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Human Sexuality

Teresita Cadiz-Brion, MD, FPOGS June 17, 2015

TOPIC OUTLINE ANATOMY OF FEMALE GENITALIA

I. History of Scientific Research on Sex

II. Anatomy of Female Genitalia
A. Variations in Vulva Shape
B. Types of Hymen
III. Physical Examination
A. Vulva : Virginal, Nulliparous, Parous
B. Speculum and Bimanual Examination
IV. Sexual Response Cycle
A. Excitement Phase
B. Plateau Phase
C. Orgasmic Phase
D. Resolution Phase
E. Grafenberg Spot
V. Models of Sexual Response Cycle
VI. Development of Sexuality
A. Childhood Sexuality Fig. 1. The Vulva
B. Pubertal Sexuality
C. Pregnancy and Puerperium
D. Aging
VII. Gender Identity
A. Masturbation
B. Marital Coitus
C. Extra-marital Coitus
D. Sadomasochism
E. Sexual Myths
VIII. Sexual Position and Positions for Pregnancy
IX. Sexual Dysfunction
A. Characteristics of Dysfunctional Couples
B. Sexual Response Cycle in Sexual Dysfunction
C. Medical Condition Affecting Sexual Desire, Arousal and
Orgasm
D. Female Sexual Dysfunction
E. Male Sexual Dysfunction
X. Paraphilia
XI. Physician’s Own Sexuality
Fig. 2. Muscles of the Floor of the Female Pelvis
Pubococcygeus – sex muscle (contracts during intercourse)
HUMAN SEXUALITY
History of Scientific Research on Sex EXTERNAL GENERATIVE ORGAN
1900 Freud and the Psychoanalytic movement
Mons Pubis / Mons Veneris
1903 Havelock Ellis: studies in the psychology of sex  fat-filled cushion that lies over the symphysis pubis
1925 Magnus Hirschfield and the German sexual reform
movement Labia Majora
 homologous to the male scrotum
1930 Malinowski, Mead anthropological studies
 2 rounded fold of adipose tissue
1940 Kinsey began his survey on sexual behavior  round ligaments (which supports the uterus) terminate at its upper
1950 Kinsey publishes sexual behavior in Human male border
and the sexual behavior in the Human female  richly supplied w/ sebaceous glands & plexus of veins (because of
1968 - Masters and Johnson; Physiology of sex response these veins, it can be edematous)
1970 and dysfunction  has a layer of dense connective tissue that is rich in elastic fibers &
adipose tissue but is nearly void of muscular elements
1970 John Money, errors in gender differentiation
1973 Social psychologist and the experimental sex Labia Minora (Nymphae)
research  mucous membrane in appearance but are covered by stratified
1985 Explosion of AIDS related research squamous epithelium
 devoid of hair follicles, has many sebaceous glands & few sweat
1993 Contemporary sex survey glands
 comprised of connective tissue w/ many vessels & some smooth
MASTERS AND JOHNSON muscle fibers
 Gynecologist William Howell Masters (1915-2001) and  extremely sensitive & richly innervated by a variety of nerve endings
Psychology researcher Virginia Eshelman Johnson pioneered  forms 2 lamellae superiorly:
o Prepuce of Clitoris- upper part
the research on the human sexual response (February 11, 1925)
o Frenulum of Clitoris- lower part
 First to observe sex in the laboratory
 Basically, the human sexual response is similar in both cases Vestibule
 Sexual stimulation causes vascular engorgement, muscular  almond shaped area
tension, and their physiologic consequences  functionally mature female structure of the urogenital sinus of the
embryo perforated by 6 openings:
 Stimulus may be somatic or psychogenic:
o Urethral Opening: 1-1.5 below the pubic arch
o Somatic or physical: rubbing of the genitalia, o Vagina
masturbation o (2) Ducts of Bartholin’s glands/ major vestibular glands
o Psychogenic: erotic pictures, fantasies o (2) Ducts of Paraurethral glands/Skene glands
 Vestibular Bulbs: aggregation of veins & corresponds to the angle
EXTERNAL GENERATIVE ORGAN of the corpus spongiosum of the penis

Mons Pubis / Mons Veneris Vagina

 fat-filled cushion that lies over the symphysis pubis  tubular, musculo-membranous structure
 functions:
Clitoris o excretory canal of the uterus
 principal erogenous organ of female;homologous with the male penis o organ of copulation
 comprised of glans, body (corpus), & 2 crura; o birth canal
 rarely exceeds 2cm in length, 0.5cm in diameter  upper portion is formed from the MULLERIAN DUCTS
 covered by stratified squamous epithelium that is richly supplied w/  lower portion is formed from the UROGENITAL SINUS
nerve endings & is therefore extremely sensitive  Vaginal pH:

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 HUMAN SEXUALITY 1.03

o before Puberty: 6.8-7.2 VARIOUS TYPES OF HYMEN

o adult: 4-5

Perineum
 Pelvic Diaphragm: consists the levator ani & coccygeus muscles
posteriorly & its fascial coverings
 Urogenital Diaphragm: positioned external to the pelvic diaphragm
in the triangular area between the ischial tuberosities & symphysis
pubis

Fig. 5. Types of Hymen

Hymen
 comprised mainly of elastic & collagenous connective tissue
 no glandular, no muscular elements
 not richly supplied w/ nerve fibers
 in newborn: it is very vascular & redundant due to maternal estrogen
 in pregnant: epithelium is thick & tissue is rich in glycogen
 after menopause: epithelium is thin & focal cornification may develop
 Imperforate Hymen: condition in w/c the vaginal orifice is occluded
Fig. 3. Lateral View of Female Anatomy completely; bluish discoloration due to blood

INTERNAL GENERATIVE ORGANS

PHYSICAL EXAMINATION
Uterus VULVA: VIRGINAL, NULLIPAROUS, PAROUS
 Anterior surface - almost flat
 Posterior surface - convex
 Weight:
o Non- pregnant :70g
o Term Pregnant: 1100g
 Size: 2.5 – 3.5 cm (before puberty)
 Position:
o Anteverted uterus – fundus is positioned towards the bladder
o Retroverted uterus – fundus is positioned away from the bladder

Cervix
 Narrow, caudal part of the uterus
 Predominantly collagenous and elastic tissue, blood vessels and 10%
smooth muscles

Ligamentary Support
 Cardinal or Transverse Cervical or Mackenrodt Ligament
o Main ligamentary support
o Most dense Fig. 6. Virginal, Nulliparous, and Parous Vulva
o United to supravaginal portion of cervix
o Anterior most ligament
 Round Ligament SPECULUM AND BIMANUAL EXAMINATION
o Female homologue of gubernaculum testis
o Terminates in upper labia majora
o Lateral ligament
o Extended downward and outward to the inguinal canal and
terminate in the upper portion of the labia majora
 Uterosacral ligament
o Extends from an attachment posterolateral to the supra
o vagina portion of cervix and encircle the rectum and
o insert into the fascia over the 2nd -3rd sacral vertebrae
o Posterior most ligament

Oviducts Or Fallopian Tubes

 Interstitium
 Isthmus – narrowest
 Ampulla – most dilated part, where the egg stays while waiting to be
fertilized Fig. 7. Speculum Examination
 Fimbriae – catches the egg after ovulation

Mullerian Ducts
 Wolffian ducts - counterpart in males
 Where uterus and fallopian tubes are derived, also the upper part of
the vagina

Ovaries
 Tunica albuginea – outermost portion (cuboidal epithelium)
 germinal epithelium of Waldeyer
 Primordial → oogonia → synapsis → primary oocyte → primordial
follicle
 Medulla: central portion, which is composed of loose connective tissue
that is continuous with that of the mesovarium
 with large number of arteries and veins

VARIATIONS IN VULVA SHAPE

Fig. 8. Bimanual Examination

 The examiner places one hand on the lower abdominal wall and
the finger(s) of the other hand in the vagina (or vagina and
rectum in the rectovaginal examination)
 Either the right or left hand may be used for vaginal palpation

Fig. 4. Vulvar Shape

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 PHASE FEMALE GENITALIA UTERUS AND VAGINA BREASTS MALE GENITALIA

1. EXCITEMENT
PHASE
- Myotonia
- Vasocongestion
- Increased
heart rate,
blood pressure Breast
- Lasts 1 min to increases
several hours in size,
(longest phase) superficial
*If there’s endometriosis, uterus remains
veins
retroverted due to the presence of
become
- adhesions, causing dyspareunia
visible

2. PLATEAU Pubococcygeus
PHASE (sex muscle) closes
- Continued vaginal opening loss of
myotonia, erection
vasoconstriction, unlikely
increased HR
HUMAN SEXUALITY

and BP
- Lasts a few
seconds to
several minutes

3. ORGASMIC

Transcribers: ADAYA, BERNARDO, FERMIN, LAGMAY, PAGADOR

PHASE
- Series of
SEXUAL RESPONSE CYLCE

muscular
contractions:
0.8 seconds
frequency

Expulsion
of semen
flatulence may occur

4.
RESOLUTION
PHASE Clitoris, labia
- Reversal of majora, and labia Breast
myotonia and minora return to returns to
vasocongestion unaroused size unaroused
- Decrease in HR and position size in 5-10
and BP minutes,
rapid loss of

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 1.03
Human Sexuality

Teresita Cadiz-Brion, MD, FPOGS June 17, 2015

GRAFENBERG SPOT (G-SPOT)
 Erogenous zones (clitoris + lower third of anterior vagina)
 High concentration of nerves in the area
 “Exquisitely” stimulating spot
 C: different pattern of transition from excitement through
 Reflects the different responses different women may have,
or different responses an individual woman may have on
different occasions
 A: smooth transition from excitement, to plateau, to orgasm,
to resolution; multiple orgasms
 B: smooth transition up to plateau, but orgasm is not
experienced
o Normally occurs occasionally
o Would be diagnosed as a sexual disorder if it occurs every
time the woman has a sexual experience
orgasm and resolution

CIRCULAR MODEL (WHIPPLE AND BRASH-McGREER)

Fig. 9. Grafenberg Spot

MODELS OF FEMALE SEXUAL RESPONSE CYCLE

TRADITIONAL MODEL

 Shows how pleasure and satisfaction during one sexual

experience can lead to the seduction phase of the next sexual
experience

DEVELOPMENT OF SEXUALITY
INTIMACY-BASED MODEL (BASSON)
CHILDHOOD SEXUALITY
 Sexuality and gender begins at birth
 Critical period in the development of a positive feeling about
one’s own sex is between 18 months to 3 years
 Extra care regarding child’s sexuality at this phase; if not,
gender identity crisis can occur.
 Take note of:
o Parental attitude toward masturbation
o Regression and negative approach tend to foster obsessive
sexual interest
o Parents should not punish kids simply for masturbating
o Sex education

 Also known as the non-linear model of female sexual response

 Model acknowledges how emotional intimacy, sexual stimuli,
and relationship satisfaction affect the female sexual response
 Emotional intimacy is the most important component in the
female sexual response

MASTERS AND JOHNSON

Fig. 10. Gender Identity

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 HUMAN SEXUALITY 1.03

PUBERTAL SEXUALITY GENDER IDENTITY

 Appearance of breast bud and pubic hair  Kinsey Reports (1948-1953) Human sexual behavior:
 Menarche and PMS o 10% of population is gay
 Boys: growth of genitals, body hair, and occurrence of “wet o veered away from 3 categories:
dreams” (nocturnal emissions)  homosexual
 Issue of unplanned teenage pregnancy  bisexual
 Possibility of STD  heterosexual
o 8-category Kinsey scale:

THE EIGHT CATEGORIES OF SEXUALITY

0 Being completely heterosexual
1 Predominantly heterosexual and only incidental
homosexual
2 Mostly heterosexual and more than incidentally
homosexual
3 Equally
4 Predominantly homosexual and only incidental
heterosexual
5 Mostly homosexual and more than incidentally
Fig. 11. Hormonal Changes at Puberty heterosexual
6 Completely homosexual
PREGNANCY AND PUERPERIUM X Was created for those who experience no sexual
 Erongenous zones (clitoris + lower third of anterior vagina) desire
 Issue of sexual activity during pregnancy
 Resumption of sexual activity after delivery (normal)
MASTURBATION
o After vaginal delivery: 4-6 weeks
 62% of females reported that they have masturbated
o After CS: 3 weeks
 45% of females who reported having masturbated indicate that
they could reach orgasm within 3 minutes
AGING
 92% of males reported that they have masturbated
 In men
o Peak activity and potency at 17-18 years with frequent
MARITAL COITUS
orgasms, short refractory period, forceful ejaculation
o Decrease as they age
AVERAGE FREQUENCY OF MARITAL COITUS AS
o Transient impotence as the men reaches 40-50 years old
REPORTED BY WOMEN
LATE TEENS 2.8 times a week
30 y/o 2.2 times a week
50y/o Once a week
 Average frequency of sex is couple dependent so there is no
definition of normal sex

 In women
o Peak sexual responsiveness in late 30’s and early 40’s that
reflect greater security with one’s sexuality
o Menopausal women may have increased or decreased
sexual activity
 Physical change may make sex more difficult (eg.
Thinning of vaginal mucosa, decrease in lubrication)
 Availability of partner (widows are more common in
society)
 Need for regular sexual activity to maintain sexual
responsiveness.
EXTRA-MARITAL SEX
 Kinsley estimated that approximately 50% of all married males
had some extra-marital experiences at some time during their
married lives.
 Among the sample, 26% of females had extra-marital sex in
their 40’s
 Between one in 6 and 1 in 10 females from age 26 to 50 were
engaged in extra-marital sex.
SADOMASOCHISM
 12% of females and 22% of males reported having an erotic
response to sadomasochistic story
 55% of females and 50% of males reported having responded
erotically to being bitten
SEXUAL MYTHS
(All of the following are FALSE BELIEFS)
 Need to aim for simultaneous orgasm (this is only true for the
satisfaction of the female partner, but has nothing to do with
pregnancy)
 Superiority of vaginal over clitoral orgasm
 Direct contact with the clitoris in missionary position (clitoris
normally retracts under the symphysis)
 Advantage of large penis over small penis as an organ of
copulation
 Circumcision increases or decreases sensation or delay
ejaculation
 Penis size depends on the height of the individual
 Man on top position is the only position
 Sexual satisfaction is brought about by the mastery of a wide
sexual repertoire
 The more challenging the position, the greater the satisfaction

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SEXUAL POSITIONS
MISSIONARY POSITION

SPOON POSITION
 19TH Century Christian missionaries believe that
this is the only normal position  Close fit of the bodies
 Comfortable  Good for later pregnancies because there is
 Good depth of penetration less pressure on the belly

LEAPFROG POSITION
WOMAN ON TOP POSITION

 Good when woman starts to feel uncomfortable

 Couple face each other
from the man’s weight
 Woman is in control and can reach orgasm more
 Protects the belly from vigorous thrusting
easily
 Maximal indirect stimulation of the clitoris
SPREAD EAGLE POSITION

 Best if male has a heart disease or is fat

 Best if female has dyspareunia
SIDE TO SIDE POSITION

 Comfortable for woman

 Can roll into spoons

 More difficult to penetrate

SEXUAL DYSFUNCTION
 Good for later months of pregnancy
 Common cause
 Less strenuous
o Lack of information or education about sex
o Failure of communication between parents
o Fear of failure
OR DORSAL ENTRY POSITION

o “Spectatoring”- intellectualizing sex preventing pleasure

REAR END POSITION OR

o Dysfunctional personality
REAR ENTRY

 Good for deep penetration

 Allow for vigorous thrusting
 May not be suitable for pregnancy
 Best for endometriosis
POSITIONS FOR PREGNANCY Fig. 12. Vicious Cycle of Sexual Dysfunction

CHARACTERISTICS OF DYSFUNCTIONAL COUPLES

 Avoidance of sexual behavior
 Reluctance to discuss sex
ASTRIDE POSITION

 Increased masturbatory activity

 Fantasies about partner substitution
 Decreased self-esteem
 Feelings of anger

SEXUAL RESPONSE CYCLE IN SEXUAL DYSFUNCTION

 Variation of woman on top
 Good for middle months of pregnancy
Desire Phase Dysfunction
 Individuals who have naturally low levels for normal sexual
gratification (nor necessarily a dysfunction)
 HSDD: Hypoactive Sexual Desire Disorder

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 HUMAN SEXUALITY 1.03

 Several aversion disorder caused by anxieties and phobias SEXUAL ANESTHESIA

relating to sexual activity  Total lack of ability to “feel anything”
 Psychiatric rather than purely sexual disorder
Arousal (Vasocongestive) Phase Dysfunction
 Problems in achieving a suitable level of sexual arousal OTHER ENTITIES
 Male erectile disorder  Pelvic congestion syndrome
 Female sexual arousal disorder, lack of vaginal lubrication, o Vague syndrome of neurovascular origin with congested
general sexual dysfunction venous channels of the pelvis causing pain that may be a
 Involuntary spasm, outer vaginal musculature in women, manifestation of psychosocial conflict
vaginismus o Gynecologic problem
 Dyspareunia
Orgasmic (Reversed Vasocongestive) o Painful intercourse
Phase Dysfunction o May be organic (infection)
 Problems in triggering orgasm, creating an inordinate orgasmic  Nymphomania
delay or a complete inability to reach orgasm o Extreme eroticism or sexual desire (cannot be considered
 Male orgasmic disorder pathologic if the affected patient has met a partner who
 Premature ejaculation, lack of ejaculatory control in men also has the same level of sexual appetite)
 Post-ejaculatory pain
MALE SEXUAL DYSFUNCTION
MEDICAL CONDITION AFFECTING SEXUAL DESIRE, ERECTILE DYSFUNCTION
AROUSAL, AND ORGASM  Impotence
 Alcoholism  May be situational or partner-dependent
 Amenia  Causes:
 Anxiety disorder o Conflicts in the relationship
 Cerebral vascular accidents o Anxiety and depression
 Cirrhosis o Drug, alcohol, and substance abuse
 Coronary disease o Medical illness eg. DM, Liver disease
 Degenerative disease
 Depression PREMATURE EJACULATION
 Diabetes  Sign of ambivalence toward women to frustrate the partner
 Drug addiction  Caused by prostitis or degenerative neurologic disorder
 Hand trauma
 Head injury RETARDED EJACULATION
 Hepatitis  Inhibition of ejaculatory reflex
 Neurological disorder  May be due to antihypertensive or antipsychotic drugs
 Nutritional disorder  Prior to traumatic experience eg. Mental conflict
 Parkinson’s disease
 Pituitary and hypothalamic insufficiencies due to tumor OTHER ENTITIES
 Testosterone deficiencies in men  Retrograde ejaculation
 Tuberculosis o Semen is expelled into the bladder

 Satyrism
o Male counterpart of nymphomania

PARAPHILIAS
 Sexual masochism: recurrent urge
or behavior or wanting to be
SADOMASOCHISM
humiliated, beaten, bound or
otherwise made to suffer
 Recurrent urge or behavior
involving acts in which the pain or
SEXUAL SADISM
humiliation of the victim is
sexually exciting
 Use of non-sexual or nonliving
FETISHISM
objects to gain sexual excitement
TRANSVERSE  Wearing clothes of another gender
FETISHISM for sexual desire
Fig. 12. Mind-Body Interactions in Sexual Arousal  Sexual attraction to prepubescent
PEDOPHILIA
FEMALE SEXUAL DYSFUNCTION children
GENERAL SEXUAL DYSFUNCTION  Recurrent urges or behavior of
FROTTEURISM touching or rubbing against a non-
 Frigidity
consenting person
 Inhibition of general arousal
 Lack of erotic feeling STATUEPHILIA  Sexual attraction to statues
 Impairment of vasocongestive aspect of sexual response (PYGMALIONISM)
 Maybe due to depression, anxiety or deep seated sexual  Attraction to other species as
ZOOPHILIA
aversion partner
 Phone sex
DIRTY TALK
VAGINISMUS  Cyber sex
 Conditioned spasm of the vaginal introitus  Recurrent urges or behavior to
 Causes: EXHIBITIONISM expose one’s genital to an
o Organic: painful episiotomy unsuspecting person
o Psychosocial: rape, trauma, fear of pregnancy, fear of  Recurrent urge or behavior to
intercourse VOYEURISM/ observe an unsuspecting person
PEEPING TOM who is naked, disrobing or
ORGASMIC DYSFUNCTION engaging in sexual activity.
 Inability to reach orgasm
 Maybe due to inadequate stimulation of underlying psychic PHYSICIAN’S OWN SEXUALITY
conflict  Education and counseling about sexuality
 May be situational  Recognition and early intervention for sexual dysfunction

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 HUMAN SEXUALITY 1.03

 Handling consequences of sexual behaviour (eg. STD,

pregnancy, rape)
 Dealing with homosexuality
 Handling of “sexual situations” in the workplace
 Proper and prompt referral to other professionals for help

QUIZLET
Identify.
1-2. Name at least two sexual positions recommended for
pregnant women.
3. The critical period in the development of a positive feeling
about one’s own sex.
4. Name an icon that was allegedly known to be a pedophile.
5. Loss of erection is very unlikely during this phase of sexual
response.
6. Also known as the non-linear model of female sexual response.
7. The G-spot.
8. Common manifestation of endometriosis.
9. A condition in which there is a total lack of ability to feel
anything.
10. Shaina Magdayao was known to suffer from this sexual
dysfunction.

True or False.
1. Simultaneous orgasm is needed for pregnancy to occur.
2. Recurrent urge or behavior involving acts in which the pain or
humiliation of the victim is sexually exciting is knwon as
ssexual sadism.
3. Sexual satisfaction is brought about by the mastery of a wide
sexual repertoire.
4. What you eat may reflect on the smell of the semen.
5. Estimated size of the penis can be determined by the knowing
the height of a person.

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