s disease, caused by a build-up of scar tissue), intercourse may be difficult and painful. However, surgical intervention can correct this. Third, penile length can vary considerably. A review of 20 studies of penis size that, together, included over 15,000 male participants who had their penises measured by trained clinicians revealed that the median (i.e., 50th percentile) flaccid penis length was 3.6 inches (9.2 centimeters) and the median circumference was 3.7 inches (9.3 centimeters; Veale et al., 2015). This same review reported that, for an erect penis, the median length was 5.2 inches (13.1 centimeters) while the median circumference was 4.6 inches (11.6 centimeters). Most men appeared to fall within a relatively narrow range, with men in the 25th percentile measuring about one centimeter less on each dimension, and men in the 75th percentile measuring about one centimeter more; how- ever, at the extreme ends of the spectrum, measurements were dramatically different. That said, keep in mind that conclusions from this review are limited because observational studies have a selection bias. For example to the extent that these studies disproportionately sampled men who are more comfortable with their bodies and, therefore, have larger than average penises, these numbers might actually be overestimates. One final note about penis size is that some studies have suggested that there are racial differences, and that those differences are consistent with common stereotypes, with men of African descent tending to be above average and men of Asian descent tending to be below average (Lynn, 2013). However, these data are based almost exclusively upon self-reports of men from nonrepresentative Internet samples, which means that a hefty dose of caution is in order when considering these findings. The question of racial differences in penis size is one that remains controversial and is far from settled.

Aside from the penis, the other major external portion of male sexual anatomy is the scrotum. The scrotum is a pouch of skin hanging behind the penis that houses the testicles. The scrotum is sparsely covered in hair (although, as previously mentioned, some men opt to shave it off ) and usually hangs loosely. However, in colder temperature and during sexual excitation, the scrotum elevates closer to the body. Like the penis, scrotal appearance varies from man to man, particularly in terms of size and symmetry. It is difficult to say what the average scrotal size is because most studies have measured only the size of the penis. With respect to appear- ance, it is perfectly normal for men to have an asymmetrical scrotum where one side hangs lower than the other. Specifically, the left testicle tends to hang lower than the right, generally because the spermatic cord (which suspends the testicles inside the scrotum) it typically longer on the left side.

It is also worth mentioning that some men regret having had their foreskin removed. This includes some men who made this decision themselves as adults, as well as some men who had this decision made for them when they were children. A few of these men have gone to great lengths to have their foreskin restored, either surgically (using skin grafts) or non-surgically (using weights to stretch existing penile skin over a period of years); however, these procedures carry risks and we do not have good data on the outcomes (Brandes & McAninch, 1999). Because regret is a possible outcome, we cannot predict who will and will not experience regret, and foreskin cannot be easily replaced, some have argued that the decision to circumcise should not be taken lightly.

As you can see, there are compelling arguments on both sides of this issue that make it difficult to state whether circumcision is categorically good or bad. The important thing is to educate yourself about the different perspectives and come to your own conclusions.

Note: Reprinted with permission from lee MAd Psmchtatgm (www.lehmiller.com).

Digging Deeper 3.1 (Continued)

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Internal Anatomy

We begin our discussion of the internal workings of the penis by considering the makeup of the shaft and glans. The shaft is composed of three long cylinders, all of which fill with blood during sexual arousal, thereby creating an erection. Two of these cylinders are known as the cavernous bodies (corpora cavernosa) and run right next to each other on the upper portion of the penis. Sitting below the cavernous bodies is the smaller spongy body (corpus spongio- sum), which encases the urethra (i.e., the tube that carries urine and semen out of the body) and expands to become the glans.

At the base of the penis is a complex musculature. The muscles here are used primarily to eject semen from the body during ejaculation. These muscles can be strengthened by doing Kegel exercises, and men who practice these exercises frequently tend to report more ejacu- latory control and better orgasms. Because of these benefits, Kegel exercises are sometimes used as a treatment for premature ejaculation (LaPera & Nicastro, 1996). These exercises are easy enough to do (if you have a penis you can even do them while you read this book, if you like). The muscles you are looking to strengthen are the ones you would use to stop the flow of urine midstream. Once you know which muscles to exercise, you simply start by squeezing and releasing them rapidly several times. When you are comfortable doing a lot of repetitions, add in some “long Kegels,” where you squeeze the muscles for a few seconds before releasing them. After a few weeks of daily exercise, the benefits are likely to start kicking in.

Inside the scrotum are the testes, or male gonads, which are suspended by the spermatic cord. Most men have two testes that are usually similar in size, with each serving two func- tions: (1) production of sex hormones (largely testosterone) and (2) production of sperm. On an interesting side note, there are some who argue that testicle size (like the distinct shape of the penis) is an evolutionary adaptation, such that the testes tend to be larger in societies that have historically had more “sperm competition” (see Ryan & Jetha, 2010). In other words, in societies where men tend to clash over access to mates, testicle size may be larger in order to enable more sperm production and, hence, the potential for intravaginal sperm wars when

Figure 3.2 The appearance of the penis and scrotum varies substantially across persons. ©stnu (Own work) [CC-BY-SA-2.0 (http://creativecommons.org/licenses/by-sa/2.0)], via Wikimedia Commons.

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multiple men have had sex with the same woman. We cannot definitively say why any differ- ences in testicle size might exist across people of different races and ethnicities; however, we will consider some additional evidence for sperm competition theory at the end of this section.

Returning to testicular functions, sperm production begins inside the testes in a series of tightly coiled tubes known as the seminiferous tubules. This is where the manufactur- ing of sperm occurs. Sperm production begins at puberty (a developmental stage known as

Figure 3.3 ©Ramjet (Own work) [CC-BY- SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

Figure 3.4 ©Krittika (Own work) [CC-BY-SA -3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

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spermarche) and continues through old age. The interstitial cells, which sit in between the seminiferous tubules, carry out the testes’ other job: production of sex hormones. These cells secrete hormones directly into the bloodstream.

In order for healthy sperm production to occur inside the testes, a constant temperature must be maintained. The testes sit outside of the body and maintain the ideal temperature for sperm health, which is slightly below a man’s normal body temperature. However, in order to account for the rapid temperature changes we experience throughout the day, the testes are capable of moving closer or further from the body via the cremaster muscle. In warmer tem- perature, the muscle relaxes, letting the testes fall further from the body; in colder temperature, the muscle contracts, drawing the testes in and generating “shrinkage.” Because this tempera- ture regulation is so vital for sperm health, men who have undescended testes (or in medical terms, cryptorchidism) are infertile.

After sperm are produced in the seminiferous tubules, they proceed to the epididymis, where they are stored for several weeks to allow them time to mature. The epididymis is shaped like a crescent moon and sits on the top and back of each testicle. Eventually, sperm are carried away from the epididymis via the vas deferens. Because the vas deferens is what transports sperm from the testes, this is the tube that is cut during a vasectomy (a procedure we will cover in more detail in chapter 11). The vas deferens exits the scrotum through the spermatic cord, goes up into the abdomen, and loops around the bladder before joining up with the prostate.

The portion of the prostate where the vas deferens enters is known as the ejaculatory duct, which empties into the urethra. In the ejaculatory duct, sperm from the vas deferens mix with secretions from the seminal vesicles and the prostate to create semen. The seminal vesicles are two small glands that empty into the ejaculatory duct. They produce the bulk of the seminal fluid (60–70% of the volume) by secreting an alkaline, sugary substance that appears designed

Cavernous body

Urethra

Bladder

Prostate

Cowper’s gland

Anus Vas deferens

Epididymus

Testis

ScrotumMeatus

Glans

Seminal vesicle

Ejaculatory duct

Figure 3.5 The male reproductive system. ©Tsaitgaist (Derivative work) [CC-BY-SA-3.0 (http:// creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

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to enable nutrition and survival of sperm (Gonzales, 2001). Once sperm come into contact with these secretions, they gain the ability to move on their own.

The remaining portion of the seminal fluid (30–40%) is produced by the prostate gland. The prostatic secretions are also very alkaline, which aids sperm survival in the acidity of the male urethra and the female reproductive tract. The prostate gland, which sits just below the blad- der, is sometimes referred to as the male equivalent of the G-spot (sometimes referred to as the P-spot), because some men have reported that prostate stimulation results in very intense orgasms. The prostate gland can be stimulated gently through rectal insertion, or by pressing on the perineum (the strip of skin that runs between the scrotum and the anus).

Where the ejaculatory duct empties into the urethra, there are the two small Cowper’s glands (bulbourethral glands). As a man becomes sexually aroused, these glands release a small amount of fluid that will appear as a drop or two on the glans prior to ejaculation. This pre- ejaculate is thought to alkalinize the urethra, making it more hospitable for sperm to travel through. Although this secretion is not semen, it can potentially contain active sperm. In one study, male participants were instructed to touch a Petri dish to the tip of the penis while mas- turbating if any fluid appeared prior to ejaculation (Killick et al., 2010). It turned out that 41% of the obtained samples contained sperm. What this means is that, even if a male–female couple stops sexual intercourse before the man ejaculates, it is theoretically possible for a pregnancy to occur and, of course, for sexual infections to be transmitted as well.

During ejaculation, semen is released from the body via contractions of the urethra and the muscles at the base of the penis. The amount of semen expelled varies from man to man and depends upon a number of factors (e.g., a longer duration of sexual activity will typically produce more semen); however, it consists of one or two teaspoons of fluid on average. Each ejaculate contains hundreds of millions of sperm. Given that a single sperm cell is necessary to fertilize an egg, the huge number of sperm produced is yet another theorized evolutionary adaptation (i.e., men may have evolved a tendency to produce sperm in such large quantities as a way of competing with other men’s sperm in the female reproductive tract; Baker & Bel- lis, 1993). The concept of human sperm competition is a controversial and unsettled subject, but researchers have produced some provocative evidence in support of this idea. For example, in one study, heterosexual male participants who viewed erotic images depicting two men with one woman (a scenario suggestive of sperm competition) subsequently produced ejaculate containing more active sperm than male participants who viewed erotic images consisting of three women together (Kilgallon & Simmons, 2005).

Psychology of the Penis: Male Genital Concerns

The biggest concern men have about their genitals is penis size. Although survey studies have reported that the majority of gay (65%) and heterosexual men (55%) sampled were satisfied with their penis size, there was a substantial minority who wished they could change it (Grov, Parsons, & Bimbi,  2010; Lever, Frederick, & Peplau,  2006). Among the latter, there was an almost unanimous desire to be larger; less than 1.5% of men of both sexualities wished for a smaller penis. Many of those men who were unhappy with their penis size were of average or above average size to begin with. So why do they want to change? Probably because we are surrounded by constant media messages telling us that “bigger is better” and “size matters.” In addition, the penises that appear in most porn videos are much larger than average, and measuring up to them is enough to make almost any guy feel inadequate. Unfortunately, most men fail to recognize just how rare those gigantic porn penises actually are. In fact, research- ers estimate that only about 2.5% of men have penises larger than 6.9 inches (17.5 centimeters; Lever et al., 2006).

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As a result of the pressure to be big, many guys have gone to great lengths to try and increase the size of their penis, including everything from the pursuit of penile augmentation surgeries to the use of “natural male enhancement,” stretching devices, and vacuum pumps. It is impor- tant to note that none of these techniques have been subject to rigorous scientific testing and, thus, it is not clear whether any provide the benefits frequently touted on the Internet and in popular men’s magazines. In fact, these methods can be quite dangerous and carry the risk of potentially serious side effects. For example, penile augmentation surgery (also known as phal- loplasty) usually involves cutting the ligaments that attach the penis to the pubic bone (which theoretically increases length by letting more of the penis hang outside of the body) and/or adding tissue grafts or fat injections to the penile shaft (the goal of which is to increase penile “girth” or circumference). Many men who have undergone phalloplasty have been disfigured and have required follow-up surgery to correct some of the complications, which frequently include scarring, penile lumps, and an erection that points down instead of up (Alter,  1997; Dillon, Chama, & Honig, 2008).

So what is all the fuss about? Does penile size really matter? Yes and no. First, men with larger penises typically report better body image (Lever et al., 2006) and greater psychosocial adjust- ment (Grov et al., 2010). Thus, having a larger penis may make men feel better about themselves. Some guys appear to let this go to their head, though, because well-endowed men also tend to be more narcissistic (i.e., self-obsessed; Moskowitz, Rieger, & Seal, 2009). In addition, having a bigger penis does not necessarily translate into a greater ability to please a sexual partner. For example, as you will see when we cover female sexual anatomy, most of the nerve endings in the female genital area are on the outside of the body, not inside of it. Thus, a penis capable of deeper penetration does not necessarily result in a more pleasurable experience for women. Consistent with this, the vast majority of heterosexual women (85%) report being satisfied with the size of their partner’s penis (Lever et al., 2006). Likewise, in a study that surveyed women about penis

Figure 3.6 Penis size is one of men’s biggest body concerns. Some men pursue dangerous and untested treatments with the hope of enhancing the size of their genitals. ©PrinceOfLove, 2016. Used under license from Shutterstock.com.

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length and sexual pleasure, most women (66.3%) reported that size made no difference in their own pleasure or that shorter than average penises were more pleasurable than longer penises (Costa, Miller, & Brody, 2012). Thus, women certainly do not seem to be clamoring for larger male genitals. Of course, there are some women who prefer larger penises and who find them to be more sexually pleasing; however, the majority of women appear to be content with their partners’ penis just the way it is, and most of those penises are of average size.

How does penis size play out with respect to sexual satisfaction in male same-sex relation- ships? Unfortunately, we do not have enough empirical data to address whether gay and bisex- ual men are typically content with their partners’ penis size and the implications this might have for sexual pleasure and enjoyment. However, I would theorize a similar pattern such that most would be satisfied with their partners’ size and, furthermore, that penis size would not necessarily affect likelihood of orgasm. I should also add that regardless of whether a man’s partner is male or female, smaller penises may be preferred to larger penises for certain sexual activities that people sometimes find to be painful (e.g., anal sex).

Although size concerns are largely confined to the length and width of the penis, there are some men who are dissatisfied with the size of their scrotum. Among the men who believe their scrotum is too small, a growing number of them have resorted to self-injecting saline solution into their scrotums in order to temporarily increase its size (Summers, 2003). There are also some men who do this because they enjoy the feeling of a distended scrotum and find it to be sexually pleasurable (i.e., it has a fetish quality to it). The fluid is usually absorbed by the body within a few days, after which time the genitals return to their normal appearance. However, this procedure is very risky and can result in serious complications (e.g., it could result in sterility if the testes themselves were injected or, potentially, an embolism should air be injected into a vein). Indeed, there are several care reports in the literature of men who have wound up in the emergency room after engaging in some variation of this practice. As a result, no matter what you read on websites about “scrotal infusion” or “scrotal inflation” being harmless, it should be avoided. Among the men who believe their scrotum is too large or too droopy, some doctors are performing scrotum reduction surgery (CBS News, 2012). Thus, male genital modification is certainly not confined to the penis!

It is important to note that male genital concerns vary considerably across cultures. Thus, not every culture is equally obsessed large penises, and some cultures have their own unique genital concerns. Two such concerns that are practically nonexistent in the modern Western world are dhat and koro (Bhugra, Popelyuk, & McMullen, 2010). Dhat, which is found almost exclusively on the Indian subcontinent, is anxiety that stems from a fear of semen loss. Persons with dhat believe that semen is made from blood, and that it takes a significant amount of blood to make even a very small amount of semen. As a result, semen is seen as a very precious and vital bodily fluid, and loss of it (e.g., through masturbation, nocturnal emissions, etc.) cre- ates anxiety and depression. In contrast, koro (found most commonly in southeast Asia) is a fear that the penis is shrinking and retracting inside the body, which creates anxiety and panic. It is thought that the term “koro” is derived from the Japanese word for “tortoise.”

Male Genital Health Issues

It is important for men to take proper care of their genitals because not only are they delicate, but they are a common site of infection and other potential health problems. First, regular geni- tal cleansing can prevent the buildup of smegma in uncircumcised men. Some in the medical community have also argued that washing one’s genitals before and after sex may reduce the likelihood of transmitting certain infections, but research in that area has been mixed and, make

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no mistake, regular washing is in no way a substitute for safer sex practices (i.e., condom or other barrier use).

Second, take care when trimming or removing pubic hair. Serious injuries related to groom- ing of pubic hair are rare, but they can happen. In fact, one study estimated there to be almost 12,000 emergency room visits between 2002 and 2010 in the United States that stemmed from such injuries (Glass et al., 2012)! Men made up about 43% of the incidents, which mostly involved cuts to the scrotum and penis. Approximately 1 in 5 incidents arose from use of scis- sors, which are not an advisable tool for pubic hair grooming under any circumstances. Instead, consider an electric shaver with a pubic hair setting or use a new, high quality safety razor—and avoid shaving while you are in a hurry and, especially, if you are inebriated.

Third, regular self-exams of the penis and scrotum can reveal signs of sexually transmitted infections and cancers. We will talk more about potential infection signs you should look for in chapter 12 when we cover sexually transmitted diseases in detail. With respect to signs of cancer, check for any kinds of bumps or masses on each of the testicles once per month. Men can do this by rolling each testicle gently between the thumb and forefinger. The surface should feel smooth, except for the epididymis, which hangs over the back of each testicle. Be sure to check for any sores or growths on the penile shaft and glans as well. Any time you detect one of these things, it is important to get it checked out by a doctor, even if you are not experiencing any pain. Many of the early signs and symptoms of testicular and penile cancer are completely painless, but can progress into major problems and potentially become deadly if left untreated. Fortunately, survival rates for both of these cancers are high if caught and treated early.

Lastly, it is important to be careful with the penis during sexual activity. For example, although you know there are no bones in the human penis, you should be aware that it is still possible to fracture an erect penis during sexual activity (Yapanoglu et al., 2009). What happens in such cases is a rupturing of the cavernous bodies due to some type of blunt trauma (e.g., attempt- ing very forceful intercourse and missing one’s target). Penile fractures are usually reported as being very painful and they have the potential to result in deformity and sexual dysfunction. However, if treated appropriately, normal functioning may return. It is also important for men to take great care when inserting their penis into any type of sex toy or (I wish I did not have to say this) household appliance. With respect to sex toys, be careful with “cock rings.” These are circular pieces of rubber or metal that tightly grip the base of the penis, with the goal of generating longer-lasting and fuller erections. If you use one of these rings, it is advisable not to wear it for more than thirty minutes at a time, otherwise it can cause death of penile tissue and lead to permanent erectile difficulties. Thus, do not put it on before you head out to the bar for the evening or fall asleep wearing it. With respect to household appliances, please watch where you put your penis! Over the years, I have read news stories about men putting their penises in everything from swimming pool suction pumps to vacuum cleaners, and these stories often do not have happy endings, ranging from embarrassing rescues from the local fire department to penile decapitation. Ouch.

Female Sexual Anatomy

A Historical and Cultural Overview of the Vulva

Throughout history, attitudes toward the vulva have varied just as much as attitudes toward the penis. In the earliest of times, the vulva was seen as the source of life and was prized above all other fertility symbols (Blackledge, 2003). In fact, the penis did not even become a fertility symbol until long after the vulva, because early societies did not necessarily see a direct link

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between the penis and childbirth. Thus, artistic representations of the female body and genita- lia were common and celebrated. More recently, however, the vulva has been seen as both dirty and pornographic—something that should be hidden. This idea is reflected in the fact that in the Western world, the female genitals are often referred to as the pudendum, which comes from the Latin word pudere, literally meaning “to be ashamed.” Also, like the penis, the vulva has no place in the modern media. It is certainly not visually depicted, and the only time it is even alluded to is in advertisements for “feminine hygiene products,” which perpetuate the idea that the female genitals are unclean.

Because our world is rather anti-vulva, most people (both men and women) know relatively little about it. For instance, most of us do not know how the vulva is “supposed” to look because it is something we see so rarely. Not only does this generate unnecessary anxiety for a lot of women who wonder whether they look normal, but this lack of familiarity with the female geni- talia creates confusion for women and their sexual partners because they often have no idea what the different structures are and how they function. This also contributes to misinforma- tion about female sexuality, such as the idea that all women “should” experience orgasm from vaginal penetration. As we will see later in this chapter, however, vaginal penetration is not the primary means by which most women reach orgasm.

External Anatomy

With this information in mind, let us discuss external sexual anatomy in biological women. The collective term that encompasses all of the external genital structures is the vulva. The vulva thus includes everything from the pubic hair to the labia to the vaginal opening. You may or may not realize this, but vulvas (like penises) can come in all different shapes and sizes. Its appearance can be incredibly variable.

One of the most prominent parts of the vulva is the mons veneris (mons pubis). This is the pad of fatty tissue that covers the front portion of the pubic bones. The mons contains many nerve endings, which makes compression of this tissue sexually pleasurable. The primary pur- pose of the mons would seemingly be to protect the internal genital structures during sexual activity. Although the mons is typically covered with pubic hair in adulthood, Western women are increasingly opting to have this hair partially or wholly removed through shaving, waxing, and/or laser treatments, usually because they feel it improves the aesthetic appearance of their genitals or makes them feel “sexier.” Research finds that most women under age 40 report hav- ing removed at least some of their pubic hair in the last month and, further, that those who remove some or all of their pubic hair report having more sex than women who go au naturel (Herbenick, Schick, Reece, Sanders, & Fortenberry, 2010); however, we do not know if that is because women who shave are simply more sexually active, or if shaving begets more sex.

Next, we have the labia. The labia majora (outer lips) are folds of tissue usually covered with pubic hair that begin at the mons and extend downward, encasing most of the remaining geni- tal structures. The labia minora (inner lips) are hairless folds of tissue situated between the outer lips that serve to protect the vaginal and urethral openings. The labia are richly endowed with nerve endings and blood vessels. As a result, they are very responsive to stimulation and they swell and deepen in color during sexual arousal. The labia may take on incredibly different appearance from one woman to the next, with wide variation in how prominent and sym- metrical the lips are. Some women are concerned about the appearance of their labia, at least partly because we typically only see “perfectly” shaped and proportioned labia in pornography. In fact, research has found that in the last few decades, the labia minora have almost become invisible in certain types of pornography (Schick, Rima, & Calabrese, 2010). Perhaps as a result, labial reduction surgery has become increasingly common. However, a recent study of women

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undergoing this procedure found that all of the women actually had normal sized labia to begin with (Crouch, Deans, Michala, Liao, & Creighton, 2011)! Thus, just as it is important for men to avoid comparing their penises to those that they see in porn, women should refrain from making the same comparisons with their vulvas.

Just below the mons, the inner lips join to form the prepuce (clitoral hood). The prepuce is akin to the male foreskin and provides a loose covering over the clitoris. As we discussed in our section on male anatomy, it is important for men to thoroughly cleanse their foreskin to avoid the buildup of smegma. It is equally important for women to gently wash under the prepuce for the same reason.

Figure 3.7 The appearance of the vulva can vary widely. ©Hutanisa, Ingrid w, Peter Klashorst, Amateurlover, and Knuter (Derivative work) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

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The clitoris is composed of a glans, a shaft containing two cavernous bodies, and crura that anchor it to the pubic bone (O’Connell, Sanjeevan, & Hutson, 2005). Given the structural simi- larities between them, the clitoris is often likened to the penis; of course, it could just as easily be claimed that the penis is like the clitoris, depending on your point of reference. The glans may be seen by gently retracting the clitoral hood, whereas the shaft and crura are completely inter- nal. Because the clitoris contains erectile tissue, it increases in size during sexual arousal. Thus, women technically get erections, too, although they are not quite as prominent as men’s tend to be. As with all features of the vulva, there is wide individual variability in the size of the clitoris.

The clitoris is unique in the sense that its sole purpose is to provide sexual pleasure—there is no other organ in the human body (male or female) like it. Although relatively small in size, the clitoris contains about as many nerve endings as a penis and is therefore a major source of sexual pleasure. Given this information, it should come as no surprise that the most com- mon means by which women reach orgasm is through clitoral stimulation, not vaginal pen- etration (Fugl-Meyer, Oberg, Lundberg, Lewin, & Fugl-Meyer, 2006). Some research suggests that women who experience orgasm during vaginal intercourse are the beneficiaries of an ana- tomic variation in which their clitoris is closer to their vaginal opening than usual (Wallen & Lloyd,  2011). Specifically, when the distance between these structures is one inch (2.5 cen- timeters) or less, the clitoris is likely to receive more friction during vaginal penetration. For women who have a larger distance between the clitoris and vagina, they may find it easier to orgasm during intercourse by trying different sexual positions or different pelvic movements that enhance clitoral contact.

Because of the unique role the clitoris plays in producing female sexual pleasure, it has become one of the most controversial aspects of female genitalia. In fact, in some cultures, the clitoris is surgically removed for a variety of social and religious reasons. For a more in-depth discussion of this topic, see the Digging Deeper 3.2 box.

Continuing our discussion of the vulva, within the labia minora is a region known as the vestibule, which houses the openings to the urethra and the vagina. The meatus (i.e., the ure- thral opening) is located between the clitoris and vaginal opening and has excretory functions. The introitus (i.e., the vaginal opening) is situated between the urethral opening and the anus. On either side of the introitus are the Bartholin’s glands, which secrete a drop or two of fluid during sexual arousal, perhaps to create a genital scent; however, scientists do not necessarily agree on the precise function of the Bartholin’s secretion. The introitus is partly covered by a thin, circular piece of tissue known as the hymen, another structure that has a variable appear- ance. In fact, scientists have described as many as seven different types of hymens, includ- ing the annular (which has a rounded appearance and one hole in the center), septated (in which a strip of tissue in the center of the hymen creates two holes), and cribiform varieties (a hymen with several small holes in it; Stukus & Zuckerbraun, 2009). The hymen often remains intact until a woman’s first intercourse, although it frequently breaks sooner as a result of other activities (e.g., masturbation, athletics). In fact, in one study involving medical examinations of female virgins, just 57% were observed to have an intact hymen, which indicates that this struc- ture is not necessarily a reliable sign of virginity status (Underhill & Dewurst, 1978). When the hymen initially breaks, it may be accompanied by light bleeding and some pain, but it is usually not a traumatic experience, especially among women who practice stretching it out prior to their first sexual experience.

The thickness and appearance of the hymen varies across women. In fact, some women’s hymens are so thick that they are difficult to break during intercourse and, on rare occasions, the hymen may close off the entire vaginal opening, not even allowing menstrual blood to flow out (this is known as an imperforate hymen). In these cases, medical intervention is usually nec- essary to allow intercourse and to prevent women’s sexual partners from mistaking the meatus

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Digging Deeper 3.2 Female Genital Cutting: What is it, and What Should Be Done about it?

Female genital cutting (FGC) involves permanently damaging or removing portions of a wom- an’s external genitals when it is not medically necessary. FGC has been practiced in many parts of the world for centuries, but today is most commonly performed in Africa and the Middle East, where millions of women have undergone some variation of it. FGC is done for a variety of rea- sons, with one of the most common being to ensure that a woman remains a virgin until mar- riage. In other cases, FGC is practiced as an initiation rite to adulthood, as a way of aesthetically “improving” the appearance of the genitals, and as a means of preventing women from becom- ing “over-sexed.”

FGC is usually performed on young girls who have not gone through puberty (although age varies across cultures, ranging from infancy to adulthood) and involves cutting the genital tis- sues with sharp objects, such as knives, scissors, or broken glass. The least invasive form, sxAAM, involves removing or creating a slit in the prepuce. Alternatively, a caiatridlecatom may be per- formed, in which the clitoris is completely removed. A few cultures have adopted the even more extreme practice of iAfibxaMaitA, in which both the clitoris and labia are removed. In this case, the remains of the labia are stitched together and the girl’s legs are bound for a few weeks to allow the tissues to heal. All that remains is a tiny opening to permit the exit of urine and menstrual blood.

Regardless of how FGC is performed, it usually occurs in unsanitary conditions and anesthetic is rarely administered. Thus, not only is there a high risk of infection, but it is incredibly painful. There is also a high likelihood of complications, especially for women undergoing infibulation. Potential problems include difficulty urinating, painful intercourse (it may take weeks or months for the opening to stretch to the point where intercourse is possible, and sometimes it never is), as well as childbirth dangers.

Most Western cultures have outlawed the practice, viewing FGC as inhumane and deeming it a form of genital “mutilation.” Westerners typically consider FGC an unnecessary threat to women’s health that permanently impairs female sexual pleasure and functioning. However, in the 28 cul- tures where FGC is currently practiced, it is rarely questioned (at least publicly), even by women. In fact, many women say they want the procedure because it is a requirement for marriage, which is usually the only path for a woman in these cultures. The resistance to ending FGC stems from the fact that this tradition dates back centuries and has become part of the cultural psyche about how to properly raise a girl.

On a side note, FGC is often referred to as “female circumcision.” However, it is unwise to equate this procedure with male circumcision because FGC is far riskier and much more invasive. Also, ­GC is M wMm ahMa oMAm stcileailes Maaleopa at ctAarta wtoleA’s sleexMaiam. This stands in stark contrast to male circumcision, which is generally not intended to affect men’s sexual behavior (although there was a time in recent history in which boys were sometimes circumcised as a means of dis- couraging masturbation). Certainly, there are some parallels between these practices (e.g., both are frequently performed on infants who cannot consent, they are often practiced as part of a cultural ritual), but they are hardly the same thing.

The controversy over FGC is unlikely to be resolved any time soon because those challenging this practice face a number of ethical and legal dilemmas. For example, what authority does one culture have to tell another that it must abandon its traditions? Think about it from this perspec- tive: What if another country tried pressuring the United States to ban male circumcision alto- gether on the grounds that it is inhumane to remove a portion of the genitals of a non-consenting male infant? Given that male circumcision is so widely accepted and practiced in American cul- ture, there would probably be a lot of resistance to any outside group that demanded an end to it.

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for the introitus, which I am sorry to say has happened in at least a few documented cases in the medical literature. Unfortunately, when neither partner has particularly good knowledge of female sexual anatomy and the only obvious orifice on the vulva is the urethral opening, some people have treated it as the entrance to the vagina.

While the hymen serves no true medical function, the fact that it has the potential to signal a woman’s virginity status (albeit unreliably) has caused many societies to place great social value on this tiny piece of tissue. For instance, in some African and Middle Eastern cultures, a woman is not eligible for marriage unless her hymen is intact. Women may be required to undergo pelvic exams prior to marriage in order to verify their virginity, or they may be required to produce a blood-stained sheet after their wedding night as proof that they lost

Also, some of the most common arguments against FGC are that women are socially pres- sured into it, that it is medically unnecessary, and that it creates health risks; however, can we not level similar arguments against many forms of cosmetic bodily modification performed on West- ern women (e.g., breast augmentation, “vaginal rejuvenation,” labial reduction)? I do Ata wish to imply that FGC and these other procedures are equivalent, because they are not, especially in terms of the risks they carry, whether the procedure is voluntary, and whether it is performed on adults or children. I am simply stating that drawing a line between which forms of bodily modifi- cation are acceptable and which are not is harder than it sounds.

Note: Reprinted with permission from lee MAd Psmchtatgm (www.lehmiller.com). To learn more about FGC, please consult Momoh (2005).

Digging Deeper 3.2 (Continued)

Introitus

Labia minora

Clitoral hood

Meatus

Labia majora

Figure 3.8 In this photo you can see some of the structures of the vulva, including the labia, clitoral hood, and introitus. ©Bobisbob (en.wikipedia) [CC-BY-SA-3.0 (http://creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

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their virginity to their new husband (Roberts,  2006). Given the great social pressure to be a demonstrable virgin at marriage, many women are undergoing “revirginization” surgery (also known as hymenoplasty) to reconstruct broken hymens. In this procedure, the original hymen is sutured back together, or a new hymen is fashioned out of other vaginal tissue. Upon request, a gelatin capsule containing artificial blood may be inserted to create the appearance of bleeding at her next intercourse. Among women who have had this procedure, they typi- cally report being very satisfied with the outcome (Logmans, Verhoeff, Raap, Creighton, & van Lent, 1998). On a side note, there are some women in the Western world who are getting “revirginized” for a completely different set of reasons. Most commonly, it is because they want to physically and psychologically recreate their first sexual experience (e.g., perhaps they regretted who they had sex with the first time and want to try it again with someone they care more about).

The final portion of the vulva is the perineum, an area of skin that runs between the introitus and the anus. During childbirth, an episiotomy is sometimes performed, in which an incision is made into the perineum to expand the size of the birth canal. This procedure reduces vaginal tearing and can make childbirth easier when the baby is larger than average or when a mother has undergone certain forms of female genital cutting (see the Digging Deeper 3.2 box).

Internal Anatomy

Beneath the vulva are several important structures, including the pelvic floor muscles, a com- plex, crisscrossed set of muscles that contract involuntarily when a woman reaches orgasm. These muscles can be strengthened through Kegel exercises, and women who do them expe- rience numerous benefits (Beji, Yalcin, & Erkan,  2003). These exercises were first developed in the 1950s by Dr. Arnold Kegel as a way of helping women who suffer from incontinence problems after childbirth. Kegel and others found that these exercises are indeed an effective means of regaining urinary control, but they have sexual benefits as well, such as relief from painful intercourse and increased ability to reach orgasm. These exercises are easy enough to do and the steps involved are similar to the Kegel exercises men do to strengthen the muscles at the base of the penis. To begin, locate the muscles used to stop the flow of urine midstream. Once familiar with the muscles, simply start by squeezing them, holding for several seconds, and then releasing. After several repetitions, move onto squeezing and releasing the muscles rapidly a few times. These exercises must be done a few times per day for several weeks before the benefits start to become noticeable.

Next, let us consider the structure of the vagina, which is the canal that extends from the introitus to the uterus. The vagina expands in size and changes in shape during sexual inter- course and childbirth. As reported by Masters and Johnson (1966), the vagina is 2.8–3.1 inches (7–8 centimeters) in an unaroused state, and up to 4.3–4.7 inches (11–12 centimeters) in an aroused state. The interior lining of the vagina (the vaginal mucosa) is a mucous membrane through which a lubricating substance is secreted during arousal. Some women produce less of this natural lubrication than others, which can make intercourse painful; however, artificial lubricants offer an inexpensive and practical solution. Surrounding the mucosa are layers of muscle and fibrous tissue that aid in expansion and contraction. Contrary to popular belief, most of the nerve endings in the vagina are concentrated around the introitus. The inner por- tions of the vagina have far fewer nerves, which means that a longer penis will not necessarily provide more pleasurable stimulation to women who have sex with men. The vaginal depth measurements reported by Masters and Johnson (which are a little shorter than the average penis length) suggest another reason why longer penises may not necessarily enhance female pleasure: there isn’t necessarily room for them.

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On each side of the vagina near the introitus are the vestibular bulbs. They consist of spongy tissue (similar to the tissue in men responsible for penile erections) and expand in size during sexual arousal, causing the vulva to extend outward.

Deeper within the vagina is the Grafenberg spot (or G-spot), another controversial portion of female sexual anatomy. The location of the G-spot is most commonly described as being a couple of inches inside the vagina on the front wall (i.e., just underneath the mons veneris) and can be stimulated by inserting two fingers into the vagina and making the “come here” motion. Many women have reported that stimulation of this area results in very intense orgasms, some- times accompanied by an ejaculation of fluid. Some women release a small amount of milk-like fluid, whereas others release a large amount of thin, watery fluid, with the latter often referred to colloquially as “squirting.” One contributor to this fluid is thought to be the Skene’s glands, which consist of prostate-like tissue and surround the urethra. However, with regard to squirt- ing in particular, the bulk of this fluid appears to originate in the bladder. Pelvic scans of women who experience squirting have shown that the bladder fills during sexual arousal and is empty following orgasm (Salama et al., 2015). The fluid released is comparable to urine in its chemical makeup, but prostatic secretions are detectable in it for most women.

A recent review of the scientific literature failed to provide conclusive evidence that the G-spot is a distinct anatomical structure (Kilchevsky, Vardi, Lowenstein, & Gruenwald, 2012). Not all women seem to have a G-spot (in fact, survey research finds that just 56% of women think they have one; Burri, Cherkas, & Spector, 2011), and studies trying to pinpoint the loca- tion of the G-spot have not provided consistent results. This has led some scientists to refer to the G-spot as a “gynecological UFO”—it has many sightings, but no confirmation of its exist- ence. This does not mean that there is no such thing as the G-spot; rather, what some scientists are arguing is that the area people typically think of as the G-spot is actually the internal por- tion of the clitoris, which falls in the same general region and is highly sensitive to stimulation.

Uterus

Fallopian tube

Ovary

Fimbriae

Cervix

Vagina

Bartholin’s gland

Introitus

Clitoris

Pubic bone

Bladder

AnusMeatus

Figure 3.9 The female reproductive system. ©Tsaitgaist (Derivative work) [CC-BY-SA-3.0 (http:// creativecommons.org/licenses/by-sa/3.0)], via Wikimedia Commons.

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At the end of the vagina is the cervix, which is the lower end of the uterus. The opening of the cervix (the os) permits sperm to enter and menstrual fluid to exit. The cervix secretes mucus that has different effects depending upon the stage of the menstrual cycle a woman is in. This mucus assists the entry of sperm during fertile periods, but blocks sperm during the rest of the cycle. A woman who is very comfortable and familiar with her body can test the consistency of her cervical mucus to figure out where she is in her cycle and whether conception is likely to occur (see chapter 11 to learn more about women who use this as a method of birth control). On a side note, the cervix may be a source of sexual pleasure for some women, with research indicating that cervical stimulation activates the same area of the brain as vaginal and clitoral stimulation (Komisaruk, Wise, Frangos, Liu, Allen, & Brody, 2011).

The uterus is a muscular organ suspended by ligaments in the pelvic cavity. Its primary purpose is to protect and nourish the fetus as it develops during pregnancy. The innermost lining of the uterus is the endometrium, which builds up and sheds during each menstrual cycle. Surrounding the endometrium are layers of muscle (the myometrium) and fibrous tissue (the perimetrium) that enable the uterus to change greatly in size during pregnancy. The uterus of a woman who has given birth will be much larger compared to a woman who has never been pregnant.

At the upper end of the uterus, a fallopian tube extends out on each side. This tube carries eggs from the ovaries to the uterus. At the end of the fallopian tubes are fimbriae, which are fingerlike projections that “catch” eggs and direct them into the tubes. Once inside the fallopian tube, an egg moves slowly toward the uterus via tiny hairs (cilia). It is in the upper portion of the tube near the fimbriae where fertilization is most likely to occur. When an egg is fertilized, it must implant itself in the uterine wall in order to generate a successful pregnancy. Occasion- ally, a fertilized egg will implant in the fallopian tube before it reaches the uterus, which creates a dangerous situation known as ectopic pregnancy. Pregnant women who experience severe abdominal pain, vaginal bleeding, and/or shoulder pain should consult a physician to check for ectopic pregnancy. If left untreated, it is potentially deadly.

Finally, we have the ovaries, or female gonads, which have two primary functions: (1) pro- duction of sex hormones (namely estrogen and progesterone), which play an important role in regulating the menstrual cycle, and (2) production and release of eggs (ova). During ovulation (i.e., the fertile period of a woman’s menstrual cycle), either the left or right ovary will release an egg. Throughout her lifetime, a woman releases somewhere between 300 and 500 eggs (Mack- lon & Fauser, 1999).

Breasts

The breasts are not technically part of a woman’s sexual anatomy (they are considered secondary sex characteristics, or physical indicators of sexual maturity); however, they are important to discuss because they have roles in both sexual pleasure and reproduction. Externally, breasts are composed of a nipple through which maternal milk can be released. The nipple is sur- rounded by a round, darkened area known as the areola. Both the nipple and areola contain many nerve endings, making them sensitive to touch. In fact, some women’s nipples are so sensitive that they can reach orgasm through nipple stimulation alone (Levin, 2006)! See the Digging Deeper 3.3 box for more on this.

Internally, breasts are composed of fatty tissue and mammary glands. What determines the size of a woman’s natural breasts is the amount of fatty tissue. All women have approximately the same number of mammary glands, the structures that generate maternal milk. Thus, women with larger breasts do not necessarily produce more milk during lactation. It is also important to note that larger breasts do not necessarily contain more nerve endings. In fact, smaller breasts may be more erotically sensitive than larger breasts because they have the same

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number of nerve endings in a much denser concentration. Women with smaller breasts may therefore find more intense forms of stimulation (e.g., biting) unpleasant.

Breast appearance varies considerably across women. Not only are there huge differences in size and shape, which have only been exaggerated by the increasingly popular trend of surgical augmentation, but the look of the nipple and areola varies too. For instance, some areolas are much larger than others, and some nipples point outward, while others are inverted. It is also often the case that one breast (usually the one on the left side of the body) is slightly larger than the other.

On a side note, some scientists have theorized that the appearance of the breasts has evolu- tionary significance (just like the size and shape of the male penis). The thought here, known as genital echo theory, proposes that women developed larger and more pendulous breasts after humans began walking upright as a way of mimicking the appearance of the buttocks, which used to be the biggest visual source of excitement for men (Fisher, 1992). In other words, women’s main fertility symbol moved from the back to the front when we stood up.

Psychology of the Breasts and Vulva: Female Bodily Concerns

One of women’s biggest concerns about their bodies is the size of their breasts. In fact, research has found that only a minority of women (30%) reported being satisfied with the appearance of their chest (Frederick, Peplau, & Lever, 2008). Of the 70% who were dissatisfied, most of these women were worried that their breasts were either too small (28%) or too droopy (33%). Only a small number of women (9%) wished they could reduce the size of their breasts. Across all

Digging Deeper 3.3 Can Women Orgasm From Nipple Stimulation?

Some women have reported that they can reach orgasm simply by having their breasts and nip- ples stimulated (Levin,  2006). The idea of a woman experiencing orgasm without any genital touching whatsoever might seem perplexing to some, but research suggests there is a sound biological basis for it.

Komisaruk and colleagues (2011) sought to determine what areas of the brain are active in response to stimulation of different parts of the female body. Female participants were asked to lie inside an fMRI machine and alternate between stimulating the clitoris, vagina, cervix, and nipple. An experimenter instructed the women to “comfortably” stimulate one of those body parts for 30 seconds, then rest for 30 seconds before repeating the process with a different part of the body. All participants were asked to stimulate themselves in the exact same way to keep the results as constant as possible (e.g., when it came to nipple stimulation, women were asked to use their right hand to “tap the left nipple rhythmically”).

The researchers discovered that stimulation of the nipple activated an area of the brain known as the gleAiaMa sleAstrm ctralee. This is the same brain region activated by stimulation of the clito- ris, vagina, and cervix. What this means is that wtoleA’s brMiAs sleleo at prtcless Aippale MAd gleAiaMa saioxaMaitA iA ahle sMole wMm. In light of this, it is not at all surprising that many women are aroused by having their nipples touched and that, for some, this may be enough to lead to orgasm.

If I may offer one note of caution, keep in mind that when it comes to nipple stimulation, there is good touching and bad touching. The nipple can be a highly sensitive part of the body, which means that more aggressive handling (e.g., twisting) can potentially be unpleasant. As always, it is best to communicate with your partner about what is and is not pleasurable.

Note: Reprinted with permission from cileAcle tf RleaMaitAships (www.scienceofrelationships.com).

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stages of the lifespan, most women expressed some form of breast dissatisfaction. The only thing that appeared to change with age is the nature of women’s concerns. Specifically, younger women were more concerned being larger, whereas older women were concerned with being less droopy. Why are women so concerned with the appearance of their chests? It is likely the product of social learning. From a very young age, women are bombarded with messages that big breasts are better. For instance, Barbie dolls are a popular toy among young girls, but the bodies of these dolls (which typically have exaggerated breasts, tiny waists, and wide hips) are far from realistic. In fact, it is estimated that only 1 in 100,000 women have bodies that match Barbie’s extreme proportions (Norton, Olds, Olive, & Dank,  1996)! Also, a large number of the female celebrities young girls look up to have had their breasts surgically enhanced, which further reinforces the notion that breasts are “supposed” to be huge and that they make women more popular, attractive, and likeable.

Given the immense pressure on women to have large chests, it should come as no surprise that breast augmentation surgery has become perhaps the most popular form of cosmetic sur- gery in the world. In 2014, more than 286,000 women had their breasts enlarged in the United States alone (American Society of Plastic Surgeons, 2015). Breast augmentation involves surgi- cally inserting implants into the chest that consist of either saline or silicone encased in rubber shells. As with any form of surgery, breast augmentation carries a number of risks, including hardening of the breasts, changes in breast and nipple sensitivity, deformity, and implant rup- ture (Food and Drug Administration, 2012). Breast implants also have the potential to impair a woman’s ability to breast feed. Overall, breast augmentation is probably safer than penile aug- mentation surgery, given that surgical breast enhancement has been around a lot longer and has been the subject of more scientific study. However, any woman considering breast implants should carefully weigh the risks before deciding whether to go forward.

Should women be so obsessed with how their breasts look? It may comfort some of you to know that, at least in heterosexual relationships, the majority of men (56%) reported being

Muscle

Fat

Milk ducts

Nipple Areola

Mammary glands

Figure 3.10 Anatomy of the female breast. ©Alexilusmedical. Used under license from Shutterstock.com.

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satisfied with the size and shape of their female partners’ chests (Frederick et al.,  2008). Of course, that still makes for a substantial minority of men who report some form of dissatis- faction. If we compare these results to the previously discussed study of penis size (Lever et al., 2006), it appears that men tend to judge women’s bodies more harshly than women judge men’s bodies. In some ways, this is not particularly surprising because most societies unfairly hold women to higher standards of beauty than they do men.

In addition to breast concerns, many women are worried about the appearance of their vulva. For instance, as previously discussed, many women are concerned that their labia are too large or asymmetrical and have thus undergone labial reduction surgery. In addition, some women believe that their vaginas are too large or too loose. It is a myth that women’s vaginas become “looser” as a result of frequent sexual activity, so do not let anyone convince you otherwise; however, some degree of looseness may occur with older age and following vaginal delivery of children. Among those women who believe they are too loose, some are pursuing “vaginal rejuvenation” surgery, which is advertised to tighten the vagina. There are also a growing num- ber of women who are concerned about their lack of ability to reach orgasm during vaginal intercourse and will try almost anything to make it happen. Some of these women have sought out “G-spot amplification,” in which collagen is injected into their supposed G-spot. Women should be especially wary of these procedures. For one thing, if scientists cannot agree on the location of the G-spot or whether it even exists (Kilchevsky et al., 2012), how can one possibly “amplify” it? More importantly, these procedures that attempt to sell women “designer vaginas” have not been subject to scientific scrutiny, which means we do not even know whether they are safe or effective (American Congress of Obstetricians and Gynecologists, 2007). Any claims to the contrary are simply deceptive marketing. It is therefore advisable to be extremely cau- tious about these and any of the other new genital surgeries.

Figure 3.11 Female dolls often have extreme and unrealistic bodily proportions, some of which would be nearly impossible to obtain in real life. ©Leah-Anne Thompson, 2016. Used under license from Shutterstock .com.

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All of the female breast and genital procedures discussed in this chapter (breast augmenta- tion, revirginization, labial reduction, vaginal rejuvenation, G-spot amplification, and female genital cutting) are evidence that societies and cultures around the world consider the female body and women’s sexuality to be highly malleable. There are many more cosmetic procedures available for women than there are for men, and women are much more likely to be socially pressured into undergoing these surgeries. This is but one small piece of evidence that there is a sexual double standard, in which men’s and women’s bodies and sexualities are evaluated very differently, with women being subject to the harshest criticism. For more on the nature and scope of the sexual double standard, check out the Your Sexuality 3.1 box.

Female Breast and Genital Health Issues

The Menstrual Cycle A healthy woman of reproductive age will likely have an established menstrual cycle. This cycle is regulated by a complex interplay of hormones that produces a number of effects in the ova- ries and uterus. There are four phases of this cycle: the follicular phase, ovulation, the luteal phase, and menstruation. Of most interest to us in this book because of their effects on female psychology are ovulation and menstruation. During ovulation, a mature egg is released by one of the ovaries. As we will discuss in chapter 11, ovulation produces a number of impor- tant changes in women’s sexual behavior, including everything from how she dresses to the types of partners she finds attractive. The other stage of interest, menstruation, is when the

Your Sexuality 3.1 Does the Sexual Double Standard Still Exist?

Researchers have recorded evidence of a sexual double standard dating back several decades. However, recent research has produced conflicting findings, with some studies finding support for the typical double standard, others showing no effect, and some even showing a rlevlersle dou- ble standard (i.e., that men are judged more harshly than women in certain cases; Milhausen & Herold, 1999). So is the notion that women’s bodies and sexual behaviors are subject to greater scrutiny than men’s actually on the wane? Answer each of the questions below and see what your own experiences would suggest about the nature of modern day sexual attitudes.

● Culture and society dictate what the “ideal” male and female body looks like; however, are men and women penalized to the same extent for falling short of these ideals? Do they experience the same degree of pressure to have their body look a certain way in order to find a sexual and/ or romantic partner?

● What names or labels would most people apply to a woman who frequently engages in one- night stands? What names or labels would most people apply to a man who engages in the same behavior? How did the number and nature of the labels you generated differ between groups?

● Would you encourage a heterosexual male friend to date a woman who you knew had ten pre- vious sexual partners? Would you encourage a heterosexual female friend to date a man who you knew had ten previous sexual partners?

● Is a woman who has sex on the first date potential “marriage material?” What about a man who does the same thing?

● Imagine someone doing a “walk of shame.” What is the sex of the first person who pops into your head?

● How would society evaluate a woman who carries condoms in her purse? How would society evaluate a man who carries condoms in his pocket?

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endometrial lining of the uterus, which has built up in anticipation of pregnancy, sheds if con- ception does not occur, thereby producing a bloody discharge (often referred to as a “period”). On average, a complete menstrual cycle lasts 28 days, although there is significant variability across women in terms of cycle length and at what point ovulation occurs. There is also a lot of variation in the age at which a woman experiences her first menstruation (menarche) and when menstruation permanently ceases (menopause).

The average age of menarche in the United States is 12.5, with earlier onset linked to race, typi- cally occurring earlier in Black and Hispanic girls and later in White girls (Chumlea et al., 2003). Earlier onset is also related to environmental factors, such as obesity and lack of exercise. Menarche is viewed in different terms cross-culturally. For instance, in some American Indian cultures, a girl’s first menstruation is a blessed event that is celebrated with an eight-day ceremony (Crawford, O’Brien, & Kelley, 2005). By contrast, menstruation is considered taboo in Nepal, where girls are banished to an outdoor shed to eat, sleep, and live during their periods (Greenhalgh, 2015).

In industrialized nations (including the United States), the median age of menopause is between 50 and 52 and, as is the case with menarche, earlier onset is linked to a number of environmental and lifestyle factors (e.g., malnourishment, smoking), as well as race (Black and Hispanic women tend to experience menopause the soonest; Gold  2011). Cultures also vary in their views on menopause, with some viewing it as a natural transition in life, and others (particularly those in the Western world) viewing it as a “condition” or set of symptoms that requires a medical fix. Menopause has several implications for older women’s sex lives, a topic we will return to in chapter 10.

Menstrual Cycle Problems Most women experience at least some physical and psychological effects during each men- strual cycle. On a psychological level, changes in mood are common. This is often chalked up to premenstrual syndrome (PMS), a very general term that encompasses all of the emotional changes and physical discomfort a woman might experience prior to getting her period. In more severe cases, the term premenstrual dysphoric disorder (PMDD) is sometimes used, which is an actual diagnostic category in the DSM-5. Specifically, PMDD is diagnosable when a woman presents with at least five of the symptoms specified by the DSM (e.g., marked changes in mood, difficulty sleeping, concentration problems, physical symptoms) and is experiencing personal distress or interference in daily life as a result.

In the medical literature, hundreds of symptoms of PMS have been identified (e.g., depres- sion, irritability; O’Brien, Wyatt, & Dimmock, 2000), and studies suggest that as many as 80% of women report at least some of them (Stanton, Lobel, Sears, & DeLuca,  2002). However, one might reasonably wonder what use there is in defining this term so broadly as to apply to almost all women and, if that is the case, why we call it a “syndrome,” which sounds like a prob- lem. In fact, some argue that we are medicalizing and pathologizing normal female experience by using terms like PMS and PMDD. It is important to keep in mind that the psychological changes that women experience during menstruation are usually small on average and the wild mood swings depicted on television sitcoms are exaggerations.

Two of the most common menstrual cycle problems are dysmenorrhea and amenorrhea. Dys- menorrhea refers to painful menstruation. The most common symptom is cramping, but other women experience nausea, headaches, disorientation, and fatigue. Primary dysmenorrhea is diag- nosed when the body produces too many prostaglandins, a substance that causes very intense contractions of the uterus. Secondary dysmenorrhea is diagnosed when a pre-existing medical condition creates painful menstruation. Perhaps the most common cause of secondary dysmenor- rhea is endometriosis, a condition in which a woman has endometrial cells outside of her uterus, often on the ovaries or fallopian tubes. These cells respond the same way as the endometrial cells

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inside the uterus (i.e., they build up and then shed during the menstrual cycle). If left untreated, endometriosis can permanently damage reproductive structures, resulting in infertility.

Amenorrhea occurs when menstruation is absent and may take two forms. Primary amen- orrhea is when an adolescent girl fails to menstruate by age 16, often because of a congenital malformation of the uterus, an imbalance of hormones, or as a result of being intersexed (i.e., not fitting the biological definitions of female or male; a topic we will return to in chapter 5). Secondary amenorrhea is when a woman who has already had at least one period experiences an interruption in her menstrual cycle. This type of amenorrhea occurs naturally during preg- nancy, but is also normal among women who have recently stopped using birth control pills and among older women who are approaching menopause. It is also common among girls who are very athletic as well as girls who have anorexia.

Gynecological Health Issues Just as proper genital health care is important for men, it is vital for women to take care of their vulvas and vaginas. First, maintaining good genital hygiene by bathing regularly can prevent the build-up of smegma and reduce the likelihood of urinary and vaginal infections. Thus, it is advisable for a woman and her partner to wash their hands and genitals prior to sexual activity. Again, this is not a substitute for safer sex—it is simply an extra precaution. A woman’s genital cleansing routine should not include douching, though. Douching (i.e., rinsing the vaginal canal with liquids) can actually make vaginal infections more likely by changing the natural pH and bacteria balance. Second, as discussed earlier in this chapter, it is important to take care when grooming pubic hair in order to avoid injury. For example, if using safety razors, make sure they are new and use them slowly and carefully. Third, women should perform regular self-exams of their genitals to look for changes that might indicate potential health issues (e.g., redness, unu- sual discharge). However, before you start looking for problems, begin by spending some time just getting acquainted with your genitalia under normal circumstances. You need this baseline so that you will know in the future what is normal for your body and what is not.

It is also important for women to have regular gynecological exams from a physician, because a physician can observe things that a woman cannot do on her own. In particular, physicians can perform Pap tests, a procedure in which a scraping of cells is taken from the cervix to test for cancer. Cervical cancer is one of the most common types of cancer in women, but if it is caught and treated early, the survival rate is very high (Mayr, Small, & Gaffney, 2011). Because one of the most common causes of cervical cancer is a sexually transmitted infection, HPV, it is especially important for sexually active women to get regular Pap tests. Specifically, the current recommendation is that women over age 21 get tested once every three years (US Preventive Services Task Force, 2012). Until recently, the medical community recommended annual test- ing, but they now believe testing at less frequent intervals is likely just as effective. Pap tests may be simultaneously combined with a test for HPV, which is the preferred strategy.

Breast Issues Breast cancer is the second most common and second most deadly type of cancer in women. The chance of an American woman developing breast cancer in her lifetime is approximately 1 out of 8, and her chance of dying from it is approximately 1 out of 36 (American Cancer Society, 2012). There appears to be a strong genetic component to breast cancer, which means that a woman’s risk of developing it is higher to the extent that she has close female relatives who have had this type of cancer.

Although women are frequently told that they should do self-exams as part of the cancer screening process, research indicates that they are not all that effective at reducing death rates (Gaskie & Nashelsky, 2005). By the time a lump can be felt, it is often too late to do anything

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about it if it is a malignant cancer. Likewise, most of the lumps detected by women end up being benign cysts or fibroadenomas, which result in a lot of unnecessary healthcare utiliza- tion. Thus, while there may be some value to performing self-exams on occasion to become familiar with one’s own body, they are by no means a substitute for regular clinical exams.

Mammography is the primary clinical technique for detecting breast cancer; it involves tak- ing an X-ray of each breast. The traditional recommendation is that women over the age of 40 should get an annual mammogram; however, a recent US government task force argued that mammograms should instead be conducted biennially starting at age 50 and that regu- lar breast cancer screenings should only begin before that if warranted by individual patient circumstances (e.g., previous family history of breast cancer; US Preventive Services Task Force, 2009). The reason for this recommendation change is that administering mammograms routinely to women under age 50 is unlikely to provide a large benefit and there is a risk that repeated exposure to radiation from mammograms may itself cause cancer. This recommenda- tion has proved controversial and the medical community remains split on it.

Conclusions

By this point, I hope I have successfully made the case that there is psychological value to learning about sexual anatomy, and that a lack of knowledge about your own body or that of your partner could have a wide range of implications. That said, you will want to keep in mind everything you have learned here about the human body because going forward in this text, you need to understand the basics of genital anatomy in order to appreciate our upcoming dis- cussions of sexual arousal and response (chapter 4), biological sex variations (chapter 5), sexual behaviors (chapter 9), lifespan sexual development (chapter 10), contraception and pregnancy (chapter 11), as well as sexual problems and sex therapy (chapter 13).

Figure 3.12 Research has found that breast self-exams are not as effective as doctors once believed. Thus, they are not a substitute for consulting with a physician. ©National Institutes of Health via Wikimedia Commons.

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Key Terms

foreskin circumcision superincision Peyronie’s disease cavernous bodies spongy body testes labia minora prepuce clitoris female genital cutting introitus Bartholin’s glands hymen perineum vagina

seminiferous tubules interstitial cells cremaster muscle epididymis vas deferens semen seminal vesicles vestibular bulbs Grafenberg spot cervix uterus fallopian tube ovaries nipple areola ovulation

prostate gland Cowper’s glands dhat koro vulva mons veneris labia majora menstruation premenstrual syndrome

(PMS) premenstrual dysphoric

disorder (PMDD) dysmenorrhea endometriosis amenorrhea

Discussion Questions: What is Your Perspective on Sex?

● How is pornography changing our perceptions and standards of physical attractiveness? Do producers of pornography select actors and actresses who conform to contemporary stand- ards of beauty? If so, what effect does this have on our perceptions of the human body?

● Some scientists believe routine male circumcision would significantly reduce rates of sexu- ally transmitted infections among men and their sexual partners, thereby lowering health- care costs by billions of dollars over time. However, others argue that everyone has a right to an intact body and that circumcision causes pain, trauma, and potentially serious side effects. What is your view on this issue?

● Should penile augmentation, vaginal rejuvenation, and other such cosmetic medical procedures be legal or illegal? Do individuals have a right or pursue experimental genital surgeries for which the benefits are unclear and the risks are very high?

References

Alter, G. (1997). Reconstruction of deformities resulting from penile enlargement surgery. The Journal of Urology, 158, 2153–2157.

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