Normal Human Sexuality

and Sexual Dysfunction

 • It is the process by which people experience and
Normal express themselves as sexual beings.

Sexuality • Sexuality has been a consistent focus of curiosity,

and interest, to humankind.
Normal Human Sexuality
• Sexuality is determined by anatomy, physiology, the culture in which a person
lives, relationships with others and developmental experiences throughout the life
cycle. It includes the perception of being male or female and private thoughts and
fantasies as well as behavior.
• Normal sexual behavior brings pleasure to oneself and one’s partner, involves
stimulation of the primary sex organs including coitus and often leads to climax;
it is devoid of inappropriate feelings of guilt or anxiety and is not compulsive.
• Societal understanding of what defines normal sexual behavior is inconstant and
varies from era to era, reflecting the cultural mores of the time.
Normal sexuality- Anatomical and
Physiological Bases
• In the 1960s emphasis was placed on psychological and social contributants to
dysfunction;
• in the 1990s, greater emphasis was placed on the genetic, neuroanatomical, and
neurochemical model of human sexuality than on psychological and social factors.
• Currently, most clinicians believe an interplay of all these factors should be
considered in treating sexual dysfunction.
Male Anatomy
• The external genitalia of the normal adult man include the penis, scrotum, testes,
epididymis, and parts of the vas deferens. Internal components include the vas
deferens, ejaculatory ducts, and prostate gland.
• PENIS- The word penis has been traced from the Latin, meaning variously “tail” or
“to hang” and refers to the pendant position of the organ in its resting or flaccid
state. Freud referred to the penis as the executive organ of sexuality.
• Does size of the penis effects on sexuality?
• Does Circumcision have effect on sexuality?
• Does volume or duration of ejaculation have any effect on satisfactory orgasm? –
The ejaculate consists of approximately 1 teaspoon (2.5 mL) of fluid and contains
approximately 120 million sperm cells. It is believed that the larger the ejaculate, the more
pleasurable the orgasm, but this belief is highly subjective.
The sense of pleasure that accompanies orgasm is thought to be a cortical
experience. Men who have had a prostatectomy and therefore no longer ejaculate, report
they still experience strong and satisfactory orgasms.
Female Anatomy
• The external genitalia of the normal woman, also called the vulva, include the mons
pubis, major and minor lips, clitoris, glans, vestibule of the vagina, and vaginal orifice.
The internal system includes the ovaries, fallopian tubes, uterus, and vagina.
• Role of Clitoris in sexuality- The clitoris is unique in that the only known function is the
generation of sexual pleasure when stimulated by touch or vibration. Its gross structure is
like an iceberg, in that only a fifth is visible on the surface while the rest is hidden deep
beneath the skin.
• G spot-
• in 1950, Ernst Gräfenberg described a site on the anterior wall of the vagina that, when
stimulated by deep pressure, becomes swollen and/or enlarged and protrudes into the vaginal
lumen and is highly effective in causing orgasm in women when stimulated.
• Authors found dozens of trials that have attempted to confirm the existence of a G-spot using
surveys, pathologic specimens, various imaging modalities and biochemical markers. The
surveys found that the majority of women believe a G-spot actually exists, although not all
women believed in it and were able to locate it.
• Attempts to characterize vaginal innervation have shown some differences in nerve distribution
across the vagina, although the findings have not proven to be universally reproducible.
Furthermore, radiographic studies have been unable to demonstrate a unique entity other than
the clitoris, whose direct stimulation leads to vaginal orgasm.
• They concluded that objective measures have failed to provide strong and consistent evidence
for the existence of an anatomical site that could be related to the famed G-spot.
Innervation of sex organs
• Innervation of the sexual organs is mediated primarily through the autonomic nervous system
(ANS).
• Penile tumescence occurs through the synergistic activity of two neurophysiological pathways.
A parasympathetic (cholinergic) component mediates reflexogenic erections via impulses
that pass through the pelvic splanchnic nerves (S2, S3, and S4). Clitoral engorgement and vaginal
lubrication also result from parasympathetic stimulation that increases blood flow to genital tissue.
A thoracolumbar, mainly sympathetic pathway transmits psychologically induced impulses.
• Evidence indicates that the sympathetic (adrenergic) system is primarily responsible for ejaculation.
In women, the sympathetic system facilitates the smooth muscle contraction of the vagina, urethra,
and uterus that occurs during orgasm.
Endocrinology
• From the time of conception, hormones play a major role in human sexual development. Unlike
the fetal gonads, which are under chromosomal influence, the fetal external genitalia are very
susceptible to hormones.
• Deprived of male and female gonads and the respective hormones, testosterone and estrogen,
the human adult does not develop normal secondary sexual characteristics, is incapable of
reproduction, and, in the case of the woman, does not develop a menstrual cycle.
• Testosterone is the hormone believed to be connected with libido in both men and women. The
release of testosterone in men is under the control of the hypothalamic–gonadal– pituitary axis.
The hormone is secreted in a pulsatile manner and in a diurnal rhythm, with the highest levels
occurring in the morning and the lowest levels in the evening. Normal concentrations range from
270 to 1,100 ng/dL. Decreased testosterone concentrations are apparent by age 50 years and
decrease at the rate of approximately 100 ng/dL per decade.
• Recent studies indicate that estrogen is also a factor in the male sexual response and that a
decrease in estrogen in the middle-aged male results in greater fat accumulation just as it does in
women. Progesterone mildly depresses desire in men and women as do excessive prolactin and
cortisol.
Genetics
• Genes are involved in gonadal differentiation, resulting in the formation of the
bipotential gonad into either a testis or ovary. The best-defined gene in this process is
SRY (sex-​determining region of the Y chromosome), located on the short arm of the Y
chromosome.
• Other genes also play a smaller role, such as WT1 (Wilms tumor 1), SF-1 (steroidogenic
factor 1), SOX9, DAX1, and MIS-12 (müllerian inhibiting substance 12).
• Defects or mutations in these genes cause failures in gonadal differentiation that produce
clinical syndromes known as intersex disorders.
CNS and Sexual behavior
• Cortex: The cortex is involved both in controlling sexual impulses and in processing sexual
stimuli that may lead to sexual activity. These areas included the orbitofrontal cortex,
which is involved in emotions, the left anterior cingulate cortex, which is involved in
hormone control and sexual arousal, and the right caudate nucleus, whose activity is a
factor in whether sexual activity follows arousal.
• Limbic System: In all mammals, the limbic system is involved in behavior required for self
preservation and the preservation of the species. the lower part of the septum and the
contiguous medial preoptic area, the fimbria of the hippocampus, the mammillary
bodies, and the anterior thalamic nuclei have all elicited penile erection.
• Brainstem: Brainstem sites exert inhibitory and excitatory control over spinal sexual
reflexes.
Brain Neurotransmitters
• A vast array of neurotransmitters is produced by the brain, including dopamine,
epinephrine, norepinephrine, and serotonin, among others. All affect sexual function.
• An increase in dopamine is presumed to increase libido.
• Serotonin produced in the upper pons and midbrain is presumed to have an inhibitory
effect on sexual function.
• Oxytocin, the neurohormone involved in the milk ejection reflex, is released with orgasm
and is believed to reinforce pleasurable activities.
Psychosexuality
• Sexuality and total personality are so entwined that it is virtually impossible to speak of
sexuality as a separate entity.
• The term psychosexual is therefore used to describe personality development and
functioning, as these are affected by sexuality.
Psychosexual Factors
• Sexuality depends on four interrelated psychosexual factors: sexual identity, gender
identity, sexual orientation, and sexual behavior. These factors affect personality,
development, and functioning.
• Sexual identity is the pattern of a person’s biological sexual characteristics:
chromosomes, external and internal genitalia, hormonal composition, gonads, and
secondary sex characteristics. In normal development, these characteristics form a
cohesive pattern that leaves individuals in no doubt about their sex.
• Gender identity is an individual’s sense of maleness or femaleness. By the age of 2 or 3
years, most children have a firm conviction that “I am a boy” or “I am a girl.” Gender
identity results from an almost infinite series of clues derived from experiences with
family members, peers, and teachers, and from cultural phenomena.
• Gender role behavior as all those things that a person says or does to disclose himself or
herself as having the status of boy or man, girl or woman, respectively.
A gender role is not established at birth, but it is built up cumulatively through
(1) experiences encountered and transacted through casual and unplanned
learning,
(2) explicit instruction and inculcation, and
(3) spontaneously putting two and two together to make sometimes four and
sometimes five.
• Sexual orientation describes the object of a person’s sexual impulses: heterosexual
(opposite sex), homosexual (same sex), or bisexual (both sexes). The majority of people
have a heterosexual orientation.
Human Sexual Response
 • lower animals are pushed to engaged in
reproductive behavior by some internal
factors called drive.
• In human motives for engaging in sexual
intercourse may be larger in number and
Motivation psychologically complex in nature.
To Sexual • People may engage themselves for sex for
• Simple reason like to reproduce, to
Activity experience pleasure, to relieve sexual
tension
• Spiritual like to get closure to God
• To please/ punish a partner,
• To make a conquest.
 Motivation to sexual activity
Reproduction
Experience pleasure
Relieve sexual tension
Express emotional closeness
Because the partner wants it
To please the partner
To make a conquest
To feel valued by partner
Expressing value for a partner
Relief from stress
Nurturing one’s partner
Enhancing feelings of
personal power
Sexual variety
Improving sexual skills
Money/favours
Revenge
Status/reputation/power
Why Humans Have Sex?

•237 reasons for having sex.

•4 large factors
•and 13 sub-factors.
Gender differences
• Many similarities (20/25) – but:
– Men more often centering on
the physical appearance and
desirability of the partner
– Women are more often
endorsing the emotional
motivations
– No data over a lifespan
 Sexual Scripts
Passivity/receptivity Strength
Maternage/caregiving Individuality
Frailty Autonomy
Pain tolerance Dominance
Stoicism
Emotionality
Physical aggression
Beauty and youth
Avoid vulnerability or emotion
Fulfilment of male desires/needs No need for help
No aggressive ,
Assertive sexuality
No assertive sexuality Perfect intercourse performance
What is a
sexual
response?

Series of emotional and physical changes that occur as a person

becomes sexually aroused and participates in sexually
stimulating activities including intercourse and masturbation.
Biopsychosocial
Biopsychosocia
Modell of Sexual
Model of
ResponseSexual
Response

•Rosen RC, Barsky JL. Obstet

Gynecol Clin North Am.
2006;334:515-526.
 Human Sexual
Response

Masters & Johnson first

Masters & Johnson first published
published “Human Sexual
“Human Sexual inResponse”
Response” 1966 in 1966
Masters & Johnson Human
Sexual Response Model
(EPOR)

•Includes 4 subsequent phases-

Excitement
Plateau
Orgasm
Resolution

•Linear model of sexual behaviour.

Masters, WH, Johnson, VE. Human sexual response. Little Brown: Boston
1966.
HUMAN SEXUAL RESPONSE PATTERN

Master and Johnson’s model with Kaplan’s modifier

 Excitement:
characterized by increased heart rate, respiration, and
blood pressure.

In addition, myotonia (an increase in muscle tension),

vasocongestion (engorgement of blood vessels), and nipple
hardening, or erection occur.
These changes are often accompanied by a flush or
reddening of the skin.

In women, a rush of blood causes engorgement of the

clitoris, labia majora, minora, and uterus, with uterine
position elevating slightly. Vaginal lubrication also begins
with this stage.
In men, the rush of blood causes penile erection and
enlargement of the testes, with the scrotal sac pulling more
tightly toward the body.
Plateau
• Breathing, blood flow, and heart rate continue to increase and stabilize. Muscle
tension increases and may extend to hands, feet, face, and other areas of the
body.
• In women as blood flow increases, the vaginal walls darken, and the clitoris
becomes increasingly sensitive. The vagina expands and the uterus becomes
fully elevated.
• The Bartholin glands produce additional lubrication in and around the vagina.
• In men, the testicles are drawn further into the scrotal sac and pre seminal fluid
from Cowper’s glands may be secreted at the penile opening.
Orgasm
• Women experience contraction of the pelvic
muscles surrounding the vagina and uterus,
followed by release of built-up muscle tension.
• In men, ejaculation/orgasm has two stages of
autonomic response.
In the first— emission —the vas deferens,
seminal vesicles, and prostate trigger the urethral
bulb to expand with seminal fluid, with internal
sphincter contraction closing the bladder neck to
prevent urine leakage.
In the second— expulsion —muscles
surrounding the base of the penis contract,
propelling semen externally.
 Male:
• Loss of erection as blood flows out of
penis
• Scrotum and testis returns to normal
Resolution stage
• A general feeling of relaxation

Female:
• Blood that had engorged areas of the
body now flows out, swelling decreases,
eventually muscle tension and skin
flushes go away.
• A general feeling of relaxation
 After orgasm, men have a refractory
period (several minutes to many hours)

They cannot be stimulated to further

Refractory orgasm.

Period Women do not have a refractory period

They are capable of multiple and

successive orgasms.
 It assumes that men and women respond
exactly the same, all four steps, every time

It ignore non-biologic experiences such as

desire, emotion, pleasure and satisfaction.
Criticism
to the It is limited to genital response
model

Based on cultural idea that sex is genital

and orgasm the ultimate goal
(overemphasis on intercourse and orgasm)
Kaplan’s model of sexual response
Three-Stage Model

Desire

Excitement

Orgasm

This model give the same importance to the physiological as well as the psychological
aspects of sexual response.
Kaplan, HS. The New Sex Therapy. Bruner Mazel: New York 1974
 • The phase is characterized by sexual fantasies and
the conscious desire to have sexual activity.
DESIRE • Desire may be biological driven. OR
• Wish to bond sexually with particular partner
 • Many women do not experience
spontaneous desire as described in
the Kaplan Model. They experience
receptive/motivational desire.
Criticism to
• Many women experience desire after
linear the arousal response
models • Importance of emotional intimacy,
sexual stimuli and relationship
satisfaction not introduced in linear
models.
Basson’s Model of
Female Sexual Response

• Circular model of womens sexual response

• An alternative model of womens normative
sexual function.
• Featured a responsive form of desire.
Basson’s Model
of Female •Basson R. Obstet Gynecol. 2001;98(2):350-353.
Sexual Response
 Sexual desire is not a
prerequisite for the sexual
response to be initiated
Key
Points of Desire may be initiated after
a woman has received
basson’s pleasurable sexual stimuli
model Emphasize on women’s
willingness to receive sexual
stimuli
SO… FEMALE PECULIARITIES

Spontaneus desire Responsive desire

Subjective arousal Genital arousal

Emotional intimacy
and relationship Orgasm
satisfaction

Desire Arousal
Brotto et al., J Sex Med 2010; 7(1 Pt 2):586-614
Basson et al., J Sex Med 2004; 1:40-8
Models
endorsed by
women and
men

•Sand, et al., Women’s

endorsement of models of
female sexual response. J Sex
Med 2007; 4: 708–719.
•Giraldi, et al., Men’s
endorsement of models of
sexual response and
motivation for sexual activity.
Seoul 2010.
FSFI cut-off

•Sand, et al., Women’s

endorsement of models of female
sexual response. J Sex Med 2007;
4: 708–719.
Giraldi, et al., Men’s endorsement
of models of sexual response and
motivation for sexual activity.
Seoul 2010.
 Majority of men endorsed the linear
models, regardless of their state of ED
or their satisfaction with their sexual
life.
KEY
POINT Women’s sexual responses were more
likely to be described by models who
emphasized arousal and desire than by
a model who focused on the wish for
intimacy, lack of spontaneous desire,
and receptive desire.
Clinical
• In traditional sex therapy, the major
implications focus is placed on increasing intimacy
and taking the focus away from the
genital responses and spontaneous
desire, that is, moving toward the
Basson model.
 • LINEAR MODELS
I mostly agree to sexual activity with my partner
or initiate it when I am feeling sexual desire.
That means I want the sexual sensations,
excitement, orgasm, and pleasant feelings that
follow. Once my partner and I start
foreplay(touching and stimulating each other), I
How to assess become aroused. My arousal increases and I
might have orgasm.
the patients’
• CIRCULAR MODEL
current sexual I mostly agree to sexual activity with my partner
experience or initiate it for reasons other than sexual desire.
For example, (1) I might want to be closer to my
partner emotionally or (2) out of habit or (3) I
don’t want to disappoint my partner or (4) I
hadn’t had sex for a while. In other words, initially
I am not “in the mood.” Once my partner and I
start foreplay (touching and stimulating each
other), I become aroused and then I feel the
desire to continue. Thus, my arousal increases and
I might have orgasm.
DSM-5 CHANGES

• Definitions based on common sexual response cycles had been

challenged suggesting that male and female sexuality are
different and therefore subject to be classified and managed
differently.
– For MSD: Kaplan’s model
– For FSD: Basson’s model
Models based on neurobiological substrate
 The dual control model
Bancroft (2000)

sexual response and associated

arousal occurs in a particular
individual, in a particular situation, is
ultimately determined by the balance
between the sexual excitation system
and the sexual inhibition system of
individual brain, each of which has a
neurobiological substrate.

Bancroft, J, Janssen, E. The dual control model of male sexual response: a theoretical approach to
centrallymediated erectile dysfunction. Neurosci Biobehav Rev 2000; 24: 571–579.
 1.the effects of different stimulations depend
ultimately on neurobiological characteristics of
Three basic the individuals involved
assumptions
2. neurobiological inhibition of sexual response
is an adaptive pattern which reduces the
likelihood of sexual response.

3. individuals vary in their propensity for both

sexual excitation and sexual inhibition

Bancroft, J, Janssen, E. The dual control model of male sexual response: a

theoretical approach to centrally mediated erectile dysfunction. Neurosci
Biobehav Rev 2000; 24: 571–579.
The dual
control model
Individual with an unusual high
propensity for excitation and/or low
propensity for inhibition would be
more likely to engage in high risk or
otherwise problematic sexual
behavior SES SIS
•To value •To value
sexual sexual
the individuals with a low propensity for excitation inhibition
sexual excitation and/or high propensity
for sexual inhibition would be more likely
to experience problem with sexual
response i.e. sexual dysfunctions.
Mutifactor models:
The sexual Tipping
point model
(Perelman, 2009)

•Perelman, M. The sexual

Tipping Point: a
mind/body model for
sexual medicine. J Sex
Med 2009; 6: 629-632.
According to this model

The sexual tipping point can vary between

individuals, as well as within or between
sexual experiences of the same individual

The specific threshold for the sexual

response is determined by multiple factors
for any given moment or circumstance, with
one factor or another dominating, while
others recede in importance.
Sexual Orientation
• An individual’s ‘sexual orientation’ describes their preference for the gender of people to whom they
are sexually attracted; some definitions also include romantic and emotional attraction.
• Traditionally, three sexual orientations are identified:
• heterosexuality: preferential sexual attraction to people of the other sex
• homosexuality (gay, lesbian): preferential sexual attraction to people of the same sex
• bisexuality: attraction to people of both sexes
• A fourth orientation, asexuality, has been proposed for individuals who have no sexual attraction or interest in men, women or any object or concept; this
remains a controversial topic.

• Sexual orientation usually exists as a continuum rather than as discrete categories.

But in some individual sexual orientation may be fluid and may change over time.
• ‘Sexual behavior’ refers to the activities that individuals practice in order to facilitate or experience a sexual response.
• In most people, their sexual orientation, identity and behaviours are congruent. Conflict between any
of these facets of sexuality may result in sexual dissatisfaction and impairment of sexual response.
• Congruent sexual orientation and identity are also congruent with behaviour in most circumstances,
Homosexuality
• Epidemiology- The prevalence of homosexual orientation in different cultures has been difficult to
establish, but values of around 4-5% in the adult male population1 and around 2-3% of the female adult
population seem reasonable estimates.
• Internalized homophobia/homonegativity (IH) refers to the personal acceptance and endorsement of
sexual stigma, as part of the individual’s value system and self-concept. It is the counterpart to sexual
prejudice among heterosexuals.
• Minority stress theory proposes that sexual minority health disparities can be explained in large part by
stressors induced by a hostile, homonegative culture, which often results in a lifetime of harassment,
maltreatment, discrimination and victimization, and may ultimately impact access to care. Minority stress
may have an impact on psychological and emotional development, and personal relationships, making
people more vulnerable to a variety of psychopathological conditions.
Determinants of sexual orientation and
identity
• The determinants of Sexual Orientation and Identity remain the subject of fierce political and scientific
debate.
• There is evidence for genetic, biological, developmental and environmental influences.
• A number of studies have calculated the prevalence of homosexual orientation among siblings where one
sibling is homosexual.3 Most studies show that the prevalence amongst brothers of a male homosexual
appears to be around 9%. The prevalence of homosexuality amongst sisters of a male homosexual appears
to be around 5%; the prevalence amongst sisters of a homosexual female range from 6% to 25%,4 the
prevalence amongst brothers of a homosexual female appears to be around 10%.
• The determinants of sexual orientation and identity remain unclear, although it seems likely that they are
multifactorial. Most authorities agree that orientation and identity are not a matter of choice or the sole
consequence of upbringing and environment.
Treatment of sexual problems in gay and
lesbian population
• There is a paucity of data on the treatment of sexual dysfunction in gay and lesbian populations.
• More recently, it has been observed that sex therapy with homosexual people is more likely to address the specific issues of
sexual identity, alternative lifestyles and the nature of some of the sexual behaviours.
• When working with same sex couples with sexual dysfunction, it is important to remember that

the relationship is influenced by specific variables of homosexuality

Sexuality is often not primarily focused on penetration and the approach to pleasure can be very different from
those of a heterosexual sexuality.
• Clinicians have an ethical obligation to practice without discrimination. However, they must also be honest with themselves
and their patients; if their moral worldview renders it impossible for them to work effectively with gay, lesbian and bisexual
people, they should explain this to their patients and offer to help them find another therapist who can meet their needs.
• As there is no good evidence that sexual orientation and identity can be permanently changed, there are serious moral and
ethical objections to interventions with this intention, as they may not only effect the individual concerned, but may also
have profound adverse effects on others.
Sexual History taking