Kaplan and Sadock's Comprehensive Textbook of Psychiatry

1. CHAPTER: 21.1
NORMAL SEXUALITY

2. Normal sexuality
Sexuality is determined by
anatomy,
physiology,
the culture in which a person lives,
relationships with others,
developmental experiences throughout the life
cycle
Normal sexual behaviour brings pleasure to
oneself and one's partner, involves stimulation
of the primary sex organs including coitus.

3. PSYCHOSOICAL FACTORS
• Sexuality depends on four interrelated
psychosexual factors:
sexual identity,
gender identity,
sexual orientation,
sexual behaviour.

4. Childhood Sexuality
• Most sexual learning experiences in
childhood occur without the parents'
knowledge, but awareness of a child's sex
does influence parental behaviour.
• Male infants, for instance, tend to be
handled more vigorously and female infants
tend to be cuddled more.

5. Sexual Identity and Gender Identity
 Sexual identity is the pattern of a person's
biological sexual characteristics:
chromosomes,
 external genitalia,
 internal genitalia,
 hormonal composition,
 gonads,
 secondary sex characteristics
 Gender identity is a person's sense of maleness
or femaleness.

6. Differentiation of male and female external
genitalia from indifferent primordia.
Male differentiation occurs only in the presence of
androgenic stimulation during the first 12 weeks of fetal life.

7. Classification of Intersexual
Disorders

8. Virilizing adrenal hyperplasia
(adrenogenital syndrome)
• Results from excess androgens in
fetus with XX genotype; most common
female intersex disorder; associated
with enlarged clitoris, fused labia,
hirsutism in adolescence

9. Turner's syndrome
• Results from absence of second
female sex chromosome (XO);
associated with web neck, dwarfism,
cubitus valgus; no sex hormones
produced; infertile

10. Klinefelter's syndrome
• Genotype is XXY; male habitus present
with small penis and rudimentary
testes because of low androgen
production; weak libido; usually
assigned as male

11. Androgen insensitivity
syndrome (testicular-feminizing
syndrome)
• Congenital X-linked recessive disorder that
results in inability of tissues to respond to
androgens; external genitals look female
and cryptorchid testes present; in extreme
form patient has breasts, normal external
genitals, short blind vagina, and absence of
pubic and axillary hair

12. Enzymatic defects in XY
genotype (e.g., 5-α-reductase
deficiency, 17-hydroxy-steroid
deficiency)
• Congenital interruption in
production of testosterone that
produces ambiguous genitals and
female habitus

13. Hermaphroditism
• True hermaphrodite is rare and
characterized by both testes and
ovaries in same person (may be 46 XX
or 46 XY)

14. Pseudohermaphroditism
• Usually the result of endocrine or enzymatic
defect (e.g., adrenal hyperplasia) in persons
with normal chromosomes; female
pseudohermaphrodites have masculine-
looking genitals but are XX; male
pseudohermaphrodites have rudimentary
testes and external genitals and are XY

15. Gender Role
• A gender role is not established at birth but
is built up cumulatively through
(1) experiences encountered and transacted
through casual and unplanned learning,
(2) explicit instruction and inculcation,
(3) spontaneously putting two and two
together to make sometimes four and
sometimes five.

16. • Persons' gender roles can seem to be
opposed to their gender identities.
Persons may identify with their own
sex and yet adopt the dress, hairstyle,
or other characteristics of the
opposite sex

17. Sexual Orientation
Sexual orientation describes the object
of a person's sexual impulses:
•heterosexual (opposite sex),
•homosexual (same sex),
•bisexual (both sexes).
•A group of people have defined
themselves as asexual and assert this as
a positive identity.

18. Sexual Behavior
The Central Nervous System and Sexual
Behavior
The Brain
Cortex - is involved both in controlling sexual
impulses and in processing sexual stimuli
that may lead to sexual activity
The limbic system - is directly involved with
elements of sexual functioning. The anterior
thalamic nuclei have all elicited penile
erections.

19. • Brainstem - sites exert inhibitory and
excitatory control over spinal sexual
reflexes.
• Brain Neurotransmitters - including
dopamine, epinephrine, norepinephrine,
and serotonin, are produced in the brain
and affect sexual function.
Dopamine - increase libido.
Serotonin - inhibitory effect on sexual
function.
• Spinal Cord
Sexual arousal and climax are ultimately
organized at the spinal level.

20. Physiological Responses
• William Masters and Virginia Johnson observed that the
physiological process involves increasing levels of
vasocongestion and myotonia (tumescence) and the
subsequent release of the vascular activity and muscle
tone as a result of orgasm (detumescence).
• A four-phase response cycle:
phase 1 - desire;
phase 2 - excitement;
phase 3 - orgasm;
phase 4 - resolution

21. Phase 1: Desire
• The classification of the desire (or
appetitive) phase, which is distinct from
any phase identified solely through
physiology, reflects the psychiatric
concern with motivations, drives, and
personality.
• The phase is characterized by sexual
fantasies and the desire to have sexual

22. Phase 2: Excitement
• The excitement and arousal phase, brought on by
psychological stimulation (fantasy or the presence of a
love object) or physiological stimulation (stroking or
kissing) or a combination of the two, consists of a
subjective sense of pleasure.

23. Phase 3: Orgasm
• The orgasm phase consists of a peaking of sexual
pleasure, with the release of sexual tension and the
rhythmic contraction of the perineal muscles and the
pelvic reproductive organs.
• A subjective sense of ejaculatory inevitability triggers
men's orgasms. The forceful emission of semen follows
• In women, orgasm is characterized by 3 to 15 involuntary
contractions of the lower third of the vagina and by strong
sustained contractions of the uterus, flowing from the

24. Male Sexual Response Cycle

25. Excitement Orgasmic Resolution
Phase Phase Phase
Lasts several 3 to 15 seconds 10 to 15 minutes;
minutes to if no orgasm, ½
several hours; to 1 day
heightened
excitement
before orgasm,
30 seconds to 3
minutes

26. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Skin Just before orgasm: Well- Flush
sexual flush developed disappears in
inconsistently flush reverse order
appears; of
maculopapular rash appearance;
originates on inconsistently
abdomen and appearing
spreads to anterior film of
chest wall, face, and perspiration
neck and can include on soles of
shoulders and feet and
forearms palms of
hands

27. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Penis Erection in 10 to 30 Ejaculation; Erection: partial
seconds caused by emission phase involution in 5 to
vasocongestion of marked by three 10 seconds with
erectile bodies of corpus to four 0.8-second variable
cavernosa of shaft; loss contractions of refractory period;
of erection may occur vas, seminal full detumescence
with introduction of vesicles, prostate; in 5 to 30 minutes
asexual stimulus, loud ejaculation proper
noise; with heightened marked by 0.8-
excitement, size of second
glands and diameter of contractions of
penile shaft increase urethra and
further ejaculatory spurt
of 12 to 20 inches
at age 18,
decreasing with
age to seepage at
70

28. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Scrotum and Tightening and lifting of No change Decrease to
testes scrotal sac and elevation of baseline size
testes; with heightened because of loss of
excitement, 50% increase in vasocongestion;
size of testes over testicular and
unstimulated state and scrotal descent
flattening against perineum, within 5 to 30
signaling impending minutes after
ejaculation orgasm; involution
may take several
hours if no orgasmic
release takes place

29. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Cowper's 2 to 3 drops of mucoid fluid No change No change
glands that contain viable sperm
are secreted during
heightened excitement

30. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Other Breasts: inconsistent nipple Loss of voluntary Return to baseline
erection with heightened muscular control state in 5 to 10
excitement before orgasm Rectum: rhythmical minutes
Myotonia: semispastic contractions of
contractions of facial, sphincter
abdominal, and intercostal Heart rate: up to
muscles 180 beats a minute
Tachycardia: up to 175 Blood pressure: up
beats a minute to 40 to 100 mm
Blood pressure: rise in systolic; 20 to 50
systolic 20 to 80 mm; in mm diastolic
diastolic 10 to 40 mm Respiration: up to
Respiration: increased 40 respirations a
minute

31. Female Sexual Response
Cycle

32. Excitement Orgasmic Resolution
Phase Phase Phase
Lasts several 3 to 15 10 to 15
minutes to seconds minutes; if no
several hours; orgasm, 1/2 to
heightened 1 day
excitement
before orgasm,
30 seconds to
3 minutes

33. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Skin Just before orgasm: Well-developed Flush disappears in
sexual flush flush reverse order of
inconsistently appearance;
appears; inconsistently
maculopapular rash appearing film of
originates on perspiration on
abdomen and soles of feet and
spreads to anterior palms of hands
chest wall, face, and
neck; can include
shoulders and
forearms

34. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Breasts Nipple erection in Breasts may Return to normal in
two thirds of become tremulous about 30 minutes
women, venous
congestion and
areolar
enlargement; size
increases to one
fourth over normal

35. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Clitoris Enlargement in No change Shaft returns to
diameter of glands normal position in 5
and shaft; just to 10 seconds;
before orgasm, detumescence in 5
shaft retracts into to 30 minutes; if no
prepuce orgasm,
detumescence
takes several hours

36. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Labia majora Nullipara: elevate No change Nullipara: decrease
and flatten against to normal size in 1 to
perineum 2 minutes
Multipara: Multipara: decrease
congestion and to normal size in 10
edema to 15 minutes

37. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Labia minora Size increased two Contractions of Return to normal
to three times over proximal labia within 5 minutes
normal; change to minora
pink, red, deep red
before orgasm

38. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Vagina Color change to 3 to 15 contractions Ejaculate forms
dark purple; vaginal of lower third of seminal pool in
transudate appears vagina at intervals upper two thirds of
10 to 30 seconds of 0.8 second vagina; congestion
after arousal; disappears in
elongation and seconds or, if no
ballooning of orgasm, in 20 to 30
vagina; lower third minutes
of vagina constricts
before orgasm

39. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Uterus Ascends into false Contractions Contractions cease,
pelvis; labor-like throughout orgasm and uterus
contractions begin descends to normal
in heightened position
excitement just
before orgasm

40. Organ Excitement Orgasmic Resolution
Phase Phase Phase
Other Myotonia Loss of voluntary Return to baseline
A few drops of muscular control status in seconds to
mucoid secretion Rectum: rhythmical minutes
from Bartholin's contractions of Cervix color and
glands during sphincter size return to
heightened Hyperventilation normal, and cervix
excitement and tachycardia descends into
Cervix swells seminal pool
slightly and is
passively elevated
with uterus

41. Phase 4: Resolution
• Resolution consists of the
disgorgement of blood from the
genitalia (detumescence), which
brings the body back to its resting
state.
• Women do not have a refractory
period and are capable of multiple and
successive orgasms.

42. Hormones and Sexual
Behavior
• Substances that increase dopamine levels
in the brain increase desire, whereas
substances that augment serotonin
decrease desire.
• Progesterone mildly depresses desire in
men and women as do excessive prolactin
and cortisol.
• Oxytocin is involved in pleasurable
sensations during sex and is found in
higher levels in men and women following
orgasm

43. Masturbation
• Masturbation is usually a normal precursor of object-related sexual
behaviour.
• When coitus is unsatisfactory or is unavailable because of illness or
the absence of the partner, self-stimulation often serves an adaptive
purpose, combining sensual pleasure and tension release.
• Kinsey reported that when women masturbate, most prefer clitoral
stimulation. Masters and Johnson stated that women prefer the shaft
of the clitoris to the glans because the glans is hypersensitive to
intense stimulation. Most men masturbate by vigorously stroking the
penile shaft and glans.

44. homosexuality
• The term homosexuality often describes a
person's overt behaviour, sexual orientation, and
sense of personal or social identity.
• Many persons prefer to identify sexual orientation
by using terms such as lesbians and gay men,
rather than homosexual, which may imply
pathology and etiology based on its origin as a
medical term, and refer to sexual behavior with
terms such as same sex and male female.

45. Prevalence
• 2 to 4 percent of the population
• According to Kinsey's data, about half of all
prepubertal boys have had some genital
experience with a male partner.

46. Theoretical Issues
Psychological Factors
• According to psychodynamic theory, early-life
situations that can result in male homosexual
behaviour include,
 a strong fixation on the mother
 lack of effective fathering
 inhibition of masculine development by the
parents;
 fixation at, or regression to the narcissistic stage
of development
 losses when competing with brothers and sisters

47. New Concepts of
Psychoanalytic Factors
• According to Richard Isay, gay men have described same-
sex fantasies that occurred when they were 3 to 5 years of
age, at about the same age that heterosexuals have male-
female fantasies.
• The child's perception of, and exposure to, these erotic
feelings may account for such atypical behaviour as
 greater secretiveness than other boys,
 self-isolation,
 excessive emotionality

48. Biological Factors
• Gay men - lower levels of circulatory androgens
• higher incidence of homosexual concordance
among monozygotic twins
• a familial distribution
• a group of cells in the hypothalamus was smaller
in women and in gay men
• Women with hyperadrenocorticalism are lesbian
and bisexual

49. Sexual Behavior Patterns
• The behavioural features of gay men
and lesbian women are as varied as
those of heterosexuals

50. Taking a Sex History
• Identifying data
– Age
– Sex
– Occupation
– Relationship status single, married, number of times previously
married, separated, divorced, cohabiting, serious involvement,
casual dating (difficulty forming or keeping relationships should be
assessed throughout the interview)
– Sexual orientation heterosexual, homosexual, or bisexual (this may
also be ascertained later in the interview)

51. Taking a Sex History
Current functioning
•Unsatisfactory to highly satisfactory
•If unsatisfactory, why?
•Feeling about partner satisfaction

52. Taking a Sex History
Dysfunctions?
–e.g., lack of desire, erectile disorder, inhibited female
arousal, anorgasmia, premature ejaculation, retarded
ejaculation, pain associated with intercourse
(dysfunction discussed below)
–Onset lifelong or acquired
– If acquired, when?
– Did onset coincide with drug use (medications or
illegal recreational drugs), life stresses (e.g., loss
of job, birth of child), interpersonal difficulties

53. Taking a Sex History
• Dysfunctions?
Generalized occurs in most situations or with most
partners
Situational
Only with current partner
In any committed relationship
Only with masturbation
In socially proscribed circumstance (e.g., affair)
In definable circumstance (e.g., very late at night, in
parental home, when partner initiated sex play)

54. Frequency partnered sex (coital and
noncoital sex play)
Desire/libido how often are sexual
feelings, thoughts, fantasies, dreams,
experienced? (per day, week, etc.)

55. Description of typical sexual interaction
• Manner of initiation or invitation (e.g., verbal or
physical? Does same person always initiate?)
• Presence, type, and extent of foreplay (e.g.,
kissing, caressing, manual or oral genital
stimulation)
• Coitus? positions used?
• Verbalization during sex? if so, what kind?
• Afterplay? (whether sex act is completed or
disrupted by dysfunction); typical activities (e.g.,
holding, talking, return to daily activities,
sleeping)

56. • Sexual compulsivity?
• intrusion of sexual thoughts or participation
in sexual activities to a degree that
interferes with relationships or work,
requires deception and may endanger the
patient

57. • Past sexual history
• Childhood sexuality
Parental attitudes about sex degree of openness
of reserve (assess unusual prudery or
seductiveness)
Parents' attitudes about nudity and modesty

58.  Learning about sex
 From parents? (initiated by child's questions or
parent volunteering information? which parent?
what was child's age?) subjects covered (e.g.,
pregnancy, birth, intercourse, menstruation,
nocturnal emission, masturbation)
 From books, magazines, or friends at school or
through religious group?
 Significant misinformation
 Feeling about information

59. • Viewing or hearing primal scene reaction?
• Viewing sex play or intercourse of person
other than parent
• Viewing sex between pets or other animals

60. – Childhood sex activities
• Genital self-stimulation before adolescence; age?
reaction if apprehended?
• Awareness of self as boy or girl; bathroom sensual
activities? (regarding urine, feces, odor, enemas)
• Sexual play or exploration with another child
(playing doctor) type of activity (e.g., looking,
manual touching, genital touching); reactions or
consequences if apprehended (by whom?)

61. • Adolescence
– Age of onset of puberty development of
secondary sex characteristics, age of
menarche for girl, wet dreams or first
ejaculation for boy (preparation for and
reaction to)
– Sense of self as feminine or masculine body
image, acceptance by peers (opposite sex and
same sex), sense of sexual desirability, onset of
coital fantasies

62. • Sex activities
 Masturbation age begun; ever punished or prohibited? method used,
accompanying fantasies, frequency (questions about masturbation
and fantasies are among the most sensitive for patients to answer)
 Homosexual activities ongoing or rare and experimental episodes,
approached by others? If homosexual, has there been any
heterosexual experimentation?
 Dating casual or steady, description of first crush, infatuation, or first
love
 Experiences of kissing, necking, petting (making out or fooling
around), age begun, frequency, number of partners, circumstances,
type(s) of activity
 Orgasm when first experienced? (may not be experienced during
adolescence), with masturbation, during sleep, or with partner? with
intercourse or other sex play? frequency?
 First coitus age, circumstances, partner, reactions (may not be
experienced during adolescence); contraception and/or safe sex
precautions used

63. • Adult sexual activities (may be experienced by some
adolescents)
Premarital sex
• Types of sex play experiences frequency of sexual
interactions, types and number of partners
• Contraception and/or safe sex precautions used
• First coitus (if not experienced in adolescence) age,
circumstances, partner
• Cohabitation age begun, duration, description of partner,
sexual fidelity, types of sexual activity, frequency,
satisfaction, number of cohabiting relationships, reasons
for breakup(s)
• Engagement age, activity during engagement period with
fiance, with others; length of engagement

64. Marriage (if multiple marriages have occurred, explore
sexual activity, reasons for marriage, and reasons for
divorce in each marriage)
•Types and frequency of sexual interaction describe typical sexual
interaction, satisfaction with sex life? view of partner's feeling
•First sexual experience with spouse when? what were the
circumstances? was it satisfying? disappointing?
•Honeymoon setting, duration, pleasant or unpleasant, sexually active,
frequency? problems? compatibility?
•Effect of pregnancies and children on marital sex
•Extramarital sex number of incidents, partner; emotional attachment to
extramarital partners? feelings about extramarital sex
•Postmarital masturbation frequency? effect on marital sex?
•Extramarital sex by partner—effect on interviewee
•Manage trois or multiple sex (swinging)
•Areas of conflict in marriage (e.g., parenting, finances, division of
responsibilities, priorities)

65. • Sex after widowhood, separation,
divorce celibacy, orgasms in sleep,
masturbation, non coital sex play,
intercourse (number of and
relationship to partners), other

66. • Special issues
• History of rape, incest, sexual or physical abuse
• Spousal abuse (current)
• Chronic illness (physical or psychiatric)
• History or presence of sexually transmitted diseases
• Fertility problems
• Abortions, miscarriages, or unwanted or illegitimate pregnancies
• Gender identity conflict (e.g., transsexualism, wearing clothes of
opposite sex)
• Paraphilias (e.g., fetishes, voyeurism, sadomasochism)

67. Psychopathology
The range of psychopathology that may be
found among distressed lesbians and gay men
parallels that found among heterosexuals.
Some gay men and lesbians with major
depressive disorder may experience guilt and self-
hatred that become directed toward their sexual
orientation

68. Love and Intimacy
• Mature love is marked by the intimacy that is a
special attribute of the relationship between two
persons
• Sex frequently acts as a catalyst in forming and
maintaining intimate relationships.
• The quality of intimacy in a mature sexual
relationship is what Rollo May called active
receiving, in which a person, while loving, permits
himself or herself to be loved

69. • Sex and the Law
Medicine and the law both assess the impact of sexuality
on the individual and society and determine what is
healthy or legal behaviour.
include abortion, pornography, prostitution, sex
education, the treatment of sex offenders, and the right to
sexual privacy, among other issues.

70. THANK YOU
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