Encyclopedia of Sex and Sexuality Understanding Biology, Psychology
Uploaded by
rochafee11Encyclopedia of Sex and Sexuality Understanding Biology, Psychology
Uploaded by
rochafee11About the pagination of this eBook
This eBook contains a multi-volume set.
To navigate the front matter of this eBook by page number, you will
need to use the volume number and the page number, separated by a
hyphen.
For example, to go to page v of volume 1, type “1-v” in the Go box at
the bottom of the screen and click "Go."
To go to page v of volume 2, type “2-v”… and so forth.
Encyclopedia of Sex and Sexuality
Encyclopedia of Sex and Sexuality
Understanding Biology, Psychology, and
Culture
VOLUME 1: A–M
Heather L. Armstrong, Editor
Copyright © 2021 by ABC-CLIO, LLC
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or
otherwise, except for the inclusion of brief quotations in a review, without prior permission in
writing from the publisher.
Library of Congress Cataloging-in-Publication Data
Names: Armstrong, Heather L., editor.
Title: Encyclopedia of sex and sexuality : understanding biology,
psychology, and culture / Heather L. Armstrong, editor.
Description: Santa Barbara, California : Greenwood, [2021] | Includes
bibliographical references and index. |
Identifiers: LCCN 2020024424 (print) | LCCN 2020024425 (ebook) | ISBN
9781440847684 (v. 1 ; hardcover ; alk. paper) | ISBN 9781440847691 (v. 2 ;
hardcover ; alk. paper) | ISBN 9781610698740 (set ; hardcover ; alk.
paper) | ISBN 9781610698757 (ebook)
Subjects: LCSH: Sex—Encyclopedias. | Sex (Biology)—Encyclopedias. | Sex
(Psychology)—Encyclopedias.
Classification: LCC HQ21 .E647 2021 (print) | LCC HQ21 (ebook) | DDC
306.703—dc23
LC record available at https://lccn.loc.gov/2020024424
LC ebook record available at https://lccn.loc.gov/2020024425
ISBN: 978-1-61069-874-0 (set)
978-1-4408-4768-4 (vol. 1)
978-1-4408-4769-1 (vol. 2)
978-1-61069-875-7 (ebook)
25 24 23 22 21 1 2 3 4 5
This book is also available as an eBook.
Greenwood
An Imprint of ABC-CLIO, LLC
ABC-CLIO, LLC
147 Castilian Drive
Santa Barbara, California 93117
www.abc-clio.com
This book is printed on acid-free paper
Manufactured in the United States of America
For the curious.
Contents
Introduction xxiii
Entries
Abortion, Elective 1
Abortion, Late-Term 3
Abortion, Medical 5
Abortion, Risks of 7
Abortion, Surgical 8
Abortion, Therapeutic (Medically Necessary) 10
Abortion, Unsafe 12
Abortion Legislation 14
Abstinence 16
Acquired Immunodeficiency Syndrome (AIDS) 17
Adolescent Sexuality 20
Adrenarche 22
Adultery 23
Advertising, Sex in 25
Advocate, The 26
Afterplay 27
Age of Consent 29
Agender 30
viii Contents
American Association of Sexuality Educators, Counselors
and Therapists (AASECT) 32
Anal Intercourse 33
Androgen Insensitivity Syndrome 34
Androgens 36
Androgyny 39
Andropause 41
Anorgasmia 43
Antigay Prejudice 44
Aphrodisiac 46
Arousal 48
Artificial Insemination 50
Asexuality 52
Assisted Reproductive Technology 53
Association of Black Sexologists and Clinicians 55
Attachment Theory of Love 57
Bacterial Vaginosis 59
Barrier Contraceptive Methods 60
Basson, Rosemary 62
BDSM 63
Benign Prostatic Hyperplasia 66
Benjamin, Harry 68
Bigender 69
Binary Gender System 71
Biological Sex 72
Biological Theories of Sexual Orientation 73
Biphobia 75
Birth Control Pills, Estrogen-Progestin 76
Birth Control Pills, Progestin-Only 78
Bisexuality 79
Black Sexuality 81
Born This Way Foundation 84
Contents ix
Bornstein, Kate 85
Breast, Female 87
Breast Cancer 89
Breastfeeding 91
Bulbourethral Glands 93
Castration 95
Casual Sex 96
Celibacy 98
Cervical Cancer 99
Cervical Cap 101
Cervical Mucus Method 102
Cervix 103
Chancroid 104
Cheating and Infidelity 106
Child Sexual Abuse 108
Childhood Gender Nonconformity 110
Childhood Sexuality 112
Chlamydia 114
Chromosomal Sex 115
Circumcision 116
Cisgender 118
Civil Union 119
Clitoris 120
Colposcopy 122
Coming Out 123
Commission on Obscenity and Pornography 125
Communication, Sexual 126
Companionate Love 128
Compulsivity, Sexual 129
Conception 131
Condoms, Female (Receptive) 133
Condoms, Male (Insertive) 134
x Contents
Congenital Adrenal Hyperplasia 136
Consummate Love 138
Contraception 139
Contraceptive Implant 141
Contraceptive Injectables 143
Contraceptive Patch 144
Date Rape 147
Dating 149
Dating, Cross-Cultural Comparison of 152
Demisexuality 156
Dental Dam 157
Desire 158
Desire, Models of 160
Desire Discrepancy 161
Desire Disorders 162
DHEA 163
Diagnostic and Statistical Manual of Mental Disorders (DSM) 165
Diamond, Milton 166
Diaphragm 168
Disabilities, Sexual Function and 169
Dodson, Betty 172
Don’t Ask, Don’t Tell 173
Double Standards, Sexual 175
Douching 176
Down Low 178
Drag 180
Dysmenorrhea 182
Dyspareunia 184
Ejaculation 187
Ellis, Albert 188
Ellis, Henry Havelock 190
Contents xi
Emergency Contraception 192
Endometriosis 193
Endometrium 195
Epididymis 196
Erectile Dysfunction 198
Erectile Dysfunction Drugs 199
Erection 200
Erogenous Zones 203
Erotophilia and Erotophobia 204
Essure Coil 207
Estrogen 208
Evolutionary Perspectives on Gender and Sexual Behavior 209
Exhibitionism 211
Extramarital Sex 212
Fallopian Tubes 215
Family Planning Clinics 216
Fantasy, Sexual and Erotic 218
Fausto-Sterling, Anne 220
Feinberg, Leslie 221
Female Ejaculation 222
Female Genital Cutting 224
Female Sexuality 226
Femininity 227
Feminist Theory 229
Fertility 230
Fertility Awareness Methods of Contraception 234
Fertility Drugs 235
Fetishism 237
5-Alpha-Reductase Deficiency 239
Fluidity, Gender 241
Fluidity, Sexual 243
xii Contents
Follicle-Stimulating Hormone 245
Foreplay 246
Foreskin 248
Foucault, Michel 249
Freud, Sigmund 251
Friends with Benefits 253
Frotteurism 254
FTMInternational 255
Galactorrhea 257
Gay Affirmative Therapy 258
Gay Rights Movement 259
Gay-Straight Alliance (GSA) 262
Gender 264
Gender Diversity 266
Gender Dysphoria 269
Gender Expression 271
Gender Identity 272
Gender Identity Development 274
Gender Roles, Socialization and 276
Gender Transition 277
GenderPAC 279
Genderqueer 280
Genital Dysphoria 282
Genital Warts 284
GLAAD 286
GLMA: Health Professionals Advancing LGBTQ Equality 288
GLSEN (Gay, Lesbian, and Straight Education Network) 289
Gonorrhea 290
Grafenberg Spot (G-Spot) 292
Green, Jamison 293
Gynecomastia 295
Contents xiii
Hepatitis 297
Herpes 298
Heterosexism 300
Heterosexuality 302
Hirschfeld, Magnus 304
Homophobia 305
Homophobia, Internalized 307
Homosexuality 309
Hooker, Evelyn 312
Hookup Culture 314
Hormone Replacement Therapy 315
Hot Flashes 317
Human Immunodeficiency Virus (HIV) 319
Human Papillomavirus (HPV) 320
Hyde Amendment 324
Hymen 326
Hymenoplasty 327
Hypersexuality 329
Hypogonadism 332
Hysterectomy 334
Incest 337
Infertility 338
Intercourse 342
International Classification of Diseases, Eleventh Revision (ICD-11) 343
International Foundation for Gender Education (IFGE) 344
Intersexuality 346
Intimacy, Sexual and Relational 348
Intracytoplasmic Sperm Injection 350
Intrauterine Device (IUD) 351
Jealousy 353
Johnson, Virginia 355
xiv Contents
Jorgenson, Christine 356
Joy of Sex, The 358
Kama Sutra 361
Kaplan, Helen Singer 362
Kaplan’s Triphasic Model 363
Kegel Exercises 366
Kellogg, John Harvey 367
Kink 368
Kinsey, Alfred 370
Kinsey’s Continuum of Sexual Orientation 371
Kissing 374
Klinefelter Syndrome 375
Krafft-Ebing, Richard von 376
Labia 379
Labiaplasty 380
Lee’s Theory of Love Styles 382
LeVay, Simon 383
LGBTQ+ 385
Love 386
Lubricants 388
Luteinizing Hormone 389
Lymphogranuloma Venereum 391
Madonna-Whore Dichotomy 393
Male Sexuality 394
Maltz Hierarchy 398
Marriage 400
Marriage, Cross-Cultural Comparison of 403
Masculinity 405
Mastectomy 408
Masters, William H. 409
Masters and Johnson Four-Stage Model of Sexual Response 411
Contents xv
Masturbation 414
Mattachine Society 415
Media and Sexuality 417
Medical Treatment of Sex Offenders 420
Megan’s Law 422
Menarche 423
Menopause 424
Menstruation 426
Miller v. California 428
Molluscum Contagiosum 429
Money, John 430
Monogamy 431
Mutual Masturbation 432
National Center for Transgender Equality 435
National Health and Social Life Survey 436
National LGBTQ Task Force 438
National Organization for Women (NOW) 439
National Transgender Advocacy Coalition (NTAC) 441
Nocturnal Emissions 442
Nonbinary Gender Identities 443
Obstetrics and Gynecology 447
Oedipus Complex 450
Online Dating 452
Online Sexual Activity 454
Oophorectomy 456
Open Marriage 458
Oral Sex 460
Orchiectomy 462
Orgasm 464
Outing 467
Out-of-Control Sexual Behavior 469
xvi Contents
Ova 471
Ova Donation 472
Ovarian Cancer 474
Ovaries 476
Ovulation 478
Oxytocin 479
Pansexuality 481
Pap Smear 483
Paraphilias 485
Passing 486
Pedophilia 488
Pelvic Floor Muscles 489
Pelvic Inflammatory Disease (PID) 490
Penile Cancer 492
Penis 493
Performance Anxiety 495
Perimenopause 496
Perineum 498
Pfizer Global Study of Sexual Attitudes and Behaviors 499
PFLAG 501
Pheromones 503
Phimosis 504
Physical Attractiveness 505
Planned Parenthood 507
Planned Parenthood v. Casey 509
PLISSIT Model of Sex Therapy 510
Polyamory 512
Polyandry 515
Polycystic Ovary Syndrome (PCOS) 516
Polygamy 518
Polygyny 519
Contents xvii
Pornography 521
Pornography Addiction 525
Preejaculate Fluid 527
Pregnancy 528
Premarital Sex 531
Premature Ejaculation 533
Premenstrual Dysphoric Disorder (PMDD) 535
Premenstrual Syndrome (PMS) 536
Priapism 537
Progesterone 539
Pronoun Usage 540
Prostate 542
Prostate Cancer 543
Prostatectomy 545
Prostatitis 546
Prostitution 547
Psychosexual Therapy 550
Puberty 552
Puberty, Delayed 554
Pubic Hair 555
Pubic Lice 557
Public Displays of Affection 559
Purity Pledges 560
Queer 563
Questioning 564
Rape 569
Rape, Abuse and Incest National Network (RAINN) 571
Rape Shield Laws 572
Rape Trauma Syndrome 573
Reimer, David 575
Religion, Diversity of Human Sexuality and 576
xviii Contents
Reparative Therapy 579
Reproductive Coercion 581
Retrograde Ejaculation 582
Roe v. Wade 584
Roman Catholic Church Sexual Abuse Scandal 586
Romantic Attraction and Orientation 587
Safer Sex 589
Same-Sex Attraction and Behavior 590
Same-Sex Marriage 593
Sanger, Margaret 594
Satcher, David 596
Savage, Dan 598
Scabies 599
Scrotum 601
Semen 602
Seminal Vesicles 603
Seminiferous Tubules 604
Sensate Focus 605
Serial Monogamy 607
Sex Chromosomes 608
Sex Differentiation of the Brain and Sexual Orientation 609
Sex Education 610
Sex Guilt 612
Sex Hormones 613
Sex Reassignment Surgery 616
Sex Tourism 617
Sex Toys 618
Sex Work 621
Sex Workers, Male 623
Sexaholics Anonymous 624
Sexism 625
Contents xix
Sexology 627
Sexting 630
Sexual Abuse 631
Sexual Assault 634
Sexual Avoidance 635
Sexual Behavior in the Human Maleand Sexual Behavior
in the Human Female 636
Sexual Consent 637
Sexual Dimorphism 640
Sexual Disorders, Female 643
Sexual Disorders, Male 644
Sexual Dysfunction, Treatment of 646
Sexual Expression 647
Sexual Harassment 649
Sexual Harassment in College 651
Sexual Harassment in Education 652
Sexual Harassment in the Workplace 654
Sexual Health 655
Sexual Identity 657
Sexual Learning 659
Sexual Orientation 660
Sexual Revolution 663
Sexual Rights 665
Sexual Satisfaction 668
Sexual Script 670
Sexual Slavery 671
Sexuality across the Life Span 674
Sexuality among Older Adults 676
Sexuality among Younger Adults 678
Sexualization 680
Sexually Transmitted Infections (STIs) 681
xx Contents
Shepard, Matthew 684
Slut Shaming 685
Smegma 687
Social Learning Theory, Gender and 688
Society for the Scientific Study of Sexuality (SSSS) 690
Sodomy Laws 691
Somnus Orgasm 693
Sperm 694
Spermicides 695
Sponge, Contraceptive 697
Start-Stop Technique 698
Statutory Rape 699
Stereotypes, Gender 700
Stereotypes, Sexual 702
Sterilization 705
Sternberg’s Triangular Theory of Love 707
Stonewall Riots 708
Storms’s Model of Sexual Orientation 710
Sugar Daddies and Sugar Babies 711
Surrogate, Sexual 712
Surrogate Mothers 713
Swinging 715
Synthetic Hormones 716
Syphilis 719
Tantric Intercourse 723
Teen Pregnancy 724
Teena, Brandon 726
Testicles 728
Testicular Cancer 729
Testing, STI 731
Testosterone 732
Contents xxi
Testosterone Replacement Therapy 734
Touching, Sexual Arousal and 736
Transexual Menace 738
Transgender 739
Transphobia 741
Transsexual 742
Transvestite 744
Trichomoniasis 745
Tubal Ligation 749
Turner Syndrome 751
Tuskegee Syphilis Study 752
Two-Spirit 754
Ulrichs, Karl 757
Unconsummated Marriage 758
Urethra 759
Uterine Cancer 760
Uterus 762
Vagina 765
Vaginal Lubrication 766
Vaginal Ring 767
Vaginal Secretions 768
Vaginismus 769
Vaginitis 771
Vas Deferens 774
Vasectomy 775
Victorian Era 777
Virginity 778
Voyeurism 781
Vulva 783
Vulvodynia 784
Withdrawal Method 787
xxii Contents
World Professional Association for Transgender Health (WPATH) 788
X Chromosome 791
Y Chromosome 793
Yeast Infection (Candidiasis) 795
About the Editor and Contributors 799
Index 827
Introduction
Sex is a funny thing. In some ways, it’s everywhere. We see it in the media, in
advertisements, in movies and TV shows, and in the headlines of many newspa-
pers and magazines. Comedians joke about it, as do most of us with our friends
and partners. With the explosion of the internet, sexual imagery is just a click
away, and an available sexual partner can be found within seconds with just a
swipe on an app. Sex is seemingly all around us, but how much do we really know
about it?
When I began studying sex as an undergraduate student, I was fascinated by
the juxtaposition of how something could simultaneously be all around us, and
(supposedly) something that nearly everyone desires, yet still be something that
felt taboo and sometimes shameful. Everyone has some kind of relationship with
sex, even those of us who have never had sex or who don’t desire sex. Because of
this, I believe that it is every individual’s right to be accurately informed about
sex, sexual health, and sexuality. It is by having this scientific and accurate infor-
mation that people can make the best choices for their own sexual health and
well-being.
Unfortunately, sex education is often woefully lacking, if it even occurs at all.
Because of this, rumors circulate about how sex is “supposed” to be, and many of
us rely on things we hear from peers and the media and from what we see on TV,
in the movies, and online. As I’m sure you well know, these are rarely accurate
sources of information. As a result, sexual myths and sexual double standards
begin to be believed as fact, and this, coupled with a lack of accurate, science-
based sexual education, often means that people are unsure and misinformed,
which can lead to sexual shame, guilt, and dysfunction. The good news is that
often, just by learning more about sex, sexuality, and sexual health, these prob-
lems and difficulties can be improved if not fixed completely.
So, this encyclopedia is for every person of every sex, gender, orientation, pref-
erence, and everything in between. In over 460 entries, written by nearly 150
sexuality experts, these volumes aim to provide a brief introduction and summary
to a wide variety of topics related to sexuality. The authors present an overview of
the latest research representing the current evidence-based understanding of the
area. In addition, at the end of each entry, you will find a section with suggestions
for further readings. Some of these are academic articles, others are books or web-
sites, so it is hoped that these resources will be accessible to a variety of readers.
xxiv Introduction
That said, our understanding of sexuality has changed drastically in the past few
decades, and new research and theories are continuously developed. As such, new
information that was not available at the time this book was written will continue
to be produced, so anyone with a particular interest should continue to explore the
state of the science beyond these pages.
As with all encyclopedias, these volumes were not written to be read cover to
cover but rather to provide a general overview on a wide variety of topics related
to sexuality. Some topics are biological, others are psychological, some are behav-
ioral, and others are social and cultural. Sex can be good, but it can also be bad,
and sometimes it can be both at the same time. To reflect this, entries include both
positive and negative aspects of sex and sexuality.
The scope of human sexuality is infinite, so inevitably some things will be
missing from these volumes, but I hope that we have covered a sufficiently broad
range of topics so that everyone who is studying—or just as importantly, everyone
who is even slightly curious about—sex will find something of interest and maybe
even learn something new about this sometimes taboo, but deeply integral, part of
who we are as human beings.
Heather L. Armstrong, PhD
A
Abortion, Elective
Voluntary termination of a pregnancy without a medical necessity is considered
an elective abortion. The National Abortion Federation (NAF) states that half of
all pregnancies in the United States are unintended, and about half of these
(1.3 million) are terminated through an elective abortion. The Guttmacher Insti-
tute estimates that 35 percent of all women of reproductive age in the United
States will have an abortion by the time they reach the age of forty-five. About
19 percent of these are elected by women between the ages of fifteen and nineteen,
while 33 percent of elective abortions are performed on women between twenty
and twenty-four years old. Women thirty years and older account for 25 percent of
all abortions.
Most women who seek elective abortion are unmarried. The NAF reports that
the majority of women who choose to abort a pregnancy do so for economic
reasons—either because of a lack of adequate income to start a family or the
inability to support more children. Women also seek abortion when pregnancy
causes significant medical complications or when they discover that their child
will have severe birth defects that will compromise its life. Roughly 13,000 women
each year choose abortion because they have become pregnant as a result of rape
or incest.
Abortions are performed around the world, with varying degrees of regulation
and standards for safety. In the United States, abortion laws went into effect by
state beginning in 1821, when Connecticut passed the first law banning the prac-
tice. The Roman Catholic Church declared its prohibition of any kind of abortion
in 1869, driving further bans on the practice around the world. By 1900, every
state in the United States had some form of antiabortion law.
Originally, these laws had some basis in practicality. Like all surgeries per-
formed before antiseptic procedures became widespread, abortions could be dan-
gerous for the patient, frequently leading to infections, sepsis, and death. Surgeries
became far safer in the early to mid-1900s, but by this time abortion had become
a moral issue rather than a medical one. Women had to seek the procedures in
secret, often from people who were not medical professionals. Deaths from back-
alley abortions were common well into the second half of the twentieth century.
Legislators had other motivations for banning abortion that went beyond medi-
cal protection and morality. Prejudices against the massive influx of arriving
immigrants led state governments to decide that native-born U.S. citizens should
have as many children as possible, to maintain white Anglo-Saxon dominance in
the face of swelling Irish, Italian, Eastern European, and Asian populations.
2 Abortion, Elective
In 1973, the U.S. Supreme Court’s landmark Roe v. Wade decision determined
that the right to privacy granted by the Fourteenth Amendment extended to a
woman’s decision to have an abortion and that a woman has a right to an abortion
until “viability,” the point in the pregnancy at which the fetus can live outside the
womb. This decision disallowed some of the state and federal restrictions on abor-
tion, essentially legalizing abortion across the country. Abortions could now be
performed in doctors’ offices, gynecological clinics, and hospitals, with the medi-
cal supervision required to handle complications and keep patients safe.
Roe v. Wade did not end the controversy over abortion rights, however. The
question of viability became the lynchpin for debate on either side of the abortion
issue, creating two political camps based on “pro-choice” and “pro-life” points of
view. The pro-choice movement focuses on a woman’s right to choose whether or
not to have a child, while the pro-life movement advocates the right of the fetus to
be born. As the terms “pro-choice” and “pro-life” have taken on moral connota-
tions that further polarize the debate, the media have relabeled the two sides as
“abortion rights” and “antiabortion.”
The abortion rights side of the debate centers on the issue of viability and the
medical fact that fetuses that are aborted during the first trimester of pregnancy
cannot exist independently outside of the womb. It asserts that a woman must have
control over her own body, making the right to have an abortion a civil rights
issue. Abortion rights activists see the government’s intervention in women’s
reproductive choices as the first step on a slippery slope, one that could lead to
forcing women to use contraception or mandating the number of children women
must or must not have.
The antiabortion side sees abortion as the act of taking a human life, making an
abortion the murder of a fetus. This side offers adoption as a viable alternative to
abortion, pointing to the statistic that 1.5 million American families are looking to
adopt a child at any given time. Some on the antiabortion side promote abstinence
as the only viable method of birth control, objecting to medical contraception
because it prevents the formation of an embryo by killing the egg or sperm before
conception can take place. Others on the antiabortion side believe contraceptives
are an acceptable means of preventing unwanted pregnancy.
Supreme Court decisions and some state laws continue to work toward restrict-
ing abortions, even as Roe v. Wade continues to stand. A law passed by Congress
in 2003 and upheld by the Supreme Court in 2007 banned late-term abortions
(called “partial-birth abortions” by their political opponents). In 2011, Texas—the
leading state on the antiabortion side of the debate—passed a law requiring all
women seeking an abortion to make at least two visits to an abortion facility, one
of which must include an ultrasound within twenty-four hours before the abortion.
In 2013, a new Texas law closed all but eight abortion clinics throughout the state
because they did not provide hospital-level treatment or facilities, shutting down
thirteen clinics in rural areas. In October 2014, the U.S. Supreme Court blocked
some of the provisions of this law.
In 2011, 2012, and 2013, thirty states enacted a total of 205 new antiabortion
statutes, banning private insurance coverage of abortion procedures and setting
limits on abortions using medications. More than half of the laws passed targeted
Abortion, Late-Term 3
regulation of abortion providers (known as TRAP laws). These require women
seeking abortions to travel to hospitals or hospital-like clinics at which doctors
have admitting privileges at area hospitals.
Randi Minetor
See also: Abortion, Medical; Abortion, Risks of; Abortion, Surgical; Abortion, Therapeu-
tic (Medically Necessary); Abortion, Unsafe; Abortion Legislation; Emergency Contra-
ception; Hyde Amendment; Roe v. Wade; Sexual Rights.
Further Reading
Boonstra, H. D., & Nash, E. (2014). A surge of state abortion restrictions puts providers—
And the women they serve—In the crosshairs. Guttmacher Policy Review, 17(1).
Retrieved from https://www.guttmacher.org/gpr/2014/03/surge-state-abortion
-restrictions-puts-providers-and-women-they-serve-crosshairs
Cole, G. F., & Frankowski, S. (Eds.) (1987). Abortion and protection of the human fetus:
Legal problems in a cross-cultural perspective (Vol. 1). Boston, MA: Martinus
Nijhoff.
Haney, J. (2009). The abortion debate: Understanding the issues. Berkeley Heights, NJ:
Enslow.
McBride, D. E., & Keys, J. L. (2018). Abortion in the United States: A reference hand-
book. Santa Barbara, CA: ABC-CLIO.
Abortion, Late-Term
A late-term abortion is a medical procedure that terminates pregnancy after the
twentieth week of gestation. The exact stage at which an abortion becomes late
term has not been clearly defined by the medical community. A very small per-
centage (about 1 percent) of abortions occur after the twentieth week and typically
are required because the pregnant patient’s health or life is at risk or because seri-
ous fetal abnormalities have been detected. While all forms of abortion have been
the subject of controversy in the United States, late-term abortion is the most con-
troversial. This is due to the fact that a fetus aborted in a late-term abortion is
usually more fully developed and sometimes viable. Late-term abortions can take
different forms, with the most common procedures being dilation and extraction
(D&E), labor-induced abortion, and intact dilation and extraction (IDX).
IDX was a common late-term abortion procedure before it was made illegal
after the passage of the Partial-Birth Abortion Act of 2003. It takes place in four
stages. First, the cervix is dilated over a few days to accommodate the size of the
fetus. Once the cervix is sufficiently dilated, the fetus is placed in position for a
footing breech either manually or through the use of forceps. The fetus is then
removed by the doctor through a series of stages. This procedure may be referred
to as “partial-birth abortion,” although the American Medical Association does
not consider that to be a medical term.
While D&E is similar to IDX, they are distinct procedures. Prior to a D&E
procedure, the doctor will insert a cervical dilator into the cervix to help dilate the
cervix for twenty-four hours. Once the cervix is dilated, the remainder of the pro-
cedure typically takes thirty minutes. The doctor uses an instrument to keep the
4 Abortion, Late-Term
uterus in place and passes a cannula—a hollow tube—into the uterus. The can-
nula, which is attached to a bottle and pump, is then used to remove tissue from
the uterus. If there are larger pieces of tissue in the uterus that the cannula cannot
handle, forceps are used to remove them. A curved instrument called a curette and
suction may also be used during the procedure to remove tissue from the lining of
the uterus. Once all the tissue is removed from the uterus, it is examined by the
doctor to make sure the procedure is complete. D&E is difficult to perform after
twenty weeks of gestation and is more commonly used at earlier stages of
pregnancy.
A labor-induced abortion is a procedure in which a substance is administered to
the fetus to cause a medically induced stillbirth. Before beginning the procedure,
the doctor will sometimes dilate the cervix using a cervical dilator to reduce the
risk of complications. Once the cervix is dilated, the doctor will inject a
substance—a salt solution, drug, or chemical compound—into the amniotic fluid
surrounding the fetus or directly into the fetus. This induces a stillbirth, and the
fetus is typically delivered within twenty-four hours of the injection. Once the
fetus has been delivered, the doctor may scrape the uterus with a curette to ensure
that all the tissue has been removed. Labor-induced abortions become more diffi-
cult to perform the later the stage of pregnancy.
Abortion is a generally safe medical procedure, although the risk of complica-
tions increases the further along the patient is in her pregnancy. Some complica-
tions that can occur during a late-term abortion include heavy bleeding, blood
clots in the uterus, infection, pain and discomfort, and injury to the cervix or other
organs. Following an abortion, the patient may experience a variety of emotions,
such as relief, sadness, guilt, and anger. However, it is important to note that in
general, late-term abortion is not associated with any negative physical health out-
comes, and the consequences of the pregnancy proceeding typically pose more
serious health risks than termination.
A woman may decide to undergo a late-term abortion procedure for a number
of reasons, including health complications, fetal birth defects, or not realizing she
was pregnant until late in the pregnancy. Late-term abortions are the rarest of all
abortion procedures, making up an average of just 1.2 percent of all abortions that
take place in the United States.
Late-term abortions have been the subject of intense controversy in the United
States since abortions were made legal through the U.S. Supreme Court’s ruling
in Roe v. Wade in 1973. However, the Supreme Court’s ruling did allow states to
impose greater restrictions on late-term abortion procedures taking place after
fetal viability than on abortions occurring at earlier stages of gestation. As of
2014, twenty-one states have passed laws prohibiting abortions performed at the
point of fetal viability, and three states have laws prohibiting abortion during the
third trimester. Nine states prohibit abortion after twenty weeks’ gestation based
on the argument that the fetus can feel pain by that point, although the scientific
validity of this argument has been challenged by the medical community. If a state
places a ban on late-term abortion, the law must contain an exception for abor-
tions “necessary to preserve the life or health” of the pregnant person in order to
be constitutional in accordance with the Supreme Court’s ruling in Roe v. Wade.
Abortion, Medical 5
In 2003, Congress passed, and President George W. Bush signed into law, the
Partial-Birth Abortion Act of 2003. This law prohibits IDX late-term abortion
procedures, referred to in the text of the legislation as “partial-birth abortion.”
Under this legislation, if a doctor performs an abortion using IDX, they would
receive a fine or be imprisoned for up to two years. The constitutionality of the
Partial-Birth Abortion Act was challenged in 2007 in the Supreme Court case
Gonzales v. Carhart. Prior to reaching the Supreme Court, three federal district
and circuit courts had ruled the act to be unconstitutional. However, in a 5–4 deci-
sion, the Supreme Court ruled that the act was constitutional since it clearly out-
lines which abortion procedure is banned and thus does not place an undue burden
on women who are seeking a late-term abortion.
Abortion providers have often been the targets of terrorism and violence car-
ried out by antiabortion activists. In 2009, Dr. George Tiller, one of the nation’s
leading abortion providers, was shot and killed while attending church in Wichita,
Kansas. Tiller was murdered by Scott Roeder, an antiabortion activist, who was
sentenced to life in prison. Previously, Tiller’s clinic had been bombed in June
1986, and in 1993 he was shot in both arms outside a clinic in Wichita by antiabor-
tion activist Shelley Shannon, who was sentenced to eleven years in prison for
attempted murder.
Renee Dubie
See also: Abortion, Elective; Abortion, Medical; Abortion, Risks of; Abortion, Surgical;
Abortion, Therapeutic (Medically Necessary); Abortion, Unsafe; Abortion Legislation;
Roe v. Wade; Sexual Rights.
Further Reading
Herring, M. Y. (2003). The pro-life/choice debate. Santa Barbara, CA: Greenwood.
McBride, D. E., & Keys, J. L. (2018). Abortion in the United States: A reference hand-
book. Santa Barbara, CA: ABC-CLIO.
Abortion, Medical
Medical abortion is the use of medication to end an early-stage pregnancy. It is
highly effective and is usually safe up to twelve weeks from the first day of the last
menstruation, although some places may restrict its use to earlier in the preg-
nancy. Medical abortion may be therapeutic (medically necessary to protect the
life and health of the pregnant patient) or elective. Early medical abortion is con-
sidered very safe, with low risk of serious side effects or complications. It enables
pregnancy termination to occur in one’s home without surgical intervention or the
risk of public exposure and violence that may accompany a clinic visit.
Medications used to induce abortion include steroid hormone drugs such as
mifepristone, prostaglandin hormone drugs such as misoprostol, and chemother-
apy drugs such as methotrexate. The exact combination depends on the prescrib-
ing physician’s preference, the specific prescription medication, presence of
pregnancy complications or fetal abnormalities, and the patient’s medical history
and condition. Treatment may consist entirely of oral tablets or may combine oral
6 Abortion, Medical
tablets with vaginal suppositories. Muscle relaxants, clotting agents, and analge-
sics (painkillers) may also be prescribed.
Medical abortion typically requires an office visit to determine the exact stage
of pregnancy and the patient’s overall health. A blood or urine test, pelvic exam,
and ultrasound are generally performed to confirm gestational age and screen for
serious medical complications. All U.S. board-certified family practice physicians
must offer counseling regarding abortion, adoption, and parenting options to pro-
spective abortion patients. In addition, some states require that patients receive
antiabortion counseling and information regarding fetal development. The attend-
ing physician usually gives the medication to the patient directly, along with
instructions for use, rather than writing a prescription.
A medical abortion may take one to three days to complete and includes strong
cramping, vaginal bleeding, and other physical effects similar to a natural mis-
carriage. A follow-up appointment is required to ensure expulsion of all uterine
contents. Patients are cautioned to avoid driving, operating heavy machinery, and
all intense physical activity during the course of the abortion, and to avoid sexual
intercourse for a minimum of two weeks following treatment. Fertility may
resume before the next menstrual period, so patients must institute an effective
birth control method immediately. Normal menstruation should resume within
six weeks.
Potential side effects and complications include nausea, vomiting, diarrhea,
fever, chills, fatigue, severe abdominal pain, severe bleeding, shock, retained tis-
sue, and infection, as well as negative reactions to specific medications (such as
unforeseen allergic reaction). Serious side effects or complications may require
additional medical treatment, such as emergency care, antibiotics, or follow-up
surgery in the case of retained tissue.
Though considered very safe and effective, medical abortion has been a source
of significant controversy in the United States because it allows discrete, safe
pregnancy termination in the privacy of one’s home. Abortifacient pharmaceuti-
cals have been widely available since the 1970s but were not legally available in
the United States for most elective abortions until 2000. As localities limit access
to abortion, black-market “abortion pills,” primarily imported from Latin Amer-
ica, are becoming popular, but these carry significantly more risk.
Angela Libal
See also: Abortion, Elective; Abortion, Risks of; Abortion, Surgical; Abortion, Therapeu-
tic (Medically Necessary); Abortion, Unsafe; Abortion Legislation; Emergency Contra-
ception; Roe v. Wade; Sexual Rights.
Further Reading
Guttmacher Institute. (2019). State laws and policies: Medication abortion. New York:
Guttmacher Institute. Retrieved from https://www.guttmacher.org/state-policy/
explore/medication-abortion
Jacobson, J. D., & Zieve, D. (Eds.). (2018). Abortion—Medical. Retrieved from http://
www.nlm.nih.gov/medlineplus/ency/article/007382.htm
University of California, San Francisco. (2019). Medical abortion. Retrieved from https://
www.ucsfhealth.org/treatments/medical-abortion
Abortion, Risks of 7
WHO Reproductive Health Library. (2016). Medical methods for first trimester abortion:
RHL summary. Geneva: World Health Organization.
Abortion, Risks of
Induced abortion is therapeutic (necessary for the health of the pregnant person)
or elective termination of pregnancy through surgical procedure or medication.
Legal first-trimester abortion is considered one of the safest medical procedures,
with a complication rate of less than 1 percent for surgical abortion and around 2
percent for abortion by medication. Abortions performed after the first trimester
use different procedures and carry different and greater risks. They are not typi-
cally performed on an elective basis. Illegal abortion carries different and far
greater risks.
“Surgical abortion” is a misleading term because these abortions do not involve
cutting. A more appropriate term is “procedural abortion.” Procedural abortions
may be performed in a physician’s office, hospital, or clinic. They do not require
sterile, operating-room conditions. Potential complications of procedural abortion
include uterine infection, retained tissue from incomplete abortion, and cervical
damage during dilation. Uterine infection is treated with antibiotics. Retained tis-
sue requires further extraction to prevent infection and severe bleeding. Cervical
damage is rarely treated and may not be apparent at the time of the procedure.
Aspiration abortion (removal of fetal tissue through suction) carries a uterine per-
foration risk of less than 0.01 percent.
Potential risks of medical abortion include side effects such as extreme pain
and gastrointestinal distress, and complications such as severe bleeding, shock,
retained tissue, and adverse reactions to the medication used. Side effects may be
treated with analgesics (painkillers). Severe complications require emergency
care, and retained tissue requires procedural abortion. Very rarely, medical abor-
tion may fail to terminate pregnancy. Research findings vary regarding whether
abortifacient medications cause significant fetal damage and birth defects if such
pregnancies are continued.
Retained tissue is the greatest risk of procedural and medical abortion. It can
cause continued, heavy bleeding and sepsis (potentially fatal blood infection).
However, the combined risk of all incomplete abortion complications is less than
0.24 percent.
Due to controversy surrounding abortion, many inaccurate claims regarding its
effects on patients’ physical health and future fertility have been perpetuated.
However, most of these claims have been disproven by research involving hun-
dreds of thousands of women. Many claims were based on older surgical tech-
niques, such as dilation and curettage, which are rarely used in a modern medical
setting; on illegal abortions; or on abortions performed after the first trimester.
Late-term abortions are almost always performed to preserve the life or health of
the pregnant patient or chosen due to severe, often fatal fetal abnormalities. Their
risks are very different from those associated with first-trimester, elective
abortion.
8 Abortion, Surgical
According to a 2009 article in the Journal of the American Board of Family
Medicine, “when abortion is safe and legal, [the patient’s] chances of getting preg-
nant and staying pregnant in the future are not affected by the abortion. There is
no increase in rates of ectopic pregnancy, spontaneous abortion, preterm birth, or
low birth weight, and no association with an increase in breast cancer risk” (Lyus,
Gianutsos, & Gold, 2009). At least one study conducted in China has shown an
association between first-trimester aspiration abortion and an increased risk of
less than 2 percent for first-trimester miscarriage in future pregnancies. However,
this risk was greatest in pregnancies occurring within three months of an
abortion.
Some women experience depression following abortion. This may be attributed
to and complicated by multiple factors, including feelings of rejection by family
members or faith communities, lack of support from a significant other for con-
tinuing pregnancy or pressure to terminate, adverse life circumstances associated
with the choice to terminate, and a sense of loss of the pregnancy itself. A 2008
study in Denmark suggests that women past their teen years who lack social sup-
port and counseling are at greatest risk for abortion-related depression. Lack of
social support strongly affects women in communities that condemn abortion.
These women may become victims of social judgment, condemnation, abuse, and
violent attacks.
Angela Libal
See also: Abortion, Elective; Abortion, Medical; Abortion, Surgical; Abortion, Therapeu-
tic (Medically Necessary); Abortion, Unsafe; Abortion Legislation; Emergency Contra-
ception; Roe v. Wade; Sexual Rights.
Further Reading
Alaska Department of Health and Social Services. (2019). Possible medical risks or com-
plications of abortion. Retrieved from http://dhss.alaska.gov/dph/wcfh/Pages/
informedconsent/abortion/risks
Louisiana Department of Health. (n.d.). Abortion & pregnancy risks. Retrieved from
http://dhh.louisiana.gov/index.cfm/page/915/n/275
Lyus, R. J., Gianutsos, P., & Gold, M. (2009). First trimester procedural abortion in fam-
ily medicine. Journal of the American Board of Family Medicine, 22(2), 169–174.
Pedersen, W. (2008). Abortion and depression: A population-based longitudinal study of
young women. Scandinavian Journal of Public Health, 36(4), 424–428.
Sun, Y., Che, Y., Gao, E., Olsen, J., & Zhou, W. (2003). Induced abortion and risk of sub-
sequent miscarriage. International Journal of Epidemiology, 32(3), 449–454.
Abortion, Surgical
Surgical abortion is a method of ending a pregnancy by manually removing the
fetus and placenta from the womb. Also known as suction-aspiration or vacuum-
aspiration abortion, a surgical abortion can be performed on a pregnancy of up to
sixteen weeks. If the fetus is between sixteen and twenty-four weeks old, a less
common and more complicated surgical procedure, known as dilation and evacu-
ation, or D&E, is necessary.
Abortion, Surgical 9
A pregnant individual may choose to have a surgical abortion for the same rea-
sons one might choose to have a medical abortion (one induced by medication): for
personal reasons, because the pregnancy is harmful to their health, because the
fetus has a genetic problem or birth defect, or because the pregnancy resulted
from rape or incest.
Although a suction-aspiration abortion procedure typically lasts only five to ten
minutes (a D&E usually lasts ten to twenty minutes), additional time is needed for
talking with the health care provider, undergoing a physical exam, reading and
signing forms, allowing time for anesthetics to take effect, and recovering after-
ward. As a result, most surgical abortions require three to six hours at a clinic,
depending on the clinic and the age of the fetus.
Once a person has decided to have a suction-aspiration abortion, they are given
pain medication—typically some combination of ibuprofen, valium, and Vicodin.
If they are more than eleven weeks pregnant, they may also receive misoprostol, a
drug that softens the cervix. Oral medications for those who are fewer than twelve
weeks pregnant require forty-five minutes to an hour to take effect; misoprostol
takes two to three hours to take effect and is therefore administered before oral
medications.
Many abortion providers also inject a numbing agent into or near the cervix.
Less commonly, a general sedative or anesthetic may be given. The opening of the
cervix is then stretched (dilated) using a series of rods of increasing diameter.
Some clinics may instead use an absorbent dilating rod that slowly stretches the
cervical opening over the course of several hours, but this must be given to the
patient the day before the abortion procedure. Some may also prescribe medica-
tions that chemically dilate the cervix. In addition, those undergoing surgical
abortion are usually prescribed an antibiotic to prevent infection.
After an examination of the patient’s uterus and cervix to ensure that all medi-
cations have taken effect and the cervix is properly dilated, a tube is inserted into
the uterus via the cervix. A machine or handheld device then suctions blood and
fetal tissue from the uterus. A medical instrument known as a curette is some-
times used to ensure that the uterus is empty or to remove any remaining tissue.
The use of this device can result in the abortion being termed a D&C, for dilation
and curettage.
After one to three hours of recovery time, the patient can return home and typi-
cally may resume work or school the following day, though recovery after a later-
term surgical abortion may take a few days. Doctors recommend refraining from
sexual intercourse, or placing any object in the vagina, for at least one week.
Most people who have surgical abortions experience cramps similar to men-
strual cramps for one to two days, though some may experience longer or more
pronounced periods of discomfort. Vaginal bleeding or spotting may continue for
up to ten days, and menstrual pads, rather than tampons, must be used to absorb
the blood.
Surgical abortions are considered very safe. The risk of death from childbirth is
eleven times higher than the risk of death from an abortion carried out in the first
twenty weeks of pregnancy. The risk of death from childbirth and abortion are
roughly equal when an abortion occurs after more than twenty weeks of
10 Abortion, Therapeutic (Medically Necessary)
pregnancy. In general, the more advanced the pregnancy, the greater the risk of
complications.
Surgical abortion risks may include blood clots, very heavy bleeding, allergic
reactions to medications, infections, injury to the cervix or uterus, scarring of the
inside of the uterus, incomplete abortion (in which some tissue remains inside the
uterus), and failure to terminate the pregnancy. In rare cases, the patient may have
complications from an undetected ectopic pregnancy.
Many people also experience strong emotions after an abortion. These may
include relief, sadness, anger, regret, or guilt. Although any negative feelings typi-
cally fade, it is important to seek professional counseling if they continue for a
longer period of time. However, it is important to note that in general, abortion is
not associated with any negative or physical health outcomes.
Terri Nichols
See also: Abortion, Elective; Abortion, Medical; Abortion, Risks of; Abortion, Therapeu-
tic (Medically Necessary); Abortion, Unsafe; Abortion Legislation; Emergency Contra-
ception; Roe v. Wade; Sexual Rights.
Further Reading
Jacobson, J. D., & Zieve, D. (Eds.). (2018). Abortion—Surgical. Retrieved from https://
www.nlm.nih.gov/medlineplus/ency/article/002912.htm
Paul, M., Lichtenberg, E. S., Borgatta, L., Grimes, D. A., & Stubblefield, P. G. (1999). A
clinician’s guide to medical and surgical abortion. London: Churchill
Livingstone.
Planned Parenthood. (2019). In-clinic abortion. Retrieved from https://www.plannedpar-
enthood.org/learn/abortion/in-clinic-abortion-procedures
Abortion, Therapeutic (Medically Necessary)
In the United States, “therapeutic abortion” refers to medically necessary termi-
nation of pregnancy. It includes all abortions performed to preserve the life and
physical health of the pregnant patient and may include abortions performed due
to severe, incurable, irreversible, and usually fatal conditions of the fetus. How-
ever, some countries, such as the United Kingdom and Canada, use the term
“therapeutic abortion” to refer to all elective abortions.
Therapeutic abortion may become necessary due to pregnancy complications,
fetal defects, or maternal health conditions. It is usually performed at any stage
prior to fetal viability (the ability of the fetus to survive outside the uterus); how-
ever, in the case of severe conditions of the fetus, therapeutic abortion may also be
performed after the age of technical viability. When physical defects are not pres-
ent and the fetus is potentially viable, pregnancy interruption may be performed
by early labor induction or cesarean surgery, with effort to preserve the life of the
infant.
Viability is considered to begin at twenty-four weeks. Survival at this stage is
around 50 percent and depends entirely on major medical intervention. The risk of
permanent disability or impairment increases significantly the further the fetus is
from being full term (considered a minimum of thirty-seven weeks’ gestation).
Abortion, Therapeutic (Medically Necessary) 11
The technique used to induce therapeutic abortion depends on the type of prob-
lem and stage of gestation. First-trimester therapeutic abortions are usually
accomplished with abortifacient medication or vacuum extraction. Second- and
third-trimester therapeutic abortions are accomplished by early induction of labor
or surgical dilation of the cervix and extraction of the fetus, placenta, and associ-
ated tissue. Feticidal drugs may be injected directly into the amniotic sac or fetus.
A few life-threatening conditions such as ectopic and molar pregnancy may
require additional surgery and medication, such as chemotherapy drugs.
Pregnancy complications that require therapeutic abortion include ectopic
pregnancy, when the amniotic sac lodges inside a fallopian tube rather than the
uterus; fetal death without expulsion, or retained miscarriage; and gestational tro-
phoblastic disease (GTD), also called hydatidiform or hydatid mole, or molar
pregnancy. Molar pregnancy may exist with or without a fetus. It is an abnormal,
cancer-like growth of placental cells throughout the uterus, which may penetrate
the uterine wall or invade other parts of the body. Roughly 20 percent of GTD
cases develop into an actual cancer called choriocarcinoma. Fetuses in all these
cases are not viable.
Complications of pregnancy that may require therapeutic abortion if they occur
prior to fetal viability include placenta previa with hemorrhage, placenta abrup-
tion, preeclampsia, hemolysis with elevated liver enzymes and low platelet count
(HELLP) syndrome, and eclampsia. Placenta previa occurs when the placenta
grows into the muscular wall of the uterus. It usually requires surgical birth and
may require hysterectomy to prevent fatal hemorrhage. When it causes hemor-
rhage before fetal viability, therapeutic abortion and emergency hysterectomy
may be necessary. Placenta abruption occurs when the placenta detaches from the
uterine wall. It can cause fatal blood loss to the pregnant individual and kill the
fetus by cutting off oxygen and nutrition. Preeclampsia, HELLP syndrome, and
eclampsia are potentially fatal hypertensive disorders that affect multiple systems
in the pregnant patient’s body and necessitate ending a pregnancy.
Rare maternal complications that may require therapeutic abortion include
advanced cervical cancer; uterine rupture or sepsis caused by severe, degenerat-
ing fibroid tumors; life-threatening hyperemesis gravidarum (uncontrollable, con-
tinuous vomiting resulting in clinical dehydration); advanced cardiovascular
disease; advanced renal failure; and serious autoimmune disease caused by fetal
antigens.
Abortion is considered therapeutic when the fetus carries fatal disorders or
defects such as Tay-Sachs disease or anencephaly or when it has a disorder likely
to result in fatal or severe, irreversible effects, such as trisomy 18, trisomy 13, or
congenital rubella syndrome.
Abortions are considered elective rather than therapeutic when they are per-
formed due to fetal abnormalities with unpredictable prognosis for the infant.
Selective termination of fetuses with Down syndrome has been particularly criti-
cized due to favorable outcomes for children living with Down syndrome who
receive early medical, behavioral, and developmental intervention. Critics note
that much of the information provided to prospective parents of fetuses affected
by Down syndrome is based on outdated material. This material dates to an era
12 Abortion, Unsafe
before modern surgical and intervention techniques. It may overestimate negative
outcomes for physical defects such as heart and gastrointestinal malformations,
which can typically be corrected with surgical intervention, and it may overstate
levels of intellectual disability, which can be strongly moderated by early behav-
ioral, developmental, and educational intervention.
Angela Libal
See also: Abortion, Elective; Abortion, Medical; Abortion, Risks of; Abortion, Surgical;
Abortion, Unsafe; Abortion Legislation; Emergency Contraception; Roe v. Wade; Sexual
Rights.
Further Reading
Breborowicz, G. H. (2001). Limits of fetal viability and its enhancement. Early Preg-
nancy, 5(1), 49–50.
Jacobson, J. D., & Zieve, D. (Eds.). (2018). Hydatidiform mole. Retrieved from http://
www.nlm.nih.gov/medlinepls/ency/article/000909.htm
Jauniaux, E., Gillerot, Y., & Hustin, J. (2001). Placental and fetal cancers. In E. R. Barnea,
E. Jauniaux, & P. E. Schwartz (Eds.), Cancer and pregnancy (6–20). London:
Springer London.
Mayo Clinic. (2019). Placental abruption. Retrieved from https://www.mayoclinic.org/
diseases-conditions/placental-abruption/symptoms-causes/syc-20376458
Mayo Clinic. (2019). Preeclampsia. Retrieved from https://www.mayoclinic.org/diseases-
conditions/preeclampsia/symptoms-causes/syc-20355745
Abortion, Unsafe
Unsafe abortion is intentional termination of pregnancy in the absence of a trained,
competent clinician; adequate, sanitary medical facilities; or both. It may be ille-
gal or legal and may be performed by the pregnant individual, a nonmedical prac-
titioner, an inadequately trained or incompetent clinician, or a trained clinician
working in unsafe conditions. Unsafe abortions are a leading cause of death for
pregnant women worldwide, where they account for 13 percent of global preg-
nancy-related deaths and take the lives of 68,000 women and girls per year world-
wide. Approximately 18.4 million unsafe abortions with 67,500 deaths occur
annually in developing countries. Developed countries account for 500,000 unsafe
abortions and 500 or fewer deaths annually.
Approximately one-fifth of all pregnancies end in abortion. This statistic is
stable throughout the world regardless of the overall birth rate and regardless of
whether abortion is legal in a region or not. Half of these abortions are unsafe.
Currently, about one-quarter of the world’s population lives in areas where abor-
tion is prohibited, and many more live in areas without access to skilled practitio-
ners or sanitary conditions that meet minimum medical standards.
Unsafe abortions may be induced by drug overdose; oral ingestion or vaginal
insertion of herbs or other traditional remedies; insertion of objects through the
cervix and into the uterus; oral consumption or vaginal insertion of caustic chemi-
cals; physical or extreme sexual abuse; or prolonged, vigorous physical activity.
Abortion, Unsafe 13
They may also be induced by unsafe or unapproved use of pharmaceuticals or
with inappropriate or unsanitary surgical or procedural equipment.
The most common cause of death from unsafe abortion is sepsis (blood infec-
tion) from retained tissue. Other causes of death include fatal infection by genital
flora, sexually transmitted infection pathogens, or wound-infecting bacteria such
as Clostridium; heavy bleeding or hemorrhage from drugs, chemicals, supposito-
ries, retained tissue, or uterine damage; uterine perforation with bowel injury,
damage to other organs, or shock; and poisoning or drug overdose. Unsafe abor-
tion can also cause chronic infection or inflammation, permanent disability, pelvic
inflammatory disease, infertility, extreme genital trauma, and reproductive tract
abscesses.
Unsafe abortion has an extremely high social and economic cost beyond the
direct loss of lives. In some regions, these abortions account for half or more of
hospital admissions and annual expenditures. In addition, they take an incalcula-
ble social, economic, and emotional toll on communities and families—especially
children left motherless.
Legalization of abortion has no impact on rates of pregnancy and birth—access
to effective contraception and women’s ability to insist on contraceptive use does.
However, legalization of abortion and easy access to safe, early abortion dramati-
cally reduces annual numbers of unsafe abortions. Modern medicine’s ability to
perform safe, first-trimester abortion is now so advanced that where trained clini-
cians, appropriate equipment, and sanitary facilities are available, deaths are vir-
tually nonexistent—however, many blockades to access exist even in regions
where abortion is technically legal. Blocks to access include distance; cost; exces-
sive bureaucratic regulations imposed on patients (such as waiting periods,
requirements for multiple written medical referrals, or parental consent); exces-
sive bureaucratic regulations imposed on clinics (such as requiring that facilities
have complete operating rooms and the ability to perform general anesthesia—
neither of which is necessary for early-term abortions); lack of equipment and
pharmaceuticals; lack of dependable, safe water supplies, fuel, and power; lack of
clinicians, facilities, and emergency care; hostility toward, ostracism, and con-
demnation of women who seek abortion; and harassment and violence targeted at
abortion providers and patients.
Lack of access to prompt and appropriate emergency medical care contributes
to unsafe abortion deaths. In the British Medical Bulletin in 2003, Dr. David A.
Grimes wrote, “Perhaps the greatest danger of all is indifference—or overt dis-
dain. The lack of commitment on the part of medical and nursing staff to provide
prompt, attentive and emotionally supportive care indirectly dooms women whose
lives could easily be saved. Many women who reach medical facilities are met
with suspicion and hostility, and their treatment deferred while other more ‘suit-
able’ candidates receive medical attention.” In addition, women who face legal
repercussions may not seek emergency care until it is too late.
Abortion is the most common surgical procedure for U.S. women, and approxi-
mately one-third have an abortion at some point in their lives. The annual death
rate from legal abortion in the United States is less than one in one hundred
14 Abortion Legislation
thousand. Yet, according to the New York Times, in 2010, “In 87% of the counties
in the U.S., where a third of women live, there is no known abortion provider.”
Angela Libal
See also: Abortion, Elective; Abortion, Medical; Abortion, Risks of; Abortion, Surgical;
Abortion, Therapeutic (Medically Necessary); Abortion Legislation; Emergency Contra-
ception; Roe v. Wade; Sexual Rights.
Further Reading
Barot, S. (2001). Unsafe abortion: The missing link in global efforts to improve maternal
health. Guttmacher Policy Review, 14(2), 24–28.
Bazelon, E. (2010, July 14). The new abortion providers. New York Times, p. MM30.
Grimes, D. A. (2003). Unsafe abortion: The silent scourge. British Medical Bulletin, 67(1),
99–113.
Haddad, L. B., & Nour, N. M. (2009). Unsafe abortion: Unnecessary maternal mortality.
Review of Obstetric Gynecology, 2(2), 122–126.
World Health Organization. (2019). Preventing unsafe abortion. Retrieved from https://
www.who.int/en/news-room/fact-sheets/detail/preventing-unsafe-abortion
Abortion Legislation
Abortion has been practiced throughout history as a means of controlling
unwanted or unsafe reproduction. In the United States, abortion legislation began
on the state level in 1821 and has continued to the present day. Legislation began
as a means of protecting women from life-threatening, amateur abortion prac-
tices, but as the general public became polarized on the issue in the later 1800s,
states began passing laws to criminalize all forms of abortion.
The first abortion legislation in the United States was passed in Connecticut in
1821 and was a law to prevent women from taking poison to terminate a preg-
nancy after the fourth month. Over the next thirty-five years, most states allowed
abortion or classified it as a misdemeanor. This position met its first major chal-
lenge in 1856, when gynecologist and antiabortion advocate Horatio Robinson
Storer started the “physicians’ crusade against abortion,” persuading the Ameri-
can Medical Association (AMA) to create the Committee on Criminal Abortion.
The committee presented a report in 1859 that led the AMA to petition state and
territory legislatures to ban elective abortions. Their campaign met with consider-
able success: by 1880, nearly every state and territory had passed legislation mak-
ing most forms of abortion a criminal act. Adding fuel to the fire, the Roman
Catholic Church declared its prohibition of any kind of abortion in 1869, driving
further bans on the practice around the world.
The AMA’s campaign made an impact on the national level as well. On March
3, 1873, Congress passed the Comstock Law, an act for the “suppression of trade
in, and circulation of, obscene literature and articles of immoral use.” The act
made it illegal to send materials including contraceptives, abortion-inducing
drugs, and information about abortions and other “obscene” topics through the
U.S. Postal Service. The Comstock Law made it virtually impossible for women
to obtain information about options for abortion. By the 1880s, most abortions
Abortion Legislation 15
were illegal across the United States, unless they were necessary “to save the life
of the woman.”
In the late nineteenth century, as the women’s suffrage movement began to gain
momentum, antiabortion legislation became a way for all-male legislatures to con-
trol women and negate their rights to make choices involving their own bodies. At
the same time, male obstetricians began to see midwives—often the practitioners
of abortions—as threats to their livelihood. The eugenics movement added more
pressure to the debate against abortion, demanding that white women continue to
reproduce to keep other races from gaining ground in the United States.
Even with all these forces in play, doctors estimated that in the 1890s, more
than two million abortions were performed in the United States each year. While
women with discretionary income could travel to another country or find a repu-
table doctor who would perform the procedure, poor women resorted to danger-
ous methods. Back-alley abortionists often demanded large sums of money and
rejected precautions like anesthesia and sterilization so they could finish the job
faster. Women often were abused or raped in the course of seeking an abortion.
The poorest women could not afford even these unsanitary and dangerous prac-
tices, so they attempted their own procedures. The coat hanger became the sym-
bol of secret do-it-yourself abortions, often resulting in severe internal damage to
the women who used these methods.
This situation continued into the 1960s, when the feminist movement brought
illegal abortions into the public eye. The movement made incremental gains as
some states passed laws allowing women to obtain abortions if they were victims
of rape or incest or if they were younger than fifteen. In general, however, abortion
had become a felony in forty-nine states by 1969. The first meaningful change in
legislation came in 1970, when Hawaii and then New York allowed abortion on
demand through the twentieth week (Hawaii) or twenty-fourth week (New York)
of pregnancy if a doctor performed the procedure in a medical facility. Soon sev-
eral other states passed similar laws, but women in the majority of states still had
to make their own way in finding someone to perform an abortion illegally.
All this changed on January 22, 1973, when the U.S. Supreme Court passed the
landmark Roe v. Wade decision. The decision determined that the right to privacy
granted by the Fourteenth Amendment extended to a woman’s decision to have an
abortion and that a woman has a right to an abortion until “viability,” the point in
the pregnancy at which the fetus can live outside the womb. This decision disal-
lowed some of the state and federal restrictions on abortion, essentially legalizing
abortion across the country. Abortions now could be performed in doctors’ offices,
gynecological clinics, and hospitals, with the medical supervision required to han-
dle complications and keep patients safe.
This decision did not end the dispute, however—in fact, it provided the point of
coalescence that created the “pro-life” and “pro-choice” factions that keep the
debate active today. The two sides argue over the question of viability and whether
life begins well into the pregnancy or at the point of conception. This controversy
led to the passage of the Hyde Amendment in 1976, just three years after Roe v.
Wade legalized abortion. The Hyde Amendment banned Medicaid funding for
abortion unless the pregnancy endangered a woman’s life. Before Hyde, 294,000
16 Abstinence
women annually received Medicaid funding for their abortions—roughly one-
third of all women seeking to terminate a pregnancy.
In 1980, the Supreme Court upheld the Hyde Amendment, opening the door to
new legislation on abortion rights. A series of cases that came before the court
throughout the 1980s and 1990s found state laws limiting abortion rights to be
unconstitutional, allowing minors to petition the court for permission to have an
abortion, eliminating waiting periods before abortions, and disallowing the decla-
ration that “life begins at conception.” In 1996, a law to ban so-called partial-birth
abortions, or abortions performed using the dilation and evacuation method,
passed Congress but was vetoed by President Bill Clinton.
Since the 2010 midterm election, states have adopted 231 new abortion restric-
tions. The year 2014 became pivotal in the passage of new state laws restricting
access to abortion—as well as laws expanding that access. The 2010 passage of
the Affordable Care Act brought new focus to the abortion debate, as the law
included the potential for government and private insurance funding of abortion
procedures. According to the Guttmacher Institute, major abortion restrictions fell
into four basic categories: targeted regulation of abortion providers (known as
TRAP), limits on providing medications that cause abortion, bans on private
insurance coverage of abortion, and bans on abortions after twenty weeks from
fertilization.
Randi Minetor
See also: Abortion, Elective; Abortion, Medical; Abortion, Risks of; Abortion, Surgical;
Abortion, Therapeutic (Medically Necessary); Abortion, Unsafe; Emergency Contracep-
tion; Hyde Amendment; Roe v. Wade; Sexual Rights.
Further Reading
Boonstra, H. D., & Nash, E. (2014). A surge of state abortion restrictions puts providers—
And the women they serve—In the crosshairs. Guttmacher Policy Review, 17(1).
Retrieved from https://www.guttmacher.org/gpr/2014/03/surge-state-abortion
-restrictions-puts-providers-and-women-they-serve-crosshairs
Cole, G. F., & Frankowski, S. (Eds.). (1987). Abortion and protection of the human
fetus: Legal problems in a cross-cultural perspective (Vol. 1). Boston: Martinus
Nijhoff.
Haney, J. (2009). The abortion debate: Understanding the issues. Berkeley Heights, NJ:
Enslow.
McBride, D. E., & Keys, J. L. (2018). Abortion in the United States: A reference hand-
book. Santa Barbara, CA: ABC-CLIO.
Abstinence
When discussing sex, abstinence generally means abstaining from sex or not hav-
ing sexual intercourse. This means people who are abstinent (or practice absti-
nence) may avoid any sexual contact at all or may only engage in certain sexual or
genital activities. Some people abstain from engaging in penile-vaginal inter-
course but engage in oral sex or penile-anal sex. People may also completely
abstain from any type of sexual contact. Because of the wide variety of what
Acquired Immunodeficiency Syndrome (AIDS) 17
constitutes “sex,” the practice of abstaining from some sexual behaviors to pre-
vent pregnancy is called selective abstinence.
People have the choice to abstain from sexual activity (or specific types of sex-
ual activities). Abstinence can be a beneficial way of engaging with one’s sexual-
ity should a person choose to do so. For some people, practicing abstinence can
help express one’s sexuality more fully, prevent the spread of sexually transmitted
infections, and prevent unwanted pregnancy.
Sexuality education in the United States has often focused on abstinence. Absti-
nence-only or abstinence-only-until-marriage education teaches about abstaining
from sex (or sexual activity) until marriage. These programs may also teach that
abstinence is the only moral choice and often do not include information on contra-
ceptive methods or safe ways to explore sexual touch or expression. Abstinence-
based or abstinence-plus education has a strong abstinence message but also
includes information on condoms and other forms of contraception. Comprehen-
sive sexuality education generally includes abstinence as one of many ways of
expressing one’s sexuality. These programs often recognize abstinence as a way for
people to express their values about sexuality within their own sexual practices.
The debate about how abstinence should be incorporated into sexuality educa-
tion often involves shame. When people are given a strong message about abstain-
ing from sexual intercourse, they may experience shame around sexual activity
(Crawford & Popp, 2003). Whether the shame comes from double standards or
being told that sexual activity makes a person “dirty,” shame around sexuality has
the potential to result in sexual difficulty later in life. These messages may inten-
tionally or unintentionally perpetuate shame and guilt and can affect people
whether the sexual activity was wanted or unwanted.
Ultimately, whether or how someone practices abstinence is a choice that each
person makes for themselves.
Mark A. Levand
See also: Celibacy; Contraception; Double Standards, Sexual; Religion, Diversity of
Human Sexuality and; Sex Education; Virginity.
Further Reading
Crawford, M., & Popp, D. (2003). Sexual double standards: A review and methodological
critique of two decades of research. Journal of Sex Research, 40(1), 13.
Cushman, N., Kantor, L. M., Schroeder, E., Eicher, L., & Gambone, G. (2014). Sexuality
education: Findings and recommendations from an analysis of 10 United States
programmes. Sex Education, 14(5), 481–496.
Hastings, A. S. (1998). Treating sexual shame: A new map for overcoming dysfunction,
abuse, and addiction. Northvale, NJ: Jason Aronson.
Hock, R. R. (2016). Human sexuality (4th ed.). New York: Pearson.
Acquired Immunodeficiency Syndrome (AIDS)
Acquired immunodeficiency syndrome (AIDS) is a chronic, and potentially
deadly, health condition caused by the human immunodeficiency virus (HIV).
HIV is a virus that is spread through certain bodily fluids. Once in the system, if
18 Acquired Immunodeficiency Syndrome (AIDS)
left untreated, HIV attacks the body’s immune system and may weaken it so that
the body can no longer fight off other infections and diseases. Although there is
presently no cure for HIV, not everyone who contracts HIV ultimately develops
AIDS. AIDS is recognized by the World Health Organization (WHO) as the most
severe stage of HIV infection; it may develop if medications, also known as anti-
retroviral therapy (ART), are not taken (WHO, 2017). An AIDS diagnosis
describes the point at which the immune system is so weak that it is susceptible to
opportunistic infections that would normally be controlled by a healthy immune
system. It is estimated that about thirty-seven million people worldwide are living
with HIV, and roughly 1 million people died of AIDS-related illnesses in 2016
(UNAIDS, 2017). Further, in 2016, 1.8 million new infections were diagnosed
(UNAIDS, 2017). While HIV or AIDS exists in all countries around the world, it
is especially prevalent in sub-Saharan Africa.
Even with the increasing accessibility to comprehensive sexual education, there
are many misconceptions about how HIV is transmitted. Due to the fact that HIV
is transmitted through bodily fluids, many people incorrectly think that HIV can
be transmitted by any and all bodily fluids, which is not the case. HIV cannot be
transmitted by the sharing of toilets, food, or drink; by insects or pets; or by sweat,
tears, or saliva; and it is not airborne or waterborne (i.e., transmitted by air or
water) (CDC, 2018a). HIV can be transmitted through contact with HIV-positive
blood (e.g., blood transfusions, organ or tissue transplants, sharing intravenous
needles) and through contact with the sexual bodily fluids of someone living with
HIV (e.g., vaginal and seminal fluids, including preejaculate fluid) (CDC, 2018a).
This means that HIV can be transmitted through both penetrative sex (e.g., vagi-
nal or anal sex) and nonpenetrative sex (e.g., oral sex). It is also possible that a
mother who is living with HIV may pass the virus to a child during pregnancy,
childbirth, or breastfeeding, if proper precautions are not taken. HIV is transmit-
ted by contact with mucous membranes, damaged tissue, or direct contact with
the bloodstream (CDC, 2018a). However, the spread of HIV can be prevented.
People who are living with HIV and who take their medication as prescribed are
unable to pass on the virus (CDC, 2017). Further, if someone is at risk of being in
contact with the virus—for example, if their sexual partner(s) has HIV—they can
take preexposure prophylaxis (PrEP) medication, which reduces the chances of
contracting the virus by more than 90 percent (CDC, 2018b). Also, safer sex meth-
ods, such as the use of condoms and dental dams, can reduce the potential for
transmission of HIV and other sexually transmitted infections (STIs). It is also
important to be regularly tested for STIs, as many, including HIV, may not have
any noticeable symptoms of infection.
Although the disease was observed in the United States by the Centers for Dis-
ease Control (CDC) in 1981, the term “AIDS” was not introduced until 1982. Prior
to the term being coined, it was initially referred to by the afflicting opportunistic
infections and soon after by the use of marginalizing misnomers based on the
most notably affected populations. Outdated and inappropriate classification
phrases such as “4H Disease” (i.e., disease affecting homosexuals, heroin users,
hemophiliacs, and Haitians) and “GRID” (i.e., “gay-related immune deficiency”)
were briefly used; however, these are misleading and discriminatory, since AIDS
Acquired Immunodeficiency Syndrome (AIDS) 19
is not isolated to any specific group of people. It does, however, show that preex-
isting social prejudices surrounding marginalized communities catalyzed a wide
spread of misinformation regarding HIV and AIDS. Socially constructed notions
of “immoral” behavior (e.g., homosexuality, drug use) and “uncleanliness” per-
petuated victim blaming, and those who were living with HIV faced stigma, prej-
udice, and hostility. The prevalence of such discrimination may also be a
contributing factor to the initial lack of public support for AIDS research. As more
and more people outside of these marginalized groups became infected, it became
clear that HIV and AIDS do not discriminate, and anyone can be affected. Thanks
to international medical intervention and increasing AIDS awareness advocacy
efforts, like World AIDS Day, which has been held every year on December 1
since 1988, rates of infection have steadily declined (WHO, 2017). Unfortunately,
many people still hold negative attitudes and prejudice toward people living with
HIV, and this HIV stigma contributes to discrimination, isolation, fear, and abuse
toward people living with AIDS. Further, people may be afraid to be tested for
fear of the stigma and discrimination they may face if diagnosed with HIV.
With greater public support over recent decades, significant scientific develop-
ments continue to improve treatment of HIV and associated symptoms as well as
to reduce and prevent transmission. While cure efforts continue to be actively
explored, advances in pharmaceutical interventions for people who are living with
HIV have led to many available options for ART. Preventative medications, known
as preexposure prophylaxis, are also more widely available. PrEP is a daily pre-
scription medication for people who are HIV-negative and who are at “ongoing
substantial risk for HIV infection” (e.g., in an ongoing sexual relationship with an
HIV-positive partner who is not virally suppressed with ART, using or sharing
illicit drug injection equipment) (CDC, 2018b). Combination prevention that
includes multiple prevention strategies, such as using PrEP in addition to con-
doms, may further decrease risk of transmission.
As the world continues to strive toward a safe and reliable cure, proper medical
education continues to spearhead advocacy work and public dialogue against the
discrimination of people living with HIV or AIDS. These efforts, in addition to
scientific advances, have helped AIDS move from a “terminal” illness to a
“chronic” yet manageable disease.
Ilyssa Boseski
See also: Human Immunodeficiency Virus (HIV); Sexually Transmitted Infections
(STIs).
Further Reading
Centers for Disease Control and Prevention. (2017). HIV treatment as prevention.
Retrieved from https://www.cdc.gov/hiv/risk/art/index.html
Centers for Disease Control and Prevention. (2018a). About HIV/AIDS. Retrieved from
https://www.cdc.gov/hiv/basics/whatishiv.html
Centers for Disease Control and Prevention. (2018b). PrEP. Retrieved from https://www
.cdc.gov/actagainstaids/basics/prep.html
UNAIDS. (2017). UNAIDS data 2017. Retrieved from http://www.unaids.org/sites/default/
files/media_asset/20170720_Data_book_2017_en.pdf
20 Adolescent Sexuality
U.S. Department of Health and Human Services, National HIV/AIDS Strategy. (2016).
HIV/AIDS Basics. Retrieved from https://www.aids.gov/
World Health Organization. (2017). WHO HIV/AIDS fact sheet. Retrieved from http://
www.who.int/mediacentre/factsheets/fs360/en/
Adolescent Sexuality
The World Health Organization describes adolescence as the transitional period
between childhood and adulthood that can range from ages ten to nineteen years.
The adolescence time period is also known as the time after puberty has started.
There has been much debate around the actual years of adolescence as it is ever-
changing, so these time periods are estimates of the transitional period. During
this period, individuals will go through many different physical, mental, sexual,
and psychological changes. Adolescents go through their own self-development;
many will feel a strong urge for independence from their parents or caregivers,
and most have to start making tough decisions for themselves as they begin to
prepare for adulthood. This is a highly critical time of life that is filled with inter-
nal and external transitions.
During adolescence, many different physical changes take place, and some
can be different for boys and girls. For both sexes during this time, usually
referred to as puberty, the endocrine glands start to produce hormones that aid
in the development of secondary sex characteristics. For girls, the ovaries start
to increase production of estrogen and progesterone. Girls also grow taller, their
hips get wider, they start having vaginal secretions, and they grow hair on their
body. Breasts also develop, and typically girls will have their first menstrual
period, also known as menarche. For boys, the testicles start to increase their
production of testosterone, and during the beginning of adolescence, both testes
enlarge. This is followed by growth in height, hair on the body, increased shoul-
der width, growth of the penis, night ejaculations, and deepening of the voice.
As these changes occur, teenagers can feel uncomfortable with their bodies,
may feel as though they are developing either too fast or too slow compared to
their peers, and can experience lots of fluctuations in their mood and tempera-
ment. During the adolescent years, it is very typical for individuals to go through
mood swings. These mood swings, or rushes of emotions and feelings, are in
part due to the influx of sex hormones that flood the body during this transi-
tional time.
As Erik Erikson’s development stages would suggest, in the beginning of ado-
lescence, individuals are starting to process the idea of identity versus identity
diffusion. This means that they are building upon the stages they have already
completed (trust versus mistrust, autonomy versus shame and doubt, initiative
versus guilt, and industry versus inferiority), and after conquering these stages,
they are starting to build their own identity. When teenagers enter the develop-
ment stage of adolescence, they are still seeing the world as black and white with
no gray areas. This can make it difficult for them to understand the relationship
between their behavior and its consequences. Adolescents tend to have a difficult
Adolescent Sexuality 21
time imagining life in the future and are much more grounded in their present life,
which is why they have difficulty thinking about the future consequences of their
actions. However, toward the later stages of adolescence, individuals are able to
start understanding the concept of their future. They can also start to solve com-
plex problems and start to understand what other people are thinking on a social
basis. This does not mean that they are no longer impulsive; however, this charac-
teristic will lessen as they develop.
Adolescence can lead individuals to question relationships in their life, and
they will often try to break away from their parents’ authority. During this time,
adolescents are still dependent on their parents in a lot of different ways, but most
are fighting this to try to find their own independence. They are also trying to
figure out where they belong in their social worlds, and their peer groups will
become the most important influence on their lives. This can have positive or
negative effects, depending on their peers. Adolescents will also want to start
forming stronger bonds with same- and other-sex friends, and eventually most
will start to develop strong feelings toward sexual and romantic partners.
As mentioned, adolescence is when most people start to feel sexual attraction
toward others. This can be an emotional time when people may be overwhelmed
with their newfound affection, and, consequently, individuals may find it diffi-
cult not to give in to peer pressure, and they may engage in high-risk behavior.
Sexual arousal also starts to take place during this time, which may lead to very
uncomfortable moments for adolescents and potentially their caregivers. Most
individuals will start to masturbate and explore their sexuality. It is important
for caregivers not to overreact to this behavior but instead to approach it in a
calm and understanding manner. Making sure adolescents and caregivers have
access to comprehensive and appropriate sex education is an important aspect of
this transitional phase.
Adolescence happens at different stages for different people. While the physi-
cal aspects of the transition tend to happen earlier for most, the intellectual, social,
and emotional aspects often occur much later in this transitional time. Even though
adolescence can be trying for everyone, with time, the adolescent will start to
understand their own body and emotions. Parents and caregivers should take the
time to remember that their children and loved ones are going through drastic
physical and mental changes, and they need love and support even when they do
not act like it.
Amanda Baker
See also: Childhood Sexuality; Gender Identity Development; Puberty; Sex Hormones;
Sexuality across the Life Span; Sexuality among Older Adults; Sexuality among Younger
Adults.
Further Reading
Allen, B., & Waterman, H. (2019). Stages of adolescence. Retrieved from https://www
.healthychildren.org/English/ages-stages/teen/Pages/Stages-of-Adolescence.aspx
Basso, M. J. (2003). The underground guide to teenage sexuality (2nd ed.). Minneapolis:
Fairview Press.
Harris, R. H., & Emberley, M. (2009). It’s perfectly normal: Changing bodies, growing
up, sex, and sexual health. Somerville, MA: Candlewick Press.
22 Adrenarche
World Health Organization. (2015). Adolescent development. Retrieved from http://www
.who.int/maternal_child_adolescent/topics/adolescence/dev/en/
Adrenarche
Adrenarche means “awakening of the adrenal glands.” It is a prepuberty shift in
the body’s production of adrenal hormones. Adrenarche only occurs in certain
species of primate, including humans, and is related to the maturation of a specific
area, the zona reticularis in the adrenal cortex (the outer portion of the adrenal
glands).
Androgenic hormones (so-called masculinizing hormones) control adrenarche
and its characteristic body changes. These body changes include the initial growth
of pubic and other body hair, called axillary hair; development of adult body odor
due to changes in the composition of sweat; changes in the skin’s sebaceous glands
with increased production of skin oils, which can cause hormonal (microcomedo-
nal) acne; heightened emotionality and mood swings; bone maturation; and
growth in height. In boys, it is also associated with an increase in circulating tes-
tosterone and a decrease in sex-hormone binding globulin, a blood protein that
prevents the body from using sex hormones.
Although characterized by physical events typically associated with puberty,
adrenarche is a separate developmental stage. Puberty is sexual and reproductive
maturation. Adrenarche is a shift in adrenal hormones that occurs independent of
puberty. It typically begins by age nine, though its resultant physical changes may
take longer to appear. Puberty usually begins within several years following the
onset of adrenarche.
The characteristic hormonal features of adrenarche include a steady level of
circulating cortisol, a constant rate of cortisol production, an increase in adrenal
androgens in the urine, and an increase in circulating adrenal androgens. Adre-
narche does not directly lead to puberty nor to sexual and reproductive maturity.
Neither its causes nor its purpose is completely understood. It does not appear to
be triggered by any known sex-related hormones, including the gonadotropins,
prolactin, or estrogen, or by adrenocorticotropic (“adrenal cortex–growing”) hor-
mone. While adrenal androgens increase during adrenarche, levels of other hor-
mones remain constant.
The relationship of adrenarche to puberty is unknown. While abnormal levels
of adrenal androgens have been associated with precocious (early-onset) puberty
in some boys, some children with adrenal insufficiency (lower-than-normal adre-
nal hormone production) still begin puberty at a normal age, while others fail to
undergo normal puberty even when treated with supplementary hormones.
Though it causes changes associated with puberty and may play a role in its onset,
adrenarche does not appear to be required for puberty to begin.
Premature adrenarche is considered a medical condition that should be
addressed by an endocrinologist. However, there is little agreement on what quali-
fies as “premature”: some say before age eight in girls and nine in boys; others say
before age six or even five. Unlike precocious puberty, children who experience
Adultery 23
premature adrenarche do not exhibit reproductive capability, and they can other-
wise develop normally. Yet, premature adrenarche is of concern because it may
signal a more serious health problem, such as an adrenal tumor. Early adrenarche
is common in obese children and in children who experienced intrauterine growth
restriction, which shows a possible relationship between adrenarche and fetal,
infantile, or early childhood body fat levels and body mass.
Angela Libal
See also: Androgen Insensitivity Syndrome; Androgens; Andropause; Puberty; Sex Hor-
mones; Testosterone.
Further Reading
Boston Children’s Hospital. (2019). Premature adrenarche. Retrieved from http://www
.childrenshospital.org/conditions-and-treatments/conditions/p/premature
-adrenarche
Forest, M. G., David, M., & Sempe, M. (1982). Does adrenarche really play a determining
role in pubertal development? A study of the dissociations between adrenarche
and gonadarche. The failure of dehydroepiandrosterone sulfate treatment in
delayed adrenarche. Annals of Endocrinology, 43(6), 465–495.
Parker, L. N. (1991). Adrenarche. Endocrinology and Metabolism Clinics of North Amer-
ica, 20(1), 71–83.
Adultery
Often seen as synonymous with “marital infidelity” or “cheating,” “adultery”
refers to sex with a person or people other than one’s spouse, primarily in a
monogamous marriage. Originating from a religious background, adultery has
been seen as engaging in extramarital sexual relations. Those who engage in adul-
tery, often called adulterers, have historically been punished in many different
ways, including socially, financially, and legally. Because of the common use of
“adultery” in the Christian Bible, much religious connotation is placed on the
word, often followed by moral judgment. In this context, the morality of adultery
is closely tied to what Christians believe to be the purpose of marriage—that is,
primarily, sexual exclusivity and procreation.
In a strict sense, adultery entails a sense of sexual transgression. It is assumed
that the other spouse would most certainly not approve of the sexual activity out-
side of the marriage. Components such as spousal permission or involvement
begin calling into question the assumed moral wrongness of such a sexual rela-
tionship, perhaps more in line with consensual nonmonogamy, while others may
still refer to the activity as adultery.
In a broader sense, the primary focus is on the breach of the marital contract.
Because monogamous marriages are often assumed to be sexually exclusive, any
sexual contact outside of one’s spouse is seen as infidelity or cheating. When cou-
ples practice communication about sexual desires and needs, what is considered
cheating can be more clearly defined and less assumed by both parties. What con-
stitutes cheating or infidelity for a particular couple may not be universally con-
sidered a breach of contract. For example, one couple may feel that holding hands
24 Adultery
with other people or giving a massage can be a form of cheating, while other
couples may agree that intense kissing or manual sexual stimulation does not con-
stitute infidelity but vaginal-penile intercourse does. It is important to note that
sexual activity is intrinsically tied to adultery. While someone can engage in
physical or emotional infidelity, the strict meaning of adultery is of a sexual nature.
There have been many thoughts on why people seek connection outside of their
marriage. In his book The Marriage Clinic, John Gottman (1999) discusses the
reasons people cheat on their spouses. After summarizing many different studies,
he points to feeling unloved as a common theme in what causes infidelity. This
reasoning is often what guides therapeutic practices that help couples work
through instances of extramarital affairs. Fife, Weeks, and Stellberg-Filbert (2013)
suggest that couples can use therapy to focus on forgiveness in situations of infi-
delity. They suggest four key components to be used with couples: empathy,
humility, commitment, and apology.
Empathy and nondefensive listening allow for the partners to better understand
each other’s positions. They can better understand their partner’s experience and
begin to see them as fallible rather than as a genuinely bad person. Humility
allows the partners to recognize their own role in the situation and decreases
blaming. Acknowledging the damage that was done is an important aspect of
being humble. Commitment to the relationship can be helpful for a couple to
remember, as well as thinking of past memories, closeness, connection, and shared
life goals. Finally, apology is the honest acknowledgment of a wrongdoing. Pledg-
ing to stay committed and faithful and asking for forgiveness are often crucial
parts of apology.
The work of therapist Esther Perel (2014) suggests a more nuanced and compli-
cated view of why affairs happen. She adds to the discussion with her new book,
The State of Affairs, on the topic of affairs and why people engage in adultery.
Perel identifies much of the literature and current dialogue around sex and sexual-
ity involved in an affair and pleads for the movement away from demonizing and
stigmatizing such behavior, claiming that this only causes more confusion and
misconception around the subject. She points to numerous causes of infidelity,
such as tainted love, revenge, unfulfilled longings, or simply lust. One of her main
talking points about infidelity is that the quest for a new lover is less than the want
for a new self—that people cheat because they are tired of the self they have
become. Her further research may be helpful for uncovering useful future thera-
peutic practices. Whether adultery is strictly interpreted with religious connota-
tions or broadly recognized, the reality remains that it can affect partnered
relationships.
Mark A. Levand
See also: Cheating and Infidelity; Marriage; Monogamy; Open Marriage.
Further Reading
Fife, S. T., Weeks, G. R., & Stellberg-Filbert, J. (2013). Facilitating forgiveness in the
treatment of infidelity: An interpersonal model. Journal of Family Therapy, 35(4),
343–367.
Gottman, J. M. (1999). The marriage clinic: A scientifically-based marital therapy. New
York: W. W. Norton & Company.
Advertising, Sex in 25
Perel, E. (2014). Changing the view on infidelity. Retrieved from http://www.estherperel
.com/2014/03/changing-the-view-on-infidelity/
Perel, E. (2017). The state of affairs: Rethinking infidelity. New York: Harper.
Advertising, Sex in
Most people have heard the phrase “sex sells,” which expresses the fact that adver-
tisers use sexual images and messages to draw attention to the products they try to
sell. In 2017, advertising expenditures in the United States amounted to over $206
billion. Advertising attempts to inform, position, convince, reinforce, differenti-
ate, and ultimately sell products and services, and sexualized ads often contribute
to these goals.
Researchers at the University of Georgia reviewed ads in six popular maga-
zines and categorized them based on the models’ clothing, or the amount of skin
shown, and the amount of physical contact between models. Between 1983 and
2003, the amount of advertisements containing sexual imagery almost doubled,
from 15 percent to 27 percent of advertisements. The products most likely to use
sexual imagery were alcohol, entertainment, and beauty products.
Using sex to sell goes back to the beginning of modern advertising in the late
1800s. An early example is collectible advertising cards, similar to baseball cards,
which many nineteenth-century tobacco companies put in packages of cigarettes.
These images showed women in revealing costumes at a time when street clothes
completely covered women from neck to toe. Early in the twentieth century,
Woodbury’s Facial Soap was the product most frequently cited as the first impor-
tant campaign that used sex to sell. The text, along with a picture of a romantic
couple and the tag line, “A Skin You Love to Touch,” was so provocative that some
women’s magazine readers canceled their subscription when the ad appeared.
Today, sexualized images and messages are in television shows, movies,
books and magazines, music, and, of course, on the internet. With pervasive and
increasingly frank sexual depictions everywhere in popular culture, advertisers
sometimes push the limits with ads that border on explicit erotica. Various strat-
egies are used to stimulate consumers sexually. Nudity is an obvious tool that
has been used since the beginning of corporate marketing. Models are shown
baring their bodies to various degrees, wearing lingerie, swimwear, underwear,
or nothing at all.
The vast majority of advertisements use models who are physically attractive.
The suggestion is that if you use whatever product they are promoting, you will
be as attractive as the models. Advertisers may provoke consumers’ anxiety
about their own appearance in order to prompt the purchase of the product or
service.
Sexual behavior is often suggested in advertising, especially in sex-related
products, like erectile dysfunction drugs or condoms. More subtle suggestions of
sexual behavior are in eye contact, flirting, or movement often used in ads for
beauty products or alcohol. Another strategy using sex to sell is to refer to sexual
objects or events through innuendo or double entendres. An example is the 1960s
26 Advocate, The
shaving cream commercial that used a woman’s voice saying, “Take it off. Take it
all off.” A further subtle tactic is to embed subliminal sexual content in advertise-
ments. An ad may have nonsexual objects arranged in such a way that they repre-
sent sexual body parts, or words like “sex” may be embedded in the image in an
unobtrusive way.
A benefit that consumers derive from sexualized ads is often a form of wish
fulfillment. When someone buys the product, they may feel more attractive, they
may feel more likely to engage in sexual behavior or enjoy the encounter more, or
they may feel sexy or sensual, with increased self-esteem. If the consumer buys
and uses the product as directed, they may hope to find themselves in the sexual
situation depicted in the ad. Beyond associating sex with a product, advertisers
also use sex to position brands as sexual and to imply that sex-related benefits can
come to consumers who purchase the brand’s goods.
Critics of sexualized advertising have pointed out the objectification of the
body, which is viewed as dehumanizing. This is especially apparent in advertising
where the models are posed in passive positions or when only body parts are
shown. Another criticism is about how these ads define who is sexual. Almost
never are the “sexy” models older, imperfect, overweight, or disabled. The models
chosen for sexualized ads are usually young, attractive, and fit, with ideal features
and bodies. This can lead the consumer to develop a poor body image because
their body varies so much from the presented ideal.
With increasing sexual images and messages in advertising, there is the sug-
gestion that it is normal to be sexually aroused, alluring, and active at all times.
The effect on consumers is that they suspect they are somehow dysfunctional or
lacking if they are not as sexually responsive and interested as the people in the
advertisements. Despite the criticisms of sex in advertising, it has been proven
effective over the decades, and advertisers are sure to continue using it.
Michael J. McGee
See also: Media and Sexuality; Physical Attractiveness; Sexualization.
Further Reading
Reichert, T., & Lambiase, J. (Eds.). (2014). Sex in advertising: Perspectives on the erotic
appeal. New York: Routledge.
Statista. (2018, April). Media advertising spending in the United States from 2015 to 2021
(in billion U.S. dollars). Retrieved from http://www.statista.com/statistics/272314/
advertising-spending-in-the-us/
Advocate, The
The Advocate is an American lesbian, gay, bisexual, and transgender interest
bimonthly magazine and website. The magazine was founded in 1967 and is the
oldest and largest LGBTQ+ publication in the United States, founded before the
Stonewall riots. Both magazine and website focus on news, politics, opinion, and
arts and entertainment of interest to LGBTQ+ people.
The Advocate was first published in Los Angeles as a local newsletter by the
activist group Personal Rights in Defense and Education (PRIDE). The newsletter
Afterplay 27
was inspired by police raids and brutality, specifically one such instance on a Los
Angeles gay bar, the Black Cat Tavern, on January 1, 1967. By early 1968, PRIDE
was struggling financially, so Richard Mitch and Bill Rau paid the group one dol-
lar for ownership of the paper. In 1969, the newspaper was renamed The Advocate,
and 40,000 copies were being printed for each issue by 1974.
The Advocate was bought by David Goodstein, an investment banker from San
Francisco, in 1974. Under his direction, The Advocate began to be published twice
a month and focused on providing information and covering events important to
the LGBTQ+ community; it also began to have advertisements from more main-
stream sponsors. In 1985, Goodstein died from complications after surgery for
bowel cancer. Soon after his death, and beginning with the October 1, 1985, issue,
the magazine was transformed from a newspaper format to a standard magazine
format.
Editor in chief Richard Rouilard was the first to feature straight celebrities on
the cover in the 1980s and early 1990s. After Rouilard’s death from AIDS, Jeff
Yarbrough became editor in chief and continued this trend. Under the leadership
of Judy Wieder, its first female editor in chief (1996–2002; editorial director,
2002–2006), The Advocate won numerous awards and set multiple sales records.
Under her direction, The Advocate also published many coming-out interviews
with LGBTQ+ celebrities like Ellen DeGeneres, George Michael, and Chastity
Bono, which increased the popularity and exposure of the magazine.
By 2008, the print edition of The Advocate could no longer compete with
local weekly LGBTQ+ newspapers and the internet, so it switched the magazine
from a biweekly to a monthly publication. The Advocate print version continues
to be published and is available but is now published bimonthly with six issues
per year.
Lauren Ewaniuk
See also: Gay Rights Movement; LGBTQ+; Stonewall Riots.
Further Reading
The Advocate. (2019). Retrieved from https://www.advocate.com
Afterplay
Afterplay is the set of interactions that occur after a sexual experience. Afterplay,
also referred to as postcoital play, spans a wide variety of possible activities,
including cuddling, holding hands, kissing, talking, stroking, massaging, or reen-
gaging in sexual acts like oral sex, mutual masturbation, outercourse, or inter-
course. Interactions can be sensual, affectionate, or sexual, and each person can
decide in which behaviors they are interested. What they all have in common is
that afterplay behaviors are meant to increase the sense of connection and safety
between partners.
There are many researched benefits to afterplay. Afterplay is often used as a
bonding tool between partners to increase intimacy. The period after sex can be
a vulnerable time and is a critical time for promoting relationship satisfaction
28 Afterplay
among partners. When sex is enjoyable, the release of the neurotransmitters
oxytocin and dopamine creates feelings of closeness and pleasure and lowers
the stress hormone cortisol, which helps create intimacy within a relationship.
Partners often naturally use the time following sex to reinforce their commit-
ment to one another, provide feedback on their experience, and demonstrate
their feelings toward the other. Research on afterplay within long-term partner-
ships suggests that it can aid in feelings of sexual satisfaction, especially when
following an orgasm. Research also suggests that for women, the experience of
afterplay can improve their experience of the sexual encounter, whereas men
may experience more indirect benefits, such as increasing the likelihood of
future sexual activity. It has also been reported that the more time people spend
engaging in postsex affectionate behaviors like afterplay, the higher their sexual
and relationship satisfaction. Further, spending more time being caring and
affectionate gave people more satisfaction overall than being sexual. This could
be explained by humans’ interactive nature, the different emotional benefits
associated with sex, or the relative lack of intimacy in many social relationships.
Regardless of the reasons, research consistently demonstrates that afterplay can
promote relationship development and healing from traumas like infidelity, and
can increase individual well-being.
In addition, kink communities consider afterplay a necessary part of power-
exchange scenes. They may refer to afterplay as aftercare, a more nuanced experi-
ence of postcoital activity that has less to do with increasing arousal and more to
do with creating safety, maintaining trust, and lowering anxiety. In these commu-
nities, afterplay is negotiated before any sexual activity has taken place to ensure
that the needs for afterplay are clear and an agreement about fulfillment of those
needs can be reached.
Not everyone feels equally inclined to participate in afterplay as their partners.
While many people enjoy ongoing engagement after sex, some people feel over-
stimulated by extended contact after a sexual encounter. Some may find afterplay
too intimate and are therefore unwilling to participate if their sexual partner is not
someone with whom they want a romantic bond. Others may not enjoy nonsexual
touch, may feel restless during afterplay, or may want to receive rather than give
care. All these positions can prevent afterplay from occurring, which may provide
a challenge when one sexual partner is seeking it and the other or others are
uninterested.
Even for those who do enjoy afterplay, barriers can exist. The most common
reasons for not engaging in as much afterplay as wanted are fatigue and a lack of
communication between partners about their desires.
Research shows that the most positive reports of afterplay come from people
who are future oriented and prone to pursuing long-term committed relationships.
Therefore, people who do not meet these criteria may not reap the same benefits
from afterplay as their counterparts or may not experience the same desire to
engage in postcoital activity.
Shadeen Francis
See also: Foreplay; Intimacy, Sexual and Relational; Kink; Touching, Sexual Arousal
and.
Age of Consent 29
Further Reading
Denes, A. (2012). Pillow talk: Exploring disclosures after sexual activity. Western Jour-
nal of Communication, 76(2), 91–108.
Denny, N. W., Field, J. K., & Quadagno, D. (1984). Sex differences in needs and desires.
Archives of Sexual Behaviors, 13(3), 233–245.
Hughes, S. M., & Kruger, D. J. (2011). Sex differences in post-coital behaviours in long
and short term mating: An evolutionary perspective. Journal of Sex Research,
48(5), 496–505.
Muise, A., Giang, E., & Impett, E. A. (2014). Post sex affectionate exchanges promote
sexual and relationship satisfaction. Archives of Sexual Behavior, 43(7),
1391–1402.
Age of Consent
“Age of consent (AoC)” is a legal term that defines when minors (persons younger
than eighteen years old) can engage in sexual intercourse without fear that their
sex partner might potentially be arrested, prosecuted, and jailed. In the United
States, AoC is the age state law determines a young person is intellectually and
emotionally responsible enough to fully appreciate the consequences of sexual
intercourse (or other activities) such that they can make a truly informed decision,
free of the undue influence or social pressure of older adults.
The concept of AoC dates back hundreds of years to British law. In 1275, the
Westminster 1 Statute established the AoC at twelve years. This was born out of
the public’s concern that young girls were largely ignorant of the potential conse-
quences of intercourse, such as sexually transmitted infections, pregnancy, and a
lowered social standing (bad reputation). Furthermore, young girls were believed
to be susceptible to deception. As such, the law had to protect them from those
who might entice them into sexual activity. Protection came in the form of arrest,
legal prosecution, and lengthy jail sentences upon conviction. In the past, this idea
of protection was so important that advocacy groups such as the Women’s Chris-
tian Temperance Union preferred the term “age of protection” rather than “age of
consent.” “Statutory rape” is the modern term to describe sex between an older
person and an individual under the AoC. Historical terms included “ravish,”
“abuse,” “ruin,” and “seduce,” among others. This is where the term “jail bait”
comes from: a girl identified as under the AoC and who—at least in the eyes of
others—appears interested in sex.
In the United States, the AoC depends on where you live; each state determines
its own. In the past, some AoCs were as low as seven. Presently, the AoC ranges
between sixteen and eighteen nationwide. A somewhat similar term is “age of
majority,” the age at which you can legally sign a contract—to purchase a car or
join the military, for example. The age of majority is eighteen in all states, except
Alabama and Nebraska, where it is nineteen.
Historical criticism of a legally enforceable AoC included (1) the belief that
AoC was unique to each girl, based on when she developed her secondary sex
characteristics (pubic hair, breasts, menstruation), (2) fears that young working
girls would blackmail their male bosses with the threat of false rape accusations,
and (3) that male chivalry was sufficient protection.
30 Agender
The historical focus on girls has led to a gender disparity. In some states, the
AoC for boys is younger than for girls, in part due to the belief that the conse-
quences are less severe for boys. Although many laws with such gender disparities
have been deemed unconstitutional, the Supreme Court has allowed those related
to AoC to stand.
Today, whether AoC violations are prosecuted, as well as potential punishments
if convicted, vary state to state and depend on the age difference between partners.
Some states allow for a wide age gap. Utah, where the AoC is eighteen, allows up to
a ten-year age difference between partners before prosecution. In other words, a
seventeen-year-old could have sex with a twenty-seven-year-old and prosecution
would be unlikely. Other states, in contrast, allow no age gap and have stiffer penal-
ties when violators are much older. For example, in New York the AoC is seventeen.
An eighteen-year-old male who has sex with a sixteen-year-old female could be
charged with a misdemeanor and face up to one year in jail, even if both parties
wanted to participate in the sexual activity. If the man were twenty-five, he could be
prosecuted for a felony and face up to ten years’ incarceration.
In the 1970s, the federal government essentially extended the concept of AoC
from sex to all reproductive health care services with the passage of the Title X
Family Planning Program. This law initially allowed poor girls age twelve or older
to consent to federally funded contraception, sexually transmitted infection treat-
ment, prenatal visits, adoption counseling, infant care, and abortions. Since then,
states have established limits on such services, either raising the AoC or else man-
dating parental notification or consent.
David J. Reynolds
See also: Adolescent Sexuality; Childhood Sexuality; Intercourse; Puberty; Sexual Con-
sent; Statutory Rape.
Further Reading
Clarke, P. (2018). Age of consent by state. Retrieved from http://www.legalmatch.com/
law-library/article/age-of-consent-by-state.html
Gardener, H. H. (1895, November). A battle for sound morality: Final paper. The Arena, p. 410.
Guttmacher Institute. (2018). An overview of minors’ consent law. Retrieved from https://
www.guttmacher.org/state-policy/explore/overview-minors-consent-law
Michael M. v. Sonoma County Superior Court. 450 U.S. 464 (1981).
Old Bailey Proceedings Online. (2011, April 17). Trial of Stephen Arrowsmith, sexual
offenses: Rape, December 11th, 1678. (t16781211). Retrieved from www
.oldbaileyonline.org, version 6.0, accessed April 22, 2017.
Ploscowe, Morris. (1951). Sex and the law. New York: Prentice-Hall.
Robertson, S. (2015). Age of consent laws. Children and youth in history. Sydney, Austra-
lia: University of Sydney. Retrieved from http://chnm.gmu.edu/cyh/case
-studies/230
Women’s Christian Temperance Union. (1887, January 13). Petition. Union Signal.
Agender
Agender is a nonbinary gender identity. The prefix “a-” means “without” and gen-
erally refers to the lack of some characteristic. In relation to gender, “agender”
Agender 31
refers to someone who identifies as not having a gender or gender identity. Other
terms that are related to agender include, but are not limited to, “genderless,”
“gender neutral,” “gendervoid,” “nongendered,” “genderblank,” and “genderfree.”
These terms are not well represented in the literature as “agender” is a newer iden-
tity term, but within the community, particularly online in social media spaces,
“agender” and related terms are currently being refined, defined, and used by indi-
viduals. Similar to the flags of other identities within the LGBTQ+ spectrum,
there is an agender flag that is comprised of black, gray, white, and green stripes.
As mentioned above, little published research on agender individuals exists. To
date, there have been no large published studies, so it is unknown how many peo-
ple identify as agender; however, in an unpublished, informal 2016 online study of
3,055 nonbinary-identified individuals across the globe, just over 30 percent of the
sample identified their gender as agender.
Agender individuals are not a monolithic group and report different interpreta-
tions of this identity in relation to their own gender(s) or lack thereof. The poten-
tial range of interpretations of agender include, but are not limited to, persons who
have no gender; are gender neutral, indicating potentially having a gender that is
neither male nor female or both male and female; having a gender that is not
aligned with any common socially defined gender category; a reflection that soci-
ety does not have any words to describe a person’s own gender; identifying more
as a person or human than as a gendered being; not feeling strongly attached to
gender as a defining characteristic in one’s own life; and refusing to label one’s
own gender. These various interpretations of the term also mean that agender
individuals may present socially (in terms of clothing, body styling, etc.) in vari-
ous ways, including more traditionally masculine or feminine presentations. Sim-
ilarly, pronoun usage varies within the agender community, with some individuals
using nongendered language to refer to themselves.
While some agender individuals may also identify as transgender, many do not.
Likewise, some agender individuals may engage in steps, medical or otherwise, so
that their body more accurately represents their identity. Some agender individu-
als have also fought for legal recognition of their genderless status, and, in some
cases, this has been legally recognized by the government.
Jay A. Irwin
See also: Asexuality; Bigender; Gender; Binary Gender System; Gender Diversity; Gen-
der Identity; Genderqueer; LGBTQ+; Nonbinary Gender Identities; Pronoun Usage.
Further Reading
cassolotl. (2016). NB/GQ survey 2016: The worldwide results. Retrieved from http://
cassolotl.tumblr.com/post/137953257500
Nonbinary wiki. (n.d.). Retrieved from nonbinary.org
O’Hara, M. E. (2017, April 28). Judge grants Oregon resident the right to be genderless.
NBC News. Retrieved from http://www.nbcnews.com/feature/nbc-out/judge
-grants-oregon-resident-right-be-genderless-n736971
Papisova, V. (2016, January 20). What it means to identify as agender. Teen Vogue.
Retrieved from http://www.teenvogue.com/story/what-is-agender
Shumer, D. E., & Araya, A. (2019). Endocrine care of transgender children and adoles-
cents. In L. Poretsky & W. C. Hembree (Eds.), Transgender medicine (165–181).
New York: Humana Press.
32 American Association of Sexuality Educators
American Association of Sexuality Educators,
Counselors and Therapists (AASECT)
The American Association of Sexuality Educators, Counselors and Therapists
(AASECT) is a nonprofit association of professionals who work in sexual health.
It was founded by Patricia Schiller, a lawyer and psychologist, in 1967. AASECT’s
mission is to advance the highest standards of professional practice for sexuality
educators, counselors, and therapists. Its offices are in Washington, D.C.
As Patricia Schiller, the founder of AASECT, wrote, “Education appears to be
the best means by which to remedy or prevent harm that comes from misinforma-
tion, and negative attitudes about sexuality” (Schiller, 1981). At the time that
AASECT was founded, the sexual revolution was in full swing. The Food and
Drug Administration had approved the birth control pill in 1960, which allowed
women to have sexual intercourse without fear of pregnancy. The women’s rights
movement was making progress toward greater equality with men, and the civil
rights movement was contributing to equality among the races. More people were
having sex outside of marriage, and gay and lesbian people were increasing their
advocacy for acceptance. By the early 1970s, homosexuality was removed from
the American Psychiatric Association’s manual of mental disorders, and abortion
was legalized throughout the United States.
All these movements created opportunities for sexual fulfillment and freedom
but also challenges for people who wanted clear boundaries for personal behavior.
Many people were seeking information about sexuality, and some were concerned
about their relationships in these changing times. Previous generations had been
quieter about sex, and individuals often found it difficult to talk about sex with
one another. In the new era of openness about sexuality, many people looked for
professional help, and AASECT was where they could find it.
AASECT provides professional development through their annual conferences,
institutes, and publications, and they certify professional members in the fields of
sexuality education, counseling, and therapy. In order to become AASECT-certi-
fied, a professional must receive extensive education and supervision, and all
members must abide by the organization’s code of ethics.
AASECT members include doctors, nurses, social workers, psychologists,
clergy members, lawyers, sociologists, marriage and family counselors, family
planning counselors, and students. These individuals share an interest in promot-
ing understanding of human sexuality and healthy sexual behavior.
Sexuality educators work in schools, colleges, social service agencies, and a
variety of other spaces. Sex counselors often work in health care settings. Sex
therapists may work in their private offices, in group practices, or in other clini-
cal locations. There are approximately 1,800 members of the association at any
given time.
In their “Vision of Sexual Health,” AASECT affirms the fundamental value of
sexuality as an inherent, essential, and beneficial dimension of being human. It
opposes all psychological, social, cultural, legislative, and governmental forces
that would restrict, curtail, or interfere with the fundamental values of sexual
health and sexual freedom that they espouse. AASECT also opposes all abuses of
Anal Intercourse 33
sexuality, including, but not limited to, harassment, intimidation, coercion, preju-
dice, and the infringement of any individual’s sexual and civil rights.
Michael J. McGee
See also: Gay Rights Movement; Psychosexual Therapy; Sex Education; Sexual Health;
Sexual Rights.
Further Reading
American Association of Sexuality Educators Counselors and Therapists. (2014). Code of
ethics and conduct for AASECT-certified members. Retrieved from http://www
.aasect.org/code-ethics
American Association of Sexuality Educators, Counselors and Therapists. (n.d.).
Retrieved from http://www.aasect.org
Schiller, P. (1981). The sex profession: What sex therapy can do. Washington, DC: Chil-
mark House.
Anal Intercourse
Anal intercourse, or anal sex, generally refers to the insertion of an erect penis
into a person’s anus and rectum for sexual pleasure. It incorporates thrusting of
the penis inside the anus in the same way as vaginal intercourse. However, it is not
limited to the insertion of the penis into the anus but can also incorporate fingers,
various sex toys (some with the specific purpose, such as butt plugs and anal
beads), and oral sex performed on the anus (also termed “anilingus” or colloqui-
ally known as “rimming”).
There are numerous nerve endings within the region of the anus, and inside the
rectum, which can make anal sex pleasurable for both men and women. For a
woman to perform anal sex on a partner, which has been termed “pegging,” she
might use a sex toy or wear a strap-on dildo to insert into her partner’s anus with
the woman then performing the thrusting action with the toy or dildo.
As with any other form of sexual act, anal intercourse also carries risks of con-
tracting sexually transmitted infections (STIs). Sexual acts involving the anus and
rectum may carry higher risks than other forms of sexual behavior because the
tissue in this area of the body is delicate and easily damaged as it is not naturally
self-lubricating. Any tear of this tissue could lead to increased risk of acquiring an
STI. As such, commercial lubricants can be used and may reduce the risk of tear-
ing and increase pleasure for both parties.
Anal sex is commonly associated with gay men; indeed, early depictions of
anal sex through art have commonly associated the act with male homosexuality.
However, the assumption that anal sex is primarily engaged in by men with other
men is somewhat of a stereotype, as research has shown that not all gay men
engage in anal sex. Anal intercourse is common among all people of all sexual
orientations.
Because of the many pleasurable nerve endings in the anus, orgasm can be
achieved through anal sex. For men, orgasm through anal sex may also be associ-
ated with stimulation of the prostate. However, some people may find anal
34 Androgen Insensitivity Syndrome
intercourse to be uncomfortable or even painful. For some, commercial lubricants
may increase comfort and pleasure, but for others, discomfort and pain may still
occur. It is also possible that this pain may be attributed to psychological factors,
such as socially learned myths about all forms of anal intercourse being painful or
even the pure anticipation and expectation that it will be painful. If an individual
expects anal intercourse to be painful, they may become tense, which can increase
any pain and discomfort they feel.
Anal sex has often been considered a taboo subject, and various views are
expressed among individuals as well as in cultures and religions. Some religions
teach that the only “true” purpose of sexual interaction is procreation and as such
consider nonprocreative sex acts like oral sex, masturbation, and anal sex to be
“wrong.” Some countries also have laws against anal sex among men; in these
countries, anal sex may be punishable by corporal or even capital punishment.
Consequently, anal sex may be seen as illegal or immoral and may be considered
by some as an unnatural act.
Yet there are other views that anal sex is just as natural as any other form of
sexual activity. Some mammals in the animal kingdom participate in anal inter-
course, which suggests that it is a very natural act. People who engage in anal sex
do so for many reasons: they enjoy it, it feels pleasurable, and it enhances their
sex lives.
Callum E. Cooper and Lesley-Ann Smith
See also: Homosexuality; Intercourse; Sex Toys; Sexually Transmitted Infections (STIs);
Sodomy Laws.
Further Reading
Gillibrand, R., & Turner, K. (2013). “Let’s talk about sex”: A post-structuralist discourse
analysis into the meanings and experiences of anal sex for gay men. Psychology of
Sexualities Review, 4, 54–67.
Herbenick, D., Reece, M., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, J. D.
(2010). Sexual behaviour in United States: Results from a national probability
sample of men and women ages 14–94. Journal of Sexual Medicine, 7, 255–265.
McBride, K. R., & Fortenberry, J. D. (2010). Heterosexual anal sexuality and anal sex
behaviours: A review. The Journal of Sex Research, 47(2–3), 123–136.
Androgen Insensitivity Syndrome
“Androgen insensitivity syndrome” is an umbrella term for several congenital
conditions where the body does not respond, or does not respond fully, to andro-
gens. Androgens are the group of sex hormones that are responsible for masculin-
izing the body (the Greek root for “male” is “andro-”). Testosterone is the most
well-known, but dihydrotestosterone, androstenedione, and dehydroepiandros-
terone (DHEA) are also androgens. When someone has androgen insensitivity,
they are less responsive to these hormones, which produce the signals that cause
the body to masculinize.
Androgen insensitivity syndromes are part of a group of conditions that are col-
lectively referred to as disorders of sexual development or differences of sexual
Androgen Insensitivity Syndrome 35
development (DSDs). DSDs are all conditions where sexual development differs
from the standard developmental pathways expected of XX females and XY
males. Although it is commonly taught that sexual development is determined by
whether people have two X chromosomes or an X and a Y chromosome, this is too
simplistic. Sexual development depends on several factors, one of the most impor-
tant of which is the body’s ability to produce and respond to androgens.
All androgen insensitivity syndromes are caused by androgen receptor gene
mutations. As such, these conditions are inherited and tend to run in families.
Because the androgen receptor gene is on the X chromosome, androgen insensi-
tivity is considered to be an X-linked trait. That means that familial androgen
insensitivity follows the maternal line. More than 1,000 mutations associated with
androgen insensitivity have been identified to date.
There are three types of androgen insensitivity syndrome—complete, partial,
and mild. Individuals with complete androgen insensitivity syndrome (CAIS)
have no ability to respond to androgens at all. People born with CAIS have the XY
chromosomes associated with male infants but appear to be typical female infants
at the time of birth. During childhood, they develop normally, and their condition
may not be discovered until they reach puberty and do not menstruate or grow
pubic or underarm hair.
Young women with CAIS have internal testes instead of ovaries and do not
have a uterus, which means they are unable to have children; however, they are
otherwise typical women. Because young women with CAIS have testes instead
of ovaries, the condition was historically known as testicular feminization syn-
drome. However, we now know that androgen insensitivity is caused by mutations
in the gene that codes for the androgen receptor and is not caused by problems
with the testes.
Individuals with partial or mild androgen insensitivity syndrome have some
ability to respond to androgens. As such, the symptoms of these conditions are
more variable. At the time of birth, individuals with partial androgen insensitivity
syndrome (PAIS) may have bodies that appear anywhere from completely female
to almost typically male. As such, infants with PAIS may be categorized as either
male or female at the time of birth, depending on the extent of their androgen
insensitivity.
Individuals with androgen insensitivity syndrome are generally quite healthy,
and there is not generally any need for medical treatment prior to puberty. Histori-
cally, many infants with ambiguous genitalia were subject to genital surgeries,
usually designed to make the genitals appear more feminine. However, there has
been a move against these surgeries, except in cases where the procedures are
medically necessary. This is, in part, because the surgeries can cause permanent
problems in sexual functioning solely for aesthetic outcomes.
After puberty, most individuals with PAIS or CAIS have their testes removed,
in part due to an elevated risk of testicular cancer. For young women with CAIS,
leaving the testes in place can also cause enlargement of the clitoris and fusion of
the labia. Some women with CAIS may also need to use vaginal dilation to
increase their vaginal depth if they are interested in vaginal intercourse. Later in
life, hormone replacement therapy may also be needed to maintain overall health.
36 Androgens
Androgen insensitivity syndrome is a rare condition, affecting only around
thirteen in every hundred thousand people. However, androgen insensitivity has
taught scientists a great deal about the role of hormones in gender identity forma-
tion. Specifically, individuals with this condition have provided evidence that gen-
der identity formation may be, at least in part, responsive to prenatal hormone
exposure in the brain.
Gender assignment for individuals with PAIS is largely based on whether or not
the infant clearly has a penis at the time of birth. The presence or absence of a
penis is directly related to how well the body was able to respond to testosterone
levels in the prenatal environment. Research has consistently shown that individu-
als with PAIS who are assigned as female at the time of birth generally have a
female gender identity, and those who are assigned as male generally have a male
gender identity. Studies on other conditions suggest that this is not simply because
of how the individuals are raised. Instead, it appears to be, at least in part, because
the extent of masculinization of an infant’s genitals also reflects the extent of mas-
culinization of that infant’s brain.
Elizabeth R. Boskey
See also: Androgens; Chromosomal Sex; Congenital Adrenal Hyperplasia; DHEA;
5-Alpha-Reductase Deficiency; Hypogonadism; Intersexuality; Sex Hormones;
Testosterone.
Further Reading
Chen, M. J., Vu, B. M., Axelrad, M., Dietrich, J. E., Gargollo, P., Gunn, S., … Karaviti, L. P.
(2015). Androgen insensitivity syndrome: Management considerations from
infancy to adulthood. Pediatric Endocrinology Reviews, 12(4), 373–387.
Gottlieb, B., Beitel, L. K., Nadarajah, A., Paliouras, M., & Trifiro, M. (2012). The androgen
receptor gene mutations database: 2012 update. Human Mutation, 33(5), 887–894.
Kolesinska, Z., Ahmed, S. F., Niedziela, M., Bryce, J., Molinska-Glura, M., Rodie, M., …
Weintrob, N. (2014). Changes over time in sex assignment for disorders of sex
development. Pediatrics, 134(3), e710–e715.
Kon, A. A. (2015). Ethical issues in decision-making for infants with disorders of sex
development. Hormone and Metabolic Research, 47(5), 340–343.
Mendoza, N., & Motos, M. A. (2013). Androgen insensitivity syndrome. Gynecological
Endocrinology, 29(1), 1–5.
Wisniewski, A., & Aston, C. E. (2015). A cross-section study of the ontogeny of gender
roles in women with DSD. Current Pediatric Review, 11(1), 27–35.
Androgens
Androgens are hormones commonly referred to as the “male sex hormones,”
though they also occur, in small amounts, in females. The two most important
androgens, in terms of their physiological effects, are testosterone and androste-
rone. Chemically, androgens are classified as steroids, as are the “female sex hor-
mones,” estrogen and progesterone. Steroids are fat molecules, formed from
cholesterol, that have a core structure made of three rings of six carbon atoms and
one ring of five carbon atoms.
Androgens 37
During fetal development, androgens prompt the development of the testes (or
testicles), penis, prostate, and other male physical traits. They are the chemical
compounds that cause a fetus to become male rather than female. In the growing
boy, only small amounts of androgens are secreted prior to puberty.
When a male reaches puberty, the testes begin to secrete large amounts of
androgens. The adrenal glands of both males and females, and the ovaries (sex
organs of females), also begin to secrete more androgens at puberty, though still in
much smaller amounts than the testes. The puberty-related ramp-up in androgen
production is medically referred to as the “adrenarche,” though that term is not
commonly used. Female bodies typically produce about one-twelfth as much
androgen as do male bodies.
As puberty progresses, androgens cause the testes and penis to grow in size and
to mature sexually. These hormones also prompt male sexual behaviors, such as
interest in sexual intercourse and masturbation (both characteristic of the “sex
drive”). Androgens further cause the development of other secondary sexual char-
acteristics in males, such as a deepened voice (caused by the lengthening and
thickening of vocal cords), beard growth, body hair growth, and increased muscle
and bone mass.
In females, androgens have more subtle influences on sexual characteristics
and behavior, such as the growth of pubic and underarm hair and an elevated sex
drive. However, some androgens are converted through metabolic processes into
estrogens, which are the main hormones that cause female secondary sexual
characteristics.
As some men age, androgens influence the regression of hair on the scalp, lead-
ing to baldness. Still other physiological factors influenced by androgens, in both
men and women, include kidney size, red blood cell production, skin pigments,
sweat gland activity, and sebaceous (oil) gland activity.
Androgen molecules produce their physiological changes by binding to recep-
tors on the surfaces of cells or to receptors inside cells that then move into the cell
nuclei (DNA-containing central part). These cellular processes lead to a series of
chemical reactions that initiate hormone secretion, tissue maturity, or other bio-
chemical changes.
Testosterone is the most active male sex hormone. Most testosterone is pro-
duced by the connective tissue cells surrounding the sperm-producing tubules in
the testes. Those connective tissue cells are known as the cells of Leydig. The
secretion of testosterone by the Leydig cells is primarily regulated by the secre-
tion of luteinizing hormone by the pituitary gland in the brain.
Androsterone plays a supportive role for the functions of testosterone as well as
for other physiological processes in the body. Androsterone and certain other
androgens—including androstenedione, dehydroepiandrosterone (DHEA), and
dehydroepiandrosterone sulfate (DHEA sulfate)—are produced mainly in the
adrenal cortex, the outer portion of the adrenal glands, on the kidneys. The testes
and ovaries also produce some of these hormones. DHEA and DHEA sulfate can
be converted into testosterone or androstenedione in other body tissues, including
the skin, fat, muscle, and brain.
38 Androgens
In men, it is normal for androgen production to gradually decrease with age,
typically beginning in the thirties. However, androgen deficiency refers to abnor-
mal conditions that occur when too few androgen compounds are produced in the
male body, leading to various health problems. Symptoms of androgen deficiency
may include a low sex drive, fatigue, depression, weak erections, reduced ejacu-
late, gynecomastia (breast development), an increase in abdominal fat, a reduction
in body hair, and decreased muscle and bone mass.
Low androgen levels are often the effect of physical problems. For example,
some males are born with malfunctioning or nonfunctioning testes. This may be
the result of failure of the testes to descend into the scrotum, a blocked blood sup-
ply, or a chromosomal abnormality called Klinefelter syndrome. Some males sus-
tain damage to the testes as a result of trauma, or they require orchiectomies
(testicle removal) for health problems, such as testicular cancer. Tumors and other
disorders of the pituitary gland or hypothalamus (parts of the brain that regulate
testicular function) may also cause low androgen levels in men.
In any of these or other cases in which males do not produce sufficient andro-
gen, testosterone or androgen replacement therapy is necessary for the individuals
to develop and maintain functioning reproductive organs and normal sperm cells.
The hormones can be administered as injections, pills, creams, gels, patches, or
implants. Androgen replacement may also be used as treatment for men who have
low sex drives. Surgical procedures, such as tumor removal, may be required to
cure some cases of androgen deficiency.
Low androgen levels are sometimes caused by exposure to chemical com-
pounds in the environment known as androgen disrupters or androgen block-
ers, which can interfere with the effects of androgens by blocking hormone
secretion, receptor binding, or genital development and function. These prob-
lems may begin as early as fetal development, or they may occur during
childhood or adulthood. Research suggests that some of these disruptive com-
pounds are phthalates, which are found in a variety of consumer products,
including skin lotions, perfumes, adhesives, pesticides, plastics, and electronic
components.
In women, medical problems develop when too many androgen compounds are
produced in the body. Excess androgen levels in women can lead to the irregular
occurrence or premature end of menstrual periods, acne, and physical changes
resembling male secondary sexual characteristics, such as growth of facial and
body hair, balding, a deepened voice, increased muscle mass, decreased breast
size, and enlargement of the clitoris.
Excess androgen levels in women can be caused by glandular or ovarian disor-
ders, including Cushing syndrome (a pituitary gland disorder), congenital adrenal
hyperplasia, polycystic ovary syndrome, and benign or malignant tumors in the
adrenal glands or ovaries. Treatment for women with any of these disorders
depends on the patient’s particular condition, but various medications or surgical
procedures are often necessary.
In addition to their use as hormone therapy for males who produce insufficient
amounts, androgens are used as treatments for a number of other disorders. Pre-
scription androgen-based medications are a common treatment for women with
Androgyny 39
breast cancer. Physicians may also prescribe androgen medications for people
with anemia, certain skin problems, and abnormally delayed growth.
Yet another use of androgens is as hormone therapy for transgender people who
are transitioning from female bodies to male bodies. For transgender people who
are transitioning from male bodies to female bodies, androgen-blocking medica-
tions are used as part of their hormone therapy.
Androgen drugs referred to as “anabolic steroids” have been used by some ath-
letes to build muscle strength. However, such use can result in serious physical
and psychological side effects—including cardiovascular problems, liver damage,
testicular shrinkage, and increased aggression (“roid rage”)—especially when
unsupervised by a physician.
A. J. Smuskiewicz
See also: Adrenarche; Androgen Insensitivity Syndrome; Andropause; Estrogen; Hor-
mone Replacement Therapy; Progesterone; Puberty; Sex Hormones; Testosterone; Tes-
tosterone Replacement Therapy.
Further Reading
The hormones: Androgens. (n.d.). Retrieved from http://e.hormone.tulane.edu/learning/
androgens.html
Lee, G. (2018). Phthalates: What you need to know. Retrieved from https://www.babycenter
.com/0_phthalates-what-you-need-to-know_3647067.bc
Mayo Clinic. (2019). Androgen (oral route, parenteral route, subcutaneous route, topical
application route, transdermal route). Retrieved from http://www.mayoclinic.org/
drugs-supplements/androgen-oral-route-parenteral-route-subcutaneous-route
-topical-application-route-transdermal-route/description/drg-20069341
Androgyny
Androgyny is defined as the expression of both “masculine” and “feminine” char-
acteristics by an individual. The nature of androgyny is controversial, with com-
peting perspectives, namely, biological, psychological, and sociological. In many
ways, “androgyny” is an outdated term. The term “gender nonconformity” is bet-
ter fitting as it accurately reflects the physical, social, and psychological compo-
nents that make up an individual’s gender identity as well as the social treatment
of a nonnormative gender expression.
“Androgyny” is a term that has been used to describe a wide variety of behav-
iors, characteristics, and appearances that are gender-ambiguous or gender-
nonconforming. That is, “androgyny” is often used today to describe a person
whose gender is difficult to determine based on their appearance. An alternative
term to “androgyny” is “gender-role transcendence,” which captures the individu-
al’s right to maintain the freedom to express their gender as they wish rather than
on the basis of popularly held definitions of “masculinity,” “femininity,” and
“androgyny.”
From a biological standpoint, the term “androgyny” was incorrectly used to
refer to the co-occurrence of both male and female physical traits in one individ-
ual, which is correctly referred to as “intersex.” For example, an individual who
40 Androgyny
has a vagina and a penis is considered intersex as they possess typically ascribed
male and female sex organs. Intersex individuals were once referred to as her-
maphrodites; however, this term has drastically declined in popularity because it
is considered by many to be stigmatizing. Although it remains unknown the exact
percentage of people who are intersex, it has been estimated that 2 percent of new-
borns may be intersex.
Contrary to the aforementioned biological viewpoint of androgyny, a sociological
framework emphasizes the behavioral aspects of androgyny, such as the individu-
al’s way of dress and mannerisms, which embodies traditional attributes of more
than one gender. For example, a female individual who dresses in suits that are tra-
ditionally associated with masculinity may be considered androgynous. Relatedly,
from a psychological perspective, androgyny refers to an individual’s gender iden-
tity, which may include both “masculine” and “feminine” characteristics. Sandra
Bem, the developer of the Bem Sex-Role Inventory (BSRI), was one of the earliest
proponents of psychological androgyny as it relates to gender identity and psycho-
logical well-being. The BSRI has four classifications of gender identity: masculine,
feminine, androgynous, and undifferentiated. Further, as early as 1977, Bem
asserted that she is of the opinion that androgynous men and women are more flex-
ible and psychologically healthy than rigidly “masculine” or “feminine” individu-
als. Today, the BSRI is widely used to measure gender in psychological research.
Androgyny has not always been a widely recognized concept in mainstream
culture. The term appeared for the first time in the context we use it today in
Plato’s seminal book Symposium. Androgynous gender expression has received
much attention in popular media over the past century. Earlier popular examples
include Elvis Presley performing wearing makeup in the 1950s and male artists
David Bowie and Prince incorporating feminine dress into their performance
wardrobe in the 1970s and 1980s. Today, many people in the fashion industry
celebrate androgyny in their design and marketing efforts. In addition, many
people nowadays dress androgynously as a statement of individuality and style.
Androgynous and gender-nonconforming individuals often face stigma and
discrimination because they are perceived as violating “normative” gender norms
and roles. These experiences of stigma and discrimination can take a toll on health
and well-being. Indeed, studies show that experiencing discrimination leads to
high levels of psychological distress among androgynous individuals. Although
one’s androgynous identity is often conflated with being gay or lesbian, it is
important to distinguish between one’s gender identity and sexual orientation.
This distinction also has implications for the health of androgynous individuals,
as it was found that androgyny has negative implications for one’s well-being,
even more so than a nonheterosexual orientation. A better understanding of atti-
tudes toward androgyny and further investigation of factors contributing to the
endorsement of such negative attitudes is needed in order to better advocate for
the rights and equal treatment of marginalized androgynous and gender-
nonconforming populations.
Ariel A. Friedman and Nadav Antebi-Gruszka
See also: Agender; Bigender; Cisgender; Femininity; Fluidity, Gender; Gender Roles,
Socialization and; Genderqueer; Intersexuality; Masculinity; Stereotypes, Gender.
Andropause 41
Further Reading
Bem, S. L. (1981). Gender schema theory: A cognitive account of sex typing. Psychologi-
cal Review, 88(4), 354–364.
Bem, S. L., & Lewis, S. A. (1975). Sex role adaptability: One consequence of psychologi-
cal androgyny. Journal of Personality and Social Psychology, 31(4), 634–643.
Blackless, M., Charuvastra, A., Derryck, A., Fausto-Sterling, A., Lauzanne, K., & Lee, E.
(2000). How sexually dimorphic are we? Review and synthesis. American Journal
of Human Biology, 12(2), 151–166.
Lippa, R. A. (2001). On deconstructing and reconstructing masculinity–femininity. Jour-
nal of Research in Personality, 35(2), 168–207.
Pleck, J. H. (1995). The gender-role strain paradigm: An update. In R. F. Levant & W. S.
Pollack (Eds.), A new psychology of men (11–32). New York: Basic Books.
Rieger, G., & Savin-Williams, R. C. (2012). Gender nonconformity, sexual orientation,
and psychological well-being. Archives of Sexual Behavior, 41(3), 611–621.
Skidmore, W. C., Linsenmeier, J. A., & Bailey, J. M. (2006). Gender nonconformity and
psychological distress in lesbians and gay men. Archives of Sexual Behavior,
35(6), 685–697.
Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S. T. (2010). Gender-
nonconforming lesbian, gay, bisexual, and transgender youth: School victimiza-
tion and young adult psychosocial adjustment. Developmental Psychology, 46(6),
1580–1589.
Andropause
Andropause, also known as late-onset hypogonadism, is a condition in men with
low levels of testosterone that results in a decrease in erections, lower sexual
desire, and possible erectile dysfunction. Andropause is often compared to female
menopause because it occurs at similar times and ages as menopause, commonly
between forty and sixty years old. Andropause is the process of a decrease in tes-
tosterone hormone levels in a male. It is a gradual decrease over time and leads to
a decline in fertility in men; however, it does not lead to a complete loss of fertil-
ity, which differs from females after menopause. Therefore, males can still pro-
duce sperm and father children during and after andropause. Andropause
contributes to a decline in sexual function, meaning a lower desire to engage in
sexual activities, which leads to a lower frequency of sexual intercourse for males
as they age. There is also a decrease in sperm count in a male’s semen and reduced
amounts of semen, which results in smaller amounts of ejaculate during orgasm.
The male hormone testosterone contributes to many of the defining male features
that are developed during puberty, such as more hair production, a deeper voice,
and an increase in muscle development. Therefore, when a man goes through
andropause and his testosterone levels decrease, it is natural that some of the fea-
tures that are developed during puberty will also be influenced by andropause.
Andropause affects male sexual function and contributes to some physical
changes. As the body ages and testosterone levels begin to decline, men typically
see a change in their muscle mass, bone density, and strength. Male bodies become
less capable of meeting strenuous physical demands that could have been met
years prior. It is common to start to see increased body fat, specifically in the
42 Andropause
stomach and waist areas of the body, in men experiencing andropause as men
experience decreased physicality and energy levels. Men may also experience hot
flashes, although these are more often associated with women going through
menopause. Due to the decreased testosterone levels in the blood, the body is not
able to regulate temperature as efficiently as it could during younger years. Men
who experience hot flashes may go from feeling a normal body temperature to
feeling as if they are burning up in a short period of time. Additional physical
changes include changes in hair structure and growth and changes in one’s skin.
There are mental symptoms of andropause that are similar to the mental symp-
toms of women going through menopause. Men experiencing andropause may
experience depressive symptoms, lack of energy, and possible mood swings. Dur-
ing andropause, there are many hormonal changes happening inside of the body.
Every year, testosterone levels are falling, which may have a negative impact on
the person’s perceptions of his own manhood. Sexual desire may decrease, the
body may not be as physically fit as it had been years prior, and men may not have
the energy they once had, which could lead to the depressive symptoms experi-
enced by some men during andropause.
Similar to menopause in women, andropause is a natural part of life and does
not necessarily need to be treated medically. Many times, outside treatments do
not have a significant effect on the symptoms of andropause, possibly because the
symptoms are a part of getting older, which is not reversible. In addition, if a man
seeks medical attention to treat his symptoms, a misdiagnosis could occur because
there are many other conditions associated with low testosterone levels.
Andropause in males and menopause in females serves a similar purpose: to
make changes to a person’s body to transition them out of the reproduction phase of
life and into a later adulthood phase. This may mean the body reverting to some of
the ways that it was before a person went through puberty. Some ways andropause
is similar to puberty are the changing hormone levels, the physical and sexual
changes, and emotional changes. Mood swings are common in both puberty and in
andropause and can be one of the symptoms that can lead a man to seek medical
guidance. Males go through many physical changes during puberty as well as dur-
ing andropause. During puberty, boys may be growing more hair in different
places, developing a deeper voice, and experiencing an increase in libido. However,
during andropause, physical changes may include a decrease in hair production, a
production of more gray hairs, and a decrease in libido. Some men may choose to
use hormone replacement treatments to try and slow this process of aging appear-
ances. However, hormone replacement treatments can be risky and are only a tem-
porary fix for symptoms of aging. Andropause is a natural process that occurs in
males with varying levels of impact, as it is a part of getting older in men.
Casey T. Tobin
See also: Androgens; Erection; Fertility; Hormone Replacement Therapy; Hot Flashes;
Hypogonadism; Menopause; Sexuality among Older Adults; Testosterone; Testosterone
Replacement Therapy.
Further Reading
Araujo, A. B., Mohr, B. A., & McKinlay, J. B. (2004). Changes in sexual function in
middle-aged and older men: Longitudinal data from the Massachusetts male aging
study. Journal of American Geriatric Society, 52, 1502–1509.
Anorgasmia 43
LeVay, S., Baldwin, J., & Baldwin, J. (2018). Discovering human sexuality (4th ed.). Sun-
derland, MA: Sinauer Associates.
Mayo Clinic. (2017). Male menopause: Myth or reality? Retrieved from https://www
.mayoclinic.org/healthy-lifestyle/mens-health/in-depth/male-menopause/
art-20048056
Preston, R. (2014). How to cope with male menopause: The andropause mystery revealed.
Charleston, SC: CreateSpace.
Anorgasmia
“Anorgasmia” is a medical term that describes the persistent delay in, or absence
of, orgasm after a prolonged sexual arousal. It can affect people of any gender or
sex, and for biological males, it is usually experienced as delayed ejaculation
rather than an inability to ejaculate.
Anorgasmia can be classified four ways: lifelong, acquired, situational, and
generalized. Someone with lifelong anorgasmia has never experienced orgasm,
while acquired anorgasmia refers to someone who may have experienced one or
more orgasms in the past but currently does not. Situational anorgasmia occurs
when someone can only experience orgasm under specific circumstances (e.g.,
with a specific sexual activity or partner). Generalized anorgasmia occurs when
someone cannot experience orgasm in any situation. While lifelong and general-
ized anorgasmia seem similar, the person with the former might be able to experi-
ence orgasm with more education or different attitudes and behaviors. For this
reason, some people prefer to use the term “preorgasmic,” since it acknowledges
the potential for orgasm to occur.
The Diagnostic and Statistical Manual of Mental Disorders includes both
female and male orgasmic disorder, defining the condition as involving difficulty
in achieving orgasm, substantially decreased intensity of orgasm, or both.
Anorgasmia can be frustrating because the myth persists that orgasm comes
naturally and easily to everyone who is sexually active. Orgasm may be difficult
to experience if people
• are unfamiliar with their sexual anatomy
• do not understand what an orgasm is
• do not feel free to express themselves sexually (e.g., they may feel embar-
rassed by their sexual interest and responses)
• have underlying emotional issues or cultural messages that impede sexual
pleasure
• fear getting pregnant or getting a sexually transmitted infection
• focus only on a partner’s needs
• spend too little time on arousal and stimulation
• are in an unhealthy or unsafe sexual relationship
• have a history of sexual abuse and/or intimate partner violence
• take medication that reduces desire, such as some blood pressure medications,
antihistamines, and some antidepressants
44 Antigay Prejudice
• have a medical condition that affects the sexual response cycle, such as diabe-
tes or a neurological disease
• have had medical treatment affecting the sexual organs or nerves involved in
orgasm
• have poor circulation throughout the body, particularly to the genitals
• experience hormonal changes that decrease sexual desire, increase time nec-
essary for arousal, or decrease the intensity of sexual response
• overindulge in alcohol and some nonprescription drugs
Orgasm involves a balance of physical, emotional, and psychological factors. For
many people, difficulties in one or more of those areas can only be overcome with
education and practice; other people may find it helpful to consult a physician or
sex psychotherapist.
Barring medical or serious psychological factors, overcoming anorgasmia is
often a matter of learning more about one’s body and sexual responses. One of the
best forms of self-education is masturbation, during which people can learn what
kind of sexual touch they find enjoyable. If they have partners, they can then
describe or demonstrate to their partners what they enjoy.
Some people may experience orgasm yet discount their experience because it
differs from the “fireworks” portrayed in mass media and explicit films. It can be
helpful to understand that everyone experiences orgasm differently, and the
expressions of orgasm portrayed in media and adult film are often overdramatic
and unrealistic.
Learning how to experience orgasm may require private, interruption-free
time as well as a basic understanding of sexual anatomy. For example, most
females do not experience orgasm through vaginal penetration; rather, they
require direct clitoral stimulation. Males may find their orgasm enhanced with
stimulation of the scrotum as well as the penis. In general, older adults require
longer and more direct stimulation of the genitals in order to experience arousal
and orgasm.
Melanie Davis
See also: Arousal; Diagnostic and Statistical Manual of Mental Disorders (DSM); Ejacu-
lation; Orgasm; Sexual Disorders, Female; Sexual Disorders, Male.
Further Reading
Jenkins, L. C., & Mulhall, J. P. (2015). Delayed orgasm and anorgasmia. Fertility and
Sterility, 104(5), 1082–1088.
Laan, E., & Rellini, A. H. (2011). Can we treat anorgasmia in women? The challenge to
experiencing pleasure. Sexual and Relationship Therapy, 26(4), 329–324.
Antigay Prejudice
Antigay prejudice involves negative beliefs and behaviors directed at individuals
who identify as, or are perceived to be, gay, lesbian, bisexual, queer, or otherwise
varying from the heterosexual norm. Antigay prejudice may also be directed
toward transgender youth and adults and those who engage in same-sex sexual
Antigay Prejudice 45
behaviors, whether or not the individual identifies as a sexual minority. Further,
antigay prejudice may be directed toward individuals who do not conform to gen-
der expectations in dress or behavior, or to the family members of sexual-minority
individuals. For example, the child, parent, sibling, or friend of a person who is, or
is perceived as, other than heterosexual may also be the recipient of antigay preju-
dice, without regard to the recipient’s sexual orientation or gender identity.
Antigay prejudice ranges from subtle exclusion to physical violence and sys-
temic discrimination. It may be expressed through derogatory speech and other
behaviors, such as discrimination in employment, housing, inheritance, and other
civil rights such as marriage or the adoption of children by same-gender couples.
Antigay prejudice is widespread and observed across many cultural contexts. Sev-
eral studies of hate speech and physical violence in the United States in the 1980s
and 1990s indicated that a majority of gay and lesbian respondents had been tar-
geted by others with antigay remarks, and a significant portion of adults reported
one or more incidents of physical violence related to perceptions of their sexual
orientation. Some studies indicate that the incidence of violence against sexual
minorities may be declining in the United States; however, it is still common. In
many U.S. states and several other countries, individuals may be legally prose-
cuted for engaging in same-sex sexual activities, and in some countries, individu-
als may receive the death penalty for participation in same-sex sexual behaviors.
Antigay prejudice may develop through exposure to implicit and explicit nega-
tive messages about sexual minorities from family members, peers, and cultural
and religious communities. Early studies of antigay prejudice focused on what is
now considered traditional homophobia or homonegativity. These forms of homo-
negativity may be expressed in derogatory statements about gay men and lesbian
women, such as “lesbians are sick” or “gay men shouldn’t be allowed to teach
school.” In contrast, modern homonegativity is often characterized by statements
indicating that sexual minorities should not receive special treatment or that sex-
ual minorities ask for too much accommodation from other members of the
society.
Overall, research in this field indicates that receiving antigay prejudice from
others contributes to negative mental health outcomes among sexual-minority
individuals, including depression, anxiety, substance abuse, and intimate partner
violence. Researchers have also explored the impact of internalized homophobia/
homonegativity, defined as negative attitudes and prejudices that sexual-minority
individuals may express toward themselves as the result of repeated exposure to
these negative messages. Consequently, studies of antigay prejudice have noted
more negative attitudes toward sexual-minority people than heterosexual people,
among both heterosexually identified and sexual-minority participants. That is,
sexual-minority individuals often report more negativity toward other sexual-
minority individuals than toward heterosexuals. Research on internalized preju-
dice, particularly internalized homonegativity, has noted correlations between
this internalized antigay prejudice and higher rates of substance abuse and sexual
compulsivity. Thus, antigay prejudice, whether from outside or inside the self,
appears to be deleterious to mental health for many sexual-minority people.
Research in this area has also revealed gender and cultural differences in anti-
gay prejudice. Overall, studies indicate that men report more antigay attitudes
46 Aphrodisiac
than women, and men are more likely to report stronger antigay attitudes toward
gay men than toward lesbian women. Some studies have noted differences between
African American and European American adults’ attitudes, with African Ameri-
can adults reporting more antigay attitudes than those of white peers. However,
studies indicate that African American and European American adults are equally
likely to engage in discriminatory behavior toward sexual minorities. Thus, while
attitudes may differ among cultural groups, the intent to discriminate against sex-
ual minorities appears to be roughly the same between these two groups. Also,
there may be generational differences in attitudes and behaviors, with younger
adults and adolescents reporting lower levels of antigay prejudice than older
adults. Antigay attitudes and behaviors appear to be shifting in many cultural and
religious groups, with a growing acceptance of same-sex marriage, parenting, and
other civil rights within the United States and many other countries.
Elizabeth A. Maynard
See also: Biphobia; Don’t Ask, Don’t Tell; Heterosexism; Homophobia; Homophobia,
Internalized; Homosexuality; Religion, Diversity of Human Sexuality and; Sexual
Assault; Transphobia.
Further Reading
Herek, G. (Ed.). (1998). Stigma and sexual orientation: Understanding prejudice against
lesbians, gay men, and bisexuals. Thousand Oaks, CA: SAGE.
Herek, G. (2000). The psychology of sexual prejudice. Current Directions in Psychologi-
cal Science, 9, 19–22. doi: 10.1111/1467-8721.00051
Morrison, M. A., & Morrison, T. G. (2003). Development and validation of a scale mea-
suring modern prejudice toward gay men and lesbian women. Journal of Homo-
sexuality, 43(2), 15–37. doi: 10.1300/J082V43n02_02
Aphrodisiac
An aphrodisiac is a substance that is said to increase one’s sexual desire and
arousal. Aphrodisiacs are often used to improve many aspects of personal sexual
experiences and romantic health and can be utilized to increase sexual desire. An
aphrodisiac may be a way to increase sexual performance or pleasure during a
sexual experience. Or, it can be used to draw in others for love and affection.
While it is nice to think about substances or objects that can magically boost one’s
libido or make someone fall in love, there are not many substances that are proven
to have this effect. While science may not be able to prove a sexual connection,
personal experiences fuel the existence and effectiveness of these substances.
People’s belief in the success of using an aphrodisiac is what fuels more people to
try them. Aphrodisiacs can be a variety of items, such as objects, foods, plants, or
even illicit drugs.
The story of the creation of aphrodisiacs is not certain. But, it is known that
people have been devising many different substances as aphrodisiacs for a long
time. The name “aphrodisiac” comes from the Greek goddess Aphrodite, the god-
dess of love, beauty, pleasure, and procreation. It is fitting that the sexually enhanc-
ing nature of these items were named after her. There have been many different
Aphrodisiac 47
plants and animals that have been proposed as aphrodisiacs, from potatoes to
skinks (a type of lizard), from Spanish flies to mandrake roots, and from chocolate
to cucumbers. It seems like humans were and still are fascinated with the idea of
improving sexual desire and performance. Using aphrodisiacs is one way that
people seek to improve sexual pleasure.
There is limited research on the effectiveness of utilizing aphrodisiacs to
increase sexual desire and arousal. Suggested aphrodisiacs such as rhino horns
and oysters are likely only thought to have sex-boosting characteristics because
they look like a penis or a vulva (the idea being that if the item resembles the
texture or structure of sexual organs, it is also associated with increased sexual
desire and stimulation). Some people may experience an increase in their sexual
desire when they eat oysters, but it is most likely their belief or desire to have it
work that is responsible, rather than an actual effect on their hormones. This
placebo effect is so powerful that people are convinced that eating oysters will
“put them in the mood.”
A well-known aphrodisiac is dark chocolate. It is thought to increase sexual
desire through three different mechanisms. The first mechanism is an amino acid
called L-arginine, which increases nitric oxide to promote better blood flow. It is
thought that better blood flow, specifically to the genitals, could increase desire.
The second mechanism is through phenylethylamine, a chemical in your brain
that is involved in the feelings of pleasure and happiness. This aspect could be one
that helps draw one into falling in “love,” a claim of aphrodisiacs. The third aspect
refers to dark chocolate acting as an energy booster, and if one has more energy,
one will also have more desire. Most aphrodisiacs are backed by little to no scien-
tific evidence; however, many aphrodisiacs are shaped and supported by individ-
ual experiences.
While most aphrodisiacs are harmless, some can be very dangerous. Some peo-
ple use illicit drugs to enhance their sexual desire and performance. Cocaine, for
example, can increase sexual stimulation. However, routine use of cocaine can
hinder the ability to have an orgasm, which is the opposite of its intended aphrodi-
siac use. A common recreational psychoactive drug 3,4-methylenedioxy-metham-
phetamine (MDMA/Ecstasy/Molly) has an impact on serotonin, a hormone that
affects mood. Initial use of Ecstasy may increase feelings of sexual arousal, but
repeated use could damage serotonin receptors and have a negative effect on
mood. By constantly flooding the brain with serotonin, one’s body can no longer
produce its own serotonin and will become dependent on the drug to sustain the
hormone, leading to possible addiction. While some illicit drugs may be initially
aphrodisiac-like in nature, they can have serious consequences.
While most aphrodisiacs have no scientific backing, one substance does have
some scientific backing. Ginseng has been used to treat sexual dysfunction, pri-
marily in men, but there has been an increase in the number of women who use it.
Red ginseng has been used in Asian countries for over 2000 years, with many
claiming health benefits, one benefit being of aphrodisiac nature. It has been used
to treat erectile dysfunction in men and more recently has been used to help boost
sexual drive in postmenopausal women. While there are a limited number of stud-
ies exploring the mechanisms of red ginseng and erectile dysfunction, it is
48 Arousal
suggested that higher levels of nitric oxide may increase sex drive. For men, nitric
oxide relaxes the corpus cavernosum and helps promote blood flow to the genital
region. When the corpus cavernosum fills with blood, an erection occurs. There-
fore, red ginseng could provide an aphrodisiac-like effect for men with erectile
dysfunction. Red ginseng helps postmenopausal women in a very similar way,
releasing nitric oxide to promote blood flow not only overall but specifically to the
vaginal region to increase stimulation.
Casey T. Tobin
See also: Arousal; Desire; Pheromones.
Further Reading
LeVay, S., Baldwin, J., & Baldwin, J. (2018). Discovering human sexuality (4th ed.). Sun-
derland, MA: Sinauer Associates.
Maier, T. (2009). Masters of sex. New York: Basic Books.
Rätsch, C., & Müller-Ebeling, C. (2013). The encyclopedia of aphrodisiacs: Psychoactive
substances for use in sexual practices. Rochester, VT: Inner Traditions/Bear.
Arousal
Sexual arousal is a construct without a widely accepted definition. When used in
a nonsexual context, “arousal” refers to the creation of excitement, awakening, or
a strong response. Sexual arousal, then, is the experience of sexual excitement,
awakening, or response. It is a series of physical, psychological, and affective
changes that prime an organism for sexual activity.
Sexual arousal has historically referred to a central physiological state. Among
males, penile erection in the presence of erotic stimuli has been used as a way to
operationalize sexual arousal. Among females, researchers and sexologists have
had greater difficulty measuring arousal. Some visible signs of female arousal are
lubrication of the vagina and swelling of the clitoris, labia, and nipples.
Researchers have also looked to hormones to determine arousal. Testosterone
levels in both sexes are implicated in the physiology of sexual arousal. People with
naturally low testosterone levels, or levels that decrease due to normal aging,
report fewer experiences of sexual arousal. In females, other hormones that con-
tribute to sexual arousal are estradiol and estrogen.
Like hormones, chemical substances can significantly affect the expression and
function of arousal. Common inhibitors of arousal are smoking, the excessive use
of alcohol, heart medications, psychotropic medications, and narcotics. Overall
wellness is important to arousal; therefore, maintaining good physical health sup-
ports sexual function. Blood flow problems, heart or lung disease, low energy,
suppressed immune function, and diabetes are all associated with issues in
arousal.
While the foundational research on sexual arousal focused primarily on the
genitals, more recent studies have considered the role that psychological function
plays in arousal. Arousal is said to occur first in the mind, spurring from thoughts
of psychological arousal, and then is felt in the body. Arousal changes the neuro-
transmission of chemicals in the forebrain and brainstem to promote changes in
Arousal 49
the genitalia, particularly the increased sensitivity and thus increased pleasure. As
arousal builds, the relationship between mind and body becomes a feedback loop:
psychological arousal produces physiological changes in receptivity that, in turn,
support and maintain the initial psychological arousal. The brain registers con-
scious and subconscious sexual stimuli such as attractiveness, fantasy, sexual con-
text, a sexual advance, or innuendo. This is a subjective experience; it doesn’t
matter how much stimuli there is if the context is wrong. The brain processes the
sexual stimuli and creates the motivation for an aroused state, which is what is
experienced as sexual desire. Sexual desire inspires individuals to act on their
psychological arousal, often leading to some form of sexual experience.
Psychological factors can preclude a person from experiencing arousal by
blocking the neurological signals that allow genital and somatic arousal responses.
Some common psychological barriers to arousal are nonsexual distractions, feel-
ings of sexual ineptitude, anxiety, lack of physical awareness, and psychological
traumas such as social exclusion or sexual abuse.
The feedback cycle between the brain and the somatic system is also mediated
by emotions; when the emotional experience of arousal is pleasurable, the somatic
changes will reflect that. Sexologist Rosemary Basson (2003) concluded that when
an emotionally satisfying sexual stimulus is added to an otherwise neutral psycho-
logical state, it promotes sexual desire, physical satisfaction, and emotional inti-
macy. If the emotional experience is not enjoyable, a negative feedback cycle turns
off the parts of the brain receptive to sexual stimuli. The change in receptivity is
experienced as physical discomfort and emotional unease, such as embarrass-
ment, anger, sadness, fear, and shame.
Some scientists believe that positive affect is necessary to promote sexual
arousal. The more positive factors present in any potentially sexual experience,
the more likely arousal is to occur. The fewer positive factors, the more likely
there are to be barriers to arousal. One such example is depression, which inhibits
sexual arousal by reducing the available levels of prosexual neurochemicals sero-
tonin and dopamine and promoting the cue-blocking hormone norepinephrine.
This limits the possibility of arousal by limiting the psychological capacity to
register sexual stimuli as well as limiting the motivation to act on any sexual
stimuli registered in the brain. Researchers Wincze and Carey (2015) found that
factors like good emotional health, attraction toward partner, a positive sexual
attitude, a focus on pleasure, good self-esteem, and a sense of ease and comfort all
allow for arousal to occur.
Shadeen Francis
See also: Desire; Erection; Sex Hormones; Sexual Disorders, Female; Sexual Disorders,
Male; Touching, Sexual Arousal and; Vaginal Lubrication.
Further Reading
Basson, R. (2003). Biopsychosocial models of women’s sexual response: Applications to
management of “desire disorders.” Sexual and Relationship Therapy, 18(1),
107–115.
Benson, E. (2003, April). The science of sexual arousal: Psychologists are gaining new
insights into sexual arousal with the help of innovative research methods. The
Monitor, 34(4). Retrieved from http://www.apa.org/monitor/apr03/arousal.aspx
50 Artificial Insemination
Madsen, P. (2012, December 13). Put your attention on sexual arousal, not orgasm.
Retrieved from https://www.psychologytoday.com/blog/shameless-woman/201212/
put-your-attention-sexual-arousal-not-orgasm
Sachs, B. D. (2007). A contextual definition of male sexual arousal. Hormones and Behav-
ior, 51(5), 569–578.
Wincze, J. P., & Carey, M. P. (2015). Sexual dysfunction: A guide for assessment and
treatment (3rd ed.). New York: Guilford Press.
Artificial Insemination
Artificial insemination (AI) is a technique in which artificial methods are used
to insert sperm directly into a woman’s cervix, uterus, or fallopian tubes. It is
used as a treatment for infertility of either the man or the woman in a mixed-sex
couple. It can also be used in other circumstances. For example, the technique
allows a woman in a same-sex relationship to become pregnant through the use
of donor sperm.
Physicians typically recommend AI as the first attempt to treat infertility. If
this relatively simple procedure does not result in pregnancy, more advanced,
complex techniques for treating infertility are attempted.
Among the most common forms of infertility that AI is used to treat are cases
in which men have abnormally low sperm levels or other sperm abnormalities. For
example, some men have sperm cells that are too weak to “swim” through the
cervix and reach a fallopian tube, where fertilization typically occurs.
Other forms of infertility that AI may be able to overcome are cases in which
women have certain abnormalities of their reproductive organs, such as endome-
triosis, in which the lining of the uterine wall grows outside the uterus. Artificial
insemination is also an option for women with a condition called unreceptive cer-
vical mucus, in which mucus in the cervix is unusually thick, blocking the sperm
from passing into the uterus and fallopian tubes. Yet another condition for which
AI is useful is semen allergy, in which ejaculation into the vagina causes severe
irritation, burning, and swelling in the woman’s body.
For women who cannot produce viable eggs, AI can still be performed using
the male partner’s sperm. But instead of injecting the sperm into that woman, they
are injected into another woman, called the surrogate mother. If the surrogate
mother’s egg is fertilized by the male’s sperm, she bears the child for the couple,
relinquishing the infant upon birth.
For AI to be successful, the woman must be ovulating at the time the procedure
is performed. Ovulation urine tests, blood tests, or ultrasonography can be used to
determine when this is happening. The woman may be prescribed fertility drugs
to make her ovaries release multiple eggs, increasing the chances that at least one
egg will be fertilized by the sperm. The use of fertility drugs also raises the
chances of multiple births. In some cases, the physician may induce ovulation
with an injection of human chorionic gonadotropin, a type of hormone.
The man provides a semen sample by masturbating into a cup—ideally after he
has refrained from ejaculation for several days (so that his sperm count is high).
Artificial Insemination 51
The semen sample is “washed” in a laboratory process to enhance the chances of
fertilization. This process involves removing certain chemical compounds that
may cause discomfort for the woman; adding a chemical that separates out the
most active, healthy sperm cells; and collecting and concentrating those sperm
cells through centrifugation.
Some women undergoing AI use donor sperm instead of sperm from a male
partner. Donor sperm are obtained from certified laboratories, commonly called
sperm banks, where the samples are kept frozen and preserved until needed. Such
samples are thawed prior to their use in AI. Donor sperm may be used when there
is no male partner, when the male partner has abnormal sperm, or when the male
partner is known to carry genes than could pass diseases or birth defects to the
offspring.
The sperm sample is placed into the woman’s body with a catheter, which is
inserted up through the vagina while the woman lies on an examination table with
her legs spread. Her legs are secured in stirrups, and her vagina is kept open with
a speculum, the same kind of tool used to perform a Pap smear.
Depending on the woman’s particular condition, different variations of AI may
be performed. The most frequently used form of AI is intrauterine insemination
(IUI), in which the sperm are released into the uterus as close to the fallopian
tubes as possible. This uterine insemination makes it easier for the sperm to swim
into a fallopian tube to fertilize an egg released by an ovary. In some cases, the
sperm may actually be placed into a fallopian tube.
The IUI technique is more likely to be successful than an older AI technique
called intracervical insemination (ICI), in which the sperm are released into the
cervix. The ICI technique requires the sperm to swim farther to reach the fallo-
pian tubes, reducing the chance of fertilization.
After the AI procedure, the woman is usually instructed to remain on her back
for fifteen to forty-five minutes to allow the sperm to more easily reach their tar-
get. The entire process typically requires less than an hour in a physician’s office
or clinic, with the actual AI technique taking only a couple minutes. Temporary
minor side effects of the procedure may include light bleeding from the vagina
and cramping. If the woman is taking fertility drugs, she is usually advised to
keep taking the drugs for about another week. A pregnancy test is taken about two
weeks after the AI procedure.
Artificial insemination fails more often than it succeeds. On average, the
chances of becoming pregnant with one AI procedure ranges from about 5–20
percent, with the use of fertility drugs raising the chances closer to 20 percent or
slightly higher. The technique is less likely to result in pregnancy if the woman is
older than age forty, if the woman has severe endometriosis, if the fallopian tubes
are blocked or damaged (such as from infection), or if either the egg or sperm have
multiple problems (such as abnormal shape and size and, for sperm, weak
movement).
Some couples try the AI procedure several times before turning to more
advanced—and more expensive—infertility treatment techniques, such as in vitro
fertilization (IVF). In IVF, an egg is combined with a sperm in the laboratory, and
the resulting embryo is transferred into the woman’s uterus. As an historical note,
52 Asexuality
modern methods of AI began in the 1970s as a result of the “sperm washing” tech-
niques developed for IVF.
A. J. Smuskiewicz
See also: Assisted Reproductive Technology; Conception; Infertility; Intracytoplasmic
Sperm Injection; Ova Donation; Surrogate Mothers.
Further Reading
Ding, K. (2017). Fertility treatment: Intrauterine insemination (IUI). Retrieved from http://
www.babycenter.com/0_fertility-treatment-artificial-insemination-iui_4092.bc
Mayo Clinic. (2019). Intrauterine insemination (IUI). Retrieved from http://www
.mayoclinic.org/tests-procedures/intrauterine-insemination/basics/definition/
prc-20018920
Asexuality
Asexuality is a sexual orientation, as are heterosexuality, bisexuality, pansexual-
ity, and other sexual identities, such as being gay, lesbian, or queer. The term
“ace” is sometimes used as an abbreviation of the term “asexual.” People who
identify as asexual do not experience sexual attraction to other people, although
they often experience emotional or romantic attraction to others. This is different
from celibacy, which is when people choose not to be sexually active with other
people for a variety of reasons, like religion or focusing on other life activities, but
still experience sexual attraction. Rather, asexuality is an internal sense of not
being attracted to others in a sexual manner. Asexuality is considered an identity;
as with other identities, there is no test to confirm someone is asexual. People may
use this identity by itself or with other asexual identities (such as demisexual or
graysexual) to be more specific about their identity, or in combination with other
identities (such as being an asexual lesbian or a demisexual heterosexual) to
explain who they are romantically or emotionally attracted to. Asexual people
may be single, dating, partnered, or married, either to other asexual individuals or
to those who do experience sexual attraction.
Research has shown that although there is sometimes confusion, with lack of
sexual behavior being an indicator of asexuality, the most accurate predictor of
asexuality is when an individual states that they do not feel sexually attracted to
others. This corroborates that people may be sexually active even though they do
not experience sexual attraction for a variety of reasons, including social pres-
sure, nonconsensual sexual experiences, experimenting, and to please a partner
who does experience sexual attraction. Despite the fact that it is not listed as a
psychological disorder in the Diagnostic and Statistical Manual, some people feel
that asexuality is problematic. While there are some medical and psychological
issues that have symptoms that may be similar to asexuality (such as low testos-
terone in women or hypoactive sexual desire disorder), asexuality itself is not
problematic from either a psychological or physical perspective.
Although there is no urge to act on attraction to others in a sexual way, some
asexual individuals may still masturbate, without a specific sexual attraction to
someone, to seek individual sexual release, while others do not experience sexual
Assisted Reproductive Technology 53
arousal at all. Like other sexual orientations, many asexual people report knowing
of their sexual orientation since they were young and not having experienced the
sexual attraction to others that their peers were experiencing. Still others come
into this identity at a later point in their life.
Within the realm of asexuality, there are additional terms that more specifically
describe individuals’ experiences and identities. While “asexuality” is used both
as an umbrella term for those who do not experience much or any sexual attraction
toward others and as a specific identity for people who have absolutely no sexual
attraction, “demisexual” and “graysexual/gray-ace” are also used to identify those
who do not often experience sexual attraction but who may feel sexual attraction
to specific people or in specific circumstances. Additional terms may be created
and used by individuals or groups who feel the need to create language more
authentic to their own experiences.
Shanna K. Kattari
See also: Bisexuality; Heterosexuality; Homosexuality; Pansexuality; Queer; Question-
ing; Romantic Attraction and Orientation; Sexual Orientation.
Further Reading
Asexual Awareness Week. (n.d.). Retrieved from http://asexualawarenessweek.com
Asexual Visibility and Education Network. (n.d.). Retrieved from http://www.asexuality
.org/home
Bogaert, A. F. (2015). Asexuality: What it is and why it matters. Journal of Sex Research,
52(4), 362–379.
Decker, J. (2014). The invisible orientation: An introduction to asexuality. New York:
Skyhorse.
Van Houdenhove, E., Gijs, L., T’Sjoen, G., & Enzlin, P. (2015). Asexuality: A multidi-
mensional approach. The Journal of Sex Research, 52(6), 669–678.
Assisted Reproductive Technology
Assisted reproductive technology (ART) is the use of laboratory or clinical pro-
cedures to manipulate gametes (i.e., eggs and sperm) or embryos for reproduc-
tive purposes. It most commonly refers to the handling of both male and female
gametes outside the human body (Mneimneh et al., 2013). When a couple’s or
individual’s infertility cannot be treated with medication, surgery, or other tech-
niques, they may choose ART. A variety of methods are available depending on
the needs of the individual(s) and can include retrieval (removing egg or sperm
from the body), cryopreservation (i.e., freezing) of gametes, manipulating and
monitoring fertilization, genomic testing, donor gametes, assisted hatching,
gamete/embryo cryopreservation, gestational surrogacy, and tracking the early
stages of pregnancy.
Spermatozoa, the male gametes, more commonly known as sperm, are pro-
duced in the testicles and are expelled from the penis through ejaculation. Sperm
retrieval is the process of collecting sperm by means of masturbation, epididymal
aspiration, or testicular biopsy. Generally, surgical removal of sperm may be
54 Assisted Reproductive Technology
required for those who have had a vasectomy, have a blockage or structural abnor-
mality, have reduced or absent testicular function, or who experience retrograde
ejaculation. If the testicles are not producing sperm or living sperm cells cannot
be obtained, donor sperm may be used to create an embryo. For most ART proce-
dures, sperm is examined for its concentration, motility, morphology, and pres-
ence of antisperm antibodies. Fertility specialists analyze the quality and
concentration of the sperm and level of antibodies in order to recommend the
optimal process for fertilization.
Methods of extracting motile sperm from semen were developed in the 1960s
and were designed to remove dead sperm, debris, proteins, and prostaglandins
from the sample. Currently, this purification system is used when preparing
sperm for any ART procedure, including cryopreservation. While not technically
ART (only male gametes are manipulated ex vivo), intrauterine insemination
(IUI) is a frequently used fertility treatment. IUI is the process of placing sperm
inside a woman’s uterus in an effort to have more sperm reach the fallopian tubes,
which can improve the chance of fertilization. This long-used method is generally
less expensive, invasive, and involved than ART procedures. The first account of
successful IUI is from 1785, and 1909 marks the first pregnancy using IUI and
donor sperm.
In vitro fertilization (IVF) is the process of preparing and pairing male and
female gametes in a sterile lab environment for the purposes of making an embryo.
The IVF cycle begins with administration of follicle-stimulating hormone and
luteinizing hormone to the female, which stimulates the ovary to mature multiple
follicles. Follicles are monitored via ultrasound and, when ready, patients are
injected with human chorionic gonadotropin, which matures oocytes. Before ovu-
lation occurs, oocytes are aspirated from the ovary using a thin needle and suction
device. Once removed from the body, oocytes are graded for their maturity and
prepared for insemination.
Insemination involves putting both gametes together in the same environment,
which is usually a drop of media inside a bath of oil. The whole environment, con-
tained inside a small petri dish, is then placed in a tri-gas incubator that is regu-
lated to mimic the uterine environment. In instances where there are few or
low-quality sperm, or if there have been failed attempts to fertilize, intracytoplas-
mic sperm injection (ICSI) is used for insemination. ICSI is the process of directly
injecting a single healthy sperm cell into the mature oocyte. Since fertilization
does not guarantee successful pregnancy, often multiple eggs are fertilized.
Combined gametes are monitored over the next several days for fertilization,
blastocyst development, and the release of the embryo (hatching) from the resid-
ual oocyte membrane. Assisted hatching occurs when a hole is put in the mem-
brane to allow the embryo to become free. All embryos are graded based on
their appearance, and those deemed highest in quality are transferred into the
uterus. Additional medications, such as progesterone, may be recommended at
the time of egg retrieval or embryo transfer to support uterine lining and recep-
tiveness to embryo implantation. Approximately two weeks after embryo trans-
fer, female patients take a pregnancy test, and positive results are monitored for
several weeks.
Association of Black Sexologists and Clinicians 55
In some situations, oocytes, sperm, and embryos may need to be cooled and
stored in liquid nitrogen for future use. This multistep process is called cryo-
preservation and can store cells long term without decreasing their quality.
Gestational surrogacy is the act of becoming pregnant with a child that is
genetically unrelated to the carrying mother. The originating embryo can be from
one, both, or neither of the intended parents and has been created with one or more
ART procedures. Surrogacy, like using donor gametes, involves in-depth screen-
ing, selection, and legal processes that can be expensive.
Genomic testing usually occurs in patients who have unexplained infertility.
Carriers of structural chromosomal abnormalities can experience infertility,
recurrent miscarriages, or chromosomally unbalanced offspring. Genomic testing
can help clarify the source of infertility and inform treatment options.
Darci Shinn
See also: Artificial Insemination; Conception; Fertility; Fertility Drugs; Follicle-Stimu-
lating Hormone; Infertility; Intracytoplasmic Sperm Injection; Luteinizing Hormone;
Ova Donation; Surrogate Mothers.
Further Reading
Centers for Disease Control and Prevention. (2019). Infertility FAQs. Retrieved from
http://www.cdc.gov/reproductivehealth/infertility/index.htm
Fertility Coalition. (2019). Getting the timing right. Retrieved from http://yourfertility
.org.au/for-women/timing-and-conception
Jones, R. E., & Lopez, K. (2006). Human reproductive biology (3rd ed.). New York: Aca-
demic Press.
Mneimneh, A. S., Boulet, S. L., Sunderam, S., Zhang, Y., Jamieson, D. J., ... Kissin, D. M.
(2013). States monitoring assisted reproductive technology (SMART) collabora-
tive: Data collection, linkage, dissemination, and use. Journal of Women’s Health,
22(7), 571–577.
Association of Black Sexologists and Clinicians
Conceptualized and created in 2014 by Dr. James C. Wadley of Lincoln Univer-
sity, the Association of Black Sexologists and Clinicians (ABSC) emerged from
the input of twenty-seven black scholars, clinicians, and educators dedicated to
formal and informal sexual health dialogue and research about persons of African
descent. The organization seeks to bring together professionals who are interested
in addressing intersectionality, sensitive issues, and social justice. A welcoming
and affirming organization, the ABSC facilitates informed sexuality discourse
through its scholarly, interdisciplinary refereed inquiry, the Journal of Black Sex-
uality and Relationships. The mission of the organization is as follows: “The
Association of Black Sexologists and Clinicians promotes the sexual health of
individuals, couples, families, and communities by advocating for culturally sen-
sitive research, informed clinical practice, and culturally sensitive educational
curricula. The organization seeks to foster ongoing dialogue in an effort to reduce
and or prevent adverse sexual health outcomes. As a welcoming and affirming
organization, we advocate for sexual, racial, and gender equality” (ABSC, 2020).
56 Association of Black Sexologists and Clinicians
The vision of the organization is to change or enhance the way intersectionality
is thought about. In addition, the ABSC strives to offer research, clinical, and edu-
cational opportunities that focus on and include race and sexuality. As an organi-
zation, it seeks to empower communities by “engaging, informing, dialoguing,
learning and collaborating about sexual health issues” (ABSC, 2020). Finally, the
ABSC aims to build and sustain community involvement of black professionals in
the field of human sexuality and mental health; to engage in ongoing dialogue,
both formally and informally, about social and sexual health issues that affect
black communities; to develop and support programs and policies that reduce sex-
ual health disparities among black communities through prevention, education,
and clinical response; to create local, national, and international networks for
members; and to be a research, educational, and clinical resource for initiatives
relating to mental and sexual health.
The ABSC hosted its first formal event, Black Families, Black Relationships,
Black Sexuality Conference, in Philadelphia in October 2015. There were over
one hundred proposals accepted, and approximately 150 people from as far west
as Alaska to as far east as Kenya attended. Participants who attended the event
shared their work that was specifically devoted to the affective, cognitive, and
behavioral experiences of persons of African descent. The keynote speakers for
this inaugural event included Drs. Loretta Sweet Jemmott, Juan Battle, and Rob-
ert Weiss. The conference also included a “Black Family Reunion,” held at Lin-
coln University, where participants had a chance to network.
In April 2016, the ABSC hosted its first Spring Roundtable Series in the U.S.
Virgin Islands. In collaboration with the University of the Virgin Islands and sev-
eral Caribbean organizations and media outlets, Black Americana attracted schol-
ars and clinicians from various institutions and mental health agencies within the
United States who shared their research and clinical best practices.
In August 2017, the ABSC and Cape Peninsula University of Technology hosted
its first International Lecture Series in Cape Town, South Africa. Scholars devoted
to research, education, policy, or clinical interventions targeted at persons of Afri-
can descent were invited to share their work at this epic event. The organization
continues to hold events around the world.
The official publication of the ABSC is the Journal of Black Sexuality and
Relationships. The journal is a scholarly, peer-reviewed publication for research-
ers, clinicians, educators, and policy makers that explores and discusses issues
related to black sexuality, including how it has evolved and how it affects and
interacts with interpersonal relationships. Journal of Black Sexuality and Rela-
tionships is an interdisciplinary journal, and contributors and readers come from
a range of fields. The concept and study of sexuality is broad and combines ele-
ments of psychology, sociology, cultural anthropology, law, and biology among
others. For those of African ancestry, other factors, such as slavery, the black fem-
inist movement, black womanist movement, and the evolution and role of
homophobia or heterosexism must also be considered as these affect not only indi-
viduals but also larger social and cultural environments. The quarterly journal
discusses the sexual health interests of persons of African descent, which
Attachment Theory of Love 57
traditionally has been an overlooked and underrepresented group within sexual
health research and literature.
James Wadley
See also: Black Sexuality; Sexology.
Further Reading
Association of Black Sexologists and Clinicians. (2020). About us. Retrieved from http://
www.theabsc.com/about-us/
Wadley, J. (2014). Editor’s note: The Journal of Black Sexuality and Relationships is
finally here. Journal of Black Sexuality and Relationships, 1(1), vii–xv.
Wadley, J. (2014). Editor’s note: “We have a lot of work to do . . .”: The emergence of the
Association of Black Sexologists and Clinicians. Journal of Black Sexuality and
Relationships, 1(2), vii–xvi.
Wadley, J. (2015). Editor’s note: It’s time . . . Journal of Black Sexuality and Relation-
ships, 1(3), vii–xi.
Attachment Theory of Love
The attachment theory of love posits that a person’s attachment relationship to
their primary caregiver as a child influences how the person will bond with others
in adult romantic and intimate relationships. Attachment theory was shaped by
British psychologist, psychiatrist, and psychoanalyst John Bowlby (1969) and fur-
ther developed by American Canadian developmental psychologist Mary Ain-
sworth in 1965 with her famous experiment known The Strange Situation. Bowlby
defined attachment as “the bond that ties” the child and their primary caretaker,
and through behavioral interactions of the caretaker and child, attachment sche-
mas and behaviors are exchanged to strengthen (or weaken) the bond. Attachment
behaviors between the infant and caretakers include eye contact, touch, crying,
grasping, smiling, vocalizing, and reaching.
These behaviors also help create attachment schemas, collective implicit mem-
ories organized in networks within the brain to help infants determine if the envi-
ronment around them is safe and if the caretakers they are bonding with are going
to protect them from danger through a goal-corrected control system. Within this
system, infants use attachment behaviors to determine how close the caretaker is
to the infant in terms of proximity. For example, if an infant cries or makes certain
physical movements and the caretaker responds and is aware of what the child
needs (to be fed, to have a diaper changed, to respond to facial cues), the infant
will feel more secure internally and externally within their environment. If the
caretaker does not meet these needs, the infant will see the environment as inse-
cure, thus creating fear within the infant.
Ainsworth’s experiment The Strange Situation consisted of her taking various
pairings of infants and their mothers, separating the two by having the infants
explore unfamiliar settings without the mother, then having the mothers return to
reunite with their infants. Depending on the infant’s reaction upon their mother’s
return, they were given a label of their attachment style: secure, avoidant,
58 Attachment Theory of Love
anxious-ambivalent, or disorganized. In general, it was found that children who
were more securely attached to their mothers were able to be soothed when the
mother returned to the room. Children who were avoidantly attached ignored their
mothers upon return. Those who were anxious-ambivalent seemed to be more
stressed when their mothers returned due to lack of internalized safety, and the
infants who had a disorganized attachment style demonstrated chaotic and self-
injurious behaviors due to internalizing their mother’s unresolved trauma and
grief issues.
These attachment styles can be used to theorize as to how these infants will
develop intimate relationships with other adults when they are older. Based on the
experiences they internalized as children from their parents, they can be securely
attached, anxiously attached, or avoidantly attached within their relationships.
Securely attached relationships, where the person has internalized their caretak-
er’s ability to comfort them, occur when people allow their partners to get close to
them without fear of abandonment. Those who are anxiously attached are con-
cerned that their partners will not want to get as close as they would like, and they
experience jealousy and fear that their partner will not return feelings of love.
Finally, those who are avoidantly attached see love and relationships as temporary,
are not comfortable with intimacy, and do not wish to be dependent on another
person, thus having a low expectation that the relationship will last. Overall, it is
expected that relationships with people who are securely attached will last longer,
and those who are anxiously or avoidantly attached are more likely to experience
shorter and less emotionally fulfilling relationships.
Shane’a Thomas
See also: Intimacy, Sexual and Relational; Lee’s Theory of Love Styles; Love; Sternberg’s
Triangular Theory of Love.
Further Reading
Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain. New
York: W. W. Norton & Company.
Harwood, R. L., Miller, J. G., & Irizarry, N. L. (1995). Culture and attachment: Percep-
tions of the child in context. New York: Guilford Press.
Lehmiller, J. J. (2014). The psychology of human sexuality. Hoboken, NJ: Wiley-
Blackwell.
B
Bacterial Vaginosis
Bacterial vaginosis (BV) is an imbalance of the vaginal ecosystem caused by
changes in the vaginal pH and a resultant overgrowth of many types of anaerobic
bacteria. BV is not a vaginitis—meaning there is no inflammation of the actual
cells lining the vagina. BV is also sometimes referred to as “Gardnerella vagina-
lis,” as this particular type of bacteria is often found in high numbers in those
women with BV.
BV is characterized by an unusual vaginal discharge that can be a grayish-
white color and usually thinly adheres to the vaginal wall. There can be a small or
large amount of discharge, and it can sometimes be frothy in appearance. It can
also have a fishy smell, which can cause embarrassment for some women and
affect their sexual relationships. Some women may also experience burning, itch-
ing, or pain. However, up to half of women with BV do not experience any symp-
toms. Presence of BV can increase susceptibility to sexually transmitted infections
(STIs), and it is possible to have both BV and other STIs.
BV is the most common cause of vaginal infection in women of childbearing
age worldwide. BV is not seen in postmenopausal women unless they commence
hormone replacement therapy, when some women find that BV recurs. The bacte-
ria use estrogen as part of their survival and reproduction inside the vagina, so
without estrogen, there is no BV.
Debate continues on whether the condition is sexually transmitted or not
because male partners do not report symptoms or test positive for the various bac-
teria that are present with BV. BV can also occur in women who are sexually
inexperienced. However, what is clear is that in sexually active women, BV is
related to sexual activity, even if it is not (yet) considered to be a sexually trans-
mitted infection. Women who have BV may pass BV to female sex partners.
The normal pH (level of acidity or alkalinity) of the vagina is ≤4.5. This acidic
environment is hostile to microbes and sperm alike—a protective factor at one of
the potentially vulnerable entry points into the body. The acid (H2O2) is hydrogen
peroxide and is produced by Lactobacilli, which are also known as “normal flora”
or healthy bacteria that live in the vagina. Anything that reduces the numbers of
these friendly bacteria also changes the amount of acid produced and therefore
alters the vaginal pH. Many things can cause this imbalance in the vaginal ecol-
ogy to occur, including antibiotic use, vaginal douching, semen, menstruation,
and use of perfumed soaps, shower gel, or bubble bath.
Semen has an alkaline pH, perhaps as an evolutionary response to assist
some sperm to survive the hostile acidity of the vagina. But as a consequence,
60 Barrier Contraceptive Methods
when semen is present in the vagina, the pH increases, resulting in a more
bacteria-friendly environment where small amounts of bacteria can multiply
and cause BV.
Menstruation similarly increases the pH of the vagina, and some women find
that menstrual blood can also wash out some of the bacteria that make the acid.
This depends on the amount of blood and Lactobacilli present and how quickly
the Lactobacilli are able to recover. This may also depend on the particular spe-
cies of Lactobacilli that are present, with some women being more susceptible to
recurrent BV compared to others.
Antibiotic medication used to treat other bacterial infections can also uninten-
tionally wipe out or reduce the population of Lactobacilli in the vagina, so some
women experience a BV episode while taking antibiotics.
Management of BV includes treating the types of bacteria that cause the
unwanted bacterial overgrowth and encouraging growth of the healthy bacteria.
Normalizing the pH of the vagina by using an acid-based intravaginal medication,
such as a gel-based product, may also be helpful. The vagina may also be repopu-
lated with Lactobacilli.
Recurrences of BV are common, and this can be very distressing for women
and their partners. Reducing the amount of semen ejaculated into the vagina
through the use of condoms or withdrawal can help to reduce reoccurrence in
some women. Women should also avoid using perfumed soaps or bubble bath, and
they should not use vaginal deodorants, washes, or douches.
Kelwyn Browne
See also: Douching; Sexually Transmitted Infections (STIs); Vagina; Vaginal Secretions;
Vaginitis.
Further Reading
Centers for Disease Control. (2017). Bacterial vaginosis—CDC fact sheet. Retrieved
from https://www.cdc.gov/std/bv/stdfact-bacterial-vaginosis.htm
National Health Service. (2019). Bacterial vaginosis. Retrieved from https://www.nhs.uk/
conditions/bacterial-vaginosis/
Spiegel, C. A. (1991). Bacterial vaginosis. Clinical Microbiology Reviews, 4(4), 485–502.
Barrier Contraceptive Methods
Barrier contraceptive methods reduce the risk of conceiving an unintended preg-
nancy by inserting a barrier between sperm and the female reproductive tract dur-
ing sexual intercourse. Many, but not all, confer the added benefit of reducing the
risk of contracting or spreading sexually transmitted infections (STIs) by prevent-
ing each partner’s bodily fluids from contacting the other’s mucous membranes.
While the role of barrier devices in contraception specifically applies to mixed-
sex couples, their role in reducing STI risk applies to all sexual partners regardless
of gender or orientation.
The main benefit of barrier methods is that they are not ingested, and there-
fore they have a very low risk of triggering adverse physical effects. They do not
alter fertility in the long term, have no rebound period between intentional
Barrier Contraceptive Methods 61
discontinuation and ability to achieve pregnancy, do not affect hormone levels
within the body, are 100 percent reversible, and do not interfere with the men-
strual cycle.
Specific methods vary in effectiveness, convenience, and availability. Some
require a prescription or a medical office visit to size and fit the device. Others
require concurrent use of pharmaceutical spermicide. Not all of them cover an
adequate area of skin to prevent the spread of some STIs. Persons with latex aller-
gies can have a severe reaction to some barrier contraceptives, and certain meth-
ods have triggered toxic shock syndrome in some women.
In addition, there are social and personal drawbacks to barrier contraceptive
use for some individuals and couples. Some methods are associated with an actual
or perceived loss of sensation during intercourse. Some individuals feel that the
need to carry a barrier device on one’s person, request its use, or pause to apply it
interferes with spontaneity. Further, all barrier methods, with the exception of the
insertive (male) condom, require the receptive partner to pause sexual relations
and properly insert and position the device.
Social issues, issues of personal agency, and interpersonal power dynamics
within relationships may complicate the use of barrier methods for some popula-
tions. Partners in abusive relationships may be unable to request or enforce the use
of a barrier device. Since it is obvious to a partner when these devices are in use,
a person in such a relationship does not have the option to control contraception
(or STI risk) over a partner’s objection. Some persons, such as adolescents, may
encounter logistical problems, such as access and expense, when attempting to
purchase barrier devices. By nature, barrier methods are typically nonbiodegrad-
able, and most involve packaging, so they may be objectionable to some consum-
ers on environmental or ethical grounds. Finally, barrier method use in the United
States is complicated by lack of comprehensive sex education and accurate medi-
cal information. Sex education curricula that focus on abstinence tend to dramati-
cally overstate failure rates for barrier methods, and young people may be strongly
discouraged from learning proper usage techniques and subjected to social stigma
when they seek further information.
Barrier contraceptive devices include the insertive (male) condom, receptive
(female) condom, diaphragm, cervical cap, and contraceptive sponge. Failure rates
listed here are annual rates for couples correctly using a method for each and
every episode of sexual intercourse. Higher failure rates are based on inconsistent
or incorrect usage.
Insertive condoms are tight-fitting latex or polyurethane sheaths that cover the
erect penis. With perfect use, they have a failure rate of one in fifty (2%) or fewer,
making them one of the most effective contraceptive methods. Receptive con-
doms are loose tubes inserted into the vagina with a ringed entrance that partially
covers the vulva. With perfect use, their failure rate is one in twenty (5%). Dia-
phragms and cervical caps are latex or silicone cups that are inserted into the
vagina to cover the mouth of the uterus. They require a prescription and custom
fitting, must be used with pharmaceutical spermicides, and carry some risk of
toxic shock syndrome. Their failure rate with perfect use is one in eighteen (5.6%);
although failure rates are higher among those who have previously been pregnant.
62 Basson, Rosemary
Contraceptive sponges contain spermicide and are inserted into the vagina. Their
failure rate with perfect use is greater than one in ten (10%) and also increases
after previous pregnancy.
Angela Libal
See also: Cervical Cap; Condoms, Female (Receptive); Condoms, Male (Insertive); Con-
traception; Diaphragm; Pregnancy; Sexually Transmitted Infections (STIs); Spermicides;
Sponge, Contraceptive.
Further Reading
Centers for Disease Control and Prevention. (2019). Contraception: Birth control meth-
ods. Retrieved from https://www.cdc.gov/reproductivehealth/contraception/
index.htm
U.S. National Institutes of Health. (2017). What are the different types of contraception?
Retrieved from https://www.nichd.nih.gov/health/topics/contraception/condition-
info/types
Basson, Rosemary
Dr. Rosemary Basson is a clinical professor in the department of psychiatry at the
University of British Columbia (UBC). She is also the director of the sexual medi-
cine program at UBC. Basson is most notably recognized for creating a circular
model of sexual response, as she felt that traditional linear models did not often
apply to women.
Basson started her career in the medical field in 1973, helping young men with
spinal cord injuries. This experience made her want to learn more about sexual
functioning. She continued to work as a generalist in family medicine until 1986,
when she began a fellowship at UBC in the sexual medicine unit. Here she met her
mentor and cofounder of the sexual medicine unit, George Szasz.
Basson’s most notable achievement has been the creation of a circular model of
sexual response, which she first published in 2000. Her model acknowledges how
emotional intimacy, sexual stimuli, and relationship satisfaction affect female sex-
ual response. In the model, arousal is mediated by feelings of being desired, the
partner’s behavior toward the female, and the woman’s body image and mood.
This model also reflects overlapping desire and arousal phases and focuses on
females becoming more aroused during a sexual experience rather than assuming
that desire must always be present before the beginning of a sexual act. Because of
this, the model also recognizes that desire is not mandatory to initiate sex, as
sometimes sex is initiated for other reasons, such as to feel more connected to the
partner.
In 2010, Basson’s research was able to show that there were no androgen dif-
ferences between women with and without hypoactive sexual desire disorder.
Instead she was able to investigate and discover that females with low sexual
desire had low serum levels of a hormone (dehydroepiandrosterone or DHEA)
that is produced in the adrenal gland and helps in the production of other hor-
mones, including testosterone and estrogen. Her further research discovered
that women with low or absent sexual desire and arousal had markers of hypo-
thalamic pituitary adrenal dysregulation, which are strong indicators of chronic
BDSM 63
stress in the early life stages, thus displaying that this chronic stress is linked to
low or absent sexual desire.
Basson has devoted her career to helping normalize female sexuality and does
so through research in many different areas. Her other research projects include
studying how different therapy techniques can be used to help individuals suffer-
ing from vestibulodynia and sexual interest or arousal disorders.
Basson has over ninety peer-reviewed publications, many around the human
sexual response detailed above. She has dedicated her career to helping to reframe,
rename, and decrease stigma associated with sexual dysfunctions. She has also
been a strong opponent of the use of Viagra-like drugs to help “cure” female sex-
ual arousal difficulties. Due to her work, Basson has written many articles, book
chapters, and manuals for students to better understand sexual function and dys-
function. She is very involved in teaching undergraduate, graduate, and postgrad-
uate courses.
Amanda Baker
See also: Arousal; Desire; Desire Disorders; Female Sexuality; Masters and Johnson
Four-Stage Model of Sexual Response; Sexual Dysfunction, Treatment of.
Further Reading
Basson, R. (2000). The female sexual response: A different model. Journal of Sex and
Marital Therapy, 26(1), 51–65.
Basson, R. (2001). Using a different model for female sexual response to address women’s
problematic low sexual desire. Journal of Sex and Marital Therapy, 27(5),
395–403.
Basson, R. (2002). A model of women’s sexual arousal. Journal of Sex and Marital Ther-
apy, 28(1), 1–10.
Basson, R. (2007). Sexual desire/arousal disorders in women. In S. R. Leiblum (Ed.),
Principles and practice of sex therapy (25–53). New York: Guilford Press.
Basson, R., McInnes, R., Smith, M. D., Hodgson, G., & Nandan, K. (2002). Efficacy and
safety of sildenafil citrate in women with sexual dysfunction associated with
female sexual arousal disorder. Journal of Women’s Health and Gender-Based
Medicine, 11(4), 367–377.
BDSM
Some people derive sexual pleasure from displays of power or inflicting (sadism)
or receiving (masochism) pain (physical or psychological) in a sexual context. A
host of terms has been used to describe these interests, the most popular of which
are “bondage and discipline (B&D),” “dominance and submission (D&S or D/S),”
and variations of “sadism,” “masochism,” or “sadomasochism,” often abbreviated
as S&M, S/M, or simply SM. In the late 1990s, people who shared these interests
increasingly adopted the term “BDSM,” a term that combines all of these (B&D,
D&S, S&M) to describe their activities.
Surveys in the last few decades indicate that as much as 10 percent of the
American population may have sexual fantasies that involve some degree of mas-
ochism or sadism. How many people act on these fantasies is unknown, but the
number of people actively involved in the BDSM community—that is, people who
64 BDSM
belong to local BDSM organizations, subscribe to BDSM magazines, participate
in online chat areas devoted to BDSM, or attend any of several dozen BDSM con-
ventions—grew steadily in the twentieth century. Nonetheless, the organized
BDSM community in the United States remains relatively small, perhaps number-
ing in the low tens of thousands.
Renaissance writer Giovanni Pico della Mirandola (1463–1494) was among the
first to comment on sexual sadism and masochism when he described a friend
who needed prostitutes to flog him so that he could perform sexually. By the Vic-
torian era, brothels that specialized in flagellation operated in most of Europe’s
major cities, and scenes of flagellation or other forms of sexual sadism and mas-
ochism commonly appeared in erotic literature. John Cleland’s Memoirs of a
Woman of Pleasure (1749), for example, contains scenes in which protagonist
Fanny Hill whips customers and is in turn whipped by them, and flagellation
developed as a niche market for nineteenth-century erotic literature.
Several early sexologists interviewed people who derived sexual pleasure from
inflicting or receiving pain or cruelty. Richard von Krafft-Ebing (1840–1902)
coined the terms “sadism” and “masochism” in the fifth edition of his book Psy-
chopathia Sexualis in 1890, deriving “sadism” from Donatien Alphonse François,
Marquis de Sade (1740–1814), a French writer famous for literary works that
mixed violent sexuality with religious and political polemics. Krafft-Ebbing
named its opposite “masochism,” after Austrian writer Leopold von Sacher-
Masoch (1836–1895), several of whose novels, particularly Venus in Furs (1870),
featured sexually submissive men and dominant women. Krafft-Ebing labeled
both sadism and masochism pathologies and presented several case studies of
people whose masochistic or sadistic interests significantly disrupted their lives.
Iwan Bloch (1872–1922) was somewhat less pejorative in his work, and Havelock
Ellis (1859–1939) described several happily married couples whose sex lives
included masochistic and sadistic activities in Love and Pain (1903).
Discussions of masochistic and sadistic sexual activities appeared periodically
in several general interest magazines, including The Englishwoman’s Domestic
Magazine during the Victorian era and London Life in the 1920s and 1930s. It was
not until after World War II (1939–1945), though, that dedicated fetish and BDSM
magazines appeared. The first of them, Bizarre, was launched by John Willie, a
pseudonym for John Alexander Coutts (1902–1962), in 1946 and spawned a host
of imitators in the 1950s. By the 1960s, many BDSM and fetish magazines pub-
lished personal ads that allowed readers with similar sexual interests to find one
another. These correspondence networks laid the foundation for the increasingly
visible BDSM community that emerged in the 1970s in the United States and
Western Europe.
Sexual sadism received only brief mention in the first edition of the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disor-
ders (DSM, 1952), which lumped it with other sexual “pathologies,” including
fetishism, homosexuality, pedophilia, and transvestism. The next edition, DSM-
II (1968), continued this practice, listing sexual sadism with other “sexual devia-
tions” in which a person’s sexual interest was directed toward particular objects
or “sexual acts not usually associated with coitus, or toward coitus performed
under bizarre circumstances as in necrophilia, pedophilia, sexual sadism, and
BDSM 65
fetishism” (DSM-II, 1968). Revisions championed by psychologist John Money
(1921–2006) substituted the less pejorative term “paraphilia” for “perversion” in
the 1980 edition (DSM-III), but DSM-III and DSM-IIIR (1987) continued to
reflect negative judgments of sexual sadism, sexual masochism, and fetishism
along with a host of other maligned sexual behaviors. They also failed to clearly
differentiate between consensual and nonconsensual sexual sadism, seeing
either as acceptable criteria for a diagnosis of mental illness. As BDSM com-
munity leaders pointed out, the DSM evinced no engagement with actual BDSM
practitioners or the organized BDSM community. It provided no discussion of
the safety practices of its members or even descriptions of BDSM activities.
Public awareness of BDSM activities increased steadily in the 1970s as bars
that catered to gay sadomasochists opened; the first BDSM organizations formed
in New York, Chicago, and San Francisco; and BDSM imagery, what the press
labeled “SM chic,” appeared in fashion shows, magazines, and other venues. By
the mid-1980s, more than a hundred BDSM organizations had formed in Ameri-
can cities. A national organization, the National Leather Association (NLA),
formed in 1986. Among its goals was to eliminate the pejorative characterization
of BDSM activities by both the general public and mental health professionals—
characterizations reflected in the 1980 film Cruising about a police officer (played
by Al Pacino) pursuing a serial killer targeting the BDSM community.
Members of the NLA and other BDSM organizations explained that their sex-
ual activities were “safe, sane, and consensual,” the latter being particularly
important in differentiating BDSM from criminal violence. Large BDSM events
employed “dungeon monitors” to keep participants safe, and those in a submissive
role could call out a “safe word” to halt activity in the event of problems. Educat-
ing BDSM practitioners in safe practice became one of the primary goals of
BDSM organizations, as well as several BDSM publications, most notably Dun-
geonMaster, which launched in 1979.
In the early 1990s, leading BDSM organizations campaigned for revisions to
the DSM that would reflect actual BDSM practice, an effort made urgent by sev-
eral legal cases involving BDSM activity, particularly the 1987 Operation Spanner
case, in which British police arrested sixteen men for their consensual BDSM
activities. Charged with assault and other crimes, twelve of the men were con-
victed after the judge refused to accept consent as a defense. Appeals, supported
by funds raised by the NLA and other North American and British BDSM groups,
continued for a decade but repeatedly failed.
Efforts to revise the DSM proved more successful. Both DSM-IV (1994) and
DSM IV-TR (2000) included revisions that reduced the negative characterizations
of sexual masochism and sexual sadism and defined them as problematic only if
they caused “clinically significant distress or impairment in social, occupational,
or other important areas of functioning” (DSM IV-TR, 2000). Nonetheless, the
DSM continued to conflate consensual and nonconsensual activities until its fifth
edition. DSM-V (2013) substantially changed its approach, differentiating
between paraphilias, which were “unusual sexual interests,” and people with
paraphilic disorders, who harmed themselves or others. Exhibiting a paraphilia,
such as fetishism, masochism, or sadism, does not justify or require clinical
intervention. DSM-V reserved the term “sexual sadism disorder” specifically for
66 Benign Prostatic Hyperplasia
nonconsensual actions—that is, people who violated the norms of BDSM behav-
ior and were likely guilty of criminal violence. These changes in the DSM
resulted from both a successful campaign by the National Coalition for Sexual
Freedom, which revived the BDSM community’s DSM revision campaign, and
changing popular perceptions of BDSM. The best-selling novel Fifty Shades of
Grey (2011) introduced millions of Americans to BDSM sexuality, while refer-
ences to BDSM sexuality became increasingly common in the media. Comedian
Stephen Colbert, for example, regularly made jokes that relied on BDSM termi-
nology, such as safe words.
The BDSM community itself changed dramatically in the first decades of the
twenty-first century. A climate of growing acceptance combined with the ease of
disseminating practical BDSM information and finding likeminded people on the
internet meant that many BDSM publications and organizations lost subscribers
and members. Many shut down entirely, among them DungeonMaster. In their
place, websites such as FetLife became centers for much BDSM discussion. None-
theless, numerous local BDSM organizations continue to thrive, and many Ameri-
can cities boast an annual BDSM convention.
Stephen K. Stein
See also: Diagnostic and Statistical Manual of Mental Disorders (DSM); Kink; Krafft-
Ebing, Richard von; Paraphilias.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Moser, C., & Kleinplatz, P. J. (2005). DSM-IV-TR and the paraphilias: An argument for
removal. Journal of Psychology and Human Sexuality, 17(3–4), 91–109.
Stein, S. (2012). Twenty-five years of living in leather: The National Leather Association,
1986–2011. Daytona Beach, FL: Adynaton.
Stoller, R. J. (1991). Pain and passion: A psychoanalyst explores the world of S&M. New
York: Plenum Press.
Thompson, B. (1994). Sadomasochism: Painful perversion or pleasurable play. New
York: Cassell.
Weinberg, T. S. (Ed.). (1995). S&M: Studies in dominance and submission. New York:
Prometheus.
Benign Prostatic Hyperplasia
Benign prostatic hyperplasia (BPH) is the enlargement of the prostate gland. BPH
is found in 50 percent of people with prostates over the age of fifty. The incidence
of BPH increases with every year over fifty, making BPH a common condition.
The prostate gland is a part of the reproductive system; it secretes prostate fluid,
which is found in semen. The muscles of the prostate gland also help to project
seminal fluid into the urethra during ejaculation. The prostate is located directly
below the bladder and the urethra, the tube-like structure that carries urine from
the bladder during urination, passes through the center of the prostate gland.
Therefore, enlargement of the prostate creates a smaller hole for the urethra to fit
into and can cause the urethra to pinch or become obstructed.
Benign Prostatic Hyperplasia 67
There are several possible explanations for why the prostate enlarges. One
hypothesis involves hormone-driven growth, specifically testosterone (T) and
dihydrotestosterone (DHT). In some cases of BPH, high levels of T and DHT are
present; however, this is not true for every case of BPH. Another hypothesis
involves chronic inflammation from infection or trauma to the prostate.
The obstruction caused by BPH can produce several different clinical uri-
nary symptoms, including a weak or intermittent urine stream, nocturia (i.e.,
urinating at night), dribbling of urine at the end of urination, and the inability
to empty the bladder. When the bladder does not empty urine properly, it
becomes more susceptible to bladder infections, bladder stones, and even kid-
ney damage.
BPH symptoms present in ways that can be disruptive to the sufferer’s every-
day life. Painful, unpredictable, and frequent urination can interrupt sleep, work
hours, and intimacy between partners. Therefore, BPH can have a far reach,
affecting not only someone’s physical health but also their psychological well-
being. For others, these lower urinary tract symptoms (LUTS) are not bothersome
and are barely noticeable. The size of the prostate does not always indicate the
severity of the LUTS that someone may experience; the symptoms can be a very
personal and subjective experience.
The American Urological Association (AUA) has developed a symptom score
to objectively measure the severity of LUTS typically caused by BPH. The AUA
separates the LUTS briefly described above into seven distinct symptoms: urinary
frequency, intermittent stream, urinary urgency, weak stream, straining to uri-
nate, incomplete emptying, and nocturia. Each of these seven symptoms are rated
on a scale of 0–5, and the total score indicates clinically mild (0–6), moderate
(7–19), and severe (20–35) symptoms.
There are several ways to diagnose BPH, including the digital rectal examina-
tion (DRE). The DRE consists of inserting a finger into the patient’s anus, where
the lobes of the prostate can be felt through the wall of the lower rectum. The DRE
can also check for indications of prostate cancer and is also used as a cancer
screening tool. The other diagnostic tool used for BPH is to measure the prostate
specific antigen (PSA) levels in one’s blood. PSA is an antigen that is only made
by prostate gland tissue. High PSA serum blood levels indicate that there is an
abundance of prostatic tissue present, which would occur with BPH. However,
high PSA can also indicate prostate cancer. BPH is so common among people
with prostates over the age of fifty that it is not uncommon for PSA levels to rise
with age. In a young person, a higher PSA level may indicate prostate cancer as
they are less likely to have BPH, whereas the same PSA level in someone in their
seventies may more likely be due to BPH.
Another diagnostic tool for BPH is to measure someone’s postvoid residual—
that is, to measure the bladder’s volume before and immediately following thor-
ough urination. If the bladder has a high postvoid residual, this could mean that
the bladder is not emptying correctly due to a BPH-produced obstruction of the
urethra. Cystourethroscopy is a procedure where a flexible microscope is fed
through the urethra and into the bladder and is also used to identify BPH. Indi-
vidually, these diagnostic tools may also indicate other disorders; however, used
together, they paint a reliable portrait of BPH.
68 Benjamin, Harry
Once diagnosed, there are several possible interventions to treat BPH. The typ-
ical first line of treatment is medication therapy paired with a healthy diet and
lifestyle changes. Dual therapy is the combination of two classes of medications
that work together to keep the urethra open and to reduce the size or muscle capac-
ity of the prostate. These medications have relatively mild side effects, including
dry mouth, dizziness, and retrograde ejaculation. If dual therapy does not work to
modify LUTS, then surgical intervention may be considered to shrink, shave, or
remove the prostate entirely via prostatectomy.
Another treatment for BPH is watchful waiting, which is recommended by the
AUA for those with mildly rated symptoms. Watchful waiting involves close
symptom monitoring paired with regular DREs and other screening tools to
observe any changes in symptoms that may necessitate further intervention;
watchful waiting is not recommended for those with severely rated LUTS or
known possible complications. BPH can become a complex urological condition
with a nuanced symptom presentation, and treatment plans may differ from per-
son to person depending on their condition.
Cassia Araujo-Lane
See also: Prostate; Prostate Cancer; Prostatectomy; Prostatitis.
Further Reading
Foster, H. K., Barry, M. J., Gandhi, M. C., Kaplan, S. A., Kohler, T. S., Lerner, L. B., …
McVary, K. T. (2019). Benign prostatic hyperplasia: Surgical management of
benign prostatic hyperplasia/lower urinary tract symptoms (2018, amended 2019).
Linthicum, MD: American Urological Association.
Kim, E. H., Larson, J. A., & Anriole, G. L. (2016). Management of benign prostatic hyper-
plasia. Annual Review of Medicine, 67(1), 137–151.
Mayo Clinic. (2019). Benign prostatic hyperplasia (BPH). Retrieved from https://www
.mayoclinic.org/diseases-conditions/benign-prostatic-hyperplasia/symptoms-causes/
syc-20370087
Shvartzman, P., Borkan, J. M., Stoliar, L., Peleg, A., Nakar, S., Nor, G., & Tabenkin, H.
(2001). Second-hand prostatism: Effects of prostatic symptoms on spouses’ quality
of life, daily routines and family relationships. Family Practice, 18(6), 610–613.
Te, A. E., & Chughtai, B. (2014). Benign prostatic hyperplasia. In S. A. Kaplan & K. T.
McVary (Eds.), Male lower urinary tract symptoms and benign prostatic hyper-
plasia (191–200). New York: John Wiley & Sons.
Benjamin, Harry
Dr. Henry (Harry) Benjamin (1885–1986) was born in Berlin, Germany, on Jan-
uary 12, 1885. Benjamin became the founding father of the study and treatment
of transsexualism. He started his career working on slowing the aging process
and then moved into working in the world of transgender care. During his career,
he helped outline treatment protocols for sex reassignment surgery and hormone
therapy that are still closely followed years after his passing. Benjamin was a
champion for providing appropriate transgender care instead of labeling indi-
viduals with psychiatric disorders.
Benjamin attended the University of Rostock and the University of Berlin and
graduated with his medical degree from the University of Tubingen in Germany
Bigender 69
in 1912. Shortly after, in 1913, he moved to the United States to work with a new
treatment for tuberculosis. Benjamin opened a general medical practice in New
York City and focused on treating the aging population via hormones and surgery.
During his time at this practice, he focused on some of his interests in the fields of
endocrinology, gerontology, and sexology. In 1935, Benjamin became licensed to
practice medicine in California and, for a time, had a summer practice in Los
Angeles and San Francisco.
While treating his aging patients in New York City, one of his male clients
asked for hormones and disclosed to Benjamin that he was a cross-dresser. Benja-
min noticed after giving him the hormone medication that he was a lot calmer and
happier. Benjamin took this discovery and moved forward with a whole career to
help transsexuals receive care for hormones and surgery. Benjamin was also one
of the charter members of the Society for the Scientific Study of Sexuality.
Benjamin published The Transsexual Phenomenon in 1966, which was the first
book on gender identity for a medical audience. In the book, he outlined an affir-
mative treatment path that he pioneered. Benjamin would give talks at hospitals
and schools to help spread his research and first coined the term “transsexual.” In
1979, the Harry Benjamin International Gender Association was formed and cre-
ated the first standard of care for transsexual individuals, with Benjamin leading
the way. Later the title of the organization was changed to the World Professional
Association of Transgender Health, and it is still active to this day.
In 1974, Benjamin officially retired from his medical practices. In August 1986,
he passed away in New York City at 101 years old. Benjamin was married to his
bride, Gretchen, for sixty years, and they had no children. During his career,
Benjamin worked with many notable scholars, such as Dr. Alfred Kinsey and
Dr. Magnus Hirschfeld.
Amanda Baker
See also: Gender Identity; Gender Transition; Sex Reassignment Surgery; Society for the
Scientific Study of Sexuality (SSSS); Transgender; Transsexual; World Professional
Association for Transgender Health (WPATH).
Further Reading
Archives Online at Indiana University. (2019). The Harry Benjamin collection. Retrieved
from http://webapp1.dlib.indiana.edu/findingaids/view?doc.view=entire_text
&docId=VAC1594
Benjamin, H. (1966). The transsexual phenomenon. New York: Julian Press.
Ihlenfeld, C. L. (2004). Harry Benjamin and psychiatrists. Journal of Gay and Lesbian
Psychotherapy, 8(1–2), 147–152.
Meyer, W., III, Bockting, W. O., Cohen-Kettenis, P., Coleman, E., DiCeglie, D., Devor,
H., … Wheeler, C. C. (2001). The Harry Benjamin International Gender Dyspho-
ria Association’s standards of care for gender identity disorders, sixth version.
Journal of Psychology and Human Sexuality, 13(1), 1–30.
Bigender
“Bigender” refers to a gender identity in which the individual is neither exclu-
sively male nor female but rather a fluid mix of male and female identities,
70 Bigender
frequently shifting from one to the other, or a simultaneous combination of male
and female identities. Each bigender individual tends to feel and express bigender-
ism in a unique way.
“Bigender” is one of many terms that have sprung from the LGBTQ+ commu-
nity in its attempts to describe diverse people whose gender identities fall some-
where between the “male” and “female” of the traditional binary gender system.
Many psychologists consider bigenderism as one of the facets of the multifaceted
concept of transgenderism. Such complex ideas are recognition of the reality that
not all people fit psychologically or physically into the strict categories of being a
“man” or a “woman.” The causes and prevalence of bigenderism—like those of
other varieties of transgenderism—are unknown.
Some bigender people also identify with the descriptive expressions “gender
fluid” or “gender flexible.” Other descriptive terms that may be applied to some
bigender people—with various degrees of overlap—include “pangender” (liter-
ally meaning “all genders”), “polygender” (“many genders”), “trigender” (refer-
ring to male, female, and any of various “third genders”), and “genderqueer”
(meant to be a comprehensive term for all genders other than male and female).
The overlapping meanings of these terms can seem very confusing to people
who identify with the binary gender system. However, for many individuals who
do not fit neatly into that traditional system, the meanings of these terms are
understandable, and they seem more appropriate and applicable to their own lives
than “male” or “female.”
Bigender people may sometimes feel like one gender and at other times like
another gender, depending on their mood and the situation of the moment.
They may express the gender that they are feeling at any given time by the
way they dress and behave. An individual might dress like a man one day and
a woman the next. Or an individual might prefer to wear gender-neutral cloth-
ing on a daily basis—or to even express a simultaneous combination of dis-
tinctly male and distinctly female genders, such as having a beard and wearing
a dress.
Many bigender people reject the gender-related pronouns of “he,” “she,” “his,”
and “her.” Some prefer the gender-neutral “they” and “their.” Others have pro-
posed new, alternative pronouns, including “zie” and “hir.”
Bigender people typically do not desire hormonal or surgical treatment to phys-
ically transition from one distinct gender to another.
A. J. Smuskiewicz
See also: Agender; Binary Gender System; Childhood Gender Nonconformity; Fluidity,
Gender; Gender; Gender Diversity; Gender Identity; Genderqueer; Nonbinary Gender
Identities; Two-Spirit.
Further Reading
Nestle, J., Howell, C., & Wilchins, R. (Eds.). (2002). GenderQueer: Voices from beyond
the sexual binary. New York: Alyson Books.
Sycamore, M. B. (2006). Nobody passes: Rejecting the rules of gender and conformity.
Berkeley, CA: Seal Press.
Wickham, K. N. (2011). The other genders: Androgyne, genderqueer, non-binary gender
variant. Charleston, SC: CreateSpace.
Binary Gender System 71
Binary Gender System
The binary, or bipolar, gender system is the system for classifying gender and sex
into the two distinct categories of male and female. It is the dominant, traditional
gender system in most world cultures—but not the only gender system. Several
cultures have long recognized alternative gender systems. In the United States and
many other countries, the traditional binary gender system is beginning to make
room for systems recognizing multiple gender identities.
The binary gender system may seem obvious. Most people are born distinctly
male or distinctly female, and men and women traditionally wear distinct types of
clothing and traditionally have distinct roles in society. Furthermore, the tradi-
tional teachings of most major religions, including Judaism, Christianity, and
Islam, reinforce the concept of only two genders. However, not all people fit neatly
into one gender or the other.
Intersex people are born with sexual characteristics that are not distinctly male
or female. Some intersex people have unusual chromosomes that do not match the
typical XX of females or the XY of males. Transgender people are people whose
psychological gender identity does not match their physical gender, leading some
to get hormonal and surgical treatments to change their bodies. Bigender people
may sometimes self-identify as male and other times as female, alternately dress-
ing and behaving as one gender or the other, or they may simultaneously feel like
both genders. Pangender, polygender, trigender, and other transgender people may
consider themselves to be various mixes of genders.
People with alternative gender conditions vary psychologically and, in some
cases, physically, from simply “male” or simply “female.” Although many causes
of physical intersex conditions are known to be related to unusual genetic varia-
tions, the causes of most alternative gender identities are unknown. They may be
related to biochemical factors that are present at birth or that develop later in life,
they may be associated with certain experiences in life, or they may be partly bio-
chemical and partly experience based. Only limited scientific research has been
published on this topic.
Among the world cultures that have long recognized nonbinary gender sys-
tems are some Native American tribes and some peoples in South Asia. The
English term “two-spirit” is broadly applied to individuals who are accepted in
various Native American cultures as having a gender that is neither male nor
female. Each of these cultures has its own native expression to refer to these
individuals, such as the Lakota winyanktehca or winkte. In some cultures, two-
spirit people dress and behave as the gender opposite to their physical gender. In
other cultures, they fulfill “third-gender” or “fourth-gender” roles, which may
be associated with special spiritual powers.
In India, “hijra” is the term applied to individuals who were born with male or
intersex physical traits but live as females. They are socially recognized as a third
gender and are allowed to marry men. There are believed to be more than five mil-
lion hijra in India. Similar groups of “third-sex” individuals are recognized in
Pakistan, Bangladesh, and certain other Asian countries.
The growing prominence of transgender people in popular culture and
LGBTQ+ communities of the United States and other Western nations is a direct
72 Biological Sex
challenge to continued adherence to the binary gender system. The increasing
rejection of traditional male and female social roles has also challenged the
binary gender system. For example, today, as compared to previous decades,
more women are the main income earners in families, and more men stay at
home raising children. Further evidence of this nonbinary shift in popular cul-
ture came in 2014 when the Facebook online social network unveiled fifty-six
gender identities for users to choose from.
Professional psychological perspectives on gender in the West have also shifted.
In 2013, the American Psychiatric Association (APA) discarded the diagnostic
term “gender identity disorder” in favor of “gender dysphoria” in the fifth edition
of its Diagnostic and Statistical Manual of Mental Disorders (DSM-V). The APA
made the change partly to remove the stigma associated with “disorder,” noting
that “gender nonconformity is not in itself a mental disorder.”
A. J. Smuskiewicz
See also: Agender; Bigender; Childhood Gender Nonconformity; Gender; Gender Diver-
sity; Gender Identity; Gender Roles, Socialization and; Nonbinary Gender Identities;
Two-Spirit.
Further Reading
Jacobs, S.-E., Thomas, W., & Lang, S. (Eds.). (1997). Two-spirit people: Native American
gender identity, sexuality, and spirituality. Champaign: University of Illinois Press.
Nanda, S. (1998). Neither man nor woman: The hijras of India. Boston: Cengage
Learning.
Nestle, J., Howell, C., & Wilchins, R. (Eds.). (2002). GenderQueer: Voices from beyond
the sexual binary. New York: Alyson Books.
Wickham, K. N. (2011). The other genders: Androgyne, genderqueer, non-binary gender
variant. Charleston, SC: CreateSpace.
Biological Sex
The term “biological sex” is commonly used to discuss a person’s primary sex
characteristics (also referred to as “sex traits”) and other components of their
anatomy and body. This includes primary sex characteristics such as a uterus,
penis, vagina, or testes, but is also understood to include one’s chromosomes,
the appearance of one’s chest, and more. While all these comprise what makes
up one’s “biological sex,” biological sex is often reduced to be a euphemism for
genitals—often when discussing transgender people or how one’s legal sex is
determined before and at the time of birth. Because of this, more and more indi-
viduals are shifting from using the term “biological sex” to discussing specific
components of anatomy or using the phrase “sex assigned at birth” or “current
sex traits.” In addition, many components of one’s biology and anatomy are able
to be altered via surgery or hormone replacement therapy (HRT). Indeed, Sari
M. Van Anders states, “Genitals are not a definitive marker of gender or sex
precisely because they can be altered” (2014). Therefore, one’s biological sex is
not a fixed component nor a great indicator of their gender, reproductive capac-
ity or desire, or transition/transgender status.
While many are familiar with the view that gender is a social construct (that is,
ideas and norms around gender can vary from culture to culture, and these
Biological Theories of Sexual Orientation 73
understandings of gender—what it means to be a man, a woman, or another
gender—can have differing impacts depending on the context one lives in), fewer
understand “biological sex” to be a social construct. However, when one considers
the number of individuals with intersex conditions—individuals born with biol-
ogy and anatomy that does not align with Western society’s current understanding
of being a biological man or woman—the argument can certainly be made. It is
currently estimated by the Intersex Society of North America (2019) that about
one person in one hundred is born with sex characteristics that naturally vary
from what is commonly thought to align with female or male.
Often, when a baby is born with genitals and hormone levels that do not align
with Western society’s binary understanding of anatomy, they are subjected to
surgeries (or HRT) at birth, during adolescence, or during or after the onset of
puberty. Altering sex traits at birth due to natural variances that occur did not
become a practice until after biology emerged as an organized discipline in Euro-
pean and U.S. culture, around the turn of the nineteenth century. At this time,
scientists who were beginning to grow their knowledge of this natural variation
also grew the authority to declare certain bodies “abnormal and in need of correc-
tion.” Because these practices and norms emerged from white conceptions of sci-
ence, bodies, and health, the sexing of bodies and altering of sex traits has racial
underpinnings.
People of any gender or sex assigned at birth might currently have sex traits or
anatomy that do not align with societal expectations for their gender. For example,
a transgender man might have a uterus, ovaries, and cervix, and therefore need to
be regularly screened for cervical cancer. Transgender women, whether or not
they are undergoing HRT, could develop breast cancer. Transgender, cisgender,
and gender-expansive individuals might use language other than “biological sex”
or “(fe)male reproductive system” to describe their anatomy. To better reflect and
respect individuals’ autonomy over their bodies, more inclusive phrases such as
“people with prostates” or “individuals with higher levels of estrogen” can be used
when referring to individuals of all genders with these characteristics.
Vern Harner
See also: Biological Theories of Sexual Orientation; Chromosomal Sex; Gender; Gender
Transition; Hormone Replacement Therapy; Hypogonadism; Intersexuality; Sex Chro-
mosomes; Sex Hormones; Sex Reassignment Surgery; Sexual Dimorphism;
Transgender.
Further Reading
Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of sexu-
ality. New York: Basic Books.
Intersex Society of North America. (2019). Retrieved from http://www.isna.org
Van Anders, S. (2014). Bio/logics. TSQ: Transgender Studies Quarterly, 1(1–2), 33–35.
Biological Theories of Sexual Orientation
Various theories attempt to explain how sexual orientation is determined, often
with a particular focus on understanding homosexuality, or same-gender orienta-
tion (SGO). An estimated 2.4 percent of the population maintains a homosexual
74 Biological Theories of Sexual Orientation
orientation, making this a significant sexual minority. Research into the origins of
SGO engages the nature-nurture debate that is often seen in discussions of human
development. Biological theories present a “nature” perspective, viewing SGO as
the expression of inborn biological characteristics. In contrast, the “nurture” per-
spective is reflected in theories that view SGO as developing from psychological
or social environmental factors or as a matter of individual choice. A combined
approach to development of sexual orientation may also be assumed, with biologi-
cal factors creating a predisposition toward this trait and environmental elements
facilitating its development.
There is considerable research evidence of a biological influence on sexual ori-
entation, though no “gay gene” or other singular identifying physical attribute has
been, or is likely to be, found. Some of the most convincing research for a genetic
basis for SGO focuses on family patterns of this trait. Other research suggests that
existence of SGO is influenced by prenatal exposure to certain hormones or other
conditions, as are other physical attributes that differ between persons with SGO
and the overall population.
One notable family study found that 9 percent of men who have gay brothers
also maintain a SGO. This is roughly four times the occurrence rate in the general
population, lending support for the notion of a genetic connection with SGO. Male
twin studies provide further evidence for this notion. Where one identical twin
had a homosexual orientation, the second twin also reported a SGO 52 percent of
the time. In the case of fraternal twins, the rate was 22 percent, and for adopted
brothers the rate was 11 percent. Similar findings were noted in female twin stud-
ies of SGO. These results support the role of genetics in determining SGO, as
higher levels of shared genetics resulted in stronger agreement in sexual orienta-
tion. At the same time, they illustrate that genetics are not the sole determinant of
SGO, as even identical twins were concordant only 52 percent of the time.
Family studies also reveal that gay men are more likely to have a later birth
order and specifically more likely to have older brothers. The number of younger
siblings or older sisters was not found relevant, but the number of older brothers
influenced the likelihood of SGO such that each additional older brother raised the
odds by 33 percent. Further study of this phenomenon led to the development of
the “fraternal birth order” hypothesis, which proposes that maternal immune sys-
tems may react to a male child by generating antibodies and that this effect
becomes more likely with each successive male fetus. The theory proposes that
prenatal exposure to these antibodies influences the development of sexual orien-
tation. Other research suggests that prenatal exposure to hormones under certain
conditions, particularly testosterone, may influence brain development in a man-
ner that creates a predisposition toward SGO.
Where the above theories suggest that prenatal exposure to antibodies or hor-
mones creates a predisposition to SGO, the specific mechanism for this has not
been uncovered. Despite this, some research has noted physical and cognitive dif-
ferences between heterosexual and homosexual men that may also be explained
by these theories. The “fraternal birth order” hypothesis is supported by findings
that gay men are not only more likely to have older brothers; they are also more
likely to be shorter in height. Further, the height difference is likely to be greater
when two or more older brothers exist. Other research notes physical differences
Biphobia 75
in finger size as well as in brain structure between homosexual and heterosexual
men. Cognitive differences in performance of language and special processing
tasks have also been noted.
Future research to explore these theories may be influenced by changing assump-
tions regarding the nature of sexual orientation. Options beyond the traditional
homosexual/heterosexual dichotomy may be incorporated, and assumptions that
orientation will remain fixed across the life span may also be challenged.
Mary McClure
See also: Homosexuality; Romantic Attraction and Orientation; Sex Differentiation of the
Brain and Sexual Orientation; Sexual Identity; Sexual Orientation.
Further Reading
Maucieri, L., & Stone, M. (2008). Adler’s interpretation of same-gender orientation from
a neurobehavioral perspective. Journal of Individual Psychology, 64(2), 214–223.
Mustanski, B. S. (2002). A critical review of recent biological research on human sexual
orientation. Annual Review of Sex Research, 13(1), 89.
Rahman, Q., & Wilson, G. D. (2003). Born gay? The psychobiology of human sexual ori-
entation. Personality and Individual Differences, 34(8), 1337–1382.
Biphobia
Bisexuality is a sexual orientation whereby a person experiences emotional, sex-
ual, romantic, or physical attractions to more than one gender or sex. Although
bisexual people make up the largest proportion of the LGBTQ+ community, they
experience significant stigmatization, exclusion, and invalidation by lesbian, gay,
and straight communities. In many cultures, such as in the United States, indi-
viduals are often socialized to think with binary or mutually exclusive categories
for social identities (e.g., gay, lesbian, or straight). Some people experience signifi-
cant discomfort when interacting with someone who does not fit neatly into binary
categories. This discomfort can at times be the foundation for insensitivity and
discrimination. Bisexual individuals, for example, may experience a unique form
of prejudice called biphobia.
“Biphobia” is a term coined by Kathleen Bennett (1992) to describe “prejudice
against bisexuality” and “the denigration of bisexuality.” Biphobia has at least two
dimensions: instability and intolerance. The instability dimension of biphobia is the
perception that bisexuality is a denial of a lesbian, gay, or straight identity and thus is
not a stable or legitimate sexual orientation. The intolerance dimension of biphobia
represents the extent to which others are hostile toward those who identify as bisex-
ual, perceiving them, for example, as a threat to society. Furthermore, “biphobia” is
considered related to “homophobia,” “transphobia,” and other terms that describe
the intolerance and discrimination faced by those who are sexual and gender minori-
ties. Importantly, biphobia is meant to capture a unique phenomenon that involves
the oppression and stereotypes experienced specifically by bisexual people.
Biphobia may pervade the everyday experiences of bisexual people. Bisexual
individuals are often misunderstood and misrepresented in society and the media.
They might be erroneously depicted as promiscuous, as traitors to the LGBTQ+
community, as too afraid to fully “come out” as their “true” sexual orientation, as
76 Birth Control Pills, Estrogen-Progestin
“going through a phase,” or simply as confused about their identity. Family and
friends are not immune to perpetuating biphobia, as they might also ask hurtful
questions based on assumptions and stereotypes. The consequences of biphobia
often result in bisexual individuals experiencing significant isolation from both
straight and LGBTQ+ communities. Research also suggests that biphobia is asso-
ciated with increased rates of negative health outcomes, including anxiety, depres-
sion, suicide ideation and attempts, and substance use for bisexual people
compared to their straight, lesbian, and gay peers.
Research has historically focused on the high rates of mental illness that bisex-
ual individuals experience without much attention to protective factors that may
buffer against negative health outcomes. Identifying factors that protect against
the harmful effects of biphobia is needed to inform bisexual-specific prevention
and intervention efforts. Although it is important to acknowledge the risk factors
and health disparities affecting bisexual individuals, equally important is recog-
nizing that many bisexual individuals are doing well and flourishing in their lives.
G. Nic Rider and Korey L. Watkins
See also: Antigay Prejudice; Bisexuality; Homophobia; Homophobia, Internalized;
LGBTQ+; Sexual Orientation; Transphobia.
Further Reading
Bennett, K. (1992). A both/and option for an either/or world. In E. R. Weise (Ed.), Closer
to home: Bisexuality and feminism (205–232). Seattle: Seal Press.
Bisexual Resource Center. Mental health in the bisexual community: Biphobia, bi era-
sure, and getting help. (n.d.). Retrieved from http://biresource.org/wp-content/
uploads/2016/11/Mental_Health_Biphobia_Brochure.pdf
Brewster, M. E., & Moradi, B. (2010). Perceived experiences of anti-bisexual prejudice:
Instrument development and evaluation. Journal of Counseling Psychology, 57(4),
451–468.
Dodge, B., Herbenick, D., Friedman, M. R., Schick, V., Fu, T.-C., Bostwick, W., … Sand-
fort, T. G. (2016). Attitudes toward bisexual men and women among a nationally
representative probability sample of adults in the United States. PLoS ONE, 11(10),
e0164430.
Eliason, M. J. (1997). The prevalence and nature of biphobia in heterosexual undergradu-
ate students. Archives of Sexual Behavior, 26(3), 317–326.
Obradors-Campos, M. (2011). Deconstructing biphobia. Journal of Bisexuality, 11,
207–226.
Ochs, R. (1996). Biphobia: It goes more than two ways. In B. Firestein (Ed.), Bisexuality:
The psychology and politics of an invisible minority (217–239). New York: SAGE.
Birth Control Pills, Estrogen-Progestin
Estrogen-progestin birth control pills are oral contraceptives containing forms of
two female hormones—estrogen and progesterone (progestin is a synthetic ver-
sion of progesterone). The estrogen in these pills is usually in the form of estra-
diol, which is the main kind of natural estrogen in the female body.
Estrogen-progestin pills are commonly called “the combination pill” to distin-
guish them from oral contraceptives containing only progestin, commonly called
“the minipill.” The combination pill contains a higher dose of progestin than the
Birth Control Pills, Estrogen-Progestin 77
minipill. Most people who use oral contraceptives take some type of combination
pill, which was initially approved by the U.S. Food and Drug Administration
in 1960.
There are many types of combination pill available. Most pills are sold in pack-
ages that contain enough pills to take one every day for either one month or three
months. They are available under several proprietary (brand) names. Many com-
bination pills are designed to vary the relative doses of estrogen and progestin
throughout the month. Some brands require taking a pill every day. Other brands
may require skipping doses or taking placebo pills for one week out of every
month in order for menstruation to occur. Many brands include some pills with
iron supplements or other inactive ingredients.
Physicians recommend that different versions of combination pills be chosen
depending on various personal factors, such as age, any existing medical condi-
tions, and how frequently menstruation is desired to occur (also called with-
drawal bleeding, this is a shedding of uterine lining that happens when inactive
pills are taken).
The combination of estrogen and progestin in oral contraceptives works to
block ovulation; to thin the endometrial lining of the uterus, preventing any fertil-
ized eggs from implanting; and to thicken the mucus of the cervix, blocking sperm
from entering the uterus. Together, these three effects are a very effective way to
prevent pregnancy. The combination pill is generally more effective at preventing
pregnancy than the minipill, with a failure rate of less than 1 percent when used
correctly. The minipill does not block ovulation as well as the combination pill,
and it must be taken at almost the exact same time every day to be optimally
effective. The combination pill, by contrast, has more flexibility in the time it can
be taken—with a several-hour window on any given day. There are other potential
advantages to using the combination pill, such as reduced emotional distress
before any menstrual periods that may occur, less painful menstrual periods,
reduced acne, and, in older people, improved bone density.
Despite the greater effectiveness of the combination pill, some people prefer to
take the minipill because it is less likely to carry certain health risks associated
with the estrogen or higher doses of progestin as in the combination pill. Potential
combination-pill risks include increased risk of uterine cancer, blood clots, heart
attack, stroke, diabetes, and migraine headaches, as well as reduced milk supply
in those who are breastfeeding. Because of the enhanced cardiovascular risk,
many physicians recommend that those who smoke and are over thirty-five avoid
using combination pills. Obese people and those with a family history of heart
disease or stroke may also want to avoid these pills. Yet another disadvantage of
the combination pill is that it may continue to interfere with fertility for two or
three months after use is stopped. A return to normal fertility happens more
quickly when the minipill is stopped. Estrogen-progestin pills, like all forms of
hormonal birth control, do not protect against sexually transmitted infections,
including HIV.
Minor side effects associated with combination pills include light vaginal
bleeding (or “spotting”), nausea, vomiting, diarrhea, breast tenderness, and weight
gain. More serious adverse effects that may occur are dizziness or faintness,
numbness in an arm or leg, coughing up blood, vision problems, and depression.
78 Birth Control Pills, Progestin-Only
Besides their use in birth control, estrogen-progestin pills are also commonly
used in hormone replacement therapy to manage the unpleasant symptoms associ-
ated with menopause.
A. J. Smuskiewicz
See also: Birth Control Pills, Progestin-Only; Contraception; Estrogen; Hormone
Replacement Therapy; Ovulation; Progesterone; Synthetic Hormones.
Further Reading
Eig, J. (2014). The birth of the pill: How four crusaders reinvented sex and launched a
revolution. New York: W.W. Norton & Company.
May, E. T. (2011). America and the pill: A history of promise, peril, and liberation. New
York: Basic Books.
Birth Control Pills, Progestin-Only
Progestin-only birth control pills are oral contraceptives containing only the hor-
mone progestin, a synthetic version of the natural female hormone progesterone.
They are commonly called the minipill to distinguish them from oral contracep-
tives containing both progestin and estrogen (the combination pill). The minipill
contains a lower dose of progestin than the combination pill. Progestin-only pills
have the generic name norethindrone and are sold in packages containing twenty-
eight daily tablets.
The effects of progestin-only pills include thinning of the endometrial lining of
the uterus and thickening of the cervical mucus. The thickened mucus serves to
block sperm from entering the uterus and fertilizing any eggs that were released
by the ovaries during ovulation. Furthermore, the pills suppress ovulation in at
least half the menstrual cycles of the user.
Progestin-only pills offer an oral contraception alternative for people who may
experience problems with the higher doses of progestin or the estrogen in combi-
nation pills. Unlike the combination pill, the minipill does not interfere with the
milk supply of people who are breastfeeding. In addition, the minipill is less likely
than the combination pill to increase the risks of cardiovascular disease, such as
heart attack and stroke, and diabetes. Thus, it is safer to use for those with a his-
tory of blood clots, high blood pressure, diabetes, and smoking. Still other advan-
tages of the minipill over the combination pill are that it does not carry the
estrogen-related risks of uterine cancer or migraine headaches and that fertility
quickly returns to normal after use of the minipill is stopped. Minipills are also
considered safer for older women.
A disadvantage of the minipill is that it is not as effective as the combination pill
at preventing pregnancy. Statistics indicate that one to thirteen of every hundred
minipill users become pregnant in the first year of use. Its efficacy is enhanced by
sticking to a strict schedule of taking the pill at the exact same time every day. A
delay of as little as three hours from the normal daily pill-taking time increases the
chance of pregnancy during the following two days. The minipill, like all forms of
hormonal contraception, does not protect against sexually transmitted infections.
Although adverse health effects are less common with the minipill than with
the combination pill, some people do experience minor side effects. Such minor
Bisexuality 79
effects, which typically dissipate after the first few months of use, include irregu-
lar menstrual cycles, sore breasts, headache, nausea, dizziness, acne, and weight
gain. Depression and discoloring of facial skin are less common adverse effects.
Some physicians discourage use of the minipill for people with a history of breast
cancer, liver disease, or unexplained vaginal bleeding, or for people taking anti-
convulsant drugs (such as for epilepsy) or antituberculosis drugs.
Some people may take progestin pills as part of hormone replacement therapy
(HRT) to manage the symptoms of menopause. However, HRT typically includes
estrogen as well as progestin.
A. J. Smuskiewicz
See also: Birth Control Pills, Estrogen-Progestin; Contraception; Hormone Replacement
Therapy; Ovulation; Progesterone.
Further Reading
Bennet, J., & Pope, A. (2009). The pill: Are you sure it’s for you? Sydney, Australia: Allen
& Unwin.
Pelton, R. (2013). The pill problem: How to protect your health from the side effects of
oral contraceptives. Portland, OR: BookBaby.
Bisexuality
Bisexuality is a sexual orientation in which people report sexual or romantic
attraction to people of both male and female genders or sexes. Some bisexual peo-
ple report that they are attracted to people regardless of gender, and as such, there
may be some similarity between bisexuality and pansexuality. Some bisexual
individuals report being sexually attracted to both men and women but only
romantically attracted to one sex or gender or the other. Alternatively, some may
be romantically attracted to both sexes or genders but may only experience sexual
desire for either the same or other sex or gender. Finally, some bisexual people
report experiencing attraction to both sexes or genders throughout their lives,
whereas others experience attraction to either sex or gender at different times,
and, as such, bisexuality for some people may be associated with sexual fluidity.
There are different ways to measure sexual orientation in general and bisexual-
ity specifically. Depending on how the question is asked, more or fewer people
may report elements of bisexuality. For example, if asked, more people will report
ever having experienced sexual attraction to both men and women than will report
having had sex with both male and female partners. Fewer people still will report
having a bisexual sexual identity.
There are many myths and misconceptions about bisexuality, and many people
hold negative attitudes toward bisexuality and bisexual people. This is referred to
as binegativity or biphobia. For example, some people wrongly believe that bisex-
uality does not exist and that people who say they are bisexual are confused, in
denial, or still in the closet about really being gay. Men who identify as bisexual
are especially likely to experience stigma and discrimination from people who
think that their bisexual identity label is a phase on the way to acknowledging a
gay identity, while women who identify as bisexual are often assumed to be “really
straight” and just experimenting or behaving bisexually for attention-seeking
80 Bisexuality
purposes. Personal accounts from bisexual individuals, as well as support from
sexual orientation research, has clearly indicated that bisexuality is a sexual orien-
tation, like being straight, gay, or lesbian.
There are other myths about the sexual behavior and preferences of bisexual
people. For example, many people believe that in order to be bisexual, people have
to have sexual partners of both genders or sexes. Consequently, many people
believe that bisexual people are hypersexual and cannot, and do not want to, be in
a monogamous relationship. Because of this mistaken belief that all bisexual peo-
ple are hypersexual, many people also believe that bisexual people are responsible
for spreading HIV and other sexually transmitted infections.
These and other negative beliefs about bisexual people may be held by mem-
bers of both the LGBTQ+ communities as well as by heterosexual communities.
Because of this “double discrimination,” bisexual people tend to experience worse
mental and physical health outcomes compared to other people. Some research
has shown that personally knowing a bisexual person, or knowing more about
bisexuality in general, may help to disconfirm these negative stereotypes and may
lead to more positive attitudes toward bisexual people.
Heather L. Armstrong
See also: Biphobia; Fluidity, Sexual; Pansexuality; Romantic Attraction and Orientation;
Sexual Identity; Sexual Orientation.
Further Reading
Armstrong, H. L., & Reissing, E. D. (2014). Attitudes toward casual sex, dating, and
committed relationships with bisexual partners. Journal of Bisexuality, 14(2),
236–264.
de Bruin, K., & Arndt, M. (2010). Attitudes toward bisexual men and women in a univer-
sity context: Relations with race, gender, knowing a bisexual man or woman and
sexual orientation. Journal of Bisexuality, 10, 233–252.
Eliason, M. (2001). Bi-negativity: The stigma facing bisexual men. Journal of Bisexuality,
1, 137–154.
Eliason, M. J. (1997). The prevalence and nature of biphobia in heterosexual undergradu-
ate students. Archives of Sexual Behavior, 26, 317–326.
Eliason, M. J., & Raheim, S. (1996). Categorical measurement of attitudes about lesbian,
gay, and bisexual people. Journal of Gay and Lesbian Social Services, 4, 51–65.
Fahs, B. (2009). Compulsory bisexuality? The challenges of modern sexual fluidity. Jour-
nal of Bisexuality, 9, 431–449.
Gustavson, M. (2009). Bisexuals in relationships: Uncoupling intimacy from gender
ontology. Journal of Bisexuality, 9, 407–429.
Herek, G. M. (2002). Heterosexuals’ attitudes toward bisexual men and women in the
United States. Journal of Sex Research, 39, 264–274.
Hinrichs, D. W., & Rosenberg, P. J. (2002). Attitudes toward gay, lesbian, and bisexual
persons among heterosexual liberal arts college students. Journal of Homosexual-
ity, 43, 61–84.
Israel, T., & Mohr, J. J. (2004). Attitudes toward bisexual women and men: Current
research, future directions. Journal of Bisexuality, 4, 117–134.
Kleese, C. (2005). Bisexual women, non-monogamy and differentialist anti-promiscuity
discourses. Sexualities, 8, 445–464.
Black Sexuality 81
Lannutti, P. J., & Denes, A. (2012). A kiss is just a kiss? Comparing perceptions related to
female-female and female-male kissing in a college social situation. Journal of
Bisexuality, 12, 49–62.
McLean, K. (2004). Negotiating (non)monogamy: Bisexuality and intimate relationships.
Journal of Bisexuality, 4, 83–97
Mint, P. (2004). The power dynamics of cheating: Effects on polyamory and bisexuality.
Journal of Bisexuality, 4, 55–76.
Mohr, J. J., & Rochlen, A. B. (1999). Measuring attitudes regarding bisexuality in lesbian,
gay and heterosexual populations. Journal of Counseling Psychology, 46, 353–369.
Mulick, P. S., & Wright, L. W., Jr. (2002). Examining the existence of biphobia in the het-
erosexual and homosexual populations. Journal of Bisexuality, 2, 45–64.
Spalding, L. R., & Peplau, L. A. (1997). The unfaithful lover: Heterosexuals’ perceptions of
bisexuals and their relationships. Psychology of Women Quarterly, 21, 611–625.
Steffans, M. C., & Wagner, C. (2004). Attitudes toward lesbians, gay men, bisexual
women, and bisexual men in Germany. Journal of Sex Research, 41, 137–149.
Black Sexuality
A number of scholars, clinicians, and educators have emerged over the years to
conceptualize the physiological, psychological, sociological, spiritual, aesthetic,
identity, cultural, reproductive, recreational, and human developmental processes
that occur for persons of African descent. These professionals have considered
some of the transhistorical factors that have evolved into present-day functioning
of those who fall within the African diaspora and how they build, maintain, and
sever relationships. Moreover, there are many narratives and manuscripts that
focus on the affective, cognitive, and behavioral experiences of those people who
identify or consider themselves to have black heritage. Some professionals agree
that a set of behaviors, ideas, assumptions, and feelings is inextricably woven into
the history of Africa and the traumatic experiences of ancestors who survived the
Middle Passage. From these works, it may be inferred that the sexual expression
of persons of African descent is socially constructed, represents a continuum of
social functioning, and contains several conceptual strands, including (but not
limited to) race, socioeconomic status, religion, media, education, and identity.
Since sexuality is the intersection of cognition, affect, behavior, and desire, black
sexuality uses race to further describe the experiences of persons who identify
with African heritage or describe themselves as being a part of the African
diaspora.
Black sexuality is about being and action, and those intentional or uninten-
tional movements are reflective of the history of Africa and migration (volun-
tary and coerced) of Africans around the world. The evolution of these sexual
phenomena has enabled an unmistakable resilience of people who have a history
of being marginalized. At the same time, black sexuality is fluid and gracefully
enriched by music, art, dance, food, and various cultural traditions. It is impor-
tant to remember that there is no single black sexuality in that it should never be
considered a monolith or essentialist by design. Rather, there are relativistic
sexualities that change as a result of individual and collective governance and
82 Black Sexuality
are influenced by a myriad of contextual factors, including time, context, and
circumstance.
From a Western perspective, some of those who identify with African ancestry
have had to demonstrate creative fortitude in relation to managing oneself as well
as the relationships that one is a part of. Because of racism, systemic oppression,
white supremacy, segregation, war, and underemployment, the perceived and
experienced sexual expression of those of African descent is sometimes distorted
and based on debilitating stereotypes, myths, and unfounded assumptions. These
belief systems have created and maintained cultural expectations that affect indi-
vidual functioning within and outside of relationships.
The literature also describes various sociopolitical constructs (e.g., issues of
socioeconomic status, systemic oppression) that are particular to this community.
In the United States, more than 25 percent of black Americans live below the pov-
erty line. Underemployment, lack of education, and insufficient access to resources
restricts decision making around sexuality and relationships and reduces life sat-
isfaction. Reduced employment and underemployment pose challenges for some
and significantly affect well-being as well as one’s familial, acquaintance, and
romantic relationships. In addition, if there is a lack of education, some individu-
als may be unaware about various forms of contraception or resources that could
potentially empower or shift relationship formation and maintenance. Systemic
oppression as a result of overt and covert forms of racism creates structural barri-
ers that restrict or reduce access to opportunities for black individuals, couples,
and families. These structural inequalities create additional stress on individuals.
Low self-esteem, self-efficacy, and self-worth can affect how positively one feels
about the sexual and relational decisions that one makes.
Perceptions, attitudes, and opportunities have shifted over the past three centu-
ries. Partially crafted from colonialism, coerced transatlantic migration, slavery,
war, separated families, public distortions and myths, restrictive laws, social ineq-
uities, and systemic oppression from white supremacy, black sexuality manifests
the cultural ethos of resilience, strength, and agility that shapes individual, couple,
and community sexual expression. It is the product of black history, art, music,
informed scholarship, public policy, and informal discourse that has affected the
cognition, affect, and intimate behaviors of persons of African descent and those
who serve this unique population.
One major influence that has shaped black sexual expression is the unique
history of slavery and the relationships of black families with whites, which is
captured in the literature. Over the years, perceptions and attitudes have changed
about blacks (e.g., extrarelational sex, same-sex relationships, autoeroticism),
while others have remained unchanged (e.g., beliefs about incest). Moreover,
stereotypes and unfounded assumptions of the sexual expression of those of
African descent that existed before and after the antebellum period are still
maintained by other ethnic groups as well as by some black individuals. These
stereotypes have created disproportionate expectations and do not allow for the
collective experience to be reconceptualized into more individualized experi-
ences and interactions.
Black Sexuality 83
Another significant factor that has a tremendous impact on the sexual expres-
sion and relationships of persons of African descent is the history of racism, seg-
regation, lack of education, and escalating unemployment. These pervasive and
debilitating phenomena have negatively affected how some people of African
heritage form and maintain romantic and familial relationships.
A possible third contributor in the formation and maintenance of black relation-
ships has been the tragic outbreak of HIV infection. Since the mid-1980s, HIV
transmission has taken on pandemic proportion among men who have sex with
men, heterosexual black women, and adolescents. Because of this, partner avail-
ability and selection, intimacy between individuals, and family systems have all
been negatively influenced. Prevention research and education continue to advo-
cate for individuals to practice safer sex and get tested regularly.
Another important factor that has influenced the sexual expression of blacks
is the increased television viewing, internet consumption, and use of social
media in the acquisition and exchange of information. The expanded capacity to
share information, engage in courtship and relational maintenance, and be pre-
sented with idealized depictions of aesthetics has enabled colorism, ageism,
feelings of entitlement, and diminished communication skill sets. The increased
number of roles for black actors in television and movies that depict a greater
range of black relationships have contributed to the expanded understanding of
experiences.
It is also noteworthy that black sexuality has been influenced over the past
decade by the election of the United States’ first black president. Not only was his
election historically significant, but President Barack Obama has endorsed same-
sex relationships. Given the history of homophobia and heterosexism in the black
community, the endorsement by the president enabled a significant shift in public
acknowledgment and acceptance of same-gender-loving relationships.
The black church also continues to evolve. As a medium for congregating, wor-
shiping, and networking, the black church has always maintained a powerful posi-
tion in communities that have faced marginalization and social challenges. For
some individuals, the black church has been a place for refuge when circumstances
seemed difficult to manage. Regarding sexuality, the black church has been consid-
ered conservative in promoting abstinence from sex until after marriage and refrain-
ing from masturbation and prohibiting same-sex relationships. The use of spirituality
to humiliate or even condemn individuals or communities based on assumptions or
breaches of cultural expectations has had a profound influence on many individuals
for over four centuries. The rebuke by black church officials and congregants has
discriminated against, oppressed, and rejected many individuals who have strug-
gled to reconcile their sexual expression with their religious affiliation.
Over the last twenty years or so, black church leaders have begun to have con-
versations about the continuum of sexuality and how it does or does not intersect
with religious dogma and traditions. While there are any number of systemic bar-
riers and sanctions that still exist for LGBTQ+ people within black churches,
leaders are beginning to acknowledge that black relationships come in a variety of
constellations and that ostracizing one member or group is destructive and
84 Born This Way Foundation
counterproductive to keeping families intact and functional. The movement
toward acceptance of safer sex (e.g., consensual and protected) before marriage
and acknowledgment of same-gender-loving individuals and people engaging in
autoeroticism continues to change black churches as they become more welcom-
ing and affirming institutions.
Finally, there are a number of scholars and books devoted to black sexuality,
and there are organizations (e.g., Association of Black Sexologists, Women of
Color Sexual Health Network) that have emerged to address the range of these
phenomena through research, clinical practice, education, and policy.
James Wadley
See also: Association of Black Sexologists and Clinicians; Down Low; LGBTQ+; Reli-
gion, Diversity of Human Sexuality and; Tuskegee Syphilis Study.
Further Reading
Battle, D. J., & Barnes, D. S. L. (Eds.). (2009). Black sexualities. New Brunswick, NJ:
Rutgers University Press.
Fausto-Sterling, A. (2000). Sexing the body. New York: Perseus Books.
Irvine, J. (1994). Sexuality across cultures. San Francisco: Josey-Bass.
Wadley, J. (2014). Editor’s note: The Journal of Black Sexuality and Relationships is
finally here. Journal of Black Sexuality and Relationships, 1(1), vii–xv.
Wadley, J. (2014). Editor’s note: “We have a lot of work to do . . .”: The emergence of the
Association of Black Sexologists and Clinicians. Journal of Black Sexuality and
Relationships, 1(2), vii–xvi.
Wilson, P. (1986). African American culture and sexuality. Journal of Social Work and
Human Sexuality, 4, 29–46.
Born This Way Foundation
The Born This Way Foundation is a United States–based nonprofit organization
established in 2012. The foundation was designed to promote youth empowerment
and foster self-expression. In addition to other targeted groups, Born This Way
aims to help troubled LGBTQ+ teens. Musical recording artist Stefani
Germanotta—more commonly known by her stage name, Lady Gaga—and her
mother, Cynthia Germanotta, are its founders; the organization was named after
Lady Gaga’s second studio album, Born This Way, which became an anthem of
sorts for the LGBTQ+ communities.
Born This Way was officially founded in 2012. It is a partnership between Lady
Gaga and three main organizations: the Berkman Center for Internet and Society
at Harvard University; the California Endowment, a private foundation aimed at
providing access to quality, affordable health care for all; and one of the largest
private foundations in the United States, the John T. and Catherine T. MacArthur
Foundation, which works to support creative endeavors and movements aimed at
fostering a more peaceful world. Run by Lady Gaga and Germanotta as joint
directors, the foundation was founded on three tenets: safety, which means creat-
ing a safe environment to celebrate individuality; skills, which means promoting
useful skills for civic engagement and expression; and opportunity, which means
providing ways for people to work toward empowerment and inclusion in their
Bornstein, Kate 85
local communities. The goal of the three is to create a more accepting society and
a “kinder, braver world.”
The organization’s kick-off event was held at Harvard University on February
29, 2012, and was attended by a host of student leaders and panel experts as well
as such distinguished guests as Oprah Winfrey, world-renowned physician and
author Deepak Chopra, and U.S. Department of Health and Human Services sec-
retary Kathleen Sebelius. The event was streamed live via the internet. In speak-
ing out about the foundation and its roots, Lady Gaga said that the impact of the
title single from her album had inspired her to delve deeper into the ideas of youth
empowerment and prejudicial attitudes toward sexuality, among other issues. At
the launch, Gaga revealed that the organization was already embarking on its first
activity, sponsorship of the Born Brave Bus, which would travel the country to
provide an interactive experience for young people to connect with likeminded
peers and local community resources and to access information about topics such
as antibullying and suicide prevention. In its first year, the tour bus hit twenty-
three events in eighteen cities and was seen by more than twenty thousand people.
To continue the momentum created by the Born Brave Bus, the foundation also
began Born Brave Groups, a grassroots collective of local groups led by teens or
young adults wanting to make a difference in their communities. The Born This
Way website was also created to promote the foundation’s message and provide a
forum for information sharing among peers. It currently boasts approximately
half a million users.
Despite its initial positive reception, Born This Way came under attack in 2014
for allegedly keeping and spending more money than it donates as a charity.
According to tax information, more than half of the $2.6 million in revenues
gained in 2012 went to operation expenses, and only a few thousand dollars were
given out in grant money. Lady Gaga and Germanotta immediately defended the
organization, stating that it was never intended to fund other charities; rather it
was built to “conduct charitable activities directly” and that Lady Gaga herself
gave personal funds to launch the organization she believes in so passionately.
The official website also clarified that none of the directors and officers were com-
pensated for their work with the foundation.
Tamar Burris
See also: Adolescent Sexuality; LGBTQ+.
Further Reading
Born This Way Foundation. Retrieved from https://bornthisway.foundation
Iddon, M., & Marshall, M. L. (2014). Lady Gaga and popular music: Performing gender,
fashion, and culture. New York: Routledge.
Monster, M. (2013). Lady Gaga: The message of Born This Way. South Paris, ME:
G.O.A.T. Publishing.
Bornstein, Kate
Kate Bornstein (Katherine Vandam Bornstein) is a transgender author, educator,
playwright, gender theorist, and performance artist, born in New Jersey in 1948,
who uses the pronouns “ze” and “hir.” These are gender-neutral pronouns used in
86 Bornstein, Kate
lieu of “he,” “him,” “she,” “her,” “they,” “them,” and so on (e.g., ze was born in
1948 and lives with hir partner).
Best known for hir work around gender, particularly moving away from the
gender binary, Bornstein has several books published, including hir famous Gen-
der Outlaw: On Men, Women, and the Rest of Us (1994), My Gender Workbook:
How to Become a Real Man, a Real Woman, the Real You, or Something Else
Entirely (1998), Gender Outlaws: The Next Generation (with S. Bear Bergman,
2010), and, most recently, Bornstein’s own autobiography, A Queer and Pleasant
Danger: The True Story of a Nice Jewish Boy Who Joins the Church of Scientol-
ogy, and Leaves Twelve Years Later to Become the Lovely Lady She Is Today
(2012). Ze travels around the world sharing hir story of hir transition of first
becoming a woman and then hir realization that ze identified as gender noncon-
forming, as well as being open about hir history with anorexia, borderline person-
ality disorder, and posttraumatic stress disorder.
Bornstein is often cited in conversations about radical gender, and hir books are
frequently found on college feminist and gender studies reading lists. Gender
Outlaw helped to reframe the conversation around gender to move beyond the idea
of men versus women and to be more inclusive of the diversity of gender that
exists in the world. My Gender Workbook, while actually including worksheets, is
also a more advanced glimpse into the nuances of gender identity, gender expres-
sion, and gender presentation, supporting individuals in exploring their own gen-
der but also helping those newer to the gender conversation to better understand
the spectrum of gender.
Bornstein is also well known for hir engagement around issues of self-harm
and suicide within many communities and the particularly elevated levels within
the transgender and gender-nonconforming community. Hir book Hello Cruel
World: 101 Alternatives to Suicide for Teens, Freaks, and Other Outlaws provides
people, particularly young people, with support systems that can be options for
them when in depressive and suicidal places. Bornstein also includes conversation
around suicide prevention when performing and presenting at colleges, high
schools, and youth conferences.
While mostly recognized for hir work on gender, sex, sexuality, and suicide
prevention, Bornstein is also fairly vocal about hir past as a now ex-communicated
member of the Church of Scientology. Ze details in hir writing about how the gen-
derless construct of an immortal soul really appealed to hir during hir grappling
with hir own gender and felt supportive in a way that Judaism (how Bornstein was
raised) never had. Given Bornstein’s choice to speak out about the church, as well
as being publicly out around hir gender, ze is now considered a “suppressive per-
son” by the church.
Shanna K. Kattari
See also: Binary Gender System; Gender; Gender Dysphoria; Pronoun Usage;
Transgender.
Further Reading
Bornstein, K. (1994). Gender outlaw: On men, women, and the rest of us. New York: Psy-
chology Press.
Breast, Female 87
Bornstein, K. (1998). My gender workbook: How to become a real man, a real woman,
the real you, or something else entirely. New York: Psychology Press.
Bornstein, K. (2012). A queer and pleasant danger: The true story of a nice Jewish boy
who joins the Church of Scientology, and leaves twelve years later to become the
lovely lady she is today. Boston: Beacon Press.
Bornstein, K., & Bergman, S. B. (2010). Gender outlaws: The next generation. Berkeley,
CA: Seal Press.
Pasulka, Nicole. (2012, May 5). “A queer and pleasant danger”: Kate Bornstein, trans
Scientology survivor. Mother Jones. Retrieved from http://www.motherjones
.com/media/2012/04/kate-bornstein-gender-outlaw-queer-and-pleasant-danger
-interview
Breast, Female
The female breasts are two roundish masses of tissue that overlay the pectoral
muscles of a woman’s chest. Breasts appear during puberty and vary widely in
size and shape from one individual to another. Although their function is to secrete
milk to feed newborns, breasts have become a highly sexualized part of the female
body in today’s culture.
The female breasts contain much fatty tissue, connective tissue, ligaments,
ducts, lymph nodes, and other structures. Small oval structures called lobules,
each containing numerous tiny sacs called alveoli, spread throughout each breast
in a branching network from the nipple. The lobules are connected to one another
with ducts (thin tubes), which transport milk secreted by glands in the alveoli to
the nipples during breastfeeding.
Fatty and connective tissues surround the lobules and ducts. The size of the
breasts is mostly determined by the amount of fat in them. The fatty tissue tends
to increase and become denser with age as a result of hormonal changes. At the
same time, the glandular and ductal tissues decrease and become less dense with
age. Because of these hormonal factors and other biochemical and physical factors
related to aging, the size and shape of breasts change throughout life. Breasts gen-
erally tend to sag as a woman enters middle age.
The nipple of a breast is filled with nerves that make it very sensitive to touch
and other stimuli, and it tends to become more erect during sexual arousal, breast-
feeding, and exposure to cold. The dark area surrounding the nipple is called the
areola. It contains sweat glands that secrete moisture to act as a lubricant for
breastfeeding.
When a girl begins to reach puberty—usually sometime between the ages of
ten and twelve—her body starts producing more of the female hormones estrogen
and progesterone. These hormones stimulate the growth of the breasts and the
breasts’ ability to secrete milk.
The eventual size of the breasts is largely determined by genetic factors that
influence fatty tissue development, and it bears no relation to ability to breastfeed.
Small breasts can generally produce as much milk as large breasts.
In a rare condition called amastia, one or both breasts may fail to develop. This
condition is usually associated with birth defects involving the absence of pectoral
88 Breast, Female
muscles or other anatomical abnormalities. Treatment involves the surgical con-
struction of breasts using implants and the patient’s available tissue.
Breast cancer is the most common form of cancer in women, developing in
about one in eight women. Breast cancer is characterized by abnormal lumps that
develop in breast tissue. If diagnosed and treated early, breast cancer can often be
cured with a combination of surgery, chemotherapy, and radiation therapy.
Depending on the extent of the malignancy, surgery might be either a lumpectomy
(removal of the tumor and surrounding tissue) or a mastectomy (removal of the
entire breast and sometimes nearby lymph nodes).
Not all breast tumors are cancerous. Some breast tumors, such as cysts and
fibroadenomas, are benign (noncancerous). These tumors can usually be success-
fully removed with surgery. Hyperplasia is a condition in which cells multiply
abnormally in the breast ducts or lobules. This condition is usually noncancerous,
though it raises the risk for the later development of breast cancer. Surgical inter-
ventions, as well as biopsies to check for cancer signs, are usually performed in
patients with hyperplasia.
Other abnormal tissue developments in breasts include fat necrosis (lumps of
scar tissue that develop in response to injuries in the fatty parts of breasts), intra-
ductal papillomas (wart-like masses that grow inside ducts, sometimes leading to
bloody leakage from the nipple), and calcifications (calcium deposits). Surgery
and biopsies are usually performed in these cases.
Breasts are subject to a variety of infections, especially as a result of breast-
feeding. In such cases—known as mastitis—abscesses (pus-filled wounds) or cel-
lulitis (spreading redness) may develop. Antibiotics are prescribed for breast
infections.
Cancer and other diseases of the breasts can be most successfully treated if they
are detected and diagnosed in an early stage. That is why women should regularly
(about once a month) perform careful self-inspections of their breasts. Such
inspections include looking and feeling for lumps, swellings, skin changes, or any
other abnormalities on or in the breasts and adjoining underarm tissue. Any unex-
plained changes should be referred to a physician.
Depending on the expert consulted, women over age forty or fifty should get
mammograms (X-ray examinations of breast tissue) once a year or once every
other year to look for early signs of cancer or other problems. Findings that are
suspicious may require follow-up tests to pinpoint the diagnosis. Such tests may
include ultrasound examinations, magnetic resonance imaging, and biopsies.
The most popular form of cosmetic surgery in the United States is breast aug-
mentation, in which the breasts are enlarged through the use of implants. In 2014,
more than 280,000 such surgeries were performed in the United States. Breast
reconstruction is a similar surgery, but it is performed on women who have had
their natural breasts removed in mastectomies, usually because of cancer. About
93,000 breast lifts (mastopexies)—to elevate sagging or drooping breasts—were
performed in 2014 in the United States. That same year, more than 110,000 breast
reduction surgeries were performed on women, most of whom had breasts so large
that they caused neck or back pain.
A. J. Smuskiewicz
Breast Cancer 89
See also: Breast Cancer; Breastfeeding; Estrogen; Galactorrhea; Progesterone; Puberty.
Further Reading
Canadian Cancer Society. (2019). The breasts. Retrieved from http://www.cancer.ca/en/
cancer-information/cancer-type/breast/breast-cancer/the-breasts/
Stöppler, M. C. (2019). Breast (anatomy and function). Retrieved from https://www.emed-
icinehealth.com/breast/article_em.htm#facts_on_the_breast
Breast Cancer
Breast cancer is the abnormal, uncontrolled multiplication of cells within the
breast. It is the most common type of cancer among women in the United States,
and it also occurs among some men.
Breast cancer usually originates in the milk ducts or glands of the breast. The
cancerous cells then spread through channels within the breast. The two main
types of breast cancer are classified as noninvasive and invasive. Noninvasive, or in
situ, breast cancer remains within the breast tissue. Invasive breast cancer spreads
out of the breast to other parts of the body through the blood or lymph system.
Roughly one in eight women in the United States will have breast cancer dur-
ing their lives. The prevalence in men is much less than this. Only about 1 percent
of all breast cancer cases occur in men.
In 2014, there were approximately 230,000 newly diagnosed cases of breast
cancer in the United States, representing about 14 percent of all new cancer cases.
Some 40,000 people died from breast cancer in 2014.
With treatment for their breast cancer, about eight of every ten women will
survive more than five years after diagnosis, and about five of ten women will
survive more than ten years.
The risk of breast cancer becomes greater with age, especially after age fifty.
This disease is most frequently diagnosed between the ages of fifty-five and
sixty-four.
A woman’s risk for breast cancer is increased by the inheritance of mutations in
either of two genes known as BRCA1 and BRCA2. Approximately 1 in 200
women has at least one of these mutated genes. These same mutations also increase
the risk for ovarian cancer. Genetic screening tests—in the form of blood tests—
can detect the presence of these genes. A woman with either of the genes may
choose to have her breasts or ovaries surgically removed preemptively to prevent
the possible development of cancer.
The actress Angelina Jolie drew attention to this issue when she underwent
breast and ovary removal to avoid the development of cancer, which her mother,
grandmother, and aunt all died from. However, it should be kept in mind that hav-
ing the BRCA1 or BRCA2 gene does not guarantee a woman will develop breast
or ovarian cancer; the genes merely raise the risk for these cancers. For a woman
whose mother, sister, or daughter had breast cancer, her own risk of having the
disease is increased two to three times.
Only about 10 percent of breast cancer cases are inherited. The majority of
cases result from other, unknown causes. Some of these possible causes include
90 Breast Cancer
exposure to high levels of radiation, obesity, a high-fat diet, and heavy alcohol
use.
Research indicates that the longer a woman is exposed to high levels of the
female sex hormone estrogen, the greater the chance that she will get breast can-
cer. Estrogen levels are affected by the menstrual cycle, by childbirth, by breast-
feeding, and by other factors. The risk of breast cancer is elevated for females who
start menstruating before age twelve, who have their first child after age thirty-
five, who have never had children, who have never breastfed, and who stop men-
struating after age fifty-five.
Overall, non-Hispanic white women are at the highest risk of breast cancer
development. Among women aged forty to fifty, however, African American
woman are at greater risk than white women.
Some studies suggest that breast cancer risk is increased by the use of birth
control pills and by hormone replacement therapy. However, other studies have
found no such associations.
The main symptom of breast cancer is an abnormal but painless lump in one of
the breasts. Doctors advise women to regularly inspect their breasts for unusual
lumps. If anything out of the ordinary is detected in breast shape, appearance, or
texture, the women should consult a physician. Many doctors also recommend
that women older than age forty get an annual mammogram, a type of X-ray pro-
cedure that can detect breast cancer before lumps become noticeable.
If a lump or other unusual feature is detected, further tests are needed to distin-
guish malignant, cancerous tissue from benign, noncancerous tissue. Images from
mammography or ultrasonography can sometimes indicate this difference, but a
biopsy is usually needed to verify the malignant or benign nature of the tissue.
Breast cancer, if detected early, is one of the most treatable forms of cancer.
The specific treatment depends on the extent to which the cancer has spread in the
patient. If the cancer is confined to a small area, the cancerous tissue and sur-
rounding tissue can be removed in a surgical procedure called a lumpectomy. This
procedure allows the surgeon to preserve the breast. Follow-up radiation therapy
and chemotherapy can then kill any possible remaining cancer cells.
If the cancerous area has spread too widely, the entire breast will be removed
in a procedure called a mastectomy. In both a lumpectomy and a mastectomy,
the surgeon also typically removes lymph nodes from the adjoining armpit.
Examination of the lymph nodes will indicate if the cancer is likely to recur in
other parts of the body. Even with a mastectomy, radiation therapy or chemo-
therapy may be necessary. Some drugs work by killing cancer cells directly,
others work by preventing estrogen and other hormones from promoting cancer
cell growth, and still others work by prompting the body’s immune system to
attack cancer cells.
In approximately one of five cases, cancer reappears in other parts of the body
in women who were treated for breast cancer. Such metastatic breast cancer can
sometimes be controlled with chemotherapy.
A. J. Smuskiewicz
See also: Breast, Female; Cervical Cancer; Estrogen; Ovarian Cancer; Uterine Cancer.
Breastfeeding 91
Further Reading
Canadian Cancer Society. (2019). What is breast cancer? Retrieved from http://www
.cancer.ca/en/cancer-information/cancer-type/breast/breast-cancer
Lesh, M. (2013). Let me get this off my chest: A breast cancer survivor over-shares. Sto-
ryRhyme.com Publishing.
National Cancer Institute. (n.d.). Cancer stat facts: Female breast cancer. Retrieved from
http://seer.cancer.gov/statfacts/html/breast.html
Breastfeeding
Breastfeeding is feeding infants or young children human milk. Its physiological
process includes milk production, letdown, and ejection. Each component is influ-
enced by hormonal and physical cues. Human milk provides complete nutrition
for human infants and immune protective factors specific to their immediate envi-
ronments. Breastfeeding was subject to considerable medical and social condem-
nation in the twentieth century and continues to be a subject of social contention.
Breast tissue develops during puberty and matures during pregnancy, usually
by the twenty-eighth week of gestation. At labor onset, the pituitary gland begins
releasing prolactin and oxytocin, which stimulate glandular milk production, let-
down into the milk ducts, and ejection from the nipples. An infant’s nursing
mechanically stimulates milk ejection and hormonally stimulates increased pro-
duction. Appropriate latch is necessary for adequate milk withdrawal, productive
stimulation, and infant nutrition. Inappropriate latch is the most common cause of
maternal pain and inadequate infant feeding.
Milk composition changes over time. For around seventy-two hours following
birth, clear, sticky colostrum is produced, which is primarily immune factors,
protein, minerals, and fat-soluble vitamins. No additional nutrition is required
until two to four days postpartum, when regular milk appears. “Mature milk”
appears seven to fourteen days postpartum and continues until the nursing child is
approximately two years of age, when composition shifts to “toddler milk.” Milk
produced by mothers of premature infants is more nutrient-dense than that of
mothers of full-term infants, and it remains “immature” longer.
Lactation may be induced without pregnancy by various programs involving
breast preparation, nutrition, frequent nipple stimulation, and sometimes pharma-
ceutical aids. Induced lactation is usually more successful for those who have
given birth and breastfed in the past and may provide between 25 percent and 50
percent of an infant’s nutritional needs. Induced lactation has been promoted as a
way to ensure survival of orphaned and abandoned infants in underdeveloped
countries. However, child welfare workers typically condemn it for foster and
adoptive infants in the United States.
World Health Organization (WHO) guidelines state that exclusive breastfeed-
ing beginning within one hour of birth and continuing until six months of age,
with continued breastfeeding until at least age two, is ideal for all infants and
essential for reducing infant morbidity and mortality worldwide. According to
WHO, universal breastfeeding would prevent more than eight hundred thousand
92 Breastfeeding
infant deaths every year, primarily because of breastfeeding’s cleanliness, antibi-
otic properties, nutrition, and availability.
Breast milk cannot be contaminated during nursing because it travels straight
into the infant’s body. The areolas secrete antimicrobial compounds through the
Montgomery glands that protect infants from being exposed to pathogens on the
nipples. In contrast, infant formula contains microorganisms and must be mixed
with clean water, which a large percentage of the world’s population lacks. Use of
unsafe water to mix infant formula is among the leading causes of infant mortality
worldwide.
Breast milk contains maternal white blood cells that kill invading microorgan-
isms in the infant’s digestive tract, immunoglobulin that prevents pathogens from
entering the infant’s body through the intestines, enzymes and proteins that kill
pathogens, sugars that coat the infant’s intestine and prevent bacterial penetration,
growth factors that speed intestinal lining maturation, bile enzymes that break
down fat, and colonies of normal human digestive flora.
Human milk completely and specifically meets all infant nutritional needs
except for vitamin D, which the skin produces when exposed to sunlight. While
infant formulas produced under food safety regulations in developed countries
contain nutrient proportions similar to human milk, they are made from vegetable
products and animal milks and subjected to substantial processing to produce
expensive products that are harder to digest and lack immune factors. Pure animal
milks and vegetable-based milk substitutes are inappropriate for human infants
under one year of age and will cause health problems, including severe anemia
and intestinal bleeding.
Most mothers who nurse on demand, express milk when separated, and do not
offer supplemental formula feedings can completely meet infant nutritional needs.
When formula feedings are introduced, lactation may be reduced, which can
endanger infant survival if formula access is lost, such as during natural disasters.
Watering down of infant formula to stretch supplies is a significant factor in infant
malnutrition and disease in the developing world and among impoverished fami-
lies in developed countries.
While these considerations are most critical to persons in developing countries
or impoverished conditions, the safety, ideal nutrient composition, and free avail-
ability of breast milk, combined with the bonding and neurological and emotional
stimulation of the breastfeeding relationship, are optimal for infant health regard-
less of region or economic circumstance.
Breastfeeding benefits maternal health by reducing risk of postpartum hemor-
rhage and postpartum depression, enabling swift loss of pregnancy-related weight
(because extra calories are needed to produce breast milk), and reducing lifelong
cancer and metabolic disease risks.
Despite WHO’s clear guidelines and a preponderance of evidence for breast-
feeding’s benefits, U.S. rates of breastfeeding hover around 80 percent at birth.
Rates drop below 20 percent for exclusive breastfeeding by six months of age.
From the 1930s through the 1970s, U.S. obstetric and pediatric medicine
actively tried to eradicate breastfeeding due to widespread opinion that it was
unscientific, unsanitary, and nutritionally inadequate, supported by social norms
that discouraged any exposure or discussion of the female breast. During this
Bulbourethral Glands 93
time, women birthing in hospitals were routinely given hormone injections to pre-
vent lactation, often without their knowledge or consent.
Between the 1930s and 1950s, physicians instructed mothers to feed newborns
powdered, evaporated, or condensed cow milk combined with corn syrup. Aggres-
sive global marketing of powdered commercial infant formulas began in the
1950s, and by 1970 only about one in five U.S. mothers had ever breastfed.
In the 1970s, feminist-initiated movements to improve childbirth health care
and maternal support raised breastfeeding rates. Rates continued to rise through
the end of the twentieth century. However, they appear to be declining once
again.
Economic pressures; cultural, religious, and social stigmas; and certain health
conditions can challenge breastfeeding. Working apart from one’s infant necessi-
tates milk expression, or “pumping,” which can be painful and is impossible if
privacy and storage facilities are lacking. While most U.S. states protect breast-
feeding, some individuals continue to face stigmas that discourage breast expo-
sure or sexualize breasts to the point where they feel psychologically unable to
breastfeed. Mothers in the adoption process may be banned from nursing under
rules meant to prevent sexual abuse. Nursing is sometimes economically stigma-
tized as a sign that a mother “can’t afford” formula.
Health conditions that interfere with milk production include insufficient glan-
dular tissue, which can occur naturally or arise from injury, breast reduction, or
anticancer surgery; maternal malnutrition, stress, and physical overexertion; and
thyroid diseases, especially Hashimoto disease. Maternal chemotherapy, active
tuberculosis, and HIV infection can potentially make breast milk unsafe.
Angela Libal
See also: Breast, Female; Oxytocin.
Further Reading
Breastfeeding USA. (2019). Breastfeeding articles. Retrieved from https://breastfeedin-
gusa.org/content/article/breastfeeding-information-articles
La Leche League International. (2019). Retrieved from https://www.llli.org
National Institutes of Health. (2019). Breastfeeding. Retrieved from https://medlineplus.
gov/breastfeeding.html
World Health Organization. (2009). The physiological basis of breastfeeding. In World
Health Organization, Infant and young child feeding: Model chapter for textbooks
for medical students and allied health professionals. Geneva: World Health Orga-
nization. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK148970/
World Health Organization. (2017). 10 facts on breastfeeding. Retrieved from http://www
.who.int/features/factfiles/breastfeeding/en/
Wright, A. L., & Schanler, R. J. (2001). The resurgence of breastfeeding at the end of the
second millennium. The Journal of Nutrition, 131(2), 4215–4255.
Bulbourethral Glands
The bulbourethral glands are two small exocrine glands found in the male repro-
ductive systems of most mammals. In humans, the glands are about the size of
peas and are found below the prostate gland and on either side of the urethra at the
94 Bulbourethral Glands
base of the penis. The bulbourethral glands are also known as Cowper’s glands,
because they were first discovered by English anatomist William Cowper in the
1600s. Their main function is to produce a clear mucus-like secretion known as
the preejaculate fluid. The preejaculate helps prepare the urethra for the safe pas-
sage of sperm during an ejaculation.
The bulbourethral glands consist of several lobules composed of acini and
ducts that conduct secretions out of the lobules. A thin fibrous membrane sur-
rounds the lobules and holds the gland together. A duct about one inch long carries
the secretions to the urethra. As an individual ages, the bulbourethral glands
decrease in size.
When sexually stimulated, the bulbourethral glands begin to produce the pree-
jaculate, a clear liquid with a consistency like mucus. The preejaculate is an alka-
line solution that neutralizes any acidic urine left in the urethra, which would be
harmful to sperm. The preejaculate also helps to moisturize and lubricate the ure-
thra and its external orifice to allow the sperm to be ejaculated without mechani-
cal damage. During penile-vaginal sex, it also helps prepare the environment in
the vagina to be more hospitable for sperm.
The preejaculate secreted by the bulbourethral glands averages about 5 percent
of the total ejaculate, although some individuals produce much more. A contro-
versy exists about whether sperm can be present in the preejaculate. Many mixed-
sex couples practice withdrawal before ejaculation as a form of birth control. If the
preejaculate includes sperm cells, pregnancy might result.
The bulbourethral glands also produce prostate-specific antigen (PSA), which
is used as an indicator for prostate cancer. High levels of PSA produced by these
glands can produce false-positive prostate cancer diagnoses.
Analogous structures to the bulbourethral glands among females are known as
Bartholin’s glands.
Tim J. Watts
See also: Ejaculation; Penis; Preejaculate Fluid; Prostate; Prostate Cancer.
Further Reading
Barclay, T. (2017). Cowper’s gland. Retrieved from http://www.innerbody.com/image
_repmov/repo16-new2.html
Chughtai, B., Sawas, A., O’Malley, R. L., Naik, R. R., Ali Khan, S., & Pentyala, S. (2005).
A neglected gland: A review of Cowper’s gland. International Journal of Androl-
ogy, 28(2), 74–77.
Healthline. (2015). Bulbourethral gland (Cowper’s gland). Retrieved from http://www
.healthline.com/human-body-maps/bulbourethral-cowpers-gland
C
Castration
Castration involves the destruction or excision of testicles. The practice originated
in primitive cultures from a desire to control animal populations. Castrated males
cannot reproduce, and they exhibit reduced aggression. Human castration began
as a way to control slaves. Owners believed the practice led to an elevated level of
compliance. Subsequently, the practice became associated with dynamics of sex-
ual pleasure. “Eunuch” is the word often associated with a castrated human.
Eunuchs existed in ancient Rome. The term “eunuch” typically refers to a male
slave castrated at a young age. In many cases, castration involved the removal of
the testicles and the penis. Eunuchs would engage in sex with masters and arrange
events such as orgies. When having sex with a master, eunuchs would often dress
in female attire and simulate the sounds of a woman losing her virginity. Litera-
ture implies that women also used eunuchs as tools for sexual gratification. Cas-
tration became less common as Christianity spread through the Western world,
but castration for purposes of celibacy continued for men interested in certain
vocations within the church. Sources indicate that the use of eunuchs in Middle
Eastern countries persisted through the early twentieth century. There have been
modern-day reports of eunuchs working as prostitutes in south Indian cities. In
addition, there are currently online cyber communities supporting male castration
and eunuch-based sexual fantasies.
Early forms of castration were crude. They involved crushing the testicles with
a mallet or removing them with a sharp blade. Medical processes involving sur-
gery and the use of chemicals currently characterize castration. Chemical castra-
tion involves giving males antiandrogen therapy, which decreases the functional
activity of the testicles and penis and is a common treatment for advanced prostate
cancer; approximately five hundred thousand men in North America have been
surgically or chemically castrated as a result of prostate cancer.
Some research also indicates that castration may decrease illicit desires exhib-
ited by sex offenders. In the United States, various states attempted to legalize
castration as a therapeutic and punitive measure for sex offenders through the
1970s and 1980s. One of the first was Maine. In 1979, a castration bill failed, but
the legislature approved funding for the study of the effectiveness of chemical
castration. Failures to pass castration legislation occurred in other states. How-
ever, in 1997, a California bill went into effect requiring repeat child sex offenders
to undergo chemical castration before prison release. Offenders can forego chemi-
cal castration if they voluntarily endure surgical castration. Other states with
96 Casual Sex
similar laws now include Iowa, Georgia, Montana, Oregon, Wisconsin, Texas, and
most recently Louisiana. Proponents argue for its effectiveness, and chemical cas-
tration for sex offenders exists in other countries around the world. Organizations
such as Amnesty International have designated the practice of castrating sex
offenders a violation of basic human rights.
Jason S. Ulsperger
See also: Male Sexuality; Medical Treatment of Sex Offenders; Prostate Cancer; Sexual
Slavery; Sterilization; Testicles.
Further Reading
Deshotels, T., & Forsyth, C. J. (2007). Postmodern masculinities and the eunuch. Deviant
Behavior, 28(3), 201–218.
Handy, A., Wassersug, R. J., Ketter, J. T., & Johnson, T. W. (2015). The sexual side of
castration narratives. The Canadian Journal of Human Sexuality, 24(2), 151–159.
Sreenivasan, S., & Weinberger, L. E. (2016). Surgical castration and sexual recidivism
risk. In A. Phenix & H. M. Hoberman (Eds.), Sexual offending (769–777). New
York: Springer.
Taylor, G. (2000). Castration: An abbreviated history of Western manhood. New York:
Routledge.
Casual Sex
“Casual sex” refers to sexual activity that takes place outside the context of a long-
term romantic relationship. Casual sex can take numerous forms, from one-night
stands to friends with benefits. Interest in this activity varies across persons, but it
can be predicted by a number of factors, including gender and personality.
Although casual sex is widely believed to be on the rise and is thought to be linked
primarily to negative outcomes, research paints a different and far more compli-
cated picture.
There are several distinct types of casual sex, which vary in terms of the nature
and frequency of sexual contact between partners, the extent of their communica-
tion, as well as whether the partners consider themselves to be friends. For
instance, some researchers distinguish between one-night stands, “booty calls,”
and friends with benefits.
One-night stands are exactly what they sound like—a singular sexual encoun-
ter, usually between people who do not know each other very well. By contrast,
booty calls are like one-night stands, except that they occur on a repeat basis.
Finally, friends with benefits involve two people who have a simultaneous friend-
ship and sexual relationship but are not romantically involved.
On the surface, one-night stands might appear to be the prototypical type of
casual sex; however, they are actually the least common in practice. Research sug-
gests that most casual sex occurs between people who have at least some history
between them as opposed to people who just met.
Several studies have found that men are more interested in casual sex than are
women. For instance, when college students are approached by an attractive
stranger who propositions them for sex, men are far more likely to say yes than
Casual Sex 97
women. However, this does not mean that women are uninterested in casual sex.
In fact, other research has found that, under certain circumstances, women are
almost as likely to say yes to casual sex as men, such as when propositioned by
someone who appears to be highly sexually competent or skilled.
Women are far less likely than men to reach orgasm during casual sex, a phe-
nomenon that has been dubbed the “orgasm gap.” In light of this, it is perhaps not
surprising that women are more likely than men to take anticipated pleasure into
account when making decisions about casual sex.
Beyond gender, attitudes toward casual sex are also related to personality. For
instance, persons with an unrestricted sociosexual orientation, or people who have
an easier time separating sex from emotion, tend to have more casual sex, but they
also enjoy their experiences more.
Casual sex is thought to have increased dramatically in recent years. Indeed,
millennials are often referred to as “the hookup generation.” However, a closer
look at the research suggests that this view is inaccurate. In fact, millennials are
actually having less sex with fewer partners compared to generations past.
Casual sex is also widely thought to be a risky behavior, both physically and
psychologically. For instance, casual sex is believed to significantly increase the
risk of contracting sexually transmitted infections (STIs). However, the degree to
which casual sex affects people’s risk for STIs depends on numerous factors,
including the specific sexual activities they engage in, their sexual communica-
tion skills, and their consistency of condom use. Categorizing the inherent riski-
ness of casual sex is thus more complicated than it first appears because not all
casual sex is created equal.
With respect to the psychological effects of casual sex, it appears that casual
sex is linked to negative outcomes for some but not others. These effects appear to
be contingent, at least in part, on one’s reasons for having casual sex in the first
place. For instance, casual sex is linked to negative outcomes for people who say
they did it in order to feel better about themselves but not for people who did it
because they wanted to experience pleasure.
The psychological effects of casual sex also depend on one’s gender, such that
men are more likely than women to look back on these experiences positively. The
“orgasm gap” is likely part of the reason behind this gender difference; however,
it may also have to do with men and women having different motivations and rea-
sons for casual sex. Alternatively, it could be the product of a sexual double stan-
dard that penalizes women more than men for having casual sex.
Justin J. Lehmiller
See also: Double Standards, Sexual; Friends with Benefits; Hookup Culture; Serial
Monogamy; Sexually Transmitted Infections (STIs).
Further Reading
Clark, R. D., & Hatfield, E. (1989). Gender differences in receptivity to sexual offers.
Journal of Psychology & Human Sexuality, 2, 39–55.
Conley, T. D. (2011). Perceived proposer personality characteristics and gender differ-
ences in acceptance of casual sex offers. Journal of Personality and Social Psy-
chology, 100, 309–329.
98 Celibacy
Garcia, J. R., Reiber, C., Massey, S. G., & Merriwether, A. M. (2012). Sexual hookup cul-
ture: A review. Review of General Psychology, 16, 161–176.
Regan, P. C., & Dreyer, C. S. (1999). Lust? Love? Status? Young adults’ motives for
engaging in casual sex. Journal of Psychology and Human Sexuality, 11, 1–24.
Vrangalova, Z. (2015). Does casual sex harm college students’ well-being? A longitudinal
investigation of the role of motivation. Archives of Sexual Behavior, 44, 945–959.
Wentland, J. J., & Reissing, E. D. (2011). Taking casual sex not too casually: Exploring
definitions of casual sexual relationships. Canadian Journal of Human Sexuality,
20, 75–89.
Celibacy
The term “celibacy” has been used differently by various people. Some use “celi-
bacy” to mean a lifestyle of refraining from sexual intercourse. Others refer to
celibacy as abstinence from all sexual contact. When referring to priests in today’s
society, often in Catholicism, celibacy is seen as the renunciation of marriage or
living a nonmarried life. Depending on the context, celibacy can simply mean not
getting married, refer to abstaining from sexual contact, or both. The sexual con-
tact can include any sexual experiences or penile-vaginal sexual intercourse spe-
cifically. This is often determined by the contextual use of the word.
Most religious traditions have a philosophy on celibacy that often stems from
asceticism—self-discipline concerning various pleasures (eating, drinking, satiat-
ing a sexual appetite, etc.). These practices are often embarked on to gain spiritual
enlightenment or direction. Some religions may require religious leaders or com-
munities to be celibate (e.g., Catholicism and Jainism), while others hold celibacy
to be a more temporary tool (e.g., Brahmacarya [brahmacharya] in Hinduism—
abstaining from sex for a period of time while studying the Vedas, the religion’s
holy texts). An indicator of how an individual or group may define celibacy will be
their philosophical view on sexuality.
There is a more recent social movement centered around people who are celi-
bate but not by choice. Seemingly gaining its name from the misplaced American
cultural value regarding when people are “supposed” to have sex, involuntary
celibates identify themselves as people who have never been in a situation where
sex with another person has presented itself, or if they have previously had sex, as
people who do not currently have opportunities to have sex. A study by Donnelly,
Burgess, Anderson, Davis, and Dillard (2001) first studied this phenomenon
through an online survey. The researchers further labeled people virginal celi-
bates (having never had sexual experiences or partners), single celibates (having
had sexual experiences but no current partner), and partnered celibates (being
currently partnered and having had past sexual experiences). While little research
has been done on the group, there seems to be an online involuntary celibate com-
munity, often abbreviated to the “incel” community.
The definition of celibacy can fluctuate depending on the perspective of the
individual or group using it. Some groups may use the word to imply certain sex-
ual behaviors because of how they view the function of sex and sexuality (e.g., in
Cervical Cancer 99
Catholicism celibacy is defined as no marriage, which is equated to no sex). With
“celibacy” meaning abstaining from marriage, sex, or both, the term can be used
to describe a wide array of sexual or marital situations in which people may find
themselves.
Mark A. Levand
See also: Abstinence; Marriage; Religion, Diversity of Human Sexuality and; Virginity.
Further Reading
Delhaye, P. (1967). Celibacy, history of. In New Catholic encyclopedia (Vol. 3, 369–374).
New York: McGraw-Hill.
Donnelly, D., Burgess, E., Anderson, S., Davis, R., & Dillard, J. (2001). Involuntary celi-
bacy: A life course analysis. Journal of Sex Research, 38(2), 159–169.
Fox, T. C. (1995). Sexuality and Catholicism. New York: George Braziller.
Westheimer, R. K. (2000). Encyclopedia of sex. New York: Continuum.
Cervical Cancer
Cervical cancer is cancer of the cervix, the lower part of the uterus. This cancer
can affect either of the two main types of cells in the cervix—the squamous cells
in the exocervix (near the vagina) or the glandular cells in the endocervix (near
the main body of the uterus). These two cell types meet in an area called the trans-
formation zone.
Approximately 90 percent of cervical cancers affect squamous cells. Such can-
cer is known as squamous cell carcinoma, and it usually begins to develop in the
transformation zone. Most other types of cervical cancer, known as adenocarci-
noma, affect the glandular cells. This cancer usually develops in the mucus-
producing cells of the cervix. Some types of cervical cancer affect both squamous
and glandular cells.
According to the American Cancer Society, about 12,900 new cases of cervical
cancer are diagnosed, and about 4,100 women die from cervical cancer each year
in the United States.
The risk for cervical cancer increases between the ages of twenty and fifty,
when most cases are diagnosed. Risk is also related to ethnicity, with Hispanic
women at the greatest risk followed by—in descending order—African Ameri-
cans, Asians and Pacific Islanders, whites, and Native Americans. Research sug-
gests that some cases are associated with an inherited condition that makes the
immune system less able to resist infection from human papilloma virus (HPV).
Infection with certain strains of this sexually transmitted infection, which can
also cause genital warts, can cause cervical cancer if left untreated. Two HPV
types (16 and 18) cause 70 percent of cervical cancers, but there are at least four-
teen types of HPV that can cause cancer.
Certain lifestyle factors are associated with increased risk for cervical cancer,
including smoking, a diet low in fruits and vegetables, being overweight, and
long-term use of birth control pills. In addition, women are at elevated risk if they
have had three or more pregnancies, if they were younger than seventeen during
100 Cervical Cancer
their first pregnancy, and if their mothers were given the drug diethylstilbestrol
(DES) when they were pregnant. DES was used between 1940 and 1971 to prevent
miscarriage.
In its early stages, cervical cancer usually does not produce noticeable symp-
toms. But after the cancer establishes itself in a relatively large area of the cervix,
symptoms commonly develop. These symptoms may include abnormal vaginal
bleeding and other unusual vaginal discharges and pain during intercourse.
Because identical symptoms could be caused by other conditions, a medical diag-
nosis is necessary to determine the cause.
Doctors advise people who have a cervix to get regular Pap tests, or Pap smears,
so that cellular changes in cervical tissue can be found and addressed in either
precancerous or early cancerous stages. Although not all precancerous conditions
develop into cancer, doctors usually recommend treatment at the precancerous
stage to minimize the risk. Pap tests can also detect HPV infection.
If a Pap test reveals suspicious results in the form of abnormal cervical cells,
additional tests are needed to arrive at a definitive diagnosis. In a colposcopy pel-
vic examination, the interior of the cervix is inspected with a magnifying instru-
ment called a colposcope, and a small piece of tissue is removed for a biopsy.
Biopsies of cervical tissue can reveal clear evidence of squamous cell carcinoma,
adenocarcinoma, or other cervical cancer under microscopic examination.
If cancer is confirmed, various imaging tests can be performed to determine
the stage of cancer development and, thus, the most appropriate treatment strat-
egy. Such tests could include computed tomography, magnetic resonance imag-
ing, and positron emission tomography.
Because HPV infection can cause cervical cancer, preventing HPV infection is
crucial to preventing cervical cancer. Thus, condoms and other safer sex practices
should be used during sexual activity. Vaccinations against HPV are recom-
mended for all children, usually around age nine to twelve, before they are exposed
to the virus. If not vaccinated at that age, people can be vaccinated as adults.
Treatment for cervical cancer is most successful when begun in its early stages.
As previously indicated, the early stages of this cancer can be detected by getting
regular Pap tests. The use of the Pap test as a screening tool is credited with reduc-
ing the death rate from cervical cancer by more than 50 percent from 1985 to
2015. Cervical cancer development is classified into nine stages, with five-year
survival rates for these stages ranging from 93 percent to 15 percent.
Once cancer is diagnosed and its stage of development is determined, a treat-
ment strategy can be initiated. The four main treatment options are surgery, radia-
tion therapy, chemotherapy, and targeted therapy. Some combination of these
therapies is usually used.
Many kinds of surgical procedures are available, ranging from destruction of
abnormal tissue with a focused laser beam to removal of the uterus and adjoining
tissues in a radical hysterectomy. In advanced cases, in which the cancer has
spread widely, even more radical surgery—involving removal of the vagina, blad-
der, rectum, and part of the colon—may be necessary.
Radiation therapy might be administered in the form of external beams or as an
internal radiation source placed near the cancerous tissue. Medications commonly
Cervical Cap 101
used in general cervical cancer treatment include cisplatin, carboplatin, and pacli-
taxel. In targeted therapy, medications are selected for their effectiveness in tar-
geting specific biological changes that occur in cervical cancer. For example,
drugs known as angiogenesis inhibitors block the development of new blood ves-
sels that cancer tumors need to grow.
A. J. Smuskiewicz
See also: Breast Cancer; Cervix; Human Papillomavirus (HPV); Hysterectomy; Ovarian
Cancer; Pap Smear; Uterine Cancer.
Further Reading
Canadian Cancer Society. (2019). Cervical cancer. Retrieved from http://www.cancer.org/
cancer/cervical-cancer.html
National Cancer Institute. (2019). Cervical cancer—Patient version. Retrieved from http://
www.cancer.gov/types/cervical
Cervical Cap
The cervical cap is a barrier method birth control device, shaped like a cup and
made of silicone, that is inserted into the vagina to cover the cervix.
The cervical cap is available in three sizes: small (for those who have never
been pregnant), medium (for those who have had an abortion or a cesarean deliv-
ery), and large (for those who have delivered vaginally). These devices can be
purchased with a doctor’s prescription at a drugstore or clinic for roughly $75
USD —with an additional cost of about $17 USD for the recommended spermi-
cide to be used with the cap.
To be most effective, the cervical cap should be used with a spermicide cream
or jelly, which is applied onto the device. The spermicide stops the movement of
sperm, while the cervical cap blocks the sperm from entering the uterus and fertil-
izing the egg.
Before inserting the cervical cap in the vagina, some spermicide is placed in
the dome and along the rim of the cap. The cap is then inserted into the vagina
while standing, sitting, or lying in a comfortable position. The cap is inserted with
the dome side facing downward. The device must be inserted all the way in to
completely cover the cervix.
Before each instance of sexual intercourse, it is important to make sure the cap
is still properly positioned. If additional spermicide is thought to be necessary, it
can be inserted deep into the vagina without removing the device. After inter-
course, the cap should be left in place for at least six hours. It should not be left in
place for more than forty-eight hours at a time.
The cervical cap should be thoroughly washed with mild soap and warm water
after removal. It can be reused and will remain effective for as long as two years.
The cap should be regularly inspected for small holes or weak spots, which may
be signs that a replacement cap is needed.
The effectiveness of the cervical cap at preventing pregnancy is greatest for
those who have never been pregnant or who have never given birth vaginally.
However, even if these conditions are met, the one-year failure rate is quite high:
102 Cervical Mucus Method
approximately 14 percent will become pregnant. Among those who have given
birth vaginally, 29 percent become pregnant each year. The cap’s effectiveness
can be further enhanced if a condom is also used.
The cervical cap offers some advantages compared with various other methods
of birth control. It does not interfere with an individual’s natural hormone balance,
and it can be safely used during breastfeeding. It can be conveniently carried in a
purse or pocket until it is needed; then it is immediately effective on insertion. Its
effects are immediately reversible on removal, as it does not affect fertility. In
most cases, neither the user nor their partner can feel the device.
There are several disadvantages with using the cervical cap. It cannot be used
during menstruation. Some also experience difficulty in inserting the device, and
some may find that the device gets pushed out of place during sexual intercourse.
Failure rates for cervical caps are relatively high compared to other birth control
methods because the cap’s effectiveness is heavily dependent on proper position-
ing. Because the cervical cap requires a prescription, it is less readily available
than other forms of birth control. Finally, the cervical cap offers no protection
against sexually transmitted infections.
A. J. Smuskiewicz
See also: Barrier Contraceptive Methods; Cervix; Spermicides.
Further Reading
Mayo Clinic. (2019). Cervical cap. Retrieved from https://www.mayoclinic.org/tests
-procedures/cervical-cap/about/pac-20393416
Planned Parenthood. (2019). Cervical cap. Retrieved from https://www.plannedparenthood
.org/learn/birth-control/cervical-cap
Cervical Mucus Method
The cervical mucus method is a way of gauging fertility by carefully monitoring
the secretions that collect on the cervix and vagina throughout the menstrual
cycle, then using this information to determine when pregnancy is most likely to
occur. Some couples use this method to avoid pregnancy; others use it to help
them conceive. Like most other forms of birth control, the cervical mucus method
is not failsafe. Every female fertility cycle is different, so using any of these meth-
ods requires careful observations over several menstrual cycles.
Also known as the ovulation method or the Billings method, the cervical mucus
method requires that the appearance and consistency of cervical secretions be
checked several times a day. Ideally this is done by inserting clean fingers into the
vagina to check the color and texture of the mucus on them, although those who
are more experienced with this method may check their mucus by wiping the
vaginal opening with tissue prior to urination or by observing secretions on their
underwear. All observations should be marked on a calendar each day until the
patterns of cervical discharge are very familiar.
In general, days when the cervical mucus is either absent or scanty, cloudy, and
sticky are days on which pregnancy is less likely to occur. Days when cervical
discharge is abundant and similar to raw egg white (stretchy, clear, and slippery)
Cervix 103
are days when pregnancy is more likely because this type of mucus indicates the
time around ovulation. Mucus patterns may also change around or during certain
events, including
• breastfeeding
• cervical surgery
• douching or use of other “feminine hygiene” products
• perimenopause
• use of hormonal contraceptives, including emergency contraception
• use of spermicides
• sexually transmitted infection
• vaginitis or a yeast infection
Because menstrual cycles can vary widely, and because this method is an impre-
cise way of determining fertility, nearly a quarter of women—twenty-three out of
one hundred—will become pregnant unintentionally in the first year with typical
use of this method as a form of birth control. Unintended pregnancy rates drop to
three out of one hundred annually for those who know their body’s cycle well and
who use the cervical mucus method perfectly.
When using the cervical mucus method or other fertility awareness–based
methods (FAMs) to avoid pregnancy, couples must still practice abstinence or use
another form of contraception during the ten to seventeen days in each cycle when
a woman is most likely to become pregnant. Many women also use the cervical
mucus method in conjunction with other FAMs, such as the basal temperature
method and the calendar method, to increase its effectiveness. When the cervical
mucus and basal temperature methods are used together, they are sometimes
known as the symptothermal or muco-thermal method.
Terri Nichols
See also: Cervix; Fertility; Fertility Awareness Methods of Contraception; Ovulation;
Vaginal Secretions.
Further Reading
Mayo Clinic. (2019). Cervical mucus method for natural family planning. Retrieved from
https://www.mayoclinic.org/tests-procedures/cervical-mucus-method/about/
pac-20393452
Weschler, T. (2015). Taking charge of your fertility: The definitive guide to natural birth
control, pregnancy achievement, and reproductive health. New York:
HarperCollins.
Cervix
The cervix is the lower portion of the uterus just above the vagina. It has the same
layers as the uterus, perimetrium, myometrium, and endometrium. The composi-
tion and physiology is different within the cervix. For example, the myometrium
in the cervix is thinner since the need for strength is not as great as in the uterus.
104 Chancroid
Another example is that the cervical endometrium is not separated into a func-
tional and basal layer. Within the uterus, the functional layer grows through the
menstrual cycle and then is shed when there is no implantation of a fertilized egg.
The basal layer is the base that is always present. Since implantation should not
occur within the cervical endometrium, it does not grow and therefore does not
need to be shed.
The cervix itself can be divided into several sections, though the entirety is
only about an inch in length. The top of the cervix is called the internal cervical
os, which is the opening between the cervix and the uterus. The middle portion in
called the cervical canal, which connects the vaginal cavity to the uterine cavity.
The last portion, the external cervical os, is where the cervical canal opens to the
vagina. Also like the uterus, the cervix can vary in sizes between people. It can
also vary in size in the same person depending on whether or not that person is
pregnant. Typically during pregnancy the cervix will increase in size. This is the
area that must flatten and open in order for the fetus to pass from the uterus to the
vagina.
While the cervix does not host a growing fetus, it does have implications in the
process of menstruation, pregnancy, and childbirth. There are glands within the
endometrium that secrete mucus. Depending on where a person is in their men-
strual cycle, the cervical mucus will be of different consistencies. These corre-
spond to fertility throughout the cycle. A person is most fertile when they observe
mucus that is similar in color and consistency to egg whites. This type of mucus
allows sperm to swim more easily. Another type of mucus is watery and slippery;
while this also helps sperm swim, it is not preferable to the egg-white consistency.
Mucus types that indicate a drop in fertility include a creamy yellow or white
mucus that resembles moisturizing lotion. Another type is a thick, chunky mucus
with the consistency of glue. Both of these also cause a drop in fertility because
they make it difficult for the sperm to travel through the cervix. Because of
mucus’s implications in fertility, one method of birth control is to monitor the
secretions to see when fertility is less likely.
Rebecca Polly
See also: Cervical Cancer; Cervical Cap; Cervical Mucus Method; Fertility; Fertility
Awareness Methods of Contraception; Pregnancy; Uterus.
Further Reading
Jordan, J. (2006). The cervix. Boston: Wiley-Blackwell.
Lowry, I. (2011). A woman’s disease: The history of cervical cancer. New York: Oxford
University Press.
Chancroid
Chancroid is the name given to one type of genital ulcer seen in both men and
women; however, it is more commonly seen in men. Chancroid is caused by the
bacteria Haemophilus ducreyi, which is transmitted primarily through sexual
activity, although nonsexual transmission is also possible. Worldwide, the number
of chancroid cases is decreasing, with rare exceptions in North India and Malawi.
Chancroid 105
Because of its rare occurrence, it may be misdiagnosed as genital herpes, and test-
ing is needed to determine the presence of the bacteria. Antibiotics are usually
effective in curing chancroid.
Due to the sexually transmitted nature of the bacteria, most people who acquire
the infection are sexually active adults. However, there are cases of nonsexual
transmission of Haemophilus ducreyi in some countries where the lesion appears
in nongenital parts of the body, such as on the lower legs of children. In addition,
an infected person can infect another part of their own body if they touch their
genital lesion and then touch another part of their body without first washing their
hands. Transmission is not possible through healthy intact skin, so the bacteria
must find a way through the skin barrier, such as an abrasion that happens when
kids play. Sex frequently involves friction and vigorous movement, and even with
natural and added lubricant sufficient for comfort and pleasure, abrasions can
occur. These small tears in the vaginal, vulval, anal, or penile skin are the entry
points for Haemophilus ducreyi.
While some cases of Haemophilus ducreyi may be asymptomatic, most people
develop a visible lesion (chancroid) within three to seven days after exposure.
Unlike the syphilis ulcer, chancroid is often painful in those who get it, and it has
a ragged edge with a soft base, whereas syphilis often has a relatively hard base to
the ulcer. This led early doctors to refer to soft and hard chancres (lesions) to dif-
ferentiate chancroid (soft lesion) from syphilis (hard lesion). Now clinics use blood
tests plus a swab test of the ulcer to determine which bacteria is the cause. Mixed
infections are also possible, in which syphilis and chancroid (or other ulcer-caus-
ing microbials, such as herpes) are present in the same ulcer. Multiple ulcers are
also possible with chancroid, as is a painful lump in the groin (inguinal lymphade-
nopathy), which may burst and spill pus if not treated early.
Chancroid, like other ulcerative sexually transmitted infections (STIs), such as
herpes and syphilis, increases the risk of acquisition and transmission of HIV. The
chancroid ulcer can increase susceptibility to HIV for HIV-negative individuals.
Among people living with HIV, chancroid has been associated with treatment fail-
ure, and, as such, lesions may take longer to heal.
Prevention of chancroid infection is the same as for the other STIs—namely,
using condoms during sexual contact and intercourse and avoiding sex if a genital
ulcer is present. Fortunately, chancroid is treatable with antibiotics, and symptoms
usually disappear after one to two weeks of treatment. There are both injectable
and oral forms of antibiotic. If the infection has caused a swelling in the groin
(inguinal lymphadenopathy), then additional treatment to drain the swelling may
be needed.
Kelwyn Browne
See also: Herpes; Human Immunodeficiency Virus (HIV); Sexually Transmitted Infec-
tions (STIs); Syphilis.
Further Reading
Bong, C. T., Hareziak, J., Katz, B. P., & Spinola, S. M. (2002). Men are more susceptible
than women to pustule formation in the experimental model of Haemophilus
ducreyi infection. Sexually Transmitted Diseases, 29(2), 114–118.
106 Cheating and Infidelity
Centers for Disease Control. (2015). Chancroid. 2015 sexually transmitted diseases treat-
ment guidelines. Atlanta: Centers for Disease Control.
Lautenschlager, S., Kemp, M., Christensen, J. J., Mayans, M. V., & Moi, H. (2017). 2017
European guideline for the management of chancroid. International Journal of
STD and AIDS, 28(4), 324–329.
Cheating and Infidelity
Infidelity occurs when one or both parties in an agreed-upon relationship engage
in behaviors that cross the decided boundaries of said relationship with an outside
individual. According to various studies, cheating is quite common; more than
30 percent of men and 20 percent of women in the United States have reported
cheating in their lifetime. Other literature suggests that cheating is especially
common in younger people, and prevalence of cheating may be rising among
college-aged adults.
It is valuable to note that infidelity is not defined in one specific way. For some,
infidelity can be classified as engaging in genital intercourse with an outside part-
ner. Others define infidelity as nongenital sexual exchanges with an outside part-
ner (which include, but are not limited to, oral sex, kissing, hugging, holding
hands, fondling, etc.). Even so, others may classify nonsexual behaviors, such as
withholding information, lying in a relationship, flirting, and emotionally bonding
with an outside partner, as forms of infidelity.
Various personality traits (i.e., extroversion, neuroticism, openness, conscien-
tiousness, and agreeableness) can contribute to individuals engaging in infidelity.
Researchers have found that a desire for sex, anger toward a partner, feeling
neglect in the relationship, and dissatisfaction in the relationship served as predic-
tors for cheating in a relationship. While conscientiousness and openness were not
found to significantly affect infidelity, neuroticism was associated with a partner’s
likelihood to neglect their primary partner and engage in outside relationships.
Low agreeableness and neuroticism were linked to the heightened potential for
anger in relationships. This means that if one partner is more prone to please their
mate and is insecure about the status of their relationship, this may influence said
partner to resent and abandon the relationship. Finally, dissatisfaction in a rela-
tionship was found to correlate with higher levels of individual extraversion,
which suggests that those who prefer interaction with others may become bored
with a dyadic (two-person partnered) pairing and may seek stimulation from out-
side partners.
Infidelity can have a variety of effects on individuals in dyadic relationships.
While some may assume that infidelity only affects the partner being cheating on,
research highlights that cheating may have negative effects on both the cheating
partner and the partner being cheated on. For some, cheating may lead to personal
shame and guilt related to potentially damaging the relationship, contributing to
the suffering of one’s partner, or potentially enjoying the extradyadic (outside)
relationship. These feelings of guilt and shame could potentially lead the cheating
partner to experience anxious and depressive symptoms. On the other hand, the
Cheating and Infidelity 107
individual being cheated on could experience depressive symptoms that relate to
feelings of jealousy, distress, and betrayal.
When it comes to the infidelity experienced by gender, research highlights that
men and women are more prone to cheat in different ways. Studies highlight that
men and women also experience infidelity-related distress differently. While men
are more likely to engage in sexual, or physical, infidelity, women have been found
to be more likely to engage in emotional infidelity that involves an emotional con-
nection with an outside partner (Martins et al., 2016). Similarly, in heterosexual
relationships, men have reported feeling more distressed when their female part-
ners have engaged in sexual infidelity. Conversely, women in heterosexual rela-
tionships have reported higher levels of distress when their male partners have
engaged in emotional relationships with outside partners.
Little research exists around gay, lesbian, and bisexual (GLB) individuals and
infidelity experiences. Nevertheless, the research that does exist suggests that
some GLB persons may be less concerned with their partners engaging in physi-
cal, or sexual, extradyadic relationships. The rationale behind this is that because
GLB individuals have, for so long, been sexually oppressed, they have now found
comfort in having relationships that are more welcoming of outside sexual part-
ners. That said, research highlights that GLB individuals may experience greater
distress when their partners engage in emotional infidelity. This finding may
speak to the fact that GLB individuals have recently been given the social space to
freely engage in relationships that go beyond the physical; therefore, emotional
cheating may lead to an increased experience of betrayal, sadness, and depressive
symptoms.
While infidelity among adolescents is highly underinvestigated, there exists a
breadth of research that highlights the way in which adults perceive, participate
in, and are affected by infidelity. Some studies communicate that adolescents
mainly conceptualize infidelity, and the distress associated with cheating, through
their own experiences and through the experiences of their peers. Due to this, the
adolescent experience should be given greater attention. Observing adult, emerg-
ing adult, and adolescent relationships may highlight unique patterns and dynam-
ics and may provide a glimpse into the ways in which these relationship structures
develop over the life span.
Shadeen Francis and Patrick R. Grant
See also: Adultery; Marriage; Monogamy; Open Marriage; Polyamory.
Further Reading
Barta, W. D., & Kiene, S. M. (2005). Motivations for infidelity in heterosexual dating
couples: The roles of gender, personality differences, and sociosexual orientation.
Journal of Social and Personal Relationships, 22(3), 339–360.
Frederick, D. A., & Fales, M. R. (2016). Upset over sexual versus emotional infidelity
among gay, lesbian, bisexual, and heterosexual adults. Archives of Sexual Behav-
ior, 45(1), 175–191.
Furr, R. E. (2006). Infidelity in adolescent romantic relationships (Unpublished master’s
thesis). University of Tennessee, Tennessee. Retrieved from http://trace.tennessee
.edu/utk_gradthes/1556
108 Child Sexual Abuse
Leeker, O., & Carlozzi, A. (2014). Effects of sex, sexual orientation, infidelity expecta-
tions, and love on distress related to emotional and sexual infidelity. Journal of
Marital and Family Therapy, 40(1), 68–91.
Martins, A., Pereira, M., Andrade, R., Dattilio, F. M., Narciso, I., & Canavarro, M. C.
(2016). Infidelity in dating relationships: Gender-specific correlates of face-to-face
and online extradyadic involvement. Archives of Sexual Behavior, 45(1),
193–205.
Norona, J. C., Khaddouma, A., Welsh, D. P., & Samawi, H. (2015). Adolescents’ under-
standings of infidelity. Personal Relationships, 22(3), 431–448.
Schützwohl, A. (2004). Which infidelity type makes you more jealous? Decision strate-
gies in a forced-choice between sexual and emotional infidelity. Evolutionary
Psychology, 2(1), 121–128.147470490400200.
Child Sexual Abuse
Child sexual abuse (CSA) is a form of sexual abuse in which children are the vic-
tims. Recently, this form of assault has gained a lot of media and research atten-
tion. In 2005, nearly 10 percent of all child abuse cases involved some sort of
sexual abuse, which equals more than 83,000 CAS victims in 2005 alone. Impor-
tantly, many instances of CSA are not reported, so these were just the incidents
that the authorities are aware of. Adult survivors of CSA are starting to speak up
more for themselves and are helping to shed light on this issue. Statistics show that
one in seven girls and one in twenty-five boys are sexually abused before they turn
eighteen.
CSA can be any form of sexual activity with a minor, and the definition is very
broad and varies by country and by state. A child cannot give consent of any kind
to perform sexual acts. Further, CSA can occur in many forms and does not have
to involve physical contact. Types of CSA can include, but are not limited to, digi-
tal interactions (e.g., sexting, chatting, or phone calls that are sexual in nature);
fondling or touching the child; exposing oneself to the child; masturbating in front
of or forcing the child to masturbate; intercourse of any kind (oral, vaginal, or
anal); having, seeing, or sharing any type of images or videos of children with
sexual content; sex trafficking; or any other sexual misconduct that can be harm-
ful to a child. Any of these actions can lead an individual to suffer legal conse-
quences, and each U.S. state has its own legal definition of CSA.
Knowing warning signs of CSA can be helpful, but each individual is different,
and sometimes the warning signs are not easily detected. Signs can be physical,
behavioral, and/or emotional. Most common physical signs are difficulty walking
or sitting; bloody, torn, or stained underclothes; bleeding, bruises, or swelling of
the genital region; pain, itching, or burning in the genital region; frequent urinary
tract or yeast infections; eating issues; vomiting; bowel problems; sexual behavior
problems; substance abuse; anger or aggression; and suicidal behaviors. Some of
the common behavioral and emotional signs are moving away from or seeming
threatened by physical contact; depression or posttraumatic stress disorder; sui-
cidal thoughts, especially in teenagers; self-harm; phobias; behavior problems in
school; changes in hygiene (not bathing enough or bathing too much); running
Child Sexual Abuse 109
away; overly protective of siblings; nightmares or bedwetting; and inappropriate
sexual knowledge or behaviors for their age range. These are just some of the
warning signs as each individual will react differently to being victimized.
The effects of CSA can extend into the individual’s life far beyond their child-
hood years. Sexual abuse can leave children with a lack of trust, feelings of shame
and guilt, and oftentimes can lead to self-harming behaviors. Many victims con-
tinue to suffer from depression, low self-worth, and many more psychological and
emotional problems. CSA can also cause problems with romantic relationships
later on in life and can make survivors more likely to experience domestic vio-
lence as adults.
According to RAINN, 93 percent of victims of CSA know their abuser. This
means that the majority of abusers are people the child knows, such as a parent,
sibling, other relative, teacher, coach, babysitter, and so on. This is not a “stranger
danger” epidemic as many may think it is. Abusers manipulate the child to keep
secrets, which oftentimes leads them to feel guilty about what is taking place.
Abusers may also threaten the child with punishment or with harm to a loved one.
It is important to support the child when they do open up about the abuse and
make sure they know they are believed.
The first line of protection is for a child to have an open and supportive dia-
logue with their parents or caretakers so that they know they have someone to talk
to about even the toughest subjects. Children should also be taught that they can
say no, and they need to understand their own body parts and who can see them.
Children also need to be reassured that they are not in trouble and are not blamed
for what has happened to them. There are many helpful websites, such as RAINN.
org, that give talking points and education around having conversations with chil-
dren. If you suspect a child is being abused, report this to local law enforcement or
child protective services.
If you suspect something, there are two different hotlines that are available to
provide support in this matter: the National Child Abuse Hotline at
1-800-4-A-CHILD (422-4453) and the National Sexual Assault Hotline at 1-800-
656-HOPE (4673). You can also chat online at online.rainn.org. Support is avail-
able 24-7 for those in need (RAINN, 2019).
Amanda Baker
See also: Childhood Sexuality; Incest; Pedophilia; Rape, Abuse and Incest National Net-
work (RAINN); Roman Catholic Church Sexual Abuse Scandal; Sexual Abuse.
Further Reading
Darkness to Light. (2017). Child sexual abuse statistics: The issue of child sexual abuse.
Retrieved from http://www.d2l.org/wp-content/uploads/2017/01/all_statistics
_20150619.pdf
Davis, L. (1988). The courage to heal: A guide for women survivors of child sexual abuse.
New York: Perennial Library.
Herman, J. L. (1997). Trauma and recovery. New York: Basic Books.
RAINN. (2019). Child sexual abuse. Retrieved from https://www.rainn.org/get
-information/types-of-sexual-assault/child-sexual-abuse
Townsend, C., & Rheingold, A. A. (2013). Estimating a child sexual abuse prevalence
rate for practitioners: A review of child sexual abuse prevalence studies.
110 Childhood Gender Nonconformity
Charleston, SC: Darkness to Light. Retrieved from https://www.d2l.org/wp
-content/uploads/2017/02/PREVALENCE-RATE-WHITE-PAPER-D2L.pdf
U.S. Department of Health and Human Services, Administration on Children, Youth, and
Families. (2007). Child maltreatment 2005. Washington, DC: U.S. Government
Printing Office.
Childhood Gender Nonconformity
Gender nonconformity occurs when one’s outward expression of interests, cloth-
ing, or behavior differs from cultural expectations based on the person’s birth-
assigned sex. Gender nonconformity differs from gender dysphoria (i.e., distress
in reaction to the incongruence between internal experience of gender and birth-
assigned sex) in that gender nonconformity relates to behavior, while gender dys-
phoria relates to internal distress. Some people who are gender nonconforming do
not experience dysphoria regarding their birth-assigned sex, while others do.
For many, gender identity development progresses as a predictable develop-
mental process that includes gender stability (i.e., gender identity is the same
across time) occurring around age three, and gender consistency (i.e., self-
recognition of gender identity remaining consistent across situations) occurring
between ages four and seven. Prior to developing gender consistency, a child’s
understanding of gender identity is often based on observable displays of expres-
sion (e.g., clothing, hairstyle, and interests), which are influenced by cultural
social-role norms. However, research examining experiences of gender-
nonconforming and gender-dysphoric children suggests that gender identity
development can be a dynamic process that may not follow a predictable progres-
sion. While childhood gender nonconformity has been associated with developing
a lesbian, gay, bisexual, or other sexual minority sexual identity, as well as trans-
gender gender identity development, not all gender-nonconforming children will
identify with these communities.
Gender nonconformity exists on a spectrum or continuum, with some chil-
dren exhibiting strong nonconformity and others exhibiting less. Once children
reach preschool age, culturally based gender stereotypes begin to solidify and
form rigid gender rules that are reinforced over the life span. Such stereotypical
gender rules have negative social implications for gender-nonconforming chil-
dren, including rejection and ridicule by others and family disapproval and
abuse. These experiences often place gender-nonconforming children at higher
risk for emotional and behavioral issues than their gender-conforming peers.
Research examining mental health protective factors for gender-
nonconforming people suggests that parental acceptance of gender identity and
expression in childhood and adolescence increases positive and decreases nega-
tive health outcomes in adulthood. Other research suggests that social accep-
tance of gender nonconformity can be mediated by early education and ongoing
exposure to the diversity of gender expression and identity. What this boils
down to is gender diversity is a cultural issue influenced by social constructs
that are taught and continually reinforced by societal gender rules. In order for
Childhood Gender Nonconformity 111
gender-nonconforming children to develop to their full potential, they need to
feel valued and seen as a legitimate part of the cultures in which they live. Such
a shift in culture begins with normalizing and educating everyone about the
complexities of gender and sexual development beyond the historical binary
view.
Rachel Becker-Warner, Leonardo Candelario-Pérez,
G. Nic Rider, and Dianne Berg
See also: Binary Gender System; Childhood Sexuality; Gender; Gender Dysphoria; Gen-
der Expression; Gender Identity; Gender Identity Development; Gender Roles, Socializa-
tion and; Nonbinary Gender Identities; Stereotypes, Gender; Stereotypes, Sexual;
Transgender.
Further Reading
Becerra-Culqui, T. A., Liu, Y., Nash, R., Cromwell, L., Flanders, W. D., Getahun, D., …
Goodman, M. (2018). Mental health of transgender and gender nonconforming
youth compared with their peers. Pediatrics, 141(5), e20173845.
Brill, S., & Pepper, R. (2008). The transgender child: A handbook for families and profes-
sionals. San Francisco: Cleis Press.
Bussey, K., & Bandura, A. (1999). Social cognitive theory of gender development and dif-
ferentiation. Psychological Review, 106(4), 676–713.
Ehrensaft, D. (2016). The gender creative child: Pathways for nurturing and supporting
children who live outside gender boxes. New York: The Experiment.
Huston, A. C. (1983). Sex typing. In E. M. Hetherington (Ed.), Handbook of child psy-
chology: Socialization, personality, and social development (387–467). New
York: Wiley.
Kohlberg, L. (1966). A cognitive-developmental analysis of children’s sex-role concepts
and attitudes. In E. E. Maccoby (Ed.), The development of sex differences (82–
173). Stanford, CA: Stanford University Press.
Kowalski, K. (2007). The development of social identity and intergroup attitudes in young
children. In O. N. Saracho & B. Spodek (Eds.), Contemporary perspectives on
social learning in early childhood education (51–84). Charlotte, NC: Information
Age.
Lev, A. I. (2005). Disordering gender identity: Gender identity disorder in the DSM-IV-
TR. Journal of Psychology and Human Sexuality, 17, 35–69.
Martin, C. L., & Ruble, D. N. (2004). Children’s search for gender cues: Cognitive per-
spectives on gender development. Current Directions in Psychological Science,
13, 67–70.
National Center for Gender Spectrum Health. (2019). Retrieved from https://www.sexual-
health.umn.edu/national-center-gender-spectrum-health
Roberts, A. L., Rosario, M., Corliss, H. L., Koenen, K. C., & Austin, S. B. (2012). Child-
hood gender nonconformity: A risk indicator for childhood abuse and posttrau-
matic stress in youth. Pediatrics, 129(3), 410–417.
Ruble, D. N., Taylor, L. J., Cyphers, L., Greulich, F. K., Lurye, L. E., & Shrout, P. E.
(2007). The role of gender constancy in early gender development. Child Develop-
ment, 78, 1121–1136.
Ryan, C., Russell, S. T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in
adolescence and the health of LGBT young adults. Journal of Child and Adoles-
cent Psychiatric Nursing, 23, 205–213.
112 Childhood Sexuality
Siegal, M., & Robinson, J. (1987). Order effects in children’s gender-constancy responses.
Developmental Psychology, 23(2), 283–286.
Silverberg, C. (2015). Sex is a funny word: A book about bodies, feelings and YOU. New
York: Seven Stories Press.
Thorne, B. (1993). Gender play: Girls and boys in school. New Brunswick, NJ: Rutgers
University.
Wallien, M. S. C., & Cohen-Kettenis, P. T. (2008). Psychosexual outcome of gender-
dysphoric children. Journal of the American Academy of Child & Adolescent Psy-
chiatry, 47(12), 1413–1423.
Zucker, K. J., & Bradley, S. J. (1995). Gender identity disorder and psychosexual prob-
lems in children and adolescents. New York: Guilford.
Zucker, K. J., Bradley, S. J., Kuksis, M., Pecore, K., Birkenfeld-Adams, A., Doering,
R. W., … Wild, J. (1999). Gender constancy judgments in children with gender
identity disorder: Evidence for a developmental lag. Archives of Sexual Behav-
ior, 28, 475–502.
Zucker, K. J., Wood, H., Singh, D., & Bradley, S. J. (2012). A developmental, biopsycho-
social model for the treatment of children with gender identity disorder. Journal of
Homosexuality, 59, 369–397.
Childhood Sexuality
Humans are born with an innate sense of sexual pleasure, and sexual development
starts even before birth. From birth, boys are able to experience erections, and
girls’ vaginas are able to lubricate. This can be very uncomfortable information
for most adults to comprehend. Childhood sexuality has been studied for centu-
ries by the likes of Sigmund Freud and Alfred Kinsey, but recently (in the 2000s)
more attention has been paid to childhood sexuality due in part to the surge of
research on childhood sexual abuse. Here we will go over healthy sexual develop-
ment in children (birth to twelve years old) and warning signs of unhealthy sexual
development and offer information for parents, caregivers, and counselors.
It is important to understand what healthy sexual development looks like in
childhood. Children of all ages are curious by nature and want to learn more about
themselves and the world around them. This is true for many things, including
their bodies and sexuality. At a young age, children start to explore their own bod-
ies and may be curious about other bodies, especially those that are different from
their own. This behavior is not sexually motivated, as children at this age do not
have the concept of sexuality that develops in later life. Instead, they are moti-
vated by curiosity, and it is important to remember that this curiosity is perfectly
normal, and overreacting can lead to shame and guilt in the child, which can have
effects lasting into adulthood. Below, some healthy behaviors and their associated
ages are described.
From birth to age four, babies and young children use their senses to explore
and quickly learn that certain areas of their bodies are more pleasurable to touch
than others. During this time, parents may see children exploring and touching
their genitals, rubbing their genitals with their hands or objects, showing off their
genitals, trying to touch breasts, having a desire to be naked, trying to watch
Childhood Sexuality 113
others when they are undressing, asking questions about bodies, and talking to
their peers about bodily functions. Children still wearing diapers will oftentimes
touch their genitals while their diapers are being changed. Around age two or
three, children will start to understand their own gender and some of the differ-
ences between genders as they begin to develop their own gender identity.
Between the ages of four and six years, children may touch themselves on pur-
pose (sometimes in front of others), attempt to see others naked, imitate dating
behavior such as kissing or holding hands, talk about genitals and use “naughty”
words, and explore their bodies with their peers.
Between the ages of seven and twelve years old, children will masturbate and
explore their genitals mainly in private, play games with children that involve
sexual behaviors (e.g., kissing games like Spin the Bottle), attempt to see others
naked, look at sexualized pictures, watch or listen to sexual content, want more
privacy, and begin to develop sexual attraction to others. As children reach this
age, their curiosity is still high, but they tend to become more private about their
exploration. They also become more curious about adult behavior and may start to
copy what they see adults doing.
Sometimes children’s behavior falls outside the realm of typical sexual explora-
tion. Signs of potentially unhealthy behavior include behaviors that are beyond the
child’s developmental stage; involve threats, force, coercion, or aggression; involve
children of wide age ranges; and provoke negative emotional reactions in the
child. If behavior is taking place with any of these signs, it could be a warning of
sexual trauma or problematic sexual behavior.
It is common for parents and caregivers to become worried about their chil-
dren’s behavior, especially if they have not been taught what to expect and what is
considered developmentally healthy. It is important to remember that it is com-
mon for children who play together often to become curious about each other. If
the children are around the same age and the sex play is unplanned, infrequent,
voluntary, and easily stopped, then it can generally be considered typical child-
hood sexual play and exploration. How an adult reacts to seeing children involved
in sexual play can make a big difference. It is important for adults to stay calm,
composed, and nonjudgmental. A parent or caregiver can use this time as a teach-
ing moment for the child or children. Open-ended questions asked in a calm voice
are encouraged when discussing what took place. When children are engaged in
honest, open, and educational discussion, they will learn the importance of healthy
sexual expression and behavior. As parents, it is important to have ongoing healthy
sexuality conversations with children as they grow and mature.
Amanda Baker
See also: Adolescent Sexuality; Child Sexual Abuse; Childhood Gender Nonconformity;
Gender Identity Development; Sexual Health; Sexuality across the Life Span.
Further Reading
American Academy of Pediatrics. (2016). Sexual behaviors in young children: What’s
normal, what’s not? Retrieved from https://www.healthychildren.org/English/
ages-stages/preschool/Pages/Sexual-Behaviors-Young-Children.aspx
Cavanagh Johnson, T. (1999). Understanding your child’s sexual behavior: What’s natu-
ral and healthy. Oakland, CA: New Harbinger.
114 Chlamydia
Dowshen, S. (2014). Understanding early sexual development. Retrieved from http://
kidshealth.org/parent/growth/sexual_health/development.html
National Child Traumatic Stress Network. (2009). Sexual development and behavior in
children. Retrieved from http://nctsn.org/nctsn_assets/pdfs/caring/sexualdevelop
mentandbehavior.pdf
SexInfo Online. (2018). Childhood sexuality. Retrieved from http://www.soc.ucsb.edu/
sexinfo/article/childhood-sexuality
Thanasiu, P. L. (2004). Childhood sexuality: Discerning healthy from abnormal sexual
behaviors. Journal of Mental Health Counseling, 26(4), 309–319.
Chlamydia
Chlamydia is a sexually transmitted infection (STI) caused by the gram-negative
bacterium Chlamydia trachomatis. It can infect the penis, vagina, cervix, anus,
urethra, eye, or throat. According to the Centers for Disease Control and Preven-
tion (CDC), it is the most commonly reported STI in the United States.
Chlamydia can be spread from the anus, penis, mouth, or vagina of an infected
individual. It is typically transmitted through sexual contact by an infected part-
ner. On rare occasions, touching the eye after touching an infected body part can
cause transmission.
Transmission occurs when the Chlamydia trachomatis bacterium infect mucus
membranes. Ejaculation does not have to occur for the disease to be transmitted.
It is also possible for chlamydia to be passed from a pregnant person to their fetus
during delivery. This can result in pneumonia or conjunctivitis in a newborn.
Chlamydia is also known as the “silent” infection because most infected indi-
viduals are asymptomatic. For people who experience symptoms, they can begin
as early as five days after exposure, or they may not appear for several weeks.
Rectal infection can potentially cause proctitis symptoms, while chlamydia eye
infections may cause conjunctivitis, and throat infections can cause soreness.
For infected females, symptoms may include yellowish vaginal discharge,
abdominal pain, bleeding between menstrual periods, painful intercourse, and
irritation. Symptoms of cervicitis and urethritis are common. Males infected
with chlamydia also commonly experience urethritis, often accompanied with
pus or a milky or watery urethral discharge. Less frequently, males may expe-
rience epididymis. Males and females may experience frequent or painful
urination.
Chlamydia can be diagnosed by a health care professional in several ways. If an
individual is exhibiting symptoms, it might be possible to make a visual diagno-
sis. They may also use a swab to get cell samples from the penis, cervix, urethra,
or anus. Urine can also be tested to detect the infection.
It is important to treat chlamydia, as it can result in severe complications. In
females, if left untreated, it can spread from the cervix to the uterus and fallopian
tubes, causing pelvic inflammatory disease, damage to the oviducts, chronic pel-
vic pain, and infertility.
Chlamydia infection can be cured through antibiotic treatments such as azithro-
mycin or doxycycline. Any person taking antibiotics should abstain from sexual
activity for at least seven days to prevent spreading the infection. According to the
Chromosomal Sex 115
CDC, people who were treated for chlamydia should be retested three months
after treating the initial infection.
Several measures can be taken to prevent contracting or transmitting chla-
mydia. Abstaining from sexual intercourse will prevent transmission. For sexu-
ally active individuals, using condoms and other barriers can greatly reduce the
risk of transmission. Getting regularly tested for STIs can also help prevent the
spread of the infection.
If someone has chlamydia, treatment and partner notification can help prevent
complications from the infection as well as transmission to others. According to
the CDC, persons diagnosed or being treated with chlamydia should tell all sexual
partners within sixty days of the diagnosis or onset of symptoms.
Sarah Gannon
See also: Infertility; Pelvic Inflammatory Disease (PID); Safer Sex; Sexually Transmitted
Infections (STIs); Testing, STI.
Further Reading
Centers for Disease Control and Prevention. (2016). Chlamydia: CDC fact sheet (detailed).
Retrieved from http://www.cdc.gov/std/chlamydia/stdfact-chlamydia-detailed.htm
Centers for Disease Control and Prevention. (2017). Chlamydia. Retrieved from https://
www.cdc.gov/std/chlamydia/default.htm
Jones, R. E., & Lopez, K. H. (2014). Human reproductive biology (4th ed.). San Diego,
CA: Academic Press.
Mayo Clinic. (2019). Chlamydia trachomatis. Retrieved from https://www.mayoclinic
.org/diseases-conditions/chlamydia/symptoms-causes/syc-20355349
Planned Parenthood (2019). Chlamydia. Retrieved from https://www.plannedparenthood.
org/learn/stds-hiv-safer-sex/chlamydia
Chromosomal Sex
“Chromosomal sex” refers to the physical sexual characteristics that an individual
has as a result of the chromosomes in their cells. Sexual characteristics may be
male, female, or intersex (a mix of male and female). Chromosomes are threadlike
structures that carry genes, sequences of molecules made of deoxyribonucleic
acid (DNA). Combinations of different types of genes, each made of specific com-
binations of DNA, determine physical and behavioral characteristics that off-
spring inherit from parents.
Sex is not the same as gender. “Gender” refers to the sense an individual has of
being male, female, or any other gender identity. Some people may have the physi-
cal sexual characteristics of a male but the psychological gender identity of a
female or vice versa.
An individual’s physical sex is set at conception, the moment after sexual inter-
course, when the egg cell is fertilized by the sperm cell. The egg and the sperm
each contain twenty-three chromosomes, including one chromosome that deter-
mines the offspring’s sex. The sex chromosome carried by the egg cell is called an
X chromosome because of its X-like shape. The sperm cell may have either an X
sex chromosome or a Y sex chromosome (also named based on its shape). If a
sperm with an X chromosome fertilizes the egg, the offspring will have female
116 Circumcision
(XX) chromosomes. If a sperm with a Y chromosome fertilizes the egg, the off-
spring will have male (XY) sex chromosomes.
Chromosome-caused sexual differences become obvious during puberty, which
starts at approximately age ten to twelve in females and age twelve to fourteen in
males. The physical changes of either male or female sexual development are trig-
gered by the increased production of chemical substances called hormones, which
are coded for by genes on the X or Y chromosome. Male sexual development,
including facial hair and a deeper voice, is triggered by the hormone testosterone.
Female sexual development, including breast growth and wider hips, is triggered
by the hormone estrogen.
Not all people are born with either XX or XY chromosomes. In some cases, a
parent’s sperm or egg cells are generated in an abnormal process of cell division
called nondisjunction. If such parental sex cells become fertilized, the offspring’s
cells will have less than, or more than, the usual number of chromosomes. The
general name for such abnormal chromosome conditions is aneuploidy. The most
common type of aneuploidy in human beings is an intersex condition called Kline-
felter syndrome, in which individuals are born with an extra X chromosome
(resulting in an XXY chromosome combination). These individuals usually have
male genitalia along with enlarged breasts, sparse facial and body hair, and other
typically female physical traits. Klinefelter syndrome occurs in from 1 in 500 to 1
in 1000 newborn males.
In contrast to the chromosomal basis of sex determination, gender identity is
determined by a combination of biochemical factors present at birth, ways in which
individuals are raised during childhood, and cultural influences. Evidence suggests
that gender identity is set by about age four or five in most individuals, though
some individuals continue to explore their gender identity into adulthood. Some
influences on a child’s gender identity include their preferred types of toys, clothes,
and chores, as well as pop culture influences like television shows, music, and fash-
ion trends. Individuals whose psychological gender differs from their physical sex
may identify as transgender. Some transgender people undergo hormone and surgi-
cal treatments so that their physical sex matches their gender identity.
A. J. Smuskiewicz
See also: Biological Sex; Intersexuality; Sex Chromosomes; Sex Hormones; X Chromo-
some; Y Chromosome.
Further Reading
Beasley, C. (2005). Gender and sexuality: Critical theories, critical thinkers. Thousand
Oaks, CA: SAGE.
Fausto-Sterling, A. (2012). Sex/gender: Biology in a social world. London: Routledge.
Richardson, S. S. (2013). Sex itself: The search for male and female in the human genome.
Chicago: University of Chicago Press.
Circumcision
Circumcision is a surgical procedure done to remove the foreskin that covers the
tip of the penis. This is usually done within ten days after birth, with painkilling
Circumcision 117
medicine applied to the penis beforehand. It is fairly common in the Muslim world
and in Israel, South Korea, the United States, and parts of Southeast Asia and
Africa. Almost all boys in the Middle East and Central Asia are circumcised. It is
fairly rare in Europe, Latin America, parts of Southern Africa and Oceania, and
other parts of Asia. After the newborn period, circumcision is a more complex
procedure, more costly, and more likely to incur complications like infection.
Circumcision is usually an elective surgery performed for religious or cultural
reasons. Circumcision is part of religious law in Judaism and is a traditional prac-
tice in Islam, Coptic Christianity, and the Ethiopian Orthodox Church. About
37–39 percent of males worldwide are circumcised, about half for religious or
cultural reasons. At the turn of the twentieth century, a circumcised penis became
a mark of distinction in the United States. It was considered a sign of good breed-
ing, sound hygiene, and middle-class medicine. This was primarily a social con-
vention and not supported by medical necessity, although circumcision was
considered by some as a remedy for many conditions, including epilepsy, paraly-
sis, malnutrition, disruption of the digestive organs, chorea, convulsions, hysteria,
and other nervous disorders, in addition to a curb to masturbation.
There are some individuals and advocacy groups who are opposed to circumci-
sion, saying that it should not be done without the child’s consent, that it has the
potential to reduce sexual pleasure, and that it risks causing injury to the penis. In
the United States, the rate of complications with newborn circumcision is low, rang-
ing between 0 percent and 3 percent. There are places (e.g., Iceland, South Africa,
Germany, Denmark, San Francisco) where legislators have introduced bills to out-
law the procedure, but these laws have not been passed. According to the Centers for
Disease Control and Prevention, the rates of circumcision in the United States
declined from the 1970s to the early 1990s but have been increasing since the late
1990s, and currently about 60 percent of newborn boys are circumcised.
The American Academy of Pediatrics (AAP) says the benefits of circumcision
outweigh the risks. The AAP leaves the circumcision decision up to parents and
supports the use of anesthetics for infants who have the procedure. They have
identified research on some of the health benefits of circumcision, including
• a slightly lower risk of urinary tract infections
• some protection from penile cancer
• reduced likelihood of developing sexually transmitted infections, including HIV
• a reduced risk for cervical cancer in female partners of circumcised men
The World Health Organization says circumcision reduces the risk of heterosexual
men contracting HIV by around 60 percent. In Tanzania, which has a high rate of
HIV infection, it has been suggested that any uncircumcised member of Parlia-
ment should be circumcised as a way to raise awareness of the health benefits of
circumcision. In Kenya, some top politicians volunteered for the procedure in
2008 as a way of inspiring men from their districts to do the same. There are a few
other medical reasons for circumcision, including phimosis, a condition where the
foreskin is so tight that it prohibits retraction of the foreskin over the head (glans)
of the penis. This can make it difficult to clean under the foreskin, leading to the
118 Cisgender
glans becoming infected or inflamed (balanitis), and it may also cause a lack of
sensation during sexual intercourse.
Michael J. McGee
See also: Female Genital Cutting; Foreskin; Penis; Phimosis; Religion, Diversity of
Human Sexuality and; Sexually Transmitted Infections (STIs).
Further Reading
American Academy of Pediatrics Task Force on Circumcision. (2012). Circumcision pol-
icy statement. Pediatrics, 130(3), 585.
Bailey, R. C., Egesah, O., & Rosenberg, S. (2008). Male circumcision for HIV prevention:
A prospective study of complications in clinical and traditional settings in Bun-
goma, Kenya. Bulletin of the World Health Organization, 86, 669–677.
Centers for Disease Control and Prevention (CDC). (2011). Trends in in-hospital newborn
male circumcision—United States, 1999–2010. Morbidity and Mortality Weekly
Report, 60(34), 1167.
Gollaher, D. L. (2000). A history of the world’s most controversial surgery. New York:
Basic Books.
Morris, B. J., Wamai, R. G., Henebeng, E. B., Tobian, A. A., Klausner, J. D., Banerjee, J.,
& Hankins, C. A. (2016). Estimation of country-specific and global prevalence of
male circumcision. Population Health Metrics, 14(1), 4.
Cisgender
“Cisgender” is a term popularized in the mid-2010s to refer to individuals whose
gender identity matches their physical sex. Individuals who were born physically
male and gender identify as male, and individuals who were born physically
female and gender identify as female, are considered to be cisgender. This term
began being used by many LGBT activists, as well as by academics, to distinguish
the sexual identification of the majority of the population from that of the minority
of people who identify themselves as nonbinary, gender diverse, or transgender. A
transgender female is an individual who was born physically male but whose gen-
der identity is female, and a transgender male is an individual who was born phys-
ically female but whose gender identity is male.
Most estimates suggest that more than 99 percent of the people in the United
States have a gender identity that coincides with their physical sex—that is, they
are cisgender—and that roughly 0.5 percent of Americans consider themselves
transgender.
Prior to the sociopolitical and cultural popularization of transgender aware-
ness in the United States and other Western nations, the term “cisgender” was
not widely known. The expression was adopted by some activists and scholars
based on the Latin meaning of “cis,” which is “on this side of”—in contrast to
“trans,” which means “on the other side of.” The editors of the Oxford dictionar-
ies added “cisgender” to their publications in 2013. However, biologist Dana
Leland Defosse of the University of Minnesota is on record as using the term as
early as 1994.
Many linguistic authorities express doubts about the widespread and long-
term use of “cisgender” as a description for the gender identification of the
majority of the population. They note that whereas “trans” has long been used as
Civil Union 119
a generally understood prefix for many words—such as transport, translate, and
transparent—the preface “cis” has never been generally understood or widely
used in the English language. As lexicographer Kerry Maxwell has noted, if a
newly minted word is not “user-friendly”—easy and comfortable to use, famil-
iar, and understandable—it is unlikely to have longevity within the culture.
A. J. Smuskiewicz
See also: Gender; Gender Diversity; Gender Identity; Transgender.
Further Reading
Blank, P. (2014, September). Will “cisgender” survive? The Atlantic. Retrieved from
http://www.theatlantic.com/entertainment/archive/2014/09/cisgenders-linguistic
-uphill-battle/380342/
Brydum, S. (2015, July). The true meaning of the word “cisgender.” The Advocate.
Retrieved from http://www.advocate.com/transgender/2015/07/31/true-meaning
-word-cisgender
Chalabi, M. (2014). Why we don’t know the size of the transgender population.
Retrieved from http://fivethirtyeight.com/features/why-we-dont-know-the-size
-of-the-transgender-population/
Steinmetz, K. (2014, December). This is what “cisgender” means. Time. Retrieved from
http://time.com/3636430/cisgender-definition/
Civil Union
On June 26, 2015, in a historic 5–4 ruling, the U.S. Supreme Court ruled that
states cannot ban same-sex marriage, thus allowing same-sex couples to marry.
Prior to this momentous ruling, same-sex couples struggled to gain the same
rights as mixed-sex couples to form long-term unions. One way that gay rights
advocates and politicians tried to circumvent hostility toward what was termed
“gay marriage” was to create another type of union. Civil unions, or domestic
partnerships in some states, became the alternative. A civil union is a legal status
that provides some of the same protections as civil marriage, but these protections
are only provided at the state level. Federal provisions, such as Social Security
benefits and tax breaks for married couples, are unavailable to couples of civil
unions. Vermont created the first civil union law in 2000, and several other states
followed suit in the following years. Other states that passed civil union laws
include Colorado, Hawaii, Illinois, New Jersey, Connecticut, Delaware, New
Hampshire, and Rhode Island. When same-sex marriage was legalized in Ver-
mont, Connecticut, Delaware, New Hampshire, and Rhode Island, civil unions
were converted to marriages.
Proponents of civil unions said that these unions would help to solve certain
problems faced by same-sex couples, such as hospital visitation rights and the
transfer of property. It was a way to give same-sex couples equality while avoiding
the controversial issue of religion and marriage. However, there were many differ-
ences between civil unions and civil marriages. Civil marriage is defined as a legal
status conferred by and recognized by governments all over the world with certain
rights, obligations, and protections. But it is also a cultural institution; it is recog-
nized as the ultimate expression of love and commitment between two people.
120 Clitoris
Civil marriages are recognized in all fifty states. And although civil unions
have legal status, these unions were recognized only within the states that had
legalized civil unions. Married couples can obtain a divorce in any state in which
they reside; however, couples in a civil union could only end the relationship in
states that recognize these civil unions. The federal government gives over 1,100
legal protections, including the right to take a leave from work to care for a family
member, the right to sponsor a spouse to immigrate to the United States, income
tax deductions and credits, Medicaid benefits, and Social Security benefits, which
can often mean the difference between poverty and financial security in a couple’s
retirement years. Civil unions did not have these legal protections. Because the
federal government did not recognize civil unions, many state and federal govern-
mental functions were not clearly defined, including such issues as taxation, pen-
sion protections, insurance for families, and Medicare and Medicaid benefits.
Finally, couples in civil unions lived a second-class status. The word “marriage”
mattered to many proponents of gay marriage. Even if there were no differences
between civil unions and civil marriages, gay marriage proponents believed that
the separate status for gay people conveyed inequality.
Amy Reynolds
See also: Gay Rights Movement; Marriage; Same-Sex Marriage.
Further Reading
Eskbridge, W. N., Jr. (2002). Equality practice: Civil unions and the future of gay rights.
New York: Routledge.
Krieger, D. (2014). Denmark’s civil unions: One giant leap for mankind. Wilson Quar-
terly. Retrieved from https://www.wilsonquarterly.com/quarterly/summer-2014
-1989-and-the-making-of-our-modern-world/denmarks-civil-unions-one-giant
-leap-for-mankind/
Soloman, M. (2014). Winning marriage: The inside story of how same-sex couples took on
the politicians and pundits—And won. Lebanon, NH: University Press of New
England.
Clitoris
The clitoris is an organ found in biological females whose sole purpose is to pro-
vide sexual pleasure—the only organ in either males or females with this sole
function. The clitoris is analogous to the male penis. Both organs develop from
the same fetal structure, and both are composed of a glans, a shaft (containing two
cavernous bodies), and crura anchoring them into the pubic bone. The external
portion of the clitoris, the glans, is located at the top of the vulva, underneath the
clitoral hood as a fibro-vascular cap. The glans, which is often considered incor-
rectly to be the entire clitoris and is often referred to as button-like, is external,
whereas the shaft and crura are internal. The glans is usually the size and shape of
a pea, although there is much variation, and some are much larger or smaller. The
internal portion of the clitoris is actually much larger than people might expect
and expands through the body on either side of the vaginal opening. As a whole,
the clitoris is comprised of the glans, the hood, the clitoral body, two clitoral crura,
and the vestibular bulbs.
Clitoris 121
As a fetus grows and develops during pregnancy, the sexual organs develop
from a part known as the “genital tubercle.” If the fetus is male, the tubercle devel-
ops into the penis. If the fetus is female, it first develops into two separate corposa
carnova. They then combine into the clitoris as the fetus develops further.
When compared to the penis, the clitoris has a similar anatomical structure.
The penis has been seen anatomically as an extended clitoris that contains a
urethral opening (while the urethra in female anatomy lies between the clitoris
and the vagina). The head or glans of the penis and the clitoris are both highly
sensitive to stimulation and are major sources of sexual pleasure. Due to the
external location of the glans of the clitoris, it is easily sexually stimulated. The
clitoris is estimated to contain more than 8,000 nerve endings and is often
argued to have as many as twice the number as the penis (although the debates
and opinions vary).
In some cultures, the clitoris is removed for a variety of social and religious
reasons; this may be known as female genital cutting, female genital mutilation,
or female circumcision. The World Health Organization has recognized Africa as
having the greatest prevalence of this practice, with millions of women having
undergone the procedure. Such practices are outlawed in many places around the
world, including Britain, the United States, Canada, France, Norway, Sweden, and
Switzerland.
For many years, the clitoris was not well understood and was considered by
some to be a rudimentary nonfunctioning part of the body. During the 1960s and
1970s, understanding of the clitoris began to change, due in part to the influence
of feminist activists, and this contributed to a new vision of female sexuality and
the female orgasm. Previously, there had been long-standing myths that women’s
orgasms came purely through vaginal stimulation. Sigmund Freud argued that
clitoral stimulation (through masturbation) represented an immature stage of
development, and for a woman to achieve maturity, her sexual interests must shift
to the vagina. However, we now know that contrary to many beliefs (especially in
previous decades) the more common cause of orgasm in females is through clito-
ral stimulation and not vaginal penetration. Interestingly, because the bulbs of the
clitoris lie on either side of the vagina, stimulation can often occur through vagi-
nal penetration, which may have led to the assumption of vaginal penetration
being the cause of orgasm. Many sex toys for women focus on clitoral stimulation
through vibration or combine vibration with vaginal penetration.
Callum E. Cooper
See also: Erogenous Zones; Female Genital Cutting; Female Sexuality; Orgasm; Sex
Toys.
Further Reading
Davis, D. K., McCafferty, C., & Momoh, C. (2005). Female genital mutilation. London:
Radcliffe.
Dutta, D. C. (2014). Textbook of gynecology. London: JP Medical.
Freud, S. (1991). Introductory lectures on psychoanalysis. London: Penguin.
O’Connell, H. E., Sanjeevan, K. V., & Hutson, J. M. (2005). Anatomy of the clitoris. The
Journal of Neurology, 174, 1189–1195.
Pomeroy, W. B. (1986). Girls and sex. Middlesex, UK: Penguin.
122 Colposcopy
Colposcopy
Colposcopy is a gynecological procedure used to more closely examine the cervix
for signs of abnormality and disease after a Pap smear (a screening test for cervi-
cal cancer) has come back with abnormal results. The colposcopy procedure is
both well regarded in the medical industry and fairly common practice—each
year, approximately 2–3 million colposcopies are performed in the United States
alone.
A special low-powered microscope called a colposcope is used to perform a
colposcopy. During the procedure, a patient will lie face up on the exam table with
legs spread, much like during a regular pelvic exam. An instrument called a spec-
ulum is inserted into the vagina to keep the vaginal walls open and make the cer-
vix more visible. Then, the colposcope is placed a few inches away from the
vaginal opening and is used to conduct a magnified examination of the vagina,
vulva, and cervix. If a practitioner sees any abnormal or suspicious-looking cell
growth, a small sample of tissue (biopsy) is collected and sent for laboratory test-
ing. It is not unusual for several samples to be collected from different areas of the
vagina and cervix during a colposcopy. It usually takes one to two weeks to con-
firm the results of the biopsy.
There are several reasons to perform a colposcopy following an abnormal Pap
smear. The procedure may be recommended if irregular vaginal bleeding is occur-
ring or if an abnormal growth has appeared on the cervix or vagina. A colposcopy
may also be recommended if a woman has genital warts or human papillomavi-
rus, a common sexually transmitted infection that can cause cervical cancer. Any
inflammation or irritation in the cervix may also be cause for a colposcopy. The
test can reveal abnormal patterns in the blood vessels, swollen or atrophied areas
of the vagina and cervix, precancerous changes in the tissues, and the presence of
both vaginal and vulvar cancer. Although procedural risks are minimal, a colpos-
copy can result in such complications as infection, severe pelvic pain, and heavy
vaginal bleeding.
The colposcopy was first introduced in Germany in 1924. Gynecologist and
researcher Dr. Hans Hinselmann spent several years experimenting with different
colposcopy techniques as he looked to find ways to detect cervical cancer in its
earliest stages. Although early colposcopy tools proved unwieldy and difficult to
use, by the 1950s a more advanced colposcope had been invented, and by the
1960s the procedure was being performed in the United States and elsewhere.
Although Hinselmann is hailed for pioneering the colposcopy, he is also reviled
by many, as it has been brought to light that much of his experimentation (aided by
Nazi SS doctor Eduard Wirths) occurred in concentration camps during World
War II and ended in often painful death for the subjects. In addition to his contro-
versial colposcopy work, at the end of World War II, Hinselmann was also found
guilty of forced sterilization of Roma (Gypsy) women in Germany.
Although the origins of the colposcopy are clouded with atrocious acts, the
procedure has in modern times become the “gold standard” for cervical cancer
detection and is nearly universally accepted as the most effective follow-up screen-
ing for cervical cancer after a Pap smear. In many developing nations where
Coming Out 123
colposcopies are not as readily available, cervical cancer remains a leading cause
of death from cancer, accounting for about 190,000 deaths per year.
Tamar Burris
See also: Cervical Cancer; Cervix; Human Papillomavirus (HPV); Pap Smear.
Further Reading
Hollen, K. H. (2004). The reproductive system. Westport, CT: Greenwood.
Paludi, M. A. (2014). The Praeger handbook on women’s cancers: Personal and psycho-
logical insights. Westport, CT: Praeger.
Coming Out
The concept of “coming out” was derived from the idea that one needed to “come
out of the closet,” or become unhidden around their sexual orientation, particu-
larly if they identified as other than heterosexual (gay, lesbian, bisexual, queer,
and others). While originally applied only to sexual orientation, “coming out” can
now refer to expressing any sexual- or gender-minority identity. Coming out is
first a personal, then public, affirmation of one’s sexual orientation or other iden-
tity, which involves many steps of personal growth and development but can also
involve other alternative lifestyles.
Though the phrase “coming out” was not used, the idea that one should be pub-
licly open about their sexual orientation has been credited to Karl Heinrich
Ulrichs. Born in 1825 in Germany, through his study and discovery of his own
homosexuality, Ulrichs felt strongly about being public about his identity, though
it was illegal. Though his family urged him to change his ways because they were
against God, he “defended his homosexuality as natural and said that because God
had given him his same-sex drive, he had the ‘right to satisfy it’” (Bullough, 1994,
p. 35).
The coming-out process, when speaking about personally and publicly reveal-
ing one’s sexual orientation or other identity, is different for everyone and may
vary according to socioeconomic status, immigrant status, race, class, and other
societal oppressing factors. In Homosexual Identity Formation: Testing a Theo-
retical Model (1984), theorist Vivienne Cass, through research, identified six
stages of the coming-out process for people identifying as homosexual: identity
confusion, identity comparison, identity tolerance, identity acceptance, identity
pride, and identity synthesis. These steps proceed from the individual questioning
their own sexual orientation, comparing their experience to that of other gay or
queer individuals, and eventually moving to find pride and support in who they
are as a gay or queer person.
For people who identify as transgender or gender nonconforming, there may be
a more complicated and longer process for people to feel congruency in their sex-
ual and gender identities. Dr. Aaron Devor (2004) created Witnessing and Mirror-
ing: A Fourteen Stage Model of Transsexual Identity Formation, which gave a
look into the proposed development of a person identifying as transgender: abid-
ing anxiety, identity confusion about originally assigned gender and sex, identity
124 Coming Out
comparisons about assigned gender and sex, discovery of transsexualism, identity
confusion about transsexualism, identity comparisons about transsexualism, tol-
erance of transsexual identity, delay before acceptance of transsexual identity,
acceptance of transsexualism identity, delay before transition, transition, accep-
tance of posttransition gender and sex identities, integration, and pride. Again,
these steps may be seemingly complete but do vary with time and ability for each
person as with the gay or queer coming-out process.
Coming out as polyamorous, or participating in an alternative lifestyle such as
kink or BDSM (bondage and discipline/dominance, submission/sadism and mas-
ochism) may also involve a process where people who engage in these relation-
ships want to be public; some may also just want to be out and open with family
and friends. Revealing this information may have some of the same consequences
as coming out as gay, queer, or transgender, such as losing support of family and
friends. Individuals going through the coming-out process may also require some
support, either professionally or from friends and family.
Some people decide to come out publicly immediately after personally realiz-
ing their sexual or gender identity. For others, the process takes more time. People
come out within these various identities depending on several factors—most
importantly, safety. For example, coming out or being public about a nonmonoga-
mous or polyamorous relationship can have negative implications if the people
involved have kids. For instance, if someone outside of their relationship sees their
relationship structure as a danger to the traditional family structure, they may
report the parents to social services. Transgender people who are out may experi-
ence violence and discrimination; some may even be denied housing or employ-
ment. Coming out as a gay teenager within a household that believes in a religion
that speaks against homosexuality may cause the loss of stable housing for that
child as well as loss of family or friend support for that individual.
Though coming out can be a difficult experience for many, there are some ways
to find support in the process so that feelings and situations around coming out
can be more manageable. First, finding a support group with other people who are
experiencing the same process is helpful in alleviating overwhelming feelings of
isolation, sadness, or depression. Individual therapy can be helpful, as can family
or couples therapy with a therapeutic service provider who is able to address the
particular needs at hand. The internet has provided increased visibility of various
sexual- and gender-minority orientations, identities, and lifestyles, and examples
of people coming out can be found on platforms such as YouTube, helping put
names, faces, and voices to a variety of experiences in the privacy of one’s own
space.
Shane’a Thomas
See also: Gender Diversity; Gender Identity; Homosexuality; Polyamory; Queer; Ques-
tioning; Sexual Identity; Sexual Orientation; Transgender; Ulrichs, Karl.
Further Reading
Bullough, V. (1994). Science in the bedroom: A history of sex research. New York: Basic
Books.
Cass, V. (1984). Homosexual identity formation: Testing a theoretical model. The Journal
of Sex Research, 20, 143–167.
Commission on Obscenity and Pornography 125
Devor, A. (2004). Witnessing and mirroring: A fourteen stage model of transsexual iden-
tity formation. Journal of Gay & Lesbian Psychotherapy, 8, 41–67.
Yarber, W. L., Sayad, B. W., & Strong, B. (2010). Human sexuality: Diversity in contem-
porary America (7th ed.). New York: McGraw-Hill.
Commission on Obscenity and Pornography
The Commission on Obscenity and Pornography—officially called the President’s
Commission on Obscenity and Pornography—was a group established by Con-
gress in 1967, with its eighteen members appointed by U.S. President Lyndon B.
Johnson in 1968, to examine the possible relationships between obscene and por-
nographic materials and antisocial behavior. The commission was also charged
with determining whether more effective methods were needed to limit the avail-
ability of such materials. The group released its final report in 1970 to Congress
and President Richard M. Nixon.
Members of the commission were considered to be experts in law, medicine,
religion, or culture. The commission’s chair was William B. Lockhart, an ordained
minister of the Disciples of Christ Church and Dean of the School of Law at the
University of Minnesota.
The commission tasked Danish criminologist Berl Kutchinsky with perform-
ing a scientific study on the criminal effects of pornography. Kutchinsky pub-
lished his results in 1970 as Studies on Pornography and Sex Crimes in Denmark.
His findings indicated that the legalization of pornography in Denmark did not
lead to an increase in sex-related crimes.
Reflecting the results of Kutchinsky’s study, the commission’s Report of the
Commission on Obscenity and Pornography, released in late 1970, found no evi-
dence that obscene or pornographic materials harmed individuals or led to social
problems or criminal actions among youth or adults. It concluded that no legal
restrictions on adult access to such materials were needed and that any existing
restrictions on such access be repealed. The commission further recommended
that sex education be provided in schools, that children’s access to pornography
remain restricted, and that more studies on pornography be funded.
A minority block of the commission, led by Charles Keating, an attorney named
to the commission by President Nixon to replace a Johnson-appointed member
who had resigned, drafted its own report opposing the majority’s conclusions,
calling them “moral anarchy.” Moreover, both the U.S. Senate, which was domi-
nated by Democrats, and President Nixon, a Republican, rejected the commis-
sion’s findings and recommendations.
The congressional and White House reactions to the commission’s report can
best be understood when placed in the context of the generally socially conserva-
tive nature of the times. President Nixon had been elected in 1969 on a platform of
restoring “law and order” to a nation reeling in youthful rebellion against the Viet-
nam War and the traditional social conventions of the older generation, which was
still in charge of most institutions.
Over the succeeding years, society’s attitudes have changed. In the internet age,
pornography is far easier and cheaper to access today than it was in the 1970s. The
126 Communication, Sexual
commission’s findings are now seemingly accepted by most people in the much
more sexually permissive modern-day United States. And the commission’s find-
ings continue to influence government policy and laws regarding obscenity and
pornography.
A. J. Smuskiewicz
See also: Pornography; Sex Education.
Further Reading
Brenner, R. (2011, May). Sins of commission: The 40th anniversary of the illustrated
presidential report of the Commission on Obscenity and Pornography. Huffington
Post. Retrieved from https://www.huffpost.com/entry/sins-of-commission-the
-fo_b_779849?guccounter=1
Kemp, E. (Ed.). (1970). The illustrated presidential report of the Commission on Obscen-
ity and Pornography. San Diego, CA: Greenleaf Classics.
Communication, Sexual
Sex is everywhere—from movies and TV to advertisements and magazines. On a
daily basis, messages about sex are communicated to people by the media and
society at large. But, despite messages about sex being so common, people find it
difficult to talk about sex. Sexual communication is, at its most basic level, any
information related to sex and sexuality that we send out or receive. This informa-
tion can come from the media, as mentioned, but it also comes from partners,
friends, and other important people, such as parents and family. Some people will
also receive messages about sex in more formal settings like schools or religious
associations. All this information shapes a person’s understanding and beliefs
about sexuality, which in turn shapes how sex is communicated in general.
Many people find talking about sex to be uncomfortable and difficult; they may
even feel embarrassed or ashamed. While there are many possible reasons for this,
there are some general ones too. Talking about sex is seen as taboo by many peo-
ple in Western culture, and the attitudes and norms of society often influence what
individuals think and how they behave. Past experiences can also influence how
people feel when they talk about sex. Children who are taught at a young age that
sex is something negative that should be avoided often grow up believing these
messages and may find it more difficult to discuss the topic with others (like their
partners and even their doctors) when older. However, even people who have rela-
tively positive views about sex often experience discomfort when talking about
their sexuality with others. Talking about sex, especially with a partner whose
opinion is valued, can be a very vulnerable experience and can leave one open to
the possibility of rejection.
Because many people feel uncomfortable talking about sex, most sexual com-
munication in intimate relationships occurs nonverbally. Rather than using words
to express sexual interest, behaviors like sexual touching or removing clothing are
often used to initiate sex. While this strategy often works, it can also be problem-
atic. Talking about sex with one’s sexual partners is important for many reasons.
To begin with, talking about sex is important for health and the health of one’s
Communication, Sexual 127
partners. Ideally, before engaging in sexual activities, partners should discuss
things like condom use, birth control, and other safer sex practices to prevent the
transmission of sexually transmitted infections and unintended pregnancies.
Numerous studies have shown that couples who talk about using condoms are
more likely to actually use them. Talking about sex can also help to increase sex-
ual enjoyment and satisfaction. Researchers have found that when one partner is
able to explain their sexual preferences to their partner, the partner’s understand-
ing increases, leading to greater sexual satisfaction. By discussing what one likes,
wants, and even things they would like to try, sex becomes more fun and pleasur-
able. Talking about sex among partners has also been shown to increase satisfac-
tion within the relationship and to build intimacy among partners. Talking about
sex in a positive and productive way with one’s partner may even have a greater
impact on relationship satisfaction than other types of communication between
partners. It should also be noted that sexual communication is important for all
couples, and there are no differences in communication between same-sex and
mixed-sex couples.
Given that sexual communication can have a significant effect on personal
lives and on the success of one’s relationships, it is important to consider what
makes sexual communication effective. First, it is important to recognize that
the beliefs and experiences of both partners will affect what they think and say
about sex. So, if one partner wishes to discuss sex in an open and frank manner,
while the other partner tends to be more reserved, the couple may face commu-
nication difficulties right from the start. Therefore, people need to be aware of
their own sexual communication style as well as the style of the person with
whom they are speaking. Second, expectations about sexual communication
matter. If people begin a difficult discussion expecting it to go poorly, research
suggests that it might; on the contrary, positive expectations may be more likely
to result in a positive conversation. Finally, how partners relate to each other
during sexual conversations also affects the success of the discussion. Good
listening skills, being able to take the other’s perspective into consideration, and
being aware of how messages and tone of voice affect sensitive sexual conversa-
tions are a few things that can improve sexual communication. Fortunately for
those who dread talking about sex with their partners, communication skills can
be learned and developed throughout the course of one’s life, making it easier to
have these discussions and potentially leading to a more satisfying sex life and
better relationships.
Heather L. Armstrong
See also: Advertising, Sex in; Contraception; Media and Sexuality; Sex Education; Sex-
ual Health; Sexual Satisfaction; Sexually Transmitted Infections (STIs).
Further Reading
Downey, G., Freitas, A. L., Michaelis, B., & Khouri, H. D. (1998). The self-fulfilling
prophecy in close relationships: Rejection sensitivity and rejection by romantic
partners. Journal of Personality and Social Psychology, 75, 545–560.
Holmberg, D., & Blair, K. L. (2009). Sexual desire, communication, satisfaction, and
preferences of men and women in same-sex versus mixed-sex relationships. Jour-
nal of Sex Research, 46, 57–66.
128 Companionate Love
MacNeil, S., & Byers, E. S. (2009). Role of sexual self-disclosure in the sexual satisfac-
tion of long-term heterosexual couples. Journal of Sex Research, 46, 3–14.
Montesi, J. L., Fauber, R. L., Gordon, E. A., & Heimberg, R. G. (2010). The specific
importance of communicating about sex to couples’ sexual and overall relation-
ship satisfaction. Journal of Social and Personal Relationships, 28, 591–609.
Noar, S. M., Carlyle, K., & Cole, C. (2006). Why communication is crucial: Meta-analysis
of the relationship between safer sexual communication and condom use. Journal
of Health Communication: International Perspectives, 11, 365–390.
Rehman, U. S., & Fallis, E. E. (2014). Sexual communication. In C. F. Pukall (Ed.), Human
sexuality: A contemporary introduction. Don Mills, ON: Oxford University Press.
Rehman, U. S., Janssen, E., Newhouse, S., Heiman, J., Holtzworth-Munroe, A., Fallis, E.,
& Rafaeli, E. (2011). Martial satisfaction and communication behaviors during
sexual and nonsexual conflict discussions in newlywed couples: A pilot study.
Journal of Sex & Marital Therapy, 37, 93–103.
Vannier, S. A., & O’Sullivan, L. F. (2011). Communicating interest in sex: Verbal and
nonverbal initiation of sexual activity in young adults’ romantic dating relation-
ships. Archives of Sexual Behavior, 40, 961–969.
Companionate Love
Companionate love is a construct created by psychologist Robert Sternberg as
part of his triangular theory of love. According to Sternberg’s model, there are
three components to love: intimacy, passion, and commitment. Intimacy repre-
sents the emotional component of love that describes the closeness and affection
people have for each other. Passion is the motivational aspect of love. Commit-
ment is the decision to love and to maintain that love. Sternberg combined these
three components into a triangle, and the components combine to produce differ-
ent types of love. Companionate love is the combination of intimacy and commit-
ment but not passion.
Companionate love is defined as an intimacy and affection felt when caring
deeply for a person, without the experience of passion or arousal in the person’s
presence. This passion may have faded over time or possibly was not present in
the early stages of the relationship. Despite its absence, the relationship continues.
An example of this type of relationship would be a married couple who do not
have sex but share interests and enjoy each other’s company. Their marriage to
one another signifies their commitment to one another, and the depth of their emo-
tional bond represents their shared intimacy despite the lack of a sexual relation-
ship. In reflection of this construct, Professor Beverley Fehr notes that the
foundational components of companionate love may underlie all types of love. For
example, the love between parent and child, the love of a caretaker for their pet, or
the love between longtime friends might match the general concept of companion-
ate love, even though not holding the title. Sternberg emphasizes that the addition
of long-term allegiance is the key differentiation between this relationship and a
deep friendship. Partners in this type of relationship are matched counterparts
that complement and support one another.
Relationship psychologist Judith Wallerstein was interested in discovering
how couples determined relationship satisfaction in a marriage. To investigate
Compulsivity, Sexual 129
this, she conducted a qualitative study on couples whose marriages survived con-
flict and were considered happy and successful. Wallerstein identified four types
of “good marriages,” each having a unique set of characteristics and challenges.
In Wallerstein’s conceptualization, companionate marriage is the most common
type of relationship among younger couples as well as the most difficult to main-
tain. Companionate loves are described as newer loves, at whose core is a friend-
ship and trust in an equal partnership. Wallerstein found that these relationships
require high levels of self-confidence, self-awareness, and the patience to post-
pone gratification. Partners in a companionate love marriage value friendship
and equality and strive toward a balance between their home life and work life.
While deep affection and commitment are the foundations, the primary long-
term risk is for the relationship to degenerate into a relationship resembling a
brother-sister bond. Sternberg, however, believed that companionate love was not
youthful or undeveloped but thought instead that at its healthiest, it represented a
deep, mature, affectionate attachment between people who love, like, and respect
each other.
Shadeen Francis
See also: Attachment Theory of Love; Consummate Love; Intimacy, Sexual and Rela-
tional; Lee’s Theory of Love Styles; Love; Marriage; Sternberg’s Triangular Theory of
Love.
Further Reading
Aronson, E., Wilson, T. D., & Akert, R. M. (2010). Social psychology (7th ed.). Upper
Saddle River, NJ: Prentice Hall.
Ashford, J., & LeCroy, C. (2009). Human behavior in the social environment: A multidi-
mensional perspective. Toronto: Nelson Education.
Fehr, B. (1995). Love. In D. Levinson (Ed.), Encyclopedia of marriage and the family.
New York: Macmillan.
Sternberg, R. J. (1986). A triangular theory of love. Psychological Review, 93, 119–135.
Compulsivity, Sexual
Compulsive sexual behavior is defined by the Society for the Advancement of
Sexual Health as a “persistent and escalating pattern of sexual behavior acted out
despite increasing negative consequences to self and others.” This behavior is
often one that the individual feels is outside of voluntary control and may involve
risky behavior, the desire to limit one’s sexual behaviors or the consequences of
those behaviors, and the use of sexual fantasies or obsessions as primary coping
strategies for life stresses. Individuals often report spending excessive amounts of
time being sexual, obtaining sex, hiding sexual behavior, or recovering from sex-
ual experiences. Important social, occupational, financial, or social responsibili-
ties may be neglected due to the sexual behavior.
Sexual compulsivity can lead to relational, occupational, legal, financial, emo-
tional, spiritual, and physical distress. For example, isolation, impairment in the
relationship with the primary sexual partner, impaired job performance, job loss,
criminal convictions for illegal sexual behaviors, financial strain if sex and sexual
130 Compulsivity, Sexual
materials are paid for, depression, anxiety, guilt, spiritual strain, and sexually
transmitted infections are common outcomes.
Sexually compulsive behaviors may include anonymous, voyeuristic, exhibi-
tionistic, intrusive, or exploitive sex. Some seductive role sex, pain exchange sex,
and fantasy sex behaviors may also be used in compulsive ways. Compulsive sex
may be both free and paid sex and may include sex trades and bartering.
Research suggests that there is no single cause for sexually compulsive behav-
ior. It is often helpful to consider several biological, psychological, social, and
spiritual contributors to compulsive behavior. From a biological perspective, both
testosterone and serotonin may play important roles in compulsive sexual behav-
iors. Classical and operant conditioning may powerfully reinforce specific sexual
behaviors to the point that they are engaged in habitually. Many individuals report
that sexual behaviors may create dissociative psychological experiences or repre-
sent reenactment of past conflicts and traumas (both sexual traumas and other
traumas, such as combat-related posttraumatic stress disorder). Some individuals
find that sexually compulsive behavior arises in response to cultural or religious
sexual prohibitions. Sexual compulsivity has been found to be comorbid (co-
occurring) with other conditions, such as other sexual disorders (dysfunctions and
paraphilias), mood and anxiety disorders, chemical dependency, and eating
disorders.
Diagnosis of sexually compulsive behavior can be difficult, as individuals are
often reluctant to disclose sexual behaviors to others. Clinicians often begin by
assessing the amount of time that the individual spends each day and week
engaged in sexual behaviors and the extent to which they have noticed negative
relational, occupational, legal, financial, emotional, and spiritual consequences as
a result of sexual behaviors. Screening tests and assessment questionnaires may
also be used, such as the Sexual Addiction Screening Test and the Sexual Com-
pulsivity Scale. The Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-5) does not include a diagnosis for sexual compulsivity among its
descriptions of substance-related and addictive disorders, though some individu-
als with sexual compulsivity may display symptoms consistent with the paraphilic
disorders. In its newest edition, the World Health Organization’s International
Classification of Diseases, Eleventh Revision included compulsive sexual behav-
ior disorder as an impulse control disorder.
A consultation with a mental health professional that specializes in sexual con-
cerns is recommended before determining if an individual is engaging in sexually
compulsive behavior. Successful treatment usually assumes that all behaviors,
including compulsive sexual behaviors, are engaged in by the individual for good
reasons; identifying and addressing the client’s needs and motivators is important.
Emphasis may be placed on addressing common motivators for compulsive sexual
behaviors, such as excitement, comfort (reduce stress, reward, relax), and escape
(dissociation, trance, avoidance, mood regulation), as well as psychological moti-
vators such as affirmation, helplessness, power, and revenge. Interventions target
decreasing the frequency of compulsive behaviors, preventing use, methods to
change behavior “in the moment,” and strategies to alter behavior after a relapse.
Specific interventions vary according to the client’s needs and may include
Conception 131
mindfulness practices, ending destructive relationships, prescriptive masturba-
tion, journaling, cognitive restructuring, and identification of coping strategies for
use when the client is upset (bored, angry, anxious, lonely, or tired). Treatment
may be offered in inpatient hospital settings, partial hospitalization programs,
outpatient counseling, twelve-step groups, and online programs. Treatment may
be focused on the individual, couple, family, or group.
Elizabeth A. Maynard
See also: Hypersexuality; International Classification of Diseases, Eleventh Revision
(ICD-11); Out-of-Control Sexual Behavior; Pornography Addiction.
Further Reading
Carnes, P., Green, B., & Carnes, S. (2010). The same yet different: Refocusing the Sexual
Addiction Screening Test (SAST) to reflect orientation and gender. Sexual Addic-
tion & Compulsivity: The Journal of Treatment & Prevention, 17(1), 7–30.
Dodge, B., Reece, M., Cole, S. L., & Theo, G. M. (2004). Sexual compulsivity among
heterosexual college students. Journal of Sex Research, 41(4), 343–350.
Kalichman, S. C., & Cain, D. (2004). The relationship between indicators of sexual com-
pulsivity and high risk sexual practices among men and women receiving services
from a sexually transmitted infection clinic. The Journal of Sex Research, 41,
235–241.
Kalichman, S. C., & Rompa, D. (1995). Sexual sensation seeking and sexual compulsivity
scales: Reliability, validity, and predicting HIV risk behaviors. Journal of Person-
ality Assessment, 65, 586–602.
Society for the Advancement of Sexual Health. (2019). Retrieved from www.sash.net
Conception
Conception, strictly speaking, is initiated with the fertilization by a male’s sperm
(spermatozoon) with a female’s egg (ovum), which eventually results in preg-
nancy. “Conception,” however, is a term that is somewhat variable with respect to
definition and connotation. To refer to a moment of conception is somewhat a
misnomer as it is actually a process that usually occurs over a forty-eight-hour
span.
The sperm and egg are, respectively, the male and female gametes produced by
meiosis. They are haploid cells, each containing twenty-three chromosomes, or
half the total needed to form a new individual.
An array of complex circumstances in both male and female bodies is neces-
sary for conception to occur. In female bodies, a viable egg must be stimulated to
mature in an ovarian follicle by follicle-stimulating hormone, which is secreted by
the pituitary gland. Estrogen levels must increase to trigger the thickening of the
lining of the uterus; as the levels of estrogen increase, the pituitary will begin
secreting luteinizing hormone, which causes the follicle to rupture and release the
mature egg, a process referred to as ovulation. Ovulation generally occurs around
twelve to fourteen days before the beginning of the next menstrual cycle. The
ruptured follicle then begins to release progesterone, at which point it becomes
known as the corpus luteum. Estrogen and progesterone cause the endometrium
132 Conception
to thicken. The released egg, hopefully, is drawn into the fallopian tube, also
known as the oviduct.
In male bodies, sperm are produced in the seminiferous tubules of the testes,
stimulated by testosterone. Mature sperm are stored in the epididymis. From
there, they travel through the vas deferens, where they are mixed with fluids
secreted from the seminal vesicles; this fluid contains a simple sugar, fructose, to
help nourish the sperm. More substances are added to the fluid mixture from the
prostate gland; these mainly serve to help neutralize the harsh acidity of the
female’s vagina. The bulbourethral glands, also known as the Cowper’s glands,
release substances that help to neutralize the environment within the male’s ure-
thra. During penile-vaginal sex, ejaculation, a complex process in itself, sends
millions of sperm into a vagina. Approximately 40 million sperm are released in
each healthy ejaculate, with at least 30 percent having normal morphology and at
least 50 percent moving forward for an optimal probability of conception to occur.
For conception to occur, one viable sperm must have access to a mature egg,
which is usually flowing down the fallopian tube toward the uterus. The survival
time of sperm in the female reproductive tract is highly variable but can last for
several days, which means that the fertile period lasts for several days on either
side of ovulation. The head of the sperm produces enzymes that permit it to bore
through the jelly coating that surrounds the egg. The sperm head that successfully
penetrates into the plasma membrane of the egg detaches its tail (flagellum) as it
enters the egg’s yolk (ooplasm). A chemical reaction is then initiated to form the
perivitelline membrane around the egg to prevent any additional sperm from pen-
etrating. For conception to occur, the sperm head must successfully penetrate the
cumulus oophorous and corona radiate cells and bind to the zona pellucida inside
the egg. The nucleus of the sperm decondenses after penetration in synchrony
with the nucleus of the egg, creating two pronuclei. The fusion of genetic material
from the sperm and egg, known as syngamy, occurs after the membranes of the
two pronuclei are broken down.
The fusion of the sperm and the egg, begun by fertilization, produces a zygote.
The zygote begins as a single diploid cell, which contains a total of forty-six chro-
mosomes. It makes its way through the fallopian tube for three to four days until it
reaches the uterus. The zygote must then implant itself into the uterine wall, which
typically happens about seven to ten days after ovulation. About five days after
the zygote is formed, it transforms into a blastocyst; about fourteen days later, it
normally becomes an embryo. By the ninth week, it has usually grown into a
fetus.
Victor B. Stolberg
See also: Contraception; Ejaculation; Fertility; Fertility Awareness Methods of Contra-
ception; Infertility; Ova; Pregnancy; Safer Sex; Sperm.
Further Reading
Aslam, I., & Fishel, S. (1996). The use of spermatids for human conception. In V. Hans-
son, F. O. Levy, & K. Taskén (Eds.), Signal transduction in testicular cells (272–
286). Berlin: Springer-Verlag.
Bongso, A., Ho, J., Fong, C.-Y., Ng, S.-C., & Ratnam, S. (1993). Human sperm function
after coculture with human fallopian tubal epithelial cell monolayers: In vitro
Condoms, Female (Receptive) 133
model for studying cell interactions in early human conception. Archives of
Human Andrology, 31(3), 183–190.
Ford, N. M. (1991). When did I begin? Conception of the human individual in history,
philosophy and science. Cambridge: Cambridge University Press.
Condoms, Female (Receptive)
The receptive condom, sometimes also called the “female condom” or internal
condom, is a barrier contraceptive method that can be used to prevent unintended
pregnancy and the transmission of sexually transmitted infections (STIs). The
name “female condom” is a misnomer as receptive condoms can be used vagi-
nally or anally by people of any sex or gender.
A receptive condom is a tube-shaped device that goes into the vagina or anus
and creates a physical barrier between sexual partners to block sperm and STI
transmission. It is usually made of polyurethane, a nonlatex synthetic material.
The receptive condom has two rings, one at each end. When used vaginally, the
interior ring and shaft of the condom is inserted into the vagina, and the outer ring
is held outside the body. The interior ring can be placed behind the pubic bone to
help keep the condom in place. The outer ring is placed outside the vagina. If used
anally, the interior ring should be removed before the condom is inserted and the
outer ring held outside the body. Once inserted, the ring is placed over the anus.
It is important to use a commercial lubricant when using receptive condoms as
this will help to prevent the condom from tearing or being dislodged, and it will
increase pleasure and sensation if a partner’s penis is being used for sexual stimu-
lation. A spermicide may be added to the condom if additional contraceptive pro-
tection is needed or desired. It is important not to also use an insertive condom
while using a receptive condom, as using both can lead to tearing and decreased
effectiveness of both devices.
When used perfectly, the receptive condom is 95 percent effective at preventing
pregnancy; however, with typical use, it is only about 79 percent effective. That
means that over the course of one year, if one hundred fertile females use the
receptive condom as their only method of birth control, twenty-one of them will
become pregnant.
The receptive condom offers many benefits. As mentioned, it can help prevent
unintended pregnancy and transmission of STIs. Also, because the receptive con-
dom is larger than the insertive condom, some material of the condom is placed
around the opening of the vagina or anus and covers the skin in this area. This
means that the receptive condom can help prevent some STIs that can be transmit-
ted via skin-to-skin contact, such as HPV or herpes. The receptive condom can
also be inserted up to eight hours ahead of sexual activity, and since it is typically
made of polyurethane, it can be used by people with latex allergies or sensitivities.
While they are not as common as insertive condoms, they can be purchased online
or in stores without a prescription.
While their use is largely beneficial, there are some potential drawbacks of the
receptive condom to consider. The biggest drawback is that they are more expen-
sive than the insertive condom, although they are cheaper than hormonal forms of
134 Condoms, Male (Insertive)
birth control. In addition, some people may not like their appearance. Receptive
condoms may also make a crinkly noise during intercourse, although this may be
reduced by using commercial lubrication. Internal condoms are not reusable, so a
new one is needed for every sexual encounter.
Heather L. Armstrong
See also: Barrier Contraceptive Methods; Condoms, Male (Insertive); Lubricants; Preg-
nancy; Sexually Transmitted Infections (STIs); Spermicides.
Further Reading
Planned Parenthood. (2019). Internal condom. Retrieved from https://www.plannedpar-
enthood.org/learn/birth-control/internal-condom
Society of Obstetricians and Gynaecologists of Canada. (2019). Female condom. Retrieved
from https://www.sexandu.ca/contraception/non-hormonal-contraception/#tc2
Sutton, K. S., & Chalmers, B. (2017). Contraception and pregnancy options. In C. F.
Pukall (Ed.), Human sexuality: A contemporary introduction (2nd ed.). Don Mills,
ON: Oxford University Press.
Condoms, Male (Insertive)
An insertive condom provides protection against sexually transmitted infections
(STIs) and pregnancy during sexual activities. Barrier methods of birth control
create a separation between an egg and sperm so that pregnancy is prevented. An
insertive condom, also sometimes called a “male condom,” fits over an erect penis,
securing to the base of the penis. As such, partners’ bodily fluids cannot be mixed,
which greatly reduces the risk of HIV and other STI transmission as well as preg-
nancy. Insertive condoms can also be used with shared sex toys to reduce the risk
of STIs.
An insertive condom is made from thin materials. It is soft, flexible, and rolls
out to become a sheath. It may be made from several different types of materials,
including latex (which is most common), polyurethane, or processed animal tis-
sue. It may be used for oral sex, anal sex, or vaginal sex. Condoms come in a
variety of different textures, colors, sizes, and shapes. Some come lubricated and
others do not. There are many options depending on preference and the desired
use for the condom. For example, condoms may be flavored or colored. These
should not be used for anal or vaginal sex but may be a great option for oral sex or
nonpenetrative sex play. Polyurethane or animal tissue condoms may be an option
for people who have a latex allergy. However, animal tissue condoms do not pro-
tect against STIs, as the material of the condom is porous and so viruses and bac-
teria are able to pass through; as such, they may only be used for pregnancy
prevention. Polyurethane condoms protect against both STIs and pregnancy.
When used correctly, insertive condoms are very effective, and their use has
greatly increased since the 1980s. With perfect use, condoms are 98 percent effec-
tive at preventing pregnancy. With typical use, they are 85 percent effective at
preventing pregnancy.
There are many benefits of using insertive condoms. They are quite easy to
obtain, as they are available at grocery stores, pharmacies, and online; they are
Condoms, Male (Insertive) 135
also commonly provided for free at various health clinics and schools. Condoms
are also relatively inexpensive and do not cause harmful side effects, so long as
you or your partner are not allergic to the material you choose for the condom.
Insertive condoms may be a great addition to safer sex practices that include
another form of birth control, such as a hormonal method, in order to protect
against STIs and further decrease risk of pregnancy.
Despite all the benefits of using condoms, some people may complain that a
condom dulls sensation. If this is a problem, users are encouraged to try a differ-
ent size, shape, or brand as different condoms fit and feel differently, so usually
this problem can be solved by finding the right condom for the user. In addition,
some people may find it to be disruptive to put a condom on while in the heat of
the moment. Sexual communication and incorporating applying the condom as
part of foreplay can make using a condom a positive part of the sexual experience.
Users should also be aware that an insertive condom might break or slip during
sex, and this risk is elevated during anal sex. Using proper lubrication decreases
this risk.
Condom use is very common among adolescents and young adults. The 2009
National Survey of Sexual Health and Behavior shows that condom use decreases
with age, and this is true for all relationship statuses.
As mentioned previously, some people think that condoms diminish sensation.
However, a study conducted by Debby Herbenick, a researcher at the Center for
Sexual Health Promotion at Indiana University, found that Americans aged four-
teen to ninety-four from all across the country mostly disagree with that assertion.
Instead, most participants noted that sex with a condom is just as pleasurable and
exciting as sex without a condom. Many younger people even responded that hav-
ing sex with a condom is more pleasurable than having sex without one.
Only about 10 percent of men need an extra-large condom. If an extra-large
condom is used when it is not necessary, the condom is more likely to slip and fall
off during intercourse. If a standard size condom does not roll down to the base of
the penis, an extra-large condom is needed.
Condoms have expiration dates on the packaging, and these must be checked
prior to use. In addition, condoms are very thin; therefore, the package must be
opened carefully. It’s important to avoid using teeth or nails to open the pack-
age, as this may result in tearing or puncturing the condom, which makes it use-
less. While holding the tip of the condom, the condom may be rolled down to the
base of the penis. It is important that the base of the penis is dry so that the
condom can grip to the base and not slip. Holding the tip of the condom allows
room for the semen and prevents the condom from breaking from the force of
thrusting. Once the condom is on, any air bubbles in the condom should be
pushed out to reduce the likelihood of breakage. If the condom was put on the
wrong way and was not able to be rolled down, the condom should be thrown
away and another should be used. A new condom should also be used for every
sexual encounter and when changing from anal sex to vaginal sex or from anal
sex to oral sex. When the sexual encounter is over, the base of the condom
should be held while the penis is removed from the vagina or anus in order to
prevent any semen from dripping out. The condom can then be thrown away in
136 Congenital Adrenal Hyperplasia
the garbage. Condoms should be stored in a cool, dry place in order to maintain
their effectiveness.
Amanda Manuel
See also: Barrier Contraceptive Methods; Condoms, Female (Receptive); Lubricants;
Pregnancy; Safer Sex; Sexually Transmitted Infections (STIs); Spermicides.
Further Reading
Herbenick, D., & Stoddard, G. (2012). Great in bed. New York: DK.
Joannides, P. (2012). Birth control: Sperm v. egg. In P. Joannides (Ed.), Guide to getting it
on (6th ed., 713–773). Waldport, OR: Goofy Foot Press.
Yarber, W., Sayad, B., & Strong, B. (2010). Human sexuality: Diversity in contemporary
America (7th ed.). New York: McGraw-Hill.
Congenital Adrenal Hyperplasia
Congenital adrenal hyperplasia describes a group of seven autosomal recessive
conditions that affect the function of the adrenal glands. More than 95 percent of
these cases are caused by a mutation in the gene for 21 hydroxylase. The classic
understanding of congenital adrenal hyperplasia is a condition where XX infants
are exposed to elevated levels of testosterone during development and are born
with external genitalia that may appear to be male. Specifically, they may have a
greatly enlarged clitoris that resembles a penis. This presentation is known as the
virilizing form of congenital adrenal hyperplasia. XY infants with the virilizing
form of congenital adrenal hyperplasia also show signs of excess androgen pro-
duction. These include rapid skeletal growth, early growth of pubic hair, and being
sexually precocious.
There is also what is known as the salt-wasting form of congenital adrenal
hyperplasia. Unlike the virilizing form, which does not have a major impact on
infant health, the salt-wasting form can be life-threatening. If not detected early,
through neonatal screening, infants with the salt-wasting form of congenital adre-
nal hyperplasia are at high risk of dying within the first two weeks of life. The
functional difference between the two types of congenital adrenal hyperplasia is
that individuals with the salt-wasting form have no enzyme activity from 21
hydroxylase, and individuals with the virilizing form have enough enzyme activ-
ity (1–2 percent) to maintain levels of aldosterone that are sufficient for health.
There are also what are known as “cryptic” forms of congenital adrenal hyperpla-
sia that have no, or minimal, symptoms but are diagnosed through genetic testing.
The mutations that cause cryptic congenital adrenal hyperplasia reduce enzyme
activity only by approximately half.
Other genes where mutations cause congenital adrenal hyperplasia lead to
what are referred to as nonclassic forms of the condition, which resemble the 21
hydroxylase varieties to varying degrees. One exception is cases of congenital
adrenal hyperplasia caused by mutations in the 17-alpha-hydroxylase gene,
where children appear to be female at the time of birth but never develop sec-
ondary sexual characteristics during adolescence. Treatment for all forms of
congenital adrenal hyperplasia is based on the principal of regulating abnormal
Congenital Adrenal Hyperplasia 137
hormone production—suppressing excess and supplementing where production
is insufficient. This reduces both the abnormally fast growth and the sexual pre-
cocity associated with the condition.
Congenital adrenal hyperplasia is considered to be a disorder of sexual devel-
opment (also known as a difference of sexual development) because of the effects
it has on infant genitalia. Historically, many surgeons have recommended genital
surgery for XX infants with congenital adrenal hyperplasia to make their genitals
appear more feminine. More recently, there has been growing concern that per-
forming such surgeries during infancy has the potential to both deny patients their
autonomy and risk permanently impairing their sexual function. Nonetheless,
early surgery remains recommended for cases of extreme virilization by the Endo-
crine Society guidelines that were released in 2010. Those guidelines note that the
presumed values of early surgery are “reducing parental anxiety and easing accep-
tance of the child’s congenital anomaly, avoiding stigmatization of a girl with
masculinized genitals, and avoiding the psychological trauma of genital surgery
during adolescence” (Speiser et al., 2010).
One of the concerns sometimes brought up in discussions of the appropriate-
ness of genital surgery for XX individuals with congenital adrenal hyperplasia is
the likely gender identity development of these children as they grow to adult-
hood. Research has generally suggested that XX individuals with congenital adre-
nal hyperplasia identify as girls, although as girls with more male-type behaviors
than XX individuals without congenital adrenal hyperplasia. Newer research sug-
gests that these children are significantly more likely to have gender identity
scores in the male domain than their peers but that it is still rare for these children
to take on a male gender identity and role.
There is limited research suggesting that many young women with congenital
adrenal hyperplasia have a preference for early surgery. However, much of the
literature supporting early genital surgery focuses on managing parental distress
rather than on how the surgery affects patient outcomes. In part, this is because
there has not yet been sufficient research to determine whether sexual and psycho-
logical outcomes are better for individuals with congenital hyperplasia who
undergo genital surgery early, late, or not at all.
Most arguments against early genital surgery focus on patient autonomy, sex-
ual health, and gender identity formation. These are concerns that may not seem
salient to parents who are faced with raising an infant whose differences make
them hesitant or uncomfortable. They are also hard to address or assess before the
infant reaches adolescence or adulthood. Finally, these arguments require
acknowledging that pleasure is an important component of sexual health. This is
something that can be both difficult and uncomfortable for parents and providers
to discuss in the context of infant and child health. Sexual pleasure may have been
codified into the World Health Organization’s definition of sexual health since
2002, but it is still a long way from being considered universally relevant to clini-
cal practice.
Elizabeth R. Boskey
See also: Androgen Insensitivity Syndrome; Androgens; Biological Sex; Chromosomal
Sex; 5-Alpha-Reductase Deficiency; Intersexuality; Sex Reassignment Surgery.
138 Consummate Love
Further Reading
Berenbaum, S. A., Beltz, A. M., Bryk, K., & McHale, S. (2018). Gendered peer involve-
ment in girls with congenital adrenal hyperplasia: Effects of prenatal androgens,
gendered activities, and gender cognitions. Archives of Sexual Behavior, 47(4),
915–929.
El-Maouche, D., Arlt, W., & Merke, D. P. (2017). Congenital adrenal hyperplasia. Lancet,
390(10108), 2194–2210.
Jesus, L. E. (2018). Feminizing genitoplasties: Where are we now? Journal of Pediatric
Urology, 14(5), 407–415.
Pasterski, V., Zucker, K. J., Hindmarsh, P. C., Hughes, I. A., Acerini, C., Spencer, D., …
Hines, M. (2015). Increased cross-gender identification independent of gender role
behavior in girls with congenital adrenal hyperplasia: Results from a standardized
assessment of 4- to 11-year-old children. Archives of Sexual Behavior, 44(5),
1363–1375.
Speiser, P. W., Azziz, R., Baskin, L. S., Ghizzoni, L., Hensle, T. W., Merke, D. P., …
White, P. C. (2010). Congenital adrenal hyperplasia due to steroid 21-hydroxylase
deficiency: An Endocrine Society clinical practice guideline. Journal of Clinical
Endocrinology and Metabolism, 95(9), 4133–4160.
World Health Organization. (2002). Defining sexual health: Report of a technical consul-
tation on sexual health, 28–31 Jan 2002. Geneva: WHO.
Consummate Love
The triangular theory of love is a model created by psychologist Robert Sternberg
in 1984. Sternberg’s theory of love holds that love can be understood in terms of a
triad of complementary components that together form the vertices of a triangle.
The three components of the theory are intimacy, passion, and commitment. Each
component represents a unique and important aspect of love. Intimacy refers to
the closeness, connection, and emotional bond in relationships. Passion is
described as the drive that leads to sexual activity as well as physical attraction
and arousal. The third component is commitment, which is the decision to sustain
a relationship. The three components of love interact with each other to create
eight different relationship types by having one, two, three, or none of the compo-
nents. Consummate love is the relationship resulting from having all three compo-
nents present at one time: a relationship containing intimacy, passion, and
commitment. This type of love sits at the very center of the triangle, because it is
said to be the ideal type of love.
Consummate love is considered the complete form of love between partners.
Satisfaction, mutual understanding, support, and concern for the other are major
components of this relationship type. These relationships are a healthy example of
balance of self and other, with each person contributing positively to the growth of
the other and to the future of the relationship. Each component is necessary to the
experience of this balance. Passion develops quickly and creates the motivational
energy needed to kindle the relationship and to keep it feeling fun and progres-
sive. Intimacy bonds people closer together and creates the feeling of love that
inspires people to stay together. Intimacy develops slowly over time and, there-
fore, requires commitment to increase and intensify. Commitment begins at zero
Contraception 139
when people first meet and grows until it levels off in a long-term relationship, if
supported by passion and intimacy.
Not all loves will reach the level of consummate love. Sternberg cautions that
while few may ascend to this peak on the relationship hierarchy, maintaining a
consummate love may be more difficult than achieving it. For example, if inti-
macy is lost over time, the relationship may shift into a less stable pattern, and the
other components may be jeopardized without the grounding influence of an inti-
mate emotional connection. However, building greater intimacy may lead to
greater passion or commitment, just as greater commitment may lead to greater
intimacy and so forth. Whenever the relationship begins to falter, strengthening
any point may help elevate and restabilize the triangle. In knowing about these
components of love, Sternberg believes that couples may be better able to avoid
impending pitfalls in their relationship, work on the areas in need of improvement,
or recognize when it is time for a relationship to end.
Shadeen Francis
See also: Attachment Theory of Love; Companionate Love; Intimacy, Sexual and Rela-
tional; Lee’s Theory of Love Styles; Love; Sternberg’s Triangular Theory of Love.
Further Reading
Sternberg, R. J. (1986). A triangular theory of love. Psychological Review, 93, 119–135.
Sternberg, R. J. (1988). Triangulating love. In R. J. Sternberg & M. Barnes (Eds.), The
psychology of love (119–138). New Haven, CT: Yale University Press.
Sternberg, R. J., & Grajek, S. (1984). The nature of love. Journal of Personality and Social
Psychology, 47, 312–329.
Contraception
“Contraception” refers to all strategies and methods meant to prevent ovulation,
prevent sperm from fertilizing the egg, or if fertilization occurs, prevent the fertil-
ized egg from implanting into the uterus. The overall goal is to prevent pregnancy
while improving sexual health and well-being. Because 95 percent of sexual activ-
ity is practiced for reasons other than procreation, contraception is of prime
importance for many people. At the same time, because contraception separates
the notions of sexuality and procreation, it continues to raise social, political, ethi-
cal, and economic issues in many countries and states. Moreover, although women
are the main users of contraceptive methods and have the main responsibility for
carrying out contraceptive strategies, the fact remains that conception requires the
coming together of two gametes, one male and one female. Despite this fact, the
social norms that guide contraception decisions persist in reflecting gender
inequalities such that women usually carry the burden of conception decision
making on their own. A more inclusive approach would be to acknowledge that
both those who possess a vagina and ovaries and those who possess a penis and
testicles should be concerned about contraception when they engage in sexual
relations.
For women, the fertile period begins at puberty, with the beginning of men-
struation. Puberty starts around age twelve years, and menopause, the point at
140 Contraception
which menstruation ends, occurs around age fifty years. Consequently, a woman
is typically fertile about thirty to forty years during her lifetime. The fertile period
for men is less well defined because unlike egg production in women, sperm pro-
duction does not end at a certain age. Men can be fertile into their very advanced
years, although their reproductive capacity (in terms of sperm count and sperma-
tozoa motility and morphology) diminishes with age, along with their fertility.
Therefore, people who engage in heterosexual relations but do not want to have
children generally end up practicing some form of contraception for lengthy peri-
ods of time.
The ideal contraceptive is 100 percent effective, convenient, safe, free of
adverse side effects, completely reversible, maintenance-free, and affordable (and
ideally, free). Furthermore, it should not inhibit sexual activity, and it should be
culturally acceptable and protect against sexually transmitted infections (STIs).
Unfortunately, this contraceptive method has not yet been invented, which is why
the choice of contraceptive strategy or method usually involves a compromise. In
practice, a contraceptive strategy or method is selected in light of several factors,
such as accessibility, cost, social acceptability, safety, and health risks. A large
variety of contraceptive methods is available. Hormonal methods prevent ovula-
tion, thicken the cervical and endometrial mucus to block sperm from entering the
uterus, and thin the lining of the uterus to prevent a fertilized egg from implant-
ing. Intrauterine devices are small devices that are inserted into the uterus, where
they remain for several years. They act by interrupting the sperm’s ability to reach
the egg. Barrier methods are physical methods that prevent contact between sperm
and ovum, such as a condom or diaphragm. Natural methods do not involve medi-
cations, devices, or surgery. Instead, fertility signals are identified and interpreted
so that the partners can abstain from penile-vaginal intercourse during the fertile
window. Surgical methods, such as a tubal ligation or vasectomy, are generally
irreversible and block the passage between sperm and egg. In addition, people
often combine methods, for example, using a hormonal method with a condom to
prevent STIs.
Contraceptive methods have been around for a long time. Historians and
archaeologists have found evidence of contraceptive use by ancient civilizations.
Down through the ages, methods have ranged from coitus interruptus (i.e., with-
drawal), condoms, vaginal douches, the calendar method, and other barrier meth-
ods such as the diaphragm and the cervical cap. The contraceptive pill was first
developed in 1960, in the face of impassioned social resistance. At the time, access
to the pill required the husband’s permission and approval as well as the doctor’s.
It took repeated battles for women to win the right to make their own choices
about contraception and family planning. Since then, several new methods have
been developed, refined, and marketed, providing a wider range of choices. When
selecting a contraceptive method, the most important criteria for North American
women have been reported to be effective prevention of pregnancy (79% ), effec-
tive prevention of HIV and STIs (67%), and convenience (49%). Fewer than one-
quarter of women (22–24% ) prioritized a method that was both hormone-free and
inexpensive.
In the United States, Canada, and elsewhere around the world, social changes
have pushed women to delay having a first child up to an average age of thirty
Contraceptive Implant 141
years. This suggests that women who have sexual relations with male partners are
exposed to the risk of unintended pregnancy for at least half their life span. Health
care clinicians and professionals can play a key role in contraceptive decision
making by providing comprehensive and practical information to help women and
their partners select and use the method that best fits their needs, priorities, and
values. The discussion should also include personal behaviors and circumstances,
and in a broader sense, medical, financial, and regulatory problems. All these
issues can discourage individuals from obtaining, using, and continuing their pre-
ferred conceptive method.
Sylvie Lévesque
See also: Barrier Contraceptive Methods; Birth Control Pills, Estrogen-Progestin; Birth
Control Pills, Progestin-Only; Cervical Cap; Cervical Mucus Method; Conception; Con-
doms, Female (Receptive); Condoms, Male (Insertive); Contraceptive Implants; Contra-
ceptive Injectables; Contraceptive Patch; Diaphragm; Emergency Contraception; Essure
Coil; Fertility; Fertility Awareness Methods of Contraception; Intrauterine Device (IUD);
Pregnancy; Safer Sex; Sexually Transmitted Infections (STIs); Spermicides; Sponge,
Contraceptive; Sterilization; Teen Pregnancy; Tubal Ligation; Vaginal Ring; Vasectomy;
Withdrawal Method.
Further Reading
Black, A., Guilbert, E., Costescu, D., Dunn, S., Fisher, W., Kives, S., … Todd, N. (2015).
Consensus canadien sur la contraception (1ere partie de 4). Journal of Obstetrics
and Gynaecology Canada, 37(10), 939–942.
Briggs, P., Kovacs, G., & Guillebaud, J. (Eds.). (2013). Contraception: A casebook from
menarche to menopause. Cambridge: Cambridge University Press.
Glasier, A., & Gebbie, A. E. (2008). Handbook of family planning and reproductive
healthcare (5th ed.). London: Churchill Linvingstone.
Liu, K., Case, A., Cheung, A. P., Sierra, S., AlAsiri, S., Carranza-Mamane, B., … Hem-
mings, R. (2011). Âge génésique avancé et fertilité. Journal of Obstetrics and
Gynaecology Canada, 33(11), 1176–1177.
Marshall, C., Guendelman, S., Mauldon, J., & Nuru‐Jeter, A. (2016). Young women’s
contraceptive decision making: Do preferences for contraceptive attributes align
with method choice? Perspectives on Sexual and Reproductive Health, 48(3),
119–127.
McVeigh, E., Guillebaud, J., & Homburg, R. (2013). Oxford handbook of reproductive
medicine and family planning. Oxford: Oxford University Press.
Society of Obstetricians and Gynaecologists of Canada. (2019). Sex & U. Retrieved from
www.sexandu.ca
Taylor, H. S., McVeigh, E., Aldad, T. S., Homburg, R., & Guillebaud, J. (2012). Oxford
American handbook of reproductive medicine. New York: Oxford University
Press.
van Lusen, R. H. W. (2013). Myths and misconceptions about sex and con(tra)ception. In
P. Briggs, G. Kovacs, & J. Guillebaud (Eds.), Contraception: A casebook from
menarche to menopause. Cambridge: Cambridge University Press.
Contraceptive Implant
In 1991, the first subdermal long-term reversible contraceptive methods were used
in the United States to prevent pregnancy. These contraceptive implants consisted
142 Contraceptive Implant
of six matchstick-sized tubes that released hormones into the body for five years.
They were taken off the market in 2002, reportedly due to injuries resulting from
the difficulty of removing the implant.
A new contraceptive implant was approved by the Federal Drug Administra-
tion in 2006. This new implant is much smaller than the previous version, contain-
ing just one flexible plastic matchstick-sized tube. A second version of the new
implant came out shortly after the first, the only difference being an easier inser-
tion and the ability to track the implant in the body.
The contraceptive implant works by releasing the synthetic hormone progestin
etonogestrel directly into a person’s bloodstream for three years. These hormones
work to prevent pregnancy primarily by preventing ovulation. They also thicken
the cervical mucus, preventing sperm from entering the uterus.
In order to get the contraceptive implant, a person needs to go to a health care
provider to discuss the method. The health care provider will collect the person’s
medical information and conduct a physical exam; they can then perform the pro-
cedure. During the procedure, the inside of the upper arm is numbed with a pain-
killer, and the contraceptive implant is surgically inserted under the skin. This
procedure typically takes a few minutes.
After three years, a person needs to go back to their health care provider, who
will numb the area again, make a tiny cut under the skin, and remove the implant.
If the person wanted to continue using the contraceptive implant, the provider can
insert another one at that appointment. If someone wanted to get the implant
removed prior to the full three years, they would just need to make an appoint-
ment with their health care provider.
The contraceptive implant is known to have positive and negative side effects.
One common side effect is irregular uterine bleeding within the first six months to
one year of use. After this, most people report having fewer and lighter periods.
Less common side effects include headaches, nausea, slight weight gain, mood
swings, sore breasts, or a change in sexual desire.
The contraceptive implant is one of the most effective methods of birth control.
Testing indicates it only has a 0.05 percent failure rate. Since it is a long-acting
method, there is little chance for human error. Any person with the implant needs
to make sure they get it removed after three years, as after this time the amount of
hormones in the implant subside.
The contraceptive implant is a relatively safe method of birth control, though
hormones affect different bodies in different ways. It can be used by people who
cannot use synthetic forms of estrogen. Sometimes the implant may become dis-
lodged from the section under the arm where it was inserted; this is rare and usu-
ally due to an error by the doctor. If this happens, the implant will still work to
prevent pregnancy; it just might be more difficult to locate and remove. Because of
this, the newest version of the implant has been built with a tracker so that the
implant can be more easily found if it becomes dislodged.
Sarah Gannon
See also: Contraception; Contraceptive Injectables; Intrauterine Device (IUD); Preg-
nancy; Sex Hormones; Synthetic Hormones.
Contraceptive Injectables 143
Further Reading
Bedsider. (2018). Implant. Retrieved from https://www.bedsider.org/methods/implant
#details
Jones, R. E., & Lopez, K. H. (2014). Human reproductive biology (4th ed.). San Diego,
CA: Academic Press.
Palomba, S., Falbo, A., Di Cello, A., Materazzo, C., & Zullo, F. (2012). Nexplanon: The
new implant for long-term contraception. A comprehensive descriptive review.
Gynecological Endocrinology, 28(9), 710–721.
Planned Parenthood. (2019). Birth control implant. Retrieved from https://www.planned-
parenthood.org/learn/birth-control/birth-control-implant-implanon
Contraceptive Injectables
Contraceptive injectables function in similar ways as oral contraceptives. Most
contain only the hormone progestin; over time, this hormone is released into the
bloodstream in order to prevent pregnancy. A few newer types of injectables
include both progestin and estrogen. Contraceptive injectables are highly effec-
tive, easy to use, and can be used by most healthy female individuals. There are
currently no contraceptive injectables approved for use in male individuals, but
clinical trials to develop this are ongoing.
Contraceptive injectables work by preventing ovulation. They also thicken the
cervical mucus, which helps prevent sperm from entering into the female repro-
ductive system, preventing fertilization. Combination injectables also change the
uterine environment by thinning the lining of the uterus, which makes it more
difficult for implantation to occur if fertilization does take place.
Contraceptive injectables are highly effective. Progestin-only injectables are
between 97– 99.7 percent effective. This means that one to three out of every hun-
dred women who use contraceptive injectables as their only means of contracep-
tion will become pregnant within one year of use. Combination injectables are
slightly less effective, between 94–99 percent effective.
In order to be effective and prevent pregnancy, a person using the progestin-
only type of contraceptive injectable needs to get the shot every eight to thirteen
weeks, depending on the type used. A person using the combination injectable
needs to get the shot every twenty-eight to thirty days (once a month). If a contra-
ceptive injectable is given for the first time during the first five days of a person’s
menstrual cycle, it is effective immediately after it is injected. If the first dose is
given at any other point during the menstrual cycle, another form of contracep-
tion, such as condoms, should be used for seven days in order to prevent
pregnancy.
There are several benefits of contraceptive injectables. Because they are
injected in a doctor’s office or sexual health clinic, the individual does not need to
remember to take a pill every day. Further, there is no preparation needed prior to
sex, such as making sure to have condoms or putting another type of barrier
method in place, and there are no interruptions during sexual activity. This also
makes them very discreet so the individual can be in complete control of their
144 Contraceptive Patch
reproductive health. Some forms of contraceptive injectable have also been
approved for helping with the symptoms of endometriosis.
As with all medications, there can be some side effects. A common side effect
is irregular bleeding or “spotting,” although this tends to get better over time, and
some individuals may stop menstruating entirely. Some individuals also report
weight gain, mood swings, abdominal pain, dizziness, headache, and fatigue. For
individuals who wish to become pregnant after using contraceptive injectables, it
may several months, and in some cases up to a year, for fertility to return to nor-
mal, depending on the type of injectable used. Combination injectables tend to
have fewer side effects than progestin-only injectables. Finally, progestin-only
contraceptive injectables have been found to be associated with a loss of bone
mineral density, so it is recommended that they not be used for an extended period
of time.
Contraceptive injectables do not protect against sexually transmitted infections
(STIs) and so a barrier method of STI protection, such as condoms, should also be
used.
Heather L. Armstrong
See also: Birth Control Pills, Estrogen-Progestin; Birth Control Pills, Progestin-Only;
Contraception; Estrogen; Ovulation; Pregnancy; Progesterone; Sex Hormones; Synthetic
Hormones.
Further Reading
Centers for Disease Control and Prevention. (2020). Contraception. Retrieved from
https://www.cdc.gov/reproductivehealth/contraception/index.htm
Mayo Clinic. (2020). Depo-Provera (contraceptive injection). Retrieved from https://
www.mayoclinic.org/tests-procedures/depo-provera/about/pac-20392204
National Health Service. (2018). The contraceptive injection. Retrieved from https://www
.nhs.uk/conditions/contraception/contraceptive-injection/
Contraceptive Patch
In 2001, the Food and Drug Administration approved the use of the transdermal
patch, or the birth control patch. The birth control patch is thin, beige, and made
of plastic. It sticks to the skin, providing a continuous flow of hormones into the
bloodstream, and is used to prevent pregnancy.
A person places a new birth control patch on their skin once a week for three
consecutive weeks, followed by one week with no patch. The patch releases syn-
thetic estrogen (ethinyl estradiol) and progesterone (norelgestromin). These hor-
mones work to prevent pregnancy primarily by preventing eggs from leaving the
ovaries. The hormones also prevent sperm from meeting an egg by thickening the
cervical mucus.
In order to get the contraceptive patch, a person needs to consult with a health
care provider and receive a prescription. Once the patches are obtained from a
drugstore or pharmacy, a person can place the sticky part of the patch on the skin
of the torso (avoiding the breasts), stomach, upper outer arm, back, or buttocks. It
is recommended to use the palm to press the patch onto the skin for ten seconds.
Contraceptive Patch 145
At the end of each week, the patch is removed and a new one is placed on a differ-
ent area of skin. Once a patch has been used for the full week, it should be sealed
and thrown in the trash. After changing patches for three weeks, a person then
goes patchless for the fourth week when, typically, menstruation is experienced.
The birth control patch is known to have both positive and negative side effects.
A common side effect of the patch that users report experiencing is lighter and
shorter periods. The patch may also prevent acne and improve menstrual cramp-
ing. Some negative side effects include bleeding between periods, nausea, vomit-
ing, and swollen or tender breasts. Typically, these side effects will cease after the
first few months of use. Sometimes, long-term side effects might include a nega-
tive skin reaction on the area where the patch is placed, vaginal irritation, increased
vaginal discharge, or a change in sexual desire.
The patch is very effective in preventing pregnancy and is more than 99 percent
effective with perfect use, meaning that a new patch is placed on the correct area
of skin on the correct day each week. This ensures the appropriate levels of hor-
mones are circulating in a person’s body. With inconsistent use, the patch is 91
percent effective in preventing pregnancy. When someone chooses to stop using
the patch, the ability to become pregnant returns quickly.
The patch is a relatively safe method of birth control. However, in some cases
and in certain bodies, it may come with more severe risks. These risks are rare but
include high blood pressure, gallstones, liver tumors, and jaundice.
Sarah Gannon
See also: Contraception; Contraceptive Implant; Contraceptive Injectables; Pregnancy;
Sex Hormones.
Further Reading
Bedsider. (2019). The patch. Retrieved from http://bedsider.org/methods/the_patch
#details_tab
Courtney, K. (2006). The contraceptive patch. AWHONN Lifelines, 10(3), 250–254.
Jones, R. E., & Lopez, K. H. (2014). Human reproductive biology (4th ed.). San Diego,
CA: Academic Press.
Planned Parenthood. (2019). Birth control patch. Retrieved from https://www.plannedpar-
enthood.org/learn/birth-control/birth-control-patch
D
Date Rape
The term “date rape” originally distinguished rapes that occur in an intimate set-
ting with a known person—such as on a date—from rapes perpetrated by strang-
ers. A more appropriate term is “acquaintance rape.” While these terms are meant
to distinguish between rapes committed by known versus unknown assailants,
they are also used to differentiate between “forcible” rape and rapes in which
severe physical injuries are not otherwise sustained.
The distinction between forcible rape and date rape is foggy and often at the
discretion of reporting officers. Most rapes where the victim knows the assailant
are classified as date rapes, regardless of whether additional physical violence was
used, as over 50 percent of acquaintance rape victims report using force to try to
stop the rape. Since the FBI only collects statistics regarding forcible rape, there
may be pressure for various institutions to minimize sexual attacks by classifying
them as “date rapes.”
The majority of acquaintance rapes occur in nonsexual settings between per-
sons who do not have a sexual relationship. They typically occur when a victim
and perpetrator are alone, and they are most common at parties, during visits or
study sessions, in cars, or in isolated workplace areas. Only around 13 percent of
acquaintance rapes occur during dates. Gang rape—the rape of one person by
multiple perpetrators at the same time or in close succession—is presumed to be
least common, though all forms are underreported, and neither acquaintance nor
gang rape are specifically counted under federal reporting guidelines.
Acquaintance rape may include alcohol or drug intoxication. This may be envi-
ronmental (such as during a party), or the perpetrator may intentionally give alco-
hol or drugs to the victim to lower their resistance, select a victim based on their
level of intoxication, or drug the victim without their knowledge.
At least one in six women, and possibly as many as one in three, are raped at
some point in their lives. The perpetrator and victim know one another in over 90
percent of cases. Fewer than 5 percent of victims report rape to the police. Native
American women, who account for slightly over 1 percent of the population, suf-
fer a 35 percent rate of rape; black women, at 13 percent of the population, suffer
an 18 percent rate; and white women, at 77 percent of the population, suffer a 17
percent rate. Most acquaintance rape victims are females between the ages of six-
teen and twenty-four, and most perpetrators are classmates or friends. Current and
past boyfriends are the second-most-common class of perpetrator, and friends of
the family and friends’ family members are third.
148 Date Rape
Until 2012, the FBI only recognized attacks against women by men as rape.
Estimates of male rape victims are based on self-reports and indicate that as many
as one in thirty-three men experience rape at some point in their lives and that up
to one-tenth of acquaintance rape victims may be male.
Forcible rape of men is most frequently committed by men who self-identify as
heterosexual against men who are perceived to be gay or feminine. Accurate sta-
tistics regarding the demographics of victims and perpetrators in male-victim
acquaintance rapes are not yet available.
While evidence presented in 2000 by authors Jerrold Greenberg, Clint Bruess,
and Debra Haffner indicate that up to 6 percent of rape perpetrators may be
female, this percentage appears to include women who participate with male part-
ners in the rape of other women or men as well as women who perpetrate inti-
mate-partner violence within same-gender relationships. Statistics regarding rape
of men by women are lacking.
While over one-third of lesbian-identified women and over one-tenth of gay-
identified men report being victims of coerced sex, this statistic neither specifi-
cally addresses acquaintance rape nor indicates the gender of perpetrators.
Acquaintance rape—along with a host of other sexual crimes, such as harass-
ment, stalking, sexual battery, and unwelcome exposure—occurs much more
frequently in association with college campuses than in the general population,
with an estimated one in four female college students suffering rape during their
time at school. This may be due to a sense of liberty and privacy on the part of
perpetrators and a perception of female college students as being alone and
vulnerable.
Like all forms of rape, campus rape is underreported, and most statistics come
from surveys and self-reports. Acquaintance rape occurs most frequently at the
beginning of the school year and primarily targets first- and second-year female
students. About 10 percent of campus rapes occur in fraternity housing. Of the
remainder, slightly over half occur off-campus, and just under half occur in dorm
rooms. According to students’ self-reports, campus rape accounts for at least one
rape per week on college campuses, though only around 2,500 are reported annu-
ally for all campuses nationwide.
Self-reports of perpetrators indicate that a minority of men account for the
majority of campus rapes. Virtually all men who acquaintance rape do so more
than once, and most who successfully evade report become serial rapists (defined
as committing four or more rapes). A study conducted by David Lisak and Paul
Miller indicates that serial rapists commit around 90 percent of all campus
acquaintance rapes, averaging six each. The assumption is that, as perpetrators
get away with rape, they gain confidence and go to greater lengths to strategize
and plan their attacks and to groom and isolate potential victims. Athletic teams
and fraternities have a strong association with campus rape and account for at
least 55 percent of reported gang rapes.
Established intervention strategies tend to focus on the behavior of poten-
tial victims, and when given on college campuses, they typically occur at a
point in the school year when most acquaintance rapes have already occurred.
Colleges may also avoid or downplay rape awareness and prevention to avoid
Dating 149
the impression that their campuses are risky. Campus rape statistics, however,
make it clear that more effective interventions are necessary.
One strategy based on studying the psychology of rape perpetrators is to train
nonrapist men to recognize rapist behavior and intervene on behalf of victims. Like
successful antibullying strategies, this creates advocates by eliminating the phe-
nomenon of silent bystanders. Another strategy is to train women and vulnerable
others to recognize warning signs in potential perpetrators. For example, most
acquaintance rapists engage in victim grooming where they “court” intend victims
in a way that is subtly intrusive and aggressive, persistently violating personal space
until the uneasiness this engenders “wears off” and they can isolate their victims.
Angela Libal
See also: Rape; Rape, Abuse and Incest National Network (RAINN); Rape Shield Laws;
Rape Trauma Syndrome; Sexual Abuse; Sexual Assault; Sexual Harassment; Statutory
Rape.
Further Reading
Girls Health. (2015). What is rape and date rape? Retrieved from http://girlshealth.gov/
safety/saferelationships/daterape.html
Greenberg, J. S., Bruess, C. E., & Haffner, D. W. (2000). Exploring the dimensions of
human sexuality. Sudbury, MA: Jones and Bartlett.
Lisak, D., & Miller, P. (2002). Repeat rape and multiple offending among undetected rap-
ists. Violence and Victims, 17(1), 73–84.
Sampson, R. (2002). Acquaintance rape of college students. Washington, DC: U.S.
Department of Justice, Office of Community Oriented Policing Services.
Solnit, R. (2013, January 24). A rape a minute, a thousand corpses a year. The Nation.
Retrieved from http://www.thenation.com/article/172408/rape-minute-thousand
-corpses-year
U.S. Centers for Disease Control and Prevention. (2019). The National Intimate Partner
and Sexual Violence Survey (NISVS). Retrieved from http://www.cdc.gov/
violenceprevention/nisvs/
Dating
“Dating” is a term that emerged in the early twentieth century as a new iteration
of courtship. In order to appreciate the magnitude of the shift from dating to court-
ship, and all the factors affecting this change and resulting from it, one must first
understand courtship. Courtship describes the process leading up to marriage and
procreation, which includes mate selection, relationship formation, and partner-
ship. At various times and geographical locations, different things are valued in
the selection of a mate, and the process by which one is selected varies as well. In
cultures where arranged or assisted marriage is practiced, spouses may be chosen
in infancy or childhood, so courtship could occur in childhood or at the time of
marriage. In these locales, “dating” may not exist at all.
Prior to industrialization, family served a very specific economic function, and
children were needed to help perform agricultural labor. At this time, the average
life span was shorter, and fertility rates were higher. Adults married at a young
150 Dating
age and could expect to raise many children before they died. Because marriage
was valuable economically to both families, the family of origin was important in
guiding young people into relationships and evaluating the suitability of a mate.
The emphasis was on family worth (or name) and economic stability. Since women
were expected to be financially dependent on their husbands, a good suitor was a
male who would be able to be a good provider (Bailey, 1989).
After industrialization, work moved from the family to the factory, resulting in
a gendered division of labor within the family and a more defined class system. It
was during this time that women were encouraged to actualize their “natural”
instincts of childbearing. Despite the lack of necessity to have more hands on the
farm, this ideology kept fertility rates high. Also during this time, the family of
origin was the judge of appropriate mates for both men and women. Dating, or
courtship, during these times took place with the family present. Young adults
would meet at family, school, or church functions, and they rarely spent time
together without a chaperone. Courting at this time was regulated by the family; it
was a social norm for young men to “call” on young women and socialize with the
young woman and her mother. Control of this process belonged to the women, as
they established days and times to receive callers, and it was they who invited
callers to visit. Calling was enmeshed within the middle class, as middle-class
homes had parlors where young women could receive callers. Dating first emerged
among the working class, who often lived in dwellings that did not facilitate call-
ing, so working-class youth were forced to socialize outside of the home.
The advent of the automobile at the turn of the twentieth century gave opportu-
nity for affluent youth to spend time together socially without supervision. How-
ever, the affordability of the Model T Ford expanded this access to the middle
class, which enabled young men to take young women out on “dates.” This brought
courtship out of the home and into public and marked the beginning of the shift
away from the family as the regulators of young adults’ choices of mates, since
this period also marked the emergence of media giving advice on dating and rela-
tionships. This advice, often in the form of magazine articles or etiquette manuals,
served as a referent against which people judged behavior and made decisions.
In addition to the shift out of the home, dating had other significant aspects
relating to the control of the date. Dates required money and places to go, such as
theaters and dance halls. In fact, something was often considered a date when
money was spent, and it was the man’s money spent on the woman. This is impor-
tant, as control of the date shifted to the man by virtue of his paying for it as well
as it taking place in the public, male, sphere. Etiquette at this time instructed
women not to pay or offer to pay for dates and instructed that there were certain
places where “respectable” women should not go.
In the nineteenth century, dating was framed in language relating to home and
family, while in the next century, these metaphors shifted to those relating to capi-
talism. As American society was experiencing abundance, the emphasis in dating
was also abundance: youth were instructed to date as many people as possible,
and those without dates faced stigma. Not only was having a date important, but
one gained status from having the “right” date. The right man was one with finan-
cial resources and the ability to pay for many dates. The right girl was one who
was popular and highly sought after by others. Youth would “rate” their peers to
Dating 151
determine popularity and suitability. “Rating and dating” echoed the themes of
competition inherent in capitalism, and the public nature of dating allowed for this
competition to be enacted in view of others, reinforcing the significance of the
peer group as an appraiser of status and popularity. Being seen out with a highly
popular young woman afforded the young man status, while “getting stuck” with
one partner on the dance floor, by not having another man cut in, was a cata-
strophic marker of unpopularity for young women.
Rating and dating, and the spirit of competition within dating, remained com-
mon until World War II. During the war years, most young men went to war, so
the ratio of women to men changed. Competition flourished when there were more
available men, but during and after the war, women outnumbered “marriageable”
men. Economically, too, the trend shifted from competition to scarcity, and this
was reflected in dating changes. After the war, the concept of “going steady,” or
only dating one person with the intention of hopefully marrying, emerged. The
average age at marriage began to decline after a rise during the Depression, as the
fear of being alone encouraged youth to marry young, which encouraged dating at
younger ages than before. By 1950, children as young as twelve experienced
“going steady,” and among older youth, having a steady partner was the marker of
status and popularity.
Steady relationships, and the public consumption they encouraged, remained
popular until the 1960s, when there was widespread social change. Feminism took
root, and many of the conventional restrictions on young adult behavior, specifi-
cally young women’s behavior, relaxed. Young people began to spend time in
mixed-sex groups, and mechanisms for relationship formation changed as well.
The availability of oral contraception affected patterns of relationships and inti-
macy, since it allowed people the availability of sexual intercourse without con-
cern of pregnancy. In spite of these changes, conceptions of dating remained fairly
consistent through the 1990s.
Media has been used to assist dating and mate selection since the 1960s, but the
advent of the internet has expanded this with the introduction of online dating,
which allows users to expand their network of potential partners as well as to
manage self-presentation in the hopes of attracting a mate. The use of internet
technology is continuing to expand, allowing for users of all social classes, and as
it does, so does social acceptance of internet dating and the decrease of stigma
associated with it. The proliferation of online dating sites, and the specificity of
such sites, allows people to seek out partners with very specific characteristics, as
there are sites designed to find a partner with a specific religion, income, height,
and even health status, such as having HIV or HSV, which may help to offset
some of the perceived risks that are associated with online dating.
Internet technology also fosters a sense of instant gratification, and this has
also affected dating trends, encouraging the shift to hooking up among emergent
adults. Hookups allow people to engage in sexual activity without the time or
monetary expenditure involved in dating, and social media technology facilitates
communication to arrange for such encounters as well as providing a platform for
peers to comment on one’s relationship. For these reasons, hookup culture has
become quite prominent as a mechanism for relationship formation, in some cir-
cumstances replacing traditional dating.
152 Dating, Cross-Cultural Comparison of
Many studies of dating and courtship focus on youth and emergent adults.
Recent work has begun to examine the process of dating in midlife. Adults reen-
tering the dating scene after the end of a long-term relationship are often chal-
lenged by a cultural emphasis on partnering and a focus on physical appearance.
Older individuals may be influenced by courtship norms from their youth and,
thus, may be unprepared to negotiate contraception use. This makes older adults
specifically vulnerable to sexually transmitted infections. Adults in midlife often
approach dating with an emphasis on gains and losses and may partner up for the
purposes of companionship, financial assistance, a need for a caretaker, or sexual
gratification. Midlife women who are financially stable may fear a partner will
take advantage of or manipulate them. For midlife adults, the internet is also per-
ceived as risky, leading women to engage in different kinds of dates to increase
safety, such as the interview date, a public meeting to evaluate safety in hopes of
a subsequent romantic date, or the companion date, a platonic friend to socialize
with, devoid of physical intimacy.
Rachel Kalish
See also: Adolescent Sexuality; Casual Sex; Dating, Cross-Cultural Comparison of;
Friends with Benefits; Hookup Culture; Marriage; Online Dating; Serial Monogamy;
Sexual Revolution.
Further Reading
Bailey, B. L. (1989). From front porch to back seat: Courtship in twentieth century Amer-
ica. Baltimore: Johns Hopkins University Press.
Bergdal, A. R., Kraft, J. M., Andes, K., Carter, M., Hatfield-Timajchy, L., & Hock-Long,
L. (2012). Love and hooking up in the new millennium: Communication technol-
ogy and relationships among urban African American and Puerto Rican young
adults. Journal of Sex Research, 49, 570–582.
Bogle, K. A. (2008). Hooking up: Sex, dating and relationships on campus. New York:
New York University Press.
Couch, D., & Liamputtong, P. (2008). Online dating and mating: The use of the internet to
meet sexual partners. Qualitative Health Research, 18, 268–279.
England, P., & Thomas, R. J. (2007). The decline of the date and the rise of the college
hook up. In A. S. Skolnick & J. H. Skolnick (Eds.), Family in transition (14th ed.,
151–162). Boston: Allyn & Bacon.
Laner, M. R., & Ventrone, N. A. (2000). Dating scripts revisited. Journal of Family Issues,
21, 488–500.
Lichtenstein, B. (2012). Starting over: Dating risks and sexual health among midlife
women after relationship dissolution. In L. M. Carpenter & J. DeLamater (Eds.),
Sex for life: From virginity to Viagra, how sexuality changes throughout our lives
(180–197). New York: New York University Press.
Waller, W. (1937). The rating and dating complex. American Sociological Review, 2,
727–734.
Dating, Cross-Cultural Comparison of
Dating is a system whereby persons who are not currently in a civil or religious
marriage develop a mutual romantic attachment to one another through a series of
personal encounters. When dating is defined by strict cultural norms with the
Dating, Cross-Cultural Comparison of 153
specific intention of facilitating a marriage, it is referred to as courtship. The
intention, trajectory, length, and expectations of dating tend to change signifi-
cantly over time and to vary across cultures.
Broadly defined, “dating” may include a constellation of relationships ranging
from friendly group recreational outings to one-on-one intimate partnerships that
include cohabitation and childrearing. Traditionally, “dating” refers to a mate
selection process, the ultimate intention of which is civil or religious marriage.
The types of behaviors that constitute dating, and the extent to which these behav-
iors are encouraged, tolerated, or forbidden, vary powerfully between different
ethnic, social, and religious cultures even within a single time and place.
In the traditional dating-as-prelude-to-marriage system, it is predominantly
young, never-married persons who date. As social expectations shift, the dating
demographic expands. As age of first marriage rises and fewer people ever marry,
it is now common throughout the United States for persons in all age groups from
puberty onward to engage in dating relationships. This includes single, divorced,
and widowed persons, regardless of their intentions to marry or remarry. It may
also include polyamorous people—persons who simultaneously engage in multi-
ple committed relationships—regardless of their current marital status.
Since the Christianization of the Roman Empire and the European Conquest,
dating and courtship have been confined to heterosexual, or mixed-sex, pairings
throughout most of the world. However, in most industrialized nations, it is now
possible for people to date and court within their own gender openly and with
relative freedom.
Since the 1950s, it has been common for persons in most ethnic groups within
the United States to begin dating in their early teens but not marry until much
later: typically in their early twenties for Latin Americans, late twenties for whites,
and late twenties to early thirties for blacks. In traditional Asian homes where
education is highly valued, young people often do not begin dating until their
undergraduate studies are well underway or completed and they are considered
ready to marry, typically in their early twenties. In general, same-sex dating tends
to commence at a later age, often after the individuals have begun living
independently.
In cultures that practice arranged marriages, an acquaintanceship period simi-
lar to courtship or dating may or may not be present. In some Orthodox Jewish
communities, parents and professional matchmakers bring couples together. Tra-
ditionally, the relationship begins with betrothal, approximately one year before
the wedding. At betrothal, the marriage contract is signed, and the man (or couple)
is expected to spend the upcoming year purchasing a home and otherwise prepar-
ing economically to set up a household. In traditional communities, actual cohabi-
tation and sexual relations do not begin until the wedding. If a couple finds
themselves incompatible during betrothal, they can leave the relationship but must
do so through a formal religious divorce proceeding. In non-Orthodox communi-
ties, the formal betrothal ceremony may be retained but is usually performed on
the same day as the wedding ceremony.
Certain fundamentalist Christian movements within and outside the United
States also practice arranged marriages, which are usually negotiated by the cou-
ple’s fathers. In many traditional Asian cultures, families negotiate with one
154 Dating, Cross-Cultural Comparison of
another to bring couples together. In some cases, the active players are the parents;
in others, all older immediate and extended relatives expect to participate in the
matchmaking. In many cultures, including Korean, Chinese, and Laotian, the
couple is introduced and may begin to date once the match is approved, and each
partner has veto power; but in a few cultures, such as many from India, the couple
does not traditionally meet until the wedding.
Where dates occur also varies between cultures. In dominant American cul-
ture, dating activities and locations primarily vary with the age of participants.
For young adolescents, dating partners may primarily spend time with one another
at school or during other group social activities without any formal “dates” occur-
ring at all. Older teens with access to transportation may go on formal or informal
dates by themselves or with larger groups of friends. College-age teens and adults
might spend time together in residences, go on formal dates, or engage in public
social activities together. Independent adults may extend the dating relationship
indefinitely, going on formal and informal dates, splitting time between each oth-
er’s residences, and eventually cohabitating.
In some cultures, parents expect their children’s dates to be chaperoned. Young
Mormon couples, for example, are expected to primarily see each other at church
and during church-oriented group activities. Korean girls traditionally bring a
female friend to chaperone public dates, while it is considered indecent for unmar-
ried Japanese and Chinese couples to be seen alone in public at all. In these cases,
dates either take place in groups or within the family home. Among these cul-
tures, all physical displays of affection are strongly discouraged, and unaccompa-
nied public dates typically signal a couple’s intention to marry.
Norms for establishing a dating relationship, and the expected outcome of such
relationships, change dramatically throughout time. For example, in the nine-
teenth century, middle- and upper-class white people established dating relation-
ships at the woman’s invitation, with her parents’ permission. Her suitors would
visit her in her parents’ home under their eye; “keeping steady company” and
being seen together in public were tantamount to announcing engagement. With
the rise of the automobile and public entertainment in the 1920s, dating became a
public, unchaperoned activity, but being seen with different dating partners
remained the norm until a couple was engaged. Which gender could initiate dat-
ing varied based on local culture, socioeconomic class, and ethnic group. It was
not until after World War II that “going steady” became the norm and women
were expected to wait for men to initiate dating.
In contemporary American culture, a person may ask another on a date regard-
less of gender, though expectations vary somewhat with region and cultural iden-
tification. The expectation that men will take the initiative to establish a
heterosexual dating relationship is more common among black and Latin Ameri-
cans than among whites, and among teenagers and older adults than young and
middle-aged adults.
In some communities, such as among certain very traditional South American
cultures, custom requires a male to gain permission from a female’s parents before
commencing a dating relationship; in others, such as African American, non-
Orthodox Jewish, and some Korean and Chinese American communities, being
Dating, Cross-Cultural Comparison of 155
introduced to a dating partner’s parents and family signals the seriousness of the
relationship and possibly the intent to marry. This is in contrast to many tradi-
tional Asian, Orthodox Jewish, and certain fundamentalist Christian communi-
ties, where heterosexual couples are introduced to one another by the parents.
For LGBTQ+ persons, establishing a dating relationship can have additional
complications, since it often involves sensitive information such as determining
the sexual orientation, and sometimes the gender, of the person of interest and
possibly coming out oneself, which in some communities may still carry the
actual risk of violent attack or extreme social censure.
Traditionally, the purpose of dating was to assess potential heterosexual mar-
riage partners. However, as the stigma attached to sexual relationships between
unmarried people declines, the purposes of dating and types of dating relation-
ships have multiplied. For mixed-sex couples, dating may now lead to cohabita-
tion and childrearing outside of marriage or may be entered into for temporary
companionship or casual sex. For same-sex couples, dating may now be conducted
openly with the express purpose of eventually marrying and establishing a
family—dramatic shifts that have slowly developed since the sexual revolution of
the 1960s and 1970s.
When sex is considered acceptable, and between whom, is the most emotion-
ally charged issue associated with dating. According to the Pew Research Center,
as of 2014, sex between unmarried persons is considered morally unacceptable by
30 percent of the U.S. population and 46 percent of persons globally, while homo-
sexuality is considered morally unacceptable by 37 percent of persons in the
United States and 59 percent of persons globally (Poushter, 2014). These opinions,
combined with those on associated issues such as contraception (7 percent unac-
ceptable in the United States and 14 percent worldwide) and divorce (22 percent
unacceptable in the United States and 24 percent worldwide) affect when sex is
considered appropriate, types of sex considered acceptable, and expectations
regarding how sex fits into a couple’s plans to marry.
The fact that only 46 percent of U.S. children now live in households with two
married, heterosexual parents who have only been married to each other testifies
that statements regarding the acceptability of various sexual, partnership, and
reproductive choices only represent broad generalizations. Typically, however,
stigma against sex outside of marriage is much stronger the younger a couple is
and relaxes the further they move into adulthood and financial independence.
Stigma against nonmarital sex also tends to relax for persons who are divorced,
widowed, or LGBTQ+; for persons of dominant racial and ethnic groups and
higher socioeconomic classes; and in urban, multiethnic populations.
In some populations, such as certain LGBTQ+ and heterosexual subcultures,
it is relatively common for a sexual encounter to occur outside of a dating rela-
tionship or to signal the beginning of a dating relationship. In others, sex is
popularly considered acceptable after a certain level of commitment has been
established, either by completing a certain number of formal dates, dating for a
certain period of time, exchanging specific tokens of affection, or announcing
an engagement. A growing number of people, especially those in urban
areas, place more importance on cohabitating or coparenting as indicators of
156 Demisexuality
relationship commitment and stability than on traditional expressions such as
engagement or marriage.
Sex outside of marriage is considered least acceptable in traditional Asian and
Asian American communities; fundamentalist Christian and Islamic communi-
ties; and Orthodox Jewish, Mormon, and Hindu communities, where even sexual
expression within marriage is strictly governed by rules regarding modesty, chas-
tity, and family relationships.
Considering the extent to which moral expectations around sexual expression
vary based on age, ethnicity, culture, religion, sexual orientation, level of educa-
tion, and subculture, expectations regarding the timing and acceptability of sex
within dating relationships are likely to continue to rapidly evolve and fluctuate
with overall shifts in global and U.S. society.
Angela Libal
See also: Dating; Hookup Culture; Marriage, Cross-Cultural Comparison of; Online Dat-
ing; Polyamory; Public Displays of Affection.
Further Reading
Jackson, P. B., Kleiner, S., Geist, C., & Cebulko, K. (2011). Conventions of courtship:
Gender and race differences in the significance of dating rituals. Journal of Fam-
ily Issues, 32(5), 629–652.
Poushter, J. (2014). What’s morally acceptable? It depends on where in the world you live.
Retrieved from http://www.pewresearch.org/fact-tank/2014/04/15/whats-morally
-acceptable-it-depends-on-where-in-the-world-you-live/
Sex Info Online. (2018). The history of dating in America. Retrieved from https://sexinfo.
soc.ucsb.edu/article/history-dating-america
Wang, W., & Parker, K. (2014). Record share of Americans have never married as
values, economics and gender patterns change. Retrieved from http://www
.pewsocialtrends.org/2014/09/24/record-share-of-americans-have-never-married/
Demisexuality
Demisexuality describes a sexual orientation in which sexual attraction and
expression are based on a strong emotional and personal connection rather than on
physical appearance or sexual desire. Demisexuality is often placed under the
umbrella of asexuality and has been considered a way to further describe those
who may not readily experience sexual attraction and desire.
Those who identify as asexual make up about 1 percent of the world’s population,
and it is thought that those who identify as demisexual represent a steadily increas-
ing portion of this group. The term “demisexual” comes from the idea that the ori-
entation is “halfway” between sexual and asexual; yet this is not to suggest that
demisexuals have half, or somehow incomplete, sexualities. As with all sexual ori-
entations, demisexuality will be different for different people. Some demisexuals
may only experience attraction to a handful of people (or less) during their lives.
And while some demisexuals may report at times experiencing strong sexual desire,
their expression of sexual attraction and desire is based on an established emotional
connection. Hookups, excessive sexual experimentation, one-night stands, and even
flirting may not be desirable to those with a demisexual orientation.
Dental Dam 157
Demisexuality has been gaining visibility around the world, thanks largely to
internet communities like the Asexual Visibility and Education Network (AVEN)
and Asexuality India. These platforms have increased the opportunity for indi-
viduals to learn, discuss, and meet other individuals with similar lived experi-
ences and identities. Members of the demisexual community advocate to increase
visibility and representation of demisexuals in media, politics, education, and
advocacy to bring greater awareness of demisexuality and representation of
demisexual-identified folk in society.
Despite growing awareness, little research exists about demisexuality or the
experiences of those who identify as demisexual. As such, much of the informa-
tion available comes from personal accounts in brief op-eds as well as other print
and online articles. Further study of demisexuality may help individuals navigate
their own experiences with demisexuality and may help promote increased under-
standing and acceptance of this sexual orientation.
Shadeen Francis and Patrick R. Grant
See also: Asexuality; Sexual Orientation.
Further Reading
D’Silva, M. D. (2017, December 4). Are you a demisexual? DNA. Retrieved from https://
www.dnaindia.com
Hosie, R. (2017, August 28). What is demisexuality? The Independent. Retrieved from
https://www.independent.co.uk
Kumar, S. (2017, March 18). Meet India’s newest sexual minority: The asexuals. The Hin-
dustan Times. Retrieved from https://www.hindustantimes.com
Williams, M. (2016, November 2016). I’m demisexual: It takes me a while to feel physical
attraction. The Washington Post. Retrieved from https://www.washingtonpost
.com
Dental Dam
Dental dams are square pieces of latex or silicon-based material that can be used
during oral sex on the penis, vulva, vagina, and anus to prevent the spread of
sexually transmitted infections (STIs). Many people are unaware that STIs can be
spread through oral-genital contact; however, transmission is possible for many
STIs, including herpes, gonorrhea, and chlamydia. Dental dams are available in a
variety of colors, and some may be flavored.
By design, dental dams are used by dentists to isolate teeth or parts of the
mouth for certain procedures. The dams help keep the area dry to improve the
performance of adhesives and composite materials. They also prevent instruments
or parts of drilled teeth from falling into the oral cavity of the patient. Dental
dams are also important protection for the patient and the dental team from body
fluids that could carry infectious bacteria or viruses. Because of their ability to
prevent transfer of fluids, dental dams have also become popular among some for
use in oral-genital and oral-anal sex to help prevent the transmission of diseases,
including HIV.
Dental dams allow a person to stimulate the genitals or anus of their partner
without the risk of contact with bodily fluids, which can carry STIs. In order to
158 Desire
use a dental dam, the sheet is spread over the vulva or anus and can be held in
place by either partner’s hands. Because the material of the dam is very thin, sex-
ual stimulation with the tongue and mouth can be performed without the risk of
STI transmission. Experts recommend that dams be disposed of after one use to
prevent possible infection. It is also important never to flip the dam over, so only
one side must be used.
Despite the benefits of using dental dams, they can be hard to find to purchase.
If a dental dam is not available, a condom can be used by cutting off both ends of
the condom and then cutting up the length of the condom and rolling it out into a
square. This square can then be placed over the genitals or anus before oral sex.
Latex dams may cause irritation for those with latex allergies, so silicon and
polyurethane dams are also available.
Tim J. Watts
See also: Condoms, Female (Receptive); Condoms, Male (Insertive); Oral Sex; Sexually
Transmitted Infections (STIs).
Further Reading
Centers for Disease Control and Prevention. (2016). Dental dam use. Retrieved from
https://www.cdc.gov/condomeffectiveness/Dental-dam-use.html
Galan, N. (2018). Dental dams: Everything you need to know. Retrieved from https://
www.medicalnewstoday.com/articles/323768.php
Desire
Sexual desire (also known as libido or sex drive) is considered to be an individu-
al’s psychological state where there is a want, need, desire, or appetite for sexual
activity of some kind. It is a term that might seem straightforward but actually
encompasses physiological drives and processes, cognitions, behaviors, emotions,
motivations, subjective experiences, and many other unknown factors. The exact
physiological, cognitive, emotional, and behavioral mechanisms that create and
interact with sexual desire are not yet fully understood. However, it has been said
that desire (an appetite for sexual activity) to some extent can be compared with
hunger (an appetite for food). An individual may feel hunger due to internal cues
(a memory of food or growling stomach) or external cues (walking past a bakery
or a friend asking if they want lunch), but whether or not they take action to seek
out food to sate this appetite depends on many factors. These include the level of
hunger they are feeling, their ability to tolerate this hunger, the individual’s prox-
imity to food, their emotions relating to food in that moment, their thoughts about
food, past experiences with food, the motivation to physically source food, and
ultimately a decision about whether to eat or not. While sexual desire is thought of
as the desire for sex, it is ultimately one of many factors that determine whether an
individual will engage in sexual activity or not.
Sexual desire has typically been considered to be spontaneous and the first
phase of the human sexual response; however, it is now known that it can also be
experienced as responsive. Responsive desire is desire that occurs at any point in
the sexual response cycle, with individuals (particularly females) being able to
Desire 159
feel aroused without desire and to experience desire as a response to arousal. This
means that desire does not always need to be present prior to the commencement
of sexual activity as many individuals choose to engage in sexual behavior with-
out, or prior to, any sense of sexual desire. However, as sexual activity continues,
desire often begins or increases in response to the sexual situation.
The current understanding of the mechanisms of sexual desire is extremely
limited, but there is some knowledge about some of the cognitive, behavioral, and
physiological aspects of this state. Historically, the cognitive element of desire has
been considered to be sexual fantasy, although this has been expanded to include
many other internal sexual cues that may lead to sexual desire, including thoughts
and memories. Sexual fantasies or daydreams can occur during or outside of sex-
ual activity, can be spontaneous or intentional, and can include any mental imag-
ery that is arousing to the individual.
Behind these cognitive elements of desire are complex mixes of physiological
mechanisms, including hormones and neurotransmitters, that serve to make sex-
ual desire possible. At the start of the sexual response cycle is a release of steroid
hormones such as norepinephrine and oxytocin, which cause the individual to pay
more attention to sexual cues. Dopamine and melanocortin assist with the stimu-
lation of attention and desire and downregulate the inhibitory systems, meaning
that the individual is more likely to act on their desire. Following sexual reward
(often orgasm but may be other rewards, such as a sense of bonding or emotional
warmth), endocannabinoids and serotonin begin the refractory period and give the
individual a sense of satiation or satisfaction.
Despite these mechanisms, it is not actually necessary for desire to be present
prior to engaging in sexual activity, as research indicates that 82 percent of all
females and 60 percent of men will regularly participate in sexual activity without
desire. This is an important distinction, as desire is commonly equated to the
amount of sexual activity in which a person engages. Regardless, researchers have
historically measured levels of desire through frequency of sexual activity, with
the assumption that if desire is present it will lead to sexual behavior. In reality,
desire is more closely related to the hunger analogy provided above with many
factors influencing whether the experience of sexual desire turns into actual sex-
ual activity. It is also important to note that sexual desire includes desire for sexual
activity of any type, including fantasy alone, masturbation, and sexual acts with
other individuals.
One question that is often raised is “How much desire is normal?” Research
has found that levels of sexual desire vary widely from one person to the next
and also vary dramatically for some individuals from day to day as well as at
different times in their lives. Many things influence an individual’s sexual
desire, including their age, health, psychological well-being, beliefs, stress and
fatigue, relationship status, and relationship satisfaction. A “normal” level of
sexual desire can only be determined by considering each individual’s own par-
ticular set of circumstances.
Rebecca Frost
See also: Arousal; Desire, Models of; Desire Discrepancy; Desire Disorders; Fantasy,
Sexual and Erotic.
160 Desire, Models of
Further Reading
Bancroft, J. (2010). Sexual desire and the brain. Sexual and Relationship Therapy, 25(2),
172–188.
Basson, R. (2002). Rethinking low sexual desire in women. BJOG: An International
Journal of Obstetrics & Gynaecology, 109(4), 357–363.
Beck, J. G., Bozman, A. W., & Qualtrough, T. (1991). The experience of sexual desire:
Psychological correlates in a college sample. The Journal of Sex Research, 28(3),
443–456.
Kaplan, H. S. (1979). Disorders of sexual desire. New York: Simon and Schuster.
Leitenberg, H., & Henning, K. (1995). Sexual fantasy. Psychological Bulletin, 117(3),
469–496.
Pfaus, J. G. (2009). Pathways of sexual desire. The Journal of Sexual Medicine, 6(6),
1506–1533.
Desire, Models of
There is not currently one all-encompassing sexual desire model but instead sev-
eral different models of sexual desire, including the triphasic model introduced by
Helen Singer Kaplan (1979) and Rosemary Basson’s circular model of female sex-
ual response (2000). The triphasic model can be considered as a timeline of the
human sexual response with desire as one of the “phases,” while the circular
model was developed as a model of female sexual response and includes both
spontaneous and responsive sexual desire.
Helen Singer Kaplan’s model of sexual response was based on the four-phase
model proposed previously by Masters and Johnson. Importantly, Masters and
Johnson’s model did not include sexual desire. The four phases of this model are
excitement, plateau, orgasm, and resolution. Kaplan revised this model to include
the three stages of desire, excitement, and orgasm.
Within the linear models, desire was traditionally considered as the original
appetite for sexual activity and the first phase of the sexual response. Arousal was
then considered to be the second phase and the physiological aspect of the begin-
ning of sexual response. Although desire and arousal were described as two sepa-
rate phases, there is now some confusion as to whether these are two distinct or
overlapping experiences, and some researchers are now considering these to be so
highly linked that they need to be considered together.
Despite their widespread acceptance, the linear models of sexual response as
proposed by Kaplan and Masters and Johnson have been found lacking, especially
when applied to the female experience. After many years of conducting clinical
work with women with low desire, Rosemary Basson (2000) arrived at a new
model of sexual response, which may be more representative of sexual response,
especially for females. In keeping with more contemporary theory and research
showing the overlap between desire and arousal, as well as research on women’s
motivations for sex, this model is based more on intimacy and emotion than the
pure behavioral and physiological model proposed by Masters and Johnson. The
circular model highlights that people, especially females, are often sexually neu-
tral at the beginning of a sexual experience and that they may choose to engage in
Desire Discrepancy 161
sexual activity for one of many reasons (sexual or otherwise). In response to the
beginning of sexual activity, they then experience subjective or physiological
arousal, which then leads to experiencing desire to continue with the sexual expe-
rience. The most important change in Basson’s model is the introduction of the
idea that people may be more likely to experience “responsive” (desire that occurs
after arousal or the start of sexual activity) rather than “spontaneous” desire
(where desire is present and drives the sexual activity). It is believed that sexual
satisfaction or nonsexual rewards such as emotional intimacy that occur as a result
of being responsive and experiencing sexual activity is reinforcing and will facili-
tate the recurrence of responsiveness in future sexual experiences.
Rebecca Frost
See also: Arousal; Basson, Rosemary; Desire; Desire Discrepancy; Desire Disorders;
Johnson, Virginia; Kaplan, Helen Singer; Kaplan’s Triphasic Model; Masters, William
H.; Masters and Johnson Four-Stage Model of Sexual Response.
Further Reading
Basson, R. (2000). The female sexual response: A different model. Journal of Sex & Mar-
ital Therapy, 26(1), 51–65.
Basson, R. (2002). Rethinking low sexual desire in women. BJOG: An International
Journal of Obstetrics & Gynaecology, 109(4), 357–363.
Kaplan, H. S. (1979). Disorders of sexual desire. New York: Simon and Schuster.
Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Toronto: Bantam
Books.
Meana, M. (2010). Elucidating women’s (hetero)sexual desire: Definitional challenges and
content expansion. Journal of Sex Research, 47(2–3), 104–122.
Desire Discrepancy
Sexual desire discrepancy is most often defined as differing levels of sexual desire
between two partners. Therefore, in a relationship where one partner reports a
greater desire for sexual activity than their partner, a desire discrepancy is said to
exist. While sexual desire discrepancy is not always distressing in relationships, it
has been found to be the most distressing sexual issue that couples face. This is
largely due to the negative impact that desire discrepancy has on sexual and rela-
tionship well-being and satisfaction. Often, this discrepancy in desired frequency
of sexual activity is associated with more obvious negative impacts in relation-
ships of longer duration.
Similar to other sexual health problems, sexual desire discrepancy can occur
for many reasons. Because of the many contributing factors, it is best to use an
approach that includes an assessment of biological, psychological, and sociocul-
tural factors (known as a biopsychosocial approach) to understand these layers of
influence. For instance, when a couple experiences conflict and distress because
of a discrepancy around sexual desire or sexual activity, one might first look at
biological factors at play: hormones, medical issues, current medications, weight,
physical ability, and so on. Next, one might explore psychological wellness: each
individual’s mental health, symptoms of anxiety, depression, body image, or
162 Desire Disorders
self-esteem. In addition, one would want to explore social and cultural factors that
might affect sexual desire: current stage of life (e.g., pregnancy, early parenthood),
external stressors (e.g., job stress, financial strain), cultural or religious factors
(e.g., restrictive attitudes about sex, history of sexual shaming), gender roles, and
relational dynamics (e.g., power differences, conflict, fighting). Together any or all
of these factors can interact and affect sexual desire.
It is important to note that, historically, issues of sexual desire have been seen
as an individual issue. In dealing with sexual desire discrepancy, however, the
primary objective is to focus on the distress caused by the discrepancy, therefore
making it a relational problem. Depending on the factors that have contributed to
and exacerbated the sexual desire discrepancy, sex therapy treatment focuses on
assisting both partners in addressing underlying concerns; improving communi-
cation, connection, and intimacy; and addressing any other co-occurring sexual
or mental health issues. For instance, often when a male partner experiences low
desire, it is coupled with an ejaculatory or erectile issue. Therefore, it is also nec-
essary to address the extenuating sexual health concerns during the treatment
process.
Abby Girard
See also: Desire; Desire, Models of; Desire Disorders; Psychosexual Therapy.
Further Reading
Bridges, S. K., & Horne, S. G. (2007). Sexual satisfaction and desire discrepancy in same-
sex women’s relationships. Journal of Sex & Marital Therapy, 33(1), 41–53.
Mark, K. P., & Murray, S. H. (2012). Gender differences in desire discrepancy as a predic-
tor of sexual and relationship satisfaction in a college sample of heterosexual
romantic relationships. Journal of Sex & Marital Therapy, 38(2), 198–215.
Desire Disorders
There is no commonly agreed on definition of what constitutes “normal” sexual
desire; however, the American Psychiatric Association’s Diagnostic and Statisti-
cal Manual, Fifth Edition (DSM-5) includes two desire disorders: female sexual
interest/arousal disorder and male hypoactive sexual desire disorder. While the
diagnostic criteria differ for males and females, both are disorders that can be
diagnosed when an individual experiences abnormally low sexual desire as well
as distress as a result of their level of desire.
There is a lack of research into disorders of sexual desire, despite their high
prevalence, and there is a false prevailing belief in the clinical community that
sexual disorders are well understood. Desire dysfunction (the presence of symp-
toms without distress) and disorders are the most prevalent of female sexual dys-
functions and disorders, having been found to occur in 26 percent to 55 percent of
the population depending on measurement; they are less prevalent (approximately
half as common) but potentially more distressing in men. One of the most obvious
differences in sexual behavior between males and females is their disparate levels
of desire, with 51.4 percent of men experiencing sexual desire at least daily com-
pared to 7 percent of women. A less pronounced result occurs when measuring
desire for sexual activity, with 23 percent of men desiring to have sex daily or
DHEA 163
more often compared to only 8.3 percent of women. Of course, any diagnosis of a
desire disorder needs to be placed within the context of the large but normal range
of an individual’s desire across age, stage of life, and relationship factors. It
requires the clinician to judge whether the deficiency or absence of desire is suf-
ficient to diagnose the disorder within the context of that individual’s life circum-
stances, even though little is known about the distinctions between normal,
healthy levels of desire and levels that constitute a dysfunction. Therefore, many
clinicians now consider desire disorders to frequently be an issue of desire dis-
crepancy within a couple rather than a disorder of the individual.
Low sexual desire is considered notoriously difficult to treat by clinicians from
many backgrounds, including psychology, psychiatry, and gynecology. To date,
there has been limited controlled research into the treatment of desire disorders,
and no medications are currently proven to be effective for treating desire disor-
ders. Trials for psychological therapy have shown only moderate effects. Cur-
rently, popular treatments for desire disorders include cognitive behavioral
therapy, sensate focus, mindfulness-based treatments, and emotion-focused ther-
apy for couples.
Rebecca Frost
See also: Desire; Desire, Models of; Desire Discrepancy; Diagnostic and Statistical Man-
ual of Mental Disorders (DSM); Sensate Focus; Sexual Disorders, Female; Sexual Disor-
ders, Male.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: America Psychiatric Association.
Basson, R. (2002). Rethinking low sexual desire in women. BJOG: An International
Journal of Obstetrics & Gynaecology, 109(4), 357–363.
Beck, J. G., Bozman, A. W., & Qualtrough, T. (1991). The experience of sexual desire:
Psychological correlates in a college sample. The Journal of Sex Research, 28(3),
443–456.
Brotto, L. A. (2010). The DSM diagnostic criteria for hypoactive sexual desire disorder in
women. Archives of Sexual Behavior, 39(2), 221–239.
Brotto, L. A. (2010). The DSM diagnostic criteria for hypoactive sexual desire disorder in
men. The Journal of Sexual Medicine, 7(6), 2015–2030.
Heiman, J. R. (2002). Psychologic treatments for female sexual dysfunction: Are they
effective and do we need them? Archives of Sexual Behavior, 31(5), 445–450.
Rissel, C. E., Richters, J., Grulich, A. E., Visser, R. O., & Smith, A. M. A. (2003). Sex in
Australia: Selected characteristics of regular sexual relationships. Austraian and
New Zealand Journal of Public Health, 27(2), 124–130.
Shifren, J. L., Monz, B. U., Russo, P. A., Segreti, A., & Johannes, C. B. (2008). Sexual
problems and distress in United States women. Obstetrics & Gynecology, 112(5),
970–978.
DHEA
Dehydroepiandrosterone (DHEA) is a hormone produced in the adrenal glands
and brain of the human body. Once adults reach the age of thirty, levels of natural
DHEA usually begin to decline. In addition, DHEA levels can also be affected by
164 DHEA
certain medications. Research suggests that low DHEA levels may be connected
to depression, fatigue, and other conditions. DHEA can be produced by extracting
certain chemicals from wild yams and soy and is touted as a dietary supplement to
aid with weight loss, antiaging, and muscle building, among other functions. It can
be taken in tablet or capsule form and is sometimes used in a topical cream or
lotion.
DHEA is considered a “parent hormone”; it leads to the production of sex hor-
mones (androgens and estrogens). These hormones decline with age, and DHEA
supplements can be used to rebuild their levels. Because of this, there have been a
number of claims made about the health benefits of DHEA and the potential that
DHEA supplements have for addressing issues associated with aging and hor-
mone imbalances. Athletes and others may take DHEA as a dietary supplement to
help build muscle mass and increase energy, although the National Collegiate
Athletic Association, the National Football League, and Major League Baseball
have all banned the use of this supplement by their athletes. Some people take
DHEA to help prevent heart disease, diabetes, and other diseases. Older women
who are no longer menstruating may take DHEA to help build bone density and
improve menopausal symptoms. DHEA has also been recommended by some to
help decrease “age spots” on the skin and as a way to improve memory and brain
functions in older adults. Others tout DHEA as a cure for depression and a way to
fight chronic fatigue. The Food and Drug Administration (FDA) is currently
investigating DHEA as a potential treatment for such conditions as osteoporosis,
which is a condition that leads to fragile, weakened bones.
When taken in small doses for short periods of time, DHEA is considered to be
a relatively safe supplement. For example, a dose of between 5 and 450 milligrams
for a six-week period has been suggested as a possible treatment for depression,
and a dose of 50 milligrams a day for three months has been recommended as a
possible treatment for fibromyalgia. To use DHEA to treat infertility, between 25
and 80 milligrams daily for four weeks to six months is the suggested dosage. Side
effects of such short-term usage may include hair loss, acne, sleep problems, nau-
sea, and blood pressure changes. Women sometimes experience irregular men-
struation, increased facial hair, and changes to breast size when taking DHEA.
Men may sometimes experience breast tenderness, increased aggression, and
changes in the size of their testes. At higher doses or with longer periods of use,
the risk of such side effects increases, as does the risk of prostate, breast, and
ovarian cancer, along with the possibility of liver and cholesterol problems.
Scientists first discovered DHEA in 1934. The FDA banned it in 1985 due to
unproven safety and effectiveness issues; however, the ban was removed in 1994,
and DHEA supplements became available in the United States shortly thereafter.
There is still a great deal to learn about DHEA as a supplement, and research is
not yet conclusive regarding its use for most functions. Because the potential long-
term effects of DHEA supplements are still unknown and the hormone may inter-
act with other medications being taken, it is always advised to seek the counsel of
a medical professional before taking DHEA.
Tamar Burris
See also: Androgens; Andropause; Estrogen; Menopause; Sex Hormones; Testosterone.
Diagnostic and Statistical Manual of Mental Disorders (DSM) 165
Further Reading
Cavanaugh, J. C., & Cavanaugh, C. K. (2009). Aging in America. Westport, CT: Praeger.
Nyborg, H. (1994). Hormones, sex, and society: The science of physicology. Westport,
CT: Praeger.
Diagnostic and Statistical Manual of Mental Disorders
(DSM)
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is a compre-
hensive listing of mental disorders and the necessary criteria that must be met in
order to diagnose each psychiatric illness. The first edition of the DSM was pub-
lished in 1952 and aligned with the then current International Classification of
Diseases (ICD-6) published in 1948. The goal of the DSM was clinical in nature,
with the hopes that researchers and clinicians would use the classification system
to promote validity and reliability among diagnoses of mental disorders. The DSM
has had multiple revisions since the first edition was published (DSM, DSM-II,
DSM-III, DSM-III-R, DSM-IV, DSM-IV-TR, DSM-5), the most current of which is
DSM-5 published in 2013. The inclusion and criteria of sexual disorders in the
DSM has evolved over time.
In the original DSM, sexual disorders were conceptualized through the lens of
Sigmund Freud and viewed as manifestations of subconscious desires. In later edi-
tions of the DSM, revisions to the classification and diagnostic criteria for sexual
disorders were influenced by biology and biochemistry. These revisions integrated
empirical evidence into the conceptualization of sexual disorders in a more objec-
tive manner. Although the goal was to utilize empirical evidence for the classifica-
tion of psychiatric disorders, social biases have historically influenced the
inclusion of sexual and gender minorities as mental illnesses. For example, homo-
sexuality was listed as a paraphilic sexual disorder in a number of editions. This
was corrected in 1973, when the American Psychiatric Association deleted homo-
sexuality from the list of paraphilias. This iteration was not without its flaws, how-
ever. Ego-dystonic homosexuality, a disorder described as the stress an individual
experiences due to their sexual orientation, was listed in the DSM after the removal
of homosexuality as a paraphilia. Ego-dystonic homosexuality was later removed
from the DSM in 1986. Paraphilic sexual disorders have also evolved over time in
the DSM, from originally being termed as “perversion” to an understanding in
today’s cultural climate that a paraphilia by itself does not equate to a mental
health disorder. For a paraphilia to be considered a disorder, it must now cause
personal distress or involve an unconsenting party.
DSM-5 was published in 2013 after several years of research and revisions by
thirteen work groups with expertise in various areas. DSM-5 is highly regarded
not only in the United States but across the world and has been translated into
eighteen different languages. Within the DSM-5, mental health diagnoses related
to sex are primarily encompassed within the sexual dysfunctions or paraphilic
disorders categories. Other conditions that may be a focus of clinical attention, a
section in the DSM-5, include topics related to sex, including relationship distress
166 Diamond, Milton
with partner, child sexual abuse, sexual abuse from a partner, sexual abuse by
nonpartner, and problems related to unwanted pregnancy.
Sexual dysfunctions include delayed ejaculation, erectile disorder, female
orgasmic disorder, female sexual interest/arousal disorder, genito-pelvic pain/
penetration disorder, male hypoactive sexual desire disorder, premature (early)
ejaculation, substance/medication-induced sexual dysfunction, other specified
sexual dysfunction, and unspecified sexual dysfunction. Sexual dysfunctions arise
when an individual has difficulty engaging in sexual behaviors or experiencing
sexual satisfaction. Multiple factors may influence the conceptualization and
diagnosis of sexual disorders, including characteristics of the individual, partner,
relationship, culture, religion, or ongoing medical issues. Sexual dysfunction may
also be the result of a different primary mental health diagnosis (e.g., depression)
and is then better conceptualized as a symptom of that mental health disorder as
opposed to a separate sexual disorder diagnosis.
Paraphilic disorders include voyeuristic disorder, exhibitionistic disorder, frot-
teuristic disorder, sexual masochism disorder, sexual sadism disorder, pedophilic
disorder, fetishistic disorder, transvestic disorder, other specified paraphilic disor-
der, and unspecified paraphilic disorder. Paraphilias are classified as their own
subset of disorders within the paraphilic disorders category in the DSM-5. Dozens
of paraphilias have been identified and linked to paraphilic disorders; however,
the DSM-5 only classifies the most commonly occurring or destructive in terms of
legal ramifications. However, “other specified paraphilic disorder” and “unspeci-
fied paraphilic disorder” are available for clinician use if one of the eight identified
paraphilias is not appropriate.
Lauren G. Masuda and Stephen K. Trapp
See also: BDSM; Child Sexual Abuse; Freud, Sigmund; Gender Dysphoria; International
Classification of Diseases, Eleventh Revision (ICD-11); Paraphilias; Premenstrual Dys-
phoric Disorder (PMDD); Sexual Abuse; Sexual Disorders, Female; Sexual Disorders,
Male.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders: DSM-5. Washington, DC: American Psychiatric Association.
American Psychiatric Association. (2019). DSM history. Retrieved from https://www.psy-
chiatry.org/psychiatrists/practice/dsm/history-of-the-dsm
American Psychiatric Association. (2019). Sexual dysfunctions. Retrieved from http://
dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm13
Pappas, S. (2013). The history of sex in the DSM. Live Science. Retrieved from http://
www.livescience.com/28380-history-of-sex-dsm.html
Diamond, Milton
Milton Diamond is a sexologist who specialized in the study of intersexuality and
the role of neurology in determining the sexual and gender identities of individu-
als. He taught anatomy and reproductive biology at the University of Hawaii med-
ical school before his retirement at the end of 2009. Diamond is most famous for
Diamond, Milton 167
his investigation of the John/Joan case of a boy raised as a girl because of his
physical condition. The results of Diamond’s research showed that nurture and
social context cannot change the sexual and gender identities with which a person
is born.
Diamond was born on March 6, 1934, in the Bronx, New York City. His parents
were European Jews who had emigrated from Ukraine after World War I. Dia-
mond’s father ran grocery stores for a living. He purchased failing stores, built
them up, and then sold them for a profit. When Diamond was in junior high, the
family moved to Manhattan. Diamond had always enjoyed school and was admit-
ted to the Bronx High School of Science. The experience awakened a love of sci-
ence, which he was anxious to pursue. He entered college in January 1951 and
joined the Reserve Officers Training Corps to help pay his way. Diamond majored
in physics at City College of New York but chose a minor in biology. He became
one of the first undergraduate students there to receive a bachelor of science degree
in biophysics, in 1955. After three years in the U.S. Army, Diamond entered grad-
uate school at the University of Kansas. He graduated with a PhD in anatomy and
psychology. His first job was teaching at the University of Louisville School of
Medicine, where he completed two years of study toward an MD degree. In 1967,
Diamond was hired by the John A. Burns School of Medicine at the University of
Hawaii as professor of anatomy and reproductive biology.
Diamond’s primary area of research was gender identity and how it was deter-
mined. He became interested in the so-called John/Joan case. John Money, a psy-
chologist and sex researcher, had become famous for his writings about the case
and his involvement in it. Identical twin boys were born in 1966 in Winnipeg. One
boy lost most of his penis in a circumcision accident. Money convinced the par-
ents that the child could be raised as a girl, after surgery to remove his male repro-
ductive organs. Hormone treatments would complete the transformation. The
child was not to be told the truth. Money believed that gender could be determined
by a child’s upbringing. He wrote extensively about the success of the process,
leading to many other children undergoing the same procedures.
Diamond searched for years to find out more about the John/Joan case. He
believed that a person’s gender was determined in the brain before birth. Eventu-
ally, Diamond made contact with a psychiatrist who had treated the child. He
found that Money’s description of success was misleading. The child raised as a
girl displayed many male traits and was very troubled. Eventually, the parents
admitted the truth. The young person resumed his male identity and eventually
had surgery to restore most of his male characteristics. After interviewing the
man, Diamond published his findings in 1997, refuting Money’s theories. John
Colapinto, a journalist, collaborated with the man to tell his tragic story in As
Nature Made Him: The Boy Who Was Raised as a Girl, in 2000. Unfortunately,
the experience drove the subject of the study to commit suicide in 2004, two years
after his twin committed suicide.
Diamond’s theories were validated by the case. He continued to research and
publish extensively on gender and sexual identity issues and the social effects
associated with them. He became well known as a supporter of gay, transgender,
and intersex rights, since he taught that their identities were not selected or
168 Diaphragm
influenced by their surroundings but were the result of biology. Diamond became
the director of the Pacific Center for Sex and Society. He received many awards
for his work and served as president of the International Academy of Sex Research.
Diamond retired from teaching in 2009.
Tim J. Watts
See also: Intersexuality; Money, John; Reimer, David; Sexology.
Further Reading
Colapinto, J. (2000). As nature made him: The boy who was raised as a girl. New York:
HarperCollins.
Diamond, M., & Sigmundson, H. K. (1997). Management of intersexuality: Guidelines
for dealing with persons with ambiguous genitalia. Archives of Pediatrics & Ado-
lescent Medicine, 151(10), 1046–1050.
Diamond, M., & Sigmundson, H. K. (1997). Sex reassignment at birth: Long-term review
and clinical implications. Archives of Pediatrics & Adolescent Medicine, 151(3),
298–304.
Diaphragm
A diaphragm is a method of birth control that does not offer any protection against
sexually transmitted infections (STIs). The diaphragm blocks the entrance to the
uterus, thus preventing sperm from reaching and fertilizing an egg. Diaphragms
are used in conjunction with spermicides, which help in the prevention of
pregnancy.
Lemons, tissue paper, wool, beeswax, silver, seaweed, and rock salt have all been
used in the past to cover the cervix in an attempt to prevent pregnancy. The idea was
to block the cervix so that sperm that have entered the vagina during vaginal inter-
course cannot swim through the cervix to get to an egg that might be waiting. Simi-
larly, the diaphragm is a kind of birth control called a barrier contraceptive method
(which also include condoms). The first versions of the modern diaphragm were
introduced in the early 1800s, and the diaphragm was further modernized when
Charles Goodyear developed a process called vulcanization, which involves a chem-
ical reaction that makes rubber more durable. Safer than barriers made of natural
material, rubber became the most common type of diaphragm.
The U.S. government passed a law in 1873 called the Comstock Act, which
made it illegal to send “obscene, lewd, or lascivious” material through the mail.
This meant that it was illegal to mail anything having to do with birth control,
including information about diaphragms. As a result, contraceptives became more
difficult to obtain, and their use was limited to wealthy people who could get
around the restrictive laws. This lasted until Margaret Sanger, a birth control and
women’s rights activist, entered the picture. Sanger spent time in Europe in the
early 1900s and tried to import diaphragms into the United States. When this was
blocked by the Comstock Act, she fought back by smuggling them into the coun-
try in 1923.
Modern diaphragms are made of silicone and have a thin, flexible rim that fits
over the cervix. Users fill them with spermicide and then place them over the cer-
vix as early as two hours before intercourse. They should be left in place six to
Disabilities, Sexual Function and 169
eight hours after intercourse. With precise use, six in one hundred women will
still get pregnant while using a diaphragm as their only method of birth control in
the first year of use. Realistically, it is more probable that sixteen in one hundred
women will get pregnant while using a diaphragm over the course of a year.
In order to get a diaphragm, one needs to be fitted by a medical care provider
because diaphragms come in different sizes depending on body size and anatomy.
In order to determine the appropriate size, the medical care provider will insert a
gloved middle and index finger into the patient’s vagina. This helps measure the
vagina to determine the correct diaphragm diameter. A fitting ring will then be
inserted into the vagina to confirm that the measurements are correct. A properly
fitted diaphragm is held in place by the pubic bone and the rear wall of the vagina.
A diaphragm that fits correctly will not move around at all and should not be
noticed by the person wearing it. If a diaphragm is too big, it may be uncomfort-
able. If a diaphragm is too small, it can fall out. Either way, an incorrectly sized
diaphragm will not protect against pregnancy as well as one that fits properly. If a
diaphragm user experiences weight gain or loss of fifteen pounds or more, gets
pregnant, or is breastfeeding, they will need to be refitted for a new diaphragm to
confirm proper fit.
The diaphragm is small, portable, reusable, and relatively inexpensive. A dia-
phragm is nonpermanent, and it will not affect the menstrual period. It can also be
inserted up to two hours before intercourse, which may be less disruptive to inti-
macy with a sexual partner. Also, a partner will not necessarily feel the diaphragm
and may not even know that one is being used.
The downsides to using a diaphragm are (as noted earlier) that it provides no
protection against STIs (such as HIV, herpes, gonorrhea, or chlamydia), it has to
be fitted and prescribed by a health care provider, and proper insertion can be dif-
ficult or uncomfortable. Because proper placement and use of spermicide are so
important, the risk of incorrect use of this form of birth control is relatively high,
thus increasing the chance of pregnancy. Also, diaphragms can increase the risk
of urinary tract infections. People who have a history of toxic shock syndrome (a
very serious but rare bacterial infection) should not use diaphragms.
Kristen Kelly and Dawn S. Tasillo
See also: Barrier Contraceptive Methods; Cervix; Contraception; Sexually Transmitted
Infections (STIs); Spermicides.
Further Reading
Allen, R. E. (2004). Diaphragm fitting. American Family Physician, 69, 97–100.
Grimes, J. A., Smith, L. A., & Fagerberg, K. (2013). Sexually transmitted disease: An
encyclopedia of diseases, prevention, treatment, and issues. Santa Barbara, CA:
Greenwood.
Tone, A. (2001). Devices and desires: A history of contraceptives in America. New York:
Hill and Wang.
Disabilities, Sexual Function and
The definition of “disability” depends on the framework used to define it. For
example, in medical terms, a disability is a physical, sensory, emotional, and/or
170 Disabilities, Sexual Function and
cognitive impairment that affects an individual’s ability to perform daily tasks
that are conceived to be within the norm of human capacity. This definition of dis-
ability is often described as a medical model of disability. In the past thirty years
or so, in social science, another model of disability has been developed to contrast
the medical model. The social model of disability, as it is commonly known in
social sciences, defines disability as the social and systemic barriers encountered
by people whose bodies do not fall under what is considered the norm of human
capacity. The social model of disability sees disability not as an individual impair-
ment, linked to someone’s physical, sensory, emotional, and/or cognitive capacity,
but rather as a social problem that stems from our conception of what is normal.
Understanding that there are contrasting models of disabilities is essential before
discussing disabilities and sexual functioning given that the definition also influ-
ences the understanding of the sex and sexualities of people with disabilities.
Regardless of the model adopted, medical or social, the range of issues with sex
and sexuality faced by people with disabilities can be vast given that it involves a
population with a wide range of different physical, sensory, emotional, and/or
cognitive conditions and barriers. In addition, people with disabilities also have
other dimensions of their identities linked, for example, to their gender, class, race
and ethnicity, religion and spirituality, sexuality, and geographic location. Further,
people with disabilities might have been born with a disability or acquired one
through an accident or aging. Sometimes those are referred to as lifelong versus
acquired disabilities. The combination of these identities and experiences means
that people with disabilities cannot be conflated under one umbrella and that they
face a range of sexual functioning issues. However, there are some common
threads among those identities and experiences, which have increasingly been
researched and described by a range of scholars both in disability studies and in
sex research.
For example, children and young people with disabilities are usually seen as
vulnerable and often do not receive adequate sexual health education, if they
receive any sex education at all. The lack of education often leaves children and
young people with disabilities more vulnerable to abusive behaviors. While evi-
dence shows that children and young people with disabilities generally experience
higher levels of physical and sexual abuse, it also shows that often they are unin-
formed and unequipped to deal with those experiences given their lack of sexual
health knowledge. Historically, many children and young people with disabilities
also experienced being sent to residential, specialist schools where the possibili-
ties for abuse were generally higher given the lack of close parental supervision
and the dependence on the adults who were both providing care and perpetrating
abusive behaviors. Considering children and young people with disabilities as
inherently vulnerable, and as such incapable of making decisions around their
sexuality, especially if they have learning disabilities, has frequently led to par-
ents and medical providers making decisions over their reproductive issues, from
implanting birth control without the young person’s consent or knowledge, or ster-
ilization, which particularly affects those young people who are assigned female
at birth. Controlling the ability to reproduce for people with disabilities has
Disabilities, Sexual Function and 171
historically also led to legislative bans that prohibited people with certain disabili-
ties to marry.
The conceptualization of people with disabilities as vulnerable, and therefore
as needing to be both protected and controlled, also affects adults with disabili-
ties. The literature in disability studies clearly indicates that people with disabili-
ties are often infantilized—that is, reduced to childlike beings without sex or
sexuality. This means that often doctors do not discuss sex and sexuality with
people with disabilities, often overlooking testing and counseling for sexual health
conditions. The infantilization of people with disabilities also means that they
usually do not have access to essential sexual health services and education, such
as HIV prevention, testing, and treatment, or sexual abuse survivors’ groups.
Given that people with disabilities, like other groups marginalized by society,
experience higher rates of substance use, which also affects sexual behaviors and
experiences, the lack of access to essential services affects their well-being and
ability to develop and maintain healthy sexualities. Lack of access and infantiliza-
tion also lead to invalidating the identities of people with disabilities who are also
transgender, gender nonconforming, lesbian, gay, bisexual, pansexual, or asexual.
Those identities are usually seen as being outside of mainstream culture and iden-
tities, and often people with disabilities are questioned on whether they identify in
those ways because they cannot conform to societal expectations around gender
and sexuality. Further, people with disabilities who identify as LGBTQIA usually
have difficulties accessing services and resources for those populations due to
physical, emotional, linguistic, and cognitive barriers.
Sexual functioning is also often defined in a way that is not inclusive of a
wide range of bodies, including sensory, emotional, and cognitive differences.
This means that there is very little information for people with disabilities to
access around sex and sexuality. For example, people who might need to make
physical adaptions in order to have sex with another person might not have
information about props available, different positions, or even the possibility of
timing pain medication or muscle relaxants in a way that facilitates their ability
to have a sexual encounter. People who might need to access different commu-
nication tools to express their boundaries and needs might not know that there
are handouts, exercises, and models of communicating their sexual boundaries
and desires that might be better suited to their needs. Sexual health information
and sex education in braille for blind and visually impaired people, or in sign
language for deaf people, are rare and often nonexistent. Disability advocates
have been raising awareness about those issues globally, and, currently, issues
affecting the sexual functioning of people with disabilities are being considered
both in legislative arenas as well as in social sciences and medical education.
Movies like The Sessions (2012) have also brought some of those issues to the
attention of the general public, showing that having a disability does not neutral-
ize a person’s sexuality.
Alex Iantaffi
See also: Asexuality; Gender Diversity; Sex Education; Sexual Health; Sexual Identity;
Sexuality among Older Adults; Surrogate, Sexual.
172 Dodson, Betty
Further Reading
Barker, M. J., & Iantaffi, A. (2015). Social models of disability and sexual distress. In H.
Spandler, J. Anderson, & B. Sapey (Eds.), Madness, distress and the politics of
disablement (139–152). Bristol: Policy Press.
Barnes, C. (2000). A working social model? Disability, work and disability politics in the
21st century. Critical Social Policy, 20(4), 441–457.
Bonnie, S. (2004). Disabled people, disability and sexuality. In J. Swain (Ed.), Disabling
barriers, enabling environments (124–132). Los Angeles: SAGE.
Greenwood, N. W., & Wilkinson, J. (2013). Sexual and reproductive health care for
women with intellectual disabilities: A primary care perspective. International
Journal of Family Medicine, 2013, 1–8.
Iantaffi, A. (2013). Sexuality and disability. In The sexualization report. Retrieved from
https://thesexualizationreport.wordpress.com/section-1-sexuality/sexuality-and
-disability/
Iantaffi, A., & Mize, S. (2015). Disability. In The Palgrave handbook of the psychology of
sexuality and gender (408–426). London: Palgrave Macmillan UK.
Kaufman, M., Silverberg, C., & Odette, F. (2007). The ultimate guide to sex and disabil-
ity: For all of us who live with disabilities, chronic pain, and illness. San Fran-
cisco: Cleis Press.
McRuer, R., & Mollow, A. (Eds.). (2012). Sex and disability. Durham, NC: Duke Univer-
sity Press.
Rainey, S. S. (2011). Love, sex, and disability: The pleasures of care. Boulder, CO: Lynne
Rienner Publishers.
Dodson, Betty
The title of Betty Dodson’s first book, Liberating Masturbation: A Meditation
on Selflove (1974), is an excellent framework to understand her importance in
the field. Her bold approach to sex education has freed many women to experi-
ence their own sexuality in a way they might not have done without learning
from Dodson. She was the author of multiple books and videos that teach peo-
ple about sexuality with a no-nonsense approach. Her style was genuine, open,
and fearless. Many women have claimed that after reading one of her books,
watching one of her videos, or attending one of her talks, they developed a
completely new appreciation for their vulvas and that the shame they previ-
ously felt melted away. Dodson offered Bodysex Workshops for women to
address genital shame and learn masturbatory techniques. Through her work,
she earned the title “Godmother of Masturbation.”
Dodson did not begin her career as a sex educator but instead as a trained artist.
Born in 1929, she went to New York City in 1950 to receive a formal education in
fine arts. Because of her artistic talent, she was hired to draw women’s lingerie
and undergarments for department store advertisements. It was not until 1965,
when she met Grant Taylor (who became her patron), that she began pursuing her
own sexual self-discovery. Her erotic artwork landed her a show at the Wicker-
sham Gallery in New York City in 1968. Amid the women’s movement of the
1960s and 1970s, Dodson realized that although women were gaining new power
in the United States, most did not understand their sexual selves, instead
Don’t Ask, Don’t Tell 173
subscribing to the idea that a man will know what to do with her body in order for
her to receive sexual pleasure. With a slideshow of multiple color pictures of
female genitals and a bag of masturbatory devices, she began traveling the coun-
try, teaching women about their vulvas. In 1973, at the NOW Sexuality Confer-
ence, more than a thousand women gathered to learn from Dodson. She taught
women that there is huge variation in vulvas and that the differences are
beautiful.
Dodson authored several books, articles, and videos and also created a masturba-
tory and Kegel exercise device, “the barbell.” In 1992, she received a doctorate
degree from the Institute for the Advanced Study of Human Sexuality. She received
the Public Service Award from the Society for the Scientific Study of Sexuality in
2011 and also received the Masters and Johnson Award from the Society for Sex
Therapy and Research. Not only did she appear on multiple television shows, such
as The View, but she was also the subject of many articles. Dodson conducted
Bodysex Workshops for more than thirty years and continued these workshops
until her death in October 2020 as sex coaching in her private practice. She and her
business partner, Carlin Ross, continue to educate others about sexuality through
their website: www.dodsonandross.com. Dodson was widely known and respected
for her amazing contributions to the field of sexuality.
Karen S. Beale
See also: Female Sexuality; Kegel Exercises; Masturbation; Sex Education; Vulva.
Further Reading
Dodson, B. (1996). Sex for one: The joy of selfloving. New York: Three Rivers Press.
Dodson, B. (2016). Sex by design: The Betty Dodson story. CreateSpace.
Dodson, B. (Producer) & Schoen, M. (Director). (2007). Betty Dodson: Her life of sex and
art. Dodson Schoen Films.
Don’t Ask, Don’t Tell
In 1993, President Bill Clinton suspended a former military policy that completely
banned lesbian, gay, and bisexual (LGB) personnel from service and enacted a
new policy that was hoped to breed more tolerance of sexual minorities in the
military. Entitled the “Don’t Ask, Don’t Tell” policy, it was similar to the previous
policy in that it did not allow known LGB personnel to join the military but was
dissimilar in that the military was no longer permitted to ask potential enlistees if
they were LGB, hence the name Don’t Ask, Don’t Tell. However, under this new
policy, if an enlistee kept their sexuality to themselves during enlistment and then
decided to come out as LGB at a later date while serving, they could still be dis-
missed from the military.
Those that supported the ban on LGB personnel in the military believed that
these personnel would receive special treatment, which would undermine unit
cohesion, morale, performance, and readiness capability. While many military
officials held negative believes that LGB personnel were in some way unfit to
serve, no supporting evidence that LGB personnel undermine military perfor-
mance at any level has been found, though many studies have taken place within
174 Don’t Ask, Don’t Tell
the military. In fact, militaries across the world that include LGB personnel have
shown that military performance is not hindered, even in situations where troops
still hold negative prejudices and homophobic attitudes.
Rather than increasing tolerance, Don’t Ask, Don’t Tell led to greater experi-
ences of discomfort, fear, and embarrassment in regard to the disclosure of sexual
orientation in the military, even under anonymous conditions. There was serious
underreporting of victimization, such as sexual assault and harassment, and a
belief that there were fewer options for assistance available for LGB military
members. From the implementation of Don’t Ask, Don’t Tell in 1993 to its repeal
in 2011, over 14,000 service members, were discharged from the military under
this policy. During this time, an assumption of inappropriate homosexual contact
was all that was needed for an investigation of personnel to begin. However, since
the policy did not define what behaviors would justify an inquiry or what grounds
would lead to discharge, there was little uniformity in its implementation.
In 2010, President Barack Obama announced his intention to repeal the law that
denied LGB Americans the right to serve in the military. A long process began as
government officials started taking apart the language of Don’t Ask, Don’t Tell.
Not only was there a lack of supporting evidence to show that LGB troops led to
poor morale and unit cohesion; there was a tremendous amount of evidence indi-
cating that the number of troops that were removed from service due to Don’t Ask,
Don’t Tell dropped after 2001. This showed the willingness to retain LGB troops
during wartime. The cost for training troops was also considered, as many well-
trained individuals were removed from service due to Don’t Ask, Don’t Tell,
which resulted in a loss of federal money and time. The policy also affected mili-
tary recruitment as supporters of the LGB community and their loved ones refused
to consider military service, which caused recruitment of less-qualified enlistees.
Lastly, troops who were suspected of violating Don’t Ask, Don’t Tell were rou-
tinely held until after completion of overseas deployments, thus serving the inter-
ests of the government.
Eventually, through court proceedings, it was determined that Don’t Ask, Don’t
Tell violated both the First and Fifth Amendments of the United States Constitu-
tion and, as of September 20, 2011, the repeal of the policy within all military
services was announced by the undersecretary of defense. This order called “for
all military service members to treat each other with dignity and respect regard-
less of sexual orientation and that all services should strive to promote an environ-
ment that is free from personal, social, or any type of institutional barriers that
might arise due to sexual orientation” (Burrelli, 2012). Repeal of Don’t Ask, Don’t
Tell means that personnel who were discharged under this policy will be given the
opportunity to reenlist and complete their military service in the way initially
intended.
Linda D. Hinkle
See also: Antigay Prejudice; Biphobia; Homophobia; Homosexuality; LGBTQ+; Sexual
Orientation.
Further Reading
Belkin, A. (2003). Don’t ask, don’t tell: Is the gay ban based on military necessity? Param-
eters, 33(2), 108–119.
Double Standards, Sexual 175
Burks, D. (2011). Lesbian, gay, and bisexual victimization in the military. American Psy-
chologist, 66(7), 604–613.
Burrelli, D. (2010). “Don’t ask, don’t tell”: The law and military policy on same-sex behav-
ior (CRS Report No. R40782). Washington, DC: Congressional Research Service.
Burrelli, D. (2012). The repeal of “don’t ask, don’t tell”: Issues for Congress (CRS Report
No. R42003). Washington, DC: Congressional Research Service.
Feder, J. (2013). “Don’t ask, don’t tell”: A legal analysis (CRS Report No. R40795). Wash-
ington, DC: Congressional Research Service.
Double Standards, Sexual
A double standard occurs when two groups are judged differently for engaging in
the same behavior. A sexual double standard involves different standards of sex-
ual permissiveness for men and women and is often used to differentiate appropri-
ate behaviors for both. Sexual double standards are often used as a tool to stratify
different groups and are often deployed as a mechanism through which some
behaviors, when demonstrated by certain people, are denigrated or stigmatized.
Beliefs about appropriate expressions of sexuality and gender factor into sexual
decision making and can even supersede an actor’s own desires, for example
encouraging a young woman to curtail her own desires to maintain a good reputa-
tion, or leading young men to make judgments about female peers that may foster
negative treatment or slut shaming. For this reason, sexual double standards are a
powerful form of social control.
Mary Crawford and Danielle Popp (2003) conducted a review of two decades
of research on the sexual double standard, illuminating the methodological
challenges of measuring the concept but also demonstrating how common the
double standard is, as seen through many studies of adolescents and young
adults. This review shows that while the traditional, or orthodox, heterosexual
double standard, prohibiting women from having sex outside of marriage, is
waning, in its place have emerged different iterations of sexual double stan-
dards, which “are local and subcultural constructions rather than a universal
mandate” (Crawford & Popp, 2003). This is supported by more current research
that demonstrates the existence of the double standard in subcultures such as
the collegiate hookup culture.
Sexual double standards often focus on appropriate sexuality for women, while
men experience more permissiveness regarding their sexual behaviors. The sexual
double standard is often found in regard to three issues: appropriateness of sexual-
ity in different forms of relationships, number of previous sex partners, and suit-
ability for someone as a mate instead of a date.
These intertwined issues all have implications for women’s sexual identity and
agency and affect contraception negotiation and sexual assault. Previous sexual
experience, including casual sex, is often used to scrutinize a woman’s assertion
of sexual assault, even with the existence of rape shield laws. This affects many
survivors’ choice to come forward with a rape case.
Men are allowed freedom to have sex anytime, but women are judged for hav-
ing sex outside of a relationship. In fact, a man may see a woman as ineligible to
176 Douching
be his girlfriend because of her choice to engage in casual sex, even if the casual
sex was with him. Women with higher numbers of partners, regardless of whether
they were boyfriends or not, are also judged more harshly. Determination of the
suitability of a woman as a potential relationship partner often hinges on how
restrictive she is sexually. Young men may desire a more sexually experienced
woman as a temporary sex partner but would not even consider a serious relation-
ship with her because of her permissiveness.
The sexual double standard makes women much more circumspect about when
to engage in sex and with whom. Concerns about reputation may make women
less apt to initiate conversations about sex or contraception, limiting their sexual
agency and autonomy as well as their safety. As such, sexual double standards
may lead women to relinquish their sexual autonomy in order to maintain social
desirability.
Rachel Kalish
See also: Binary Gender System; Casual Sex; Female Sexuality; Hookup Culture;
Madonna/Whore Dichotomy; Male Sexuality; Sexual Expression; Slut Shaming; Stereo-
types, Gender; Stereotypes, Sexual.
Further Reading
Crawford, M., & Popp, D. (2003). Sexual double standards: A review and methodological
critique of two decades of research. Journal of Sex Research, 40, 13–27.
Hamilton, L., & Armstrong, E. A. (2009). Gendered sexuality in young adulthood: Dou-
ble binds and flawed options. Gender and Society, 23(5), 589–616.
Reid, J. A., Elliot, S., & Webber, G. R. (2011). Casual hookups to formal dates: Refining
the sexual double standard. Gender and Society, 25(5), 545–568.
Reiss, I. L. (1967). The social context of premarital sexual permissiveness. New York:
Holt, Rinehart and Winston.
Douching
Some women mistakenly believe that vaginal douching is an important part of
feminine hygiene and consider douching a method to prevent or even treat sexu-
ally transmitted infections (STIs). Some people, mostly men who have sex with
men, also practice rectal douching as a method to clean the anus and rectum prior
to engaging in receptive anal sex. Medical professionals, however, recommend
against douching, especially vaginal douching, because it can be harmful and lead
to irritation and infection. Douching is the practice of flushing a stream of water
or water-based fluid into the vaginal or anal cavity via an inserted tube. An
attached bulb or bag is used to hold the fluid, and squeezing that bulb forces the
contents into the vagina or rectum under varying amounts of pressure. The termi-
nology “douche” comes from the French verb for showering (doucher). The fluid
content is usually either plain water, a home mixture of water and vinegar, or a
commercially available product that can be purchased over the counter (without a
prescription) at common drugstore chains.
The origins of douching are unclear but date back to ancient times. Douching is
a practice that has been prevalent across various national and cultural backgrounds
Douching 177
and throughout many parts of the world. In fact, in the nineteenth century, it was
a commonly recognized means of postcoital birth control in a time when little else
was available. The theory was that irrigating the vagina after sexual intercourse
would flush away the sperm, thus preventing pregnancy. However, this was not
(and still is not) an effective means of contraception. In the twentieth century,
douching was popularized as a cleansing method during a new wave of body and
odor awareness that dawned during the late Victorian era. This theme continued
via advertising practices through the 1980s with television commercials for douch-
ing products.
However, with new medical knowledge and greater understanding of vaginal
health in the last twenty to thirty years, it is now understood that vaginal douching
does more harm than good. Public health pressure has helped to remove the false
and misleading advertising from the general viewing audience, and more com-
munities are becoming aware of its dangers. While medical knowledge and sexual
health education were limited in the past, it is now known that the vagina is a self-
contained environment that is fully capable of, and was designed to, clean itself.
Cervical and vaginal mucus clear out blood, sperm, and other debris by them-
selves without any help, and if disturbed and interrupted from doing this work,
many problems can arise.
Vaginal douching has been found to have several unintended consequences, as
it has been directly linked to various infections as well as pregnancy- and birth-
related problems. Complications occur both because of the force or pressure
involved with injecting the fluid and because douching strips the vagina of healthy
and normal bacteria and protective mucus.
Pelvic inflammatory disease (PID) and STIs are seen more frequently in those
who douche than in those who do not. The risk of PID grows higher the more fre-
quently douching occurs. Bacterial vaginosis (BV) is 2.5 times more likely to
occur in women who douche. BV is a condition of discharge and odor directly
caused by the overgrowth of abnormal and unhealthy bacteria in the vagina, which
can occur when the normal bacteria are removed during the act of douching.
Women who douche frequently also have higher risks for pregnancy-related com-
plications such as premature labor and low-birth weight babies as well as higher
risk of ectopic pregnancies. Rectal douching is safer than vaginal douching as the
rectum does not have the same delicate flora balance; however, damage to tissue
from incorrect technique can occur.
Overall, approximately one out of every three women in the United States
douche on a regular basis, and in some studies, up to 75 percent have done so at
least once; there is some variation in frequency of douching by age, race, ethnic-
ity, and education. The prevalence of rectal douching is less known; however, in
one study, half of the gay men surveyed reported douching at least once. Gener-
ally, the reasons why women report douching include hygiene, after a period, after
sex, or because they believe it will treat or prevent infection or discharge. While
some teens surveyed in one study were aware that having some discharge is nor-
mal, outdated and misinformed cultural and family beliefs surrounding vaginal
douching practices still persist.
Lara E. Stewart
178 Down Low
See also: Anal Intercourse; Bacterial Vaginosis; Vagina; Vaginal Secretions.
Further Reading
Grimes, J. A., Smith, L. A., & Fagerberg, K. (2013). Sexually transmitted disease: An
encyclopedia of diseases, prevention, treatment, and issues. Santa Barbara, CA:
Greenwood.
Newton, D. E. (2009). Sexual health: A reference handbook. Santa Barbara, CA:
ABC-CLIO.
Noor, S. W., & Rosser, B. R. (2014). Enema use among men who have sex with men: A
behavioral epidemiological study with implications for HIV/STI prevention.
Archives of Sexual Behavior, 43(4), 755–759.
Tepper, M. S., & Owens, A. F. (Eds.). (2006). Sexual health. Santa Barbara, CA: Praeger.
Down Low
The down low (DL) typically refers to a man who is, or claims to be, involved in a
heterosexual relationship with a woman and who develops romantic feelings or
becomes sexually intimate with another man without his female companion’s
knowledge. Publicly, the man has a companionate or romantic relationship with a
woman and is typically able to acknowledge this arrangement to family, peers,
and colleagues, while his feelings or sexual behavior with another man remains a
secret. Being on the DL can refer to men being in a relationship with a woman but
secretly having fantasies about being sexual with another man, having clandestine
romantic feelings or attachment to another man, or, as previously mentioned, pri-
vately engaging in intimate behaviors (e.g., kissing, hugging, petting, oral sex,
anal sex). The heterosexist assumption follows that the man with whom the man
has sex knows about the relationship with the woman. Paradoxically, the woman
with whom the man has sex does not know about the other man or any feelings
associated with that relationship.
For centuries, men have been having romantic feelings for or having sex with
men without their female partners knowing. However, it was only in the mid-
1990s that this phenomenon became more public when associated with black
men. Some African American communities rejected this because of negative
sentiments about same-sex relationships, homophobia within and outside of the
black church, and pervasive heterosexist discourse. However, more people
started talking about the DL during this time in an attempt to explain and pathol-
ogize black relationships, as the prevalence of HIV was increasing among black
women. It was assumed that black men on the DL were having intimate relation-
ships with women and secretly with men, which resulted in greater exposure to
sexually transmitted infections including HIV. Depictions by media and other
social institutions suggested that black men would callously prey on unsuspect-
ing women and then not be forthcoming with potential male partners about their
sexual history and HIV status. This stereotype created much tension and appre-
hension between some black men and women who had an interest in developing
intimate relationships with another. Some literature suggests that men are afraid
to adopt sexual identity labels other than heterosexual out of fear of public back-
lash or scrutiny.
Down Low 179
The general discourse around black men on the DL has continued to contribute
to homophobic and heterosexist attitudes in many communities. Secrecy of fanta-
sies, feelings, and behaviors is necessary in order to maintain concurrent hetero-
sexual and same-gender-loving relationships. The effects and implications of
racism and systemic oppression have created tension in the black community
between some men and women. Debilitating belief systems and stereotypes of
black men being hypersexual, animalistic, and unable to control their sexual
impulses continues to be maintained both within and external to black communi-
ties. It is believed that men on the DL are sexually insatiable and unable to have
enough sex with females or males, and they are seen as selfish, self-centered, and
greedy. Because of this faulty assumption, some black women are fearful of form-
ing or maintaining relationships with black men because of the notion of secret
encounters with other men. Some black men are equally concerned about being
given the social latitude to examine having romantic or sexual feelings for other
men and the diminished possibility of receiving support.
Some scholars have pointed out that women can also be on the down low such
that they publicly maintain a heterosexual relationship with a man but engage in
intimate encounters or have romantic feelings for women. According to Phillips
(2005), society’s conservative attitudes toward sexuality “contribute to black
women’s silence around their own sexual desires and relationships, obscuring the
amount and type of sex that black women actually have. Due to its enforcement of
silence, this ‘culture of respectability’ contributes to the oppression of black wom-
en’s sexuality, sexual agency, and access to sexual health care.”
Critically, sexism and patriarchy make women’s sexuality less of a priority than
men’s sexual expression. There is a tendency to negate, minimize, or ridicule the
feelings and behaviors of women. There is a greater risk of male-to-female sexu-
ally transmitted infection than there is from female to female. More research
needs to be done that examines women who are in heterosexual relationships and
are sexually intimate with women without their male partners knowing. Finally,
research on DL women and men needs to take into account that the phenomenon
may be a deflection from the acknowledgment of HIV transmission.
James Wadley
See also: Black Sexuality; Heterosexism; Homophobia; Human Immunodeficiency Virus
(HIV); Intimacy, Sexual and Relational; Same-Sex Attraction and Behavior; Sexual
Identity.
Further Reading
Ford, C. L., Whetten, K. D., Hall, S. A., Kaufman, J. S., & Thrasher, A. D. (2007). Black
sexuality, social construction, and research targeting “The Down Low” (“the DL”).
Annals of Epidemiology, 17(3), 209–216.
Hammonds, E. (1994). Black (w)holes and the geometry of black female sexuality. Differ-
ences, 6(2–3), 126–145.
Malebranche, D. J. (2008). Bisexually active black men in the United States and HIV:
Acknowledging more than the “down low.” Archives of Sexual Behavior, 37(5),
810–816.
Phillips, L. (2005). Deconstructing “down low” discourse: The politics of sexuality, gen-
der, race, AIDS, and anxiety. Journal of African American Studies, 9(2), 3–15.
180 Drag
Drag
Drag involves a person performing a gender identity that does not correspond to
cultural standards of biological sex. It has a long history. Historically, men pre-
sented themselves as women in the theater. However, this was often a necessity
since women were typically not permitted on stage. It is important to note that
throughout history, because of cultural restrictions on same-sex relationships,
men and women were pushed into appearing in drag so that they could safely go
to public places with their partners. Contemporary drag has a different focus. Peo-
ple now dress as the other sex in their personal lives to gain gender self-realization.
In addition, drag queens and kings participate in public shows to challenge socially
constructed gender norms. It is also possible for a person to wear the typical cloth-
ing of the opposite sex as a matter of preference related to comfort or sexual desire,
though not all scholars would consider these instances to be drag.
Because understanding of gender is growing, classifying drag can be compli-
cated. Cross-dressing and drag have similarities in that they both involve gender
bending by wearing clothing typical of the other sex. However, depending on the
source referenced, there is a strong directive to keep the two separate. In the cross-
dressing community, where participants are largely straight, “drag” can serve as
an acronym for “Dressed As a Girl” or “Dress Resembling A Girl.” Alternatively,
the term “drab” represents “Dressed As a Boy.” Cross-dressers, historically known
as transvestites, want to achieve feelings of normality while passing as the other
sex in public settings, and many feel comfortable moving between gender presen-
tations depending on the situation. In the context of nonheterosexual communi-
ties, drag explicitly concerns queens and kings who are predominantly gay and
lesbian. While one goal of engaging in this performance art is to entertain others,
there are also intentional exaggerations of long-standing gender stereotypes to
downplay traditional binary ideals while highlighting gender fluidity.
Drag has a long history. Greek mythology notes that Hercules may have dressed
as a woman. Aphroditus was a masculine god who donned female attire. In cele-
brations of the deity, followers would theatrically dress in other-sex attire as a
form of worship. In ancient Greece, soldiers would dress as women to gain access
to strategic locations and to avoid capture. Other historical military-based exam-
ples also exist. Consider Hua Mulan dressing as a man to take her father’s place in
the army and Joan of Arc wearing male soldier attire in the Hundred Years’ War.
In addition, British reporter Dorothy Lawrence took the name Denis Smith and
participated in World War I. Some European folktales focus on drag, and many
cultures have rituals reflecting the practice. For instance, some North American
Mennonite groups have young men dress as mischievous characters, some in fem-
inine clothing, around New Year’s Eve. The men raid community houses, play
music and tricks, and demand money, food, or drink. Cross-cultural dynamics of
dress can provide interesting insight on gender and power. Consider the Scottish
tradition of men wearing kilts, which leads some men to feel objectified when
women make suggestive comments or raise their skirt-type garments without con-
sent. Debates about identity, sexual preference, and motives exist with all these
examples. Regardless, they seem to fall under the classification of drag from the
cross-dressing community perspective.
Drag 181
Drag as related specifically to the LGBTQ+ community has roots in the late
1800s. During this time, people in American and British dance halls, early forms
of nightclubs, began to perform as drag queens and kings to entertain patrons.
Some scholars argue that when a man would first wear a woman’s dress, people
would say it would “drag” the floor until he became comfortable with it. Nearly a
century later, organized groups of flamboyant attendees at gay-friendly establish-
ments, such as the Club Kids, would make wearing clothing that challenges gen-
der dynamics customary. Scholars imply that prominent entertainers in the late
1900s helped to promote the acceptance of drag themes in wider culture. This
includes, but is not limited to, David Bowie, Boy George, Grace Jones, and Annie
Lenox. The foundation they laid opened the door for drag personalities such as
RuPaul to achieve success not only in the music industry but also with product
sponsorships, movies, and television.
Today, drag shows predominantly occur in LGBTQ+-associated nightclubs.
Costumes for drag queens involve corsets, jumpsuits, and dresses with boots or
heeled shoes. Wigs, intricately applied makeup, and sometimes body paint accen-
tuate the presentation. For drag kings, male attire is essential. However, engaging
in rituals associated with the application of faux facial hair and binding of the
breasts is key as well. Drag shows can involve monologues, skits, lip-synching of
popular music, and dancing. Audience participation is encouraged, and comedy at
the expense of viewers is commonplace. Though queens give the impression of
confidence on stage, research shows that some experience considerable perfor-
mance anxiety. Their onstage personas can help to shield them from fears. Per-
formers will adopt a stage name for shows and character traits to match. The name
typically plays on popular culture themes for a sexualized, comedic effect. For
example, names of former contestants on RuPaul’s Drag Race include Rebecca
Glasscock, Madame LaQueer, Jiggly Caliente, and Kandy Ho. Some shows have a
pageant format that allows for winners in smaller communities to move up to
larger venues to compete for prestigious titles such as Miss Continental USA,
which occurs over Labor Day weekend in Chicago. People are generally more
familiar with drag queens as compared to kings. Drag kings are more likely to
perform in groups and keep performances located around one specific geographic
location. In both cases, performers frequently give the money generated from
shows to community groups supporting LGBTQ causes.
Scholars argue that drag shows provide a form of political protest against
homophobia and heteronormativity. However, critics contend that they also sup-
port existing power structures when they emphasize and reward physical charac-
teristics that create oppression in the first place. In other words, drag queen shows
can focus too much on narrow understandings of femininity and fail to foster
acceptance and respect for multiple femininities. This could be one reason some
people in the gay community discriminate against drag queens. On the other
hand, king shows provide the acceptance of a wider understanding of gender with
participants not only being lesbians but also straight women, queer women, trans
men, and masculine-gendered women.
Jason S. Ulsperger
See also: Gender Expression; Gender Identity; LGBTQ+; Transvestite.
182 Dysmenorrhea
Further Reading
Berkowitz, D., Belgrave, L., & Halberstein, R. (2008). The interaction of drag queens and
gay men in public and private spaces. Journal of Homosexuality, 52, 11–32.
Brennan, N., & Gudelunas, D. (2017). RuPaul’s drag race and the shifting visibility of
drag culture: The boundaries of reality TV. New York: Palgrave Macmillan.
Garber, M. (2012). Vested interests: Cross-dressing and cultural anxiety. New York:
Routledge.
Greaf, C. (2016). Drag queens and gender identity. Journal of Gender Studies, 25, 655–665.
Greenhill, P., & Tye, D. (2014). Unsettling assumptions: Tradition, gender, and drag.
Boulder, CO: University Press of Colorado.
Knutson, D., Koch, J., Sneed, J., & Lee, A. (2018). The emotional and psychological expe-
riences of drag performers: A qualitative study. Journal of LGBT Issues in Coun-
seling, 12, 32–50.
Kramer, G., & Bernstein, R. (2017). Drags. New York: KMW Studio.
Senelick, L. (2000). The changing room: Sex, drag, and theatre. New York: Routledge.
Dysmenorrhea
Dysmenorrhea is painful cramping during menstruation. It is a common problem,
affecting around 50 percent of postpubescent women. The condition is most regu-
larly seen in people between the ages of twenty and twenty-four, and symptoms
often decrease with age. In the United States, about 10–20 percent of those affected
by dysmenorrhea have severe pain that leaves them unable to participate in every-
day functions like work and school for several days each month. Those who smoke
or who entered puberty at a young age (under eleven) are at greater risk for dys-
menorrhea, as are those who have irregular menstrual cycles or heavy bleeding
during their period.
There are two types of dysmenorrhea: primary dysmenorrhea and secondary
dysmenorrhea. The first occurs in otherwise healthy individuals and is usually
seen in younger adults. The menstrual pain felt as a result of primary dysmenor-
rhea is not related to uterine or other issues. While the cause is not entirely known,
the increased level of hormone-like substances (prostaglandins) during menstrua-
tion is thought to play a role in the condition. Prostaglandins are the natural sub-
stances that trigger the uterus to contract and expel menstrual blood. So far,
research has shown that the higher the level of prostaglandins, the greater the
chance of dysmenorrhea.
Secondary dysmenorrhea is a condition that typically develops in people older
than twenty-five as a result of problems associated with the uterus or pelvic organs.
These individuals have usually had normal, relatively pain-free menstruation until
the onset of their uterine or pelvic disorders. Issues that may trigger secondary
dysmenorrhea include uterine fibroids, which are noncancerous growths in the
uterus; pelvic inflammatory disease, a bacterial infection in the pelvic organs; and
endometriosis, a condition in which uterine lining tissues mistakenly implant and
grow on the fallopian tubes, ovaries, or elsewhere outside of the uterus. Stress and
anxiety are also factors that may trigger secondary dysmenorrhea.
Dysmenorrhea 183
The symptoms of dysmenorrhea include an intense throbbing or aching in the
lower abdomen, sharp pains that come and go, and a persistent ache that radiates
through the lower back and legs. Some people also experience diarrhea, nausea,
headaches, or dizziness during menstruation as a result of dysmenorrhea.
Although dysmenorrhea itself does not lead to other medical conditions, the
underlying issues that cause secondary dysmenorrhea may if left untreated. For
example, endometriosis can lead to fertility issues, and pelvic inflammatory dis-
ease may increase the risk of ectopic pregnancy, a sometimes life-threatening
problem that occurs when a fertilized egg implants outside of the uterus.
A pelvic exam should be able to show whether an individual has primary dys-
menorrhea or secondary dysmenorrhea. If the exam reveals no irregularities or
abnormalities, the problem is most likely primary dysmenorrhea. Primary dys-
menorrhea is often treatable with home remedies like a low-sugar, low-sodium,
and no-caffeine diet, or increased stress-reducing activity such as yoga and medi-
tation. Warm showers and baths and over-the-counter anti-inflammatory medica-
tion are also often recommended. If the pain is severe, a medical practitioner may
recommend prescription anti-inflammatory medication and pain relievers or birth
control pills. If secondary dysmenorrhea is suspected, a doctor may recommend
additional tests such as an ultrasound, a CT scan, or other imaging tests. In addi-
tion, a complete blood count test can be used to pinpoint infections and other such
problems. Laparoscopic outpatient surgery can also be used to explore the pelvic
region and reproductive organs for signs of fibroids, endometriosis, cysts, and
other issues that may be creating the painful menstrual cramps. This is usually
only recommended for a small percentage of women who have not responded to
other tests and treatments.
Evidence shows that dysmenorrhea was a known problem in ancient civiliza-
tions such as Egypt and Greece. Early practitioners applied aromatic oils and oint-
ments to treat inflammation and pain associated with the problem. Roman
physicians wrote extensively about their use of asparagus root to relieve menstrual
pain. By the nineteenth century, dysmenorrhea was seen as a common but serious
problem, though the suspected causes were wide and varied. In 1938, a connection
between ovulation and dysmenorrhea was made, followed by the discovery of
increased prostaglandins creating menstrual pain in 1965. Over time, different
courses of treatment were prescribed and studied. Newer research has shown that
calcium channel-blocking agents are helpful in decreasing pain associated with
dysmenorrhea. Experimentation has also revealed that transcutaneous electrical
nerve stimulation, a noninvasive procedure in which electrical impulses are used
to block pain in the pelvis, may also be effective for some people.
Tamar Burris
See also: Menstruation; Premenstrual Dysphoric Disorder (PMDD); Premenstrual Syn-
drome (PMS).
Further Reading
Gannon, L. R. (1985). Menstrual disorders and menopause. Westport, CT: Praeger.
Hollen, K. H. (2004). The reproductive system. Westport, CT: Greenwood.
184 Dyspareunia
Dyspareunia
“Dyspareunia” is a medical term referring to the symptom of pain with sexual
intercourse. It is commonly used in reference to painful intercourse in both men
and women and can include pain as a result of physical, psychological, and com-
bined causes.
Apart from use as a medical term, dyspareunia also has a history of being clas-
sified as a type of mental disorder. In a previous edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM), dyspareunia was included as a
sexual disorder, and one that applied to both men and women. The DSM criteria
for this diagnosis included (1) pain that occurs before, during, or just after inter-
course; (2) the presence of distress or interpersonal difficulty as a result of the
condition; and (3) the condition is not caused by vaginismus (involuntary spasm of
the muscles of the vagina), insufficient lubrication, use of a drug or medication, or
another psychological or medical condition.
However, the fifth edition of the DSM does not include dyspareunia. Instead,
both it and vaginismus have been removed and replaced with the term genito-
pelvic pain/penetration disorder (GPPPD). GPPPD is classified as a sexual dys-
function, but in the DSM-5 it only applies to women. In addition to pain with
intercourse, this diagnosis also includes women who experience difficulty with
vaginal penetration or fear or anxiety about pain with penetration even if they do
not experience pain.
In the more common usage of the term, “dyspareunia” describes the symptom
of pain with intercourse and requires further assessment to determine the cause.
Assessment includes a thorough medical history, visual examination, and tests for
physical causes.
In both men and women, causes of dyspareunia include sexually transmitted
infections, skin disorders, allergy to latex condoms or spermicide, bladder disor-
ders, and pelvic floor dysfunction (a condition where the muscles supporting the
reproductive organs are either too tight or too loose, both of which may cause
pain). In women, some additional causes of dyspareunia include endometriosis,
vaginismus, vulvodynia, vaginal atrophy, lack of lubrication, adhesions, hormonal
changes from perimenopause or menopause, and traumatic childbirth.
Some additional causes of dyspareunia in men include prostatitis (infection of
the prostate gland), Peyronie’s disease (a condition where the penis has an abnor-
mal shape when erect), and phimosis (where the foreskin is too tight).
The prevalence of dyspareunia is unknown due to the fact that there are multi-
ple conditions that include dyspareunia as a symptom, and many cases go unre-
ported. Dyspareunia is more common in women, and there is little research about
the condition in men.
Treatment for dyspareunia varies depending on the cause and may include
medication for sexually transmitted infections, surgery for endometriosis, and
pelvic floor physical therapy (e.g., for conditions including pelvic floor dysfunc-
tion, prostatitis, and vaginismus). Regardless of the cause, a multidisciplinary
approach is recommended, including sex therapy for psychological factors and to
Dyspareunia 185
address the impact of painful intercourse on the individual and his or her
relationships.
Adrienne M. Bairstow
See also: Diagnostic and Statistical Manual of Mental Disorders (DSM); Endometriosis;
Menopause; Pelvic Floor Muscles; Phimosis; Prostatitis; Psychosexual Therapy; Sexual
Dysfunction, Treatment of; Sexually Transmitted Infections (STIs); Vaginal Lubrication;
Vaginismus; Vulvodynia.
Further Reading
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., text rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Goldstein, A., & Burrows, L. J. (2009). Sexual pain disorders in women. Retrieved from
http://www.issm.info/news/review-reports/sexual-pain-disorders-in-women/
Mayo Clinic. (2019). Painful intercourse (dyspareunia). Retrieved from http://www
.mayoclinic.org/diseases-conditions/painful-intercourse/basics/definition/CON
-20033293?p=1
E
Ejaculation
Ejaculation can occur in both penises and vulvas. (Female ejaculation is discussed
in a separate entry.) Ejaculation in both cases involves the expulsion of fluids from
the genitals, usually produced in response to sexual excitement. It may or may not
accompany an orgasm. Even though orgasm and ejaculation are widely believed
to be the same, they are in fact separate events, and one is not guaranteed by the
presence of the other.
For penises, ejaculation is usually the result of excitement and is the mecha-
nism that allows sperm (semen) to leave the body. The testes are the home of
sperm production, and ejaculate for penises is comprised of a tiny amount of
sperm produced in the testes. The fluids that house the sperm travel from the tes-
tes via the vas deferens, a tube connecting the testes to the prostate, where it
mixes with prostatic fluid and fluid from the seminal vesicles before heading out
the urethra for an ejaculation. The process of ejaculation is helped by clear, extra-
slippery fluid from the bulbourethral glands. This substance is known as preejacu-
late fluid (commonly known as precum).
Because the majority of the ejaculate is comprised of seminal fluid and pros-
tatic fluid, it is still possible to have ejaculations after a vasectomy because the
majority of the fluid comes from the prostate gland. The vasectomy only prevents
sperm from mixing with the other ejaculation fluids. Penis ejaculation happens
when the bulbospongiosus and ischiocavernosus muscles contract to help propel
the ejaculate from the urethra. Penis ejaculate usually travels two to three inches
outside the body after having traveled two feet within the body to make its way
outside. Ejaculate may carry sexually transmitted infections such as HIV.
Sometimes males wake in the morning with sticky underwear or sheets after
ejaculating in their sleep. This is called a wet dream, or nocturnal emission, and it
is totally normal, especially during puberty. Sometimes while sleeping, the penis
becomes erect and ejaculates. It may or may not be accompanied by erotic dreams
or rubbing on the bed while sleeping. Wet dreams are common and tend to become
less frequent with age. Ejaculation can occur even without erections present.
Premature ejaculation (when someone ejaculates sooner than they would like)
is a common physical sexual problem experienced by around 30 percent of people
with penises worldwide. Delayed ejaculation (when someone does not ejaculate
despite sufficient sexual stimulation) is also a common problem. Frequent ejacula-
tion may be linked to a decreased risk of prostate cancer.
Cyndi Darnell
188 Ellis, Albert
See also: Female Ejaculation; Nocturnal Emissions; Orgasm; Penis; Preejaculate Fluid;
Premature Ejaculation; Retrograde Ejaculation; Semen.
Further Reading
Carson, C., & Gunn, K. (2006). Premature ejaculation: Definition and prevalence. Inter-
national Journal of Impotence Research, 18(S1), 5–13.
Gottlieb, S. (2004). Frequent ejaculation may be linked to decreased risk of prostate can-
cer. BMJ, 328, 857.
Montorsi, F. (2005). Prevalence of premature ejaculation: A global and regional perspec-
tive. The Journal of Sexual Medicine, 2, 96–102.
Pryor, J. P. (2002). Orgasmic and ejaculatory dysfunction. Sexual and Relationship Ther-
apy, 17(1), 87–95.
Waldinger, M. D. (2017). Physiology of ejaculation. In S. Minhas & J. Mulhall (Eds.),
Male sexual dysfunction: A clinical guide (8–13). West Sussex: John Wiley &
Sons.
Ellis, Albert
Albert Ellis (1913–2007), while best known as one of the main pioneers of the
cognitive revolution in psychotherapy with his approach of rational emotive
behavior therapy (REBT), was a key force in the sexual revolution of the 1950s
and 1960s. He was one of the founders, and first president, of the Society for the
Scientific Study of Sexuality and the first major cognitive behavioral sex therapist.
One of his main goals was to make the field of sexology a respectable and vital
area of science.
Ellis was born in Pittsburgh, Pennsylvania, and moved to New York with his
family when he was an infant. New York remained his home base for the rest of
his life. Throughout his teens and young adult years, he researched any and all
studies and books about sex and sexuality that he could find. A main source for his
readings was the New York Public Library. His expertise on sex, sexuality, “non-
conforming” sexual behavior, and more drew people seeking help with issues that
included, or were related to, their sex activities with others, masturbation, rela-
tionships, and marriage. As a result of his success in helping his clients suffer less
anxiety and concern about sex and relationship issues, and their consequential
greater harmony and contentment, he founded the Love and Marriage Problems
Institute in 1939 for research and therapy.
Because there were no academic programs offering courses about sexuality
and relationships at this time, Ellis completed the master’s and PhD programs at
Columbia University’s Teachers College clinical psychology program. He com-
pleted writing The Case for Promiscuity in 1938, which was considered by pub-
lishers to be too liberal for that time; consequently, it was first published in 1965.
From the late 1930s onward, Ellis fought vigorously in talks, books, and arti-
cles against censorship, the ignoring of sexual liberty, and other social restric-
tions. He presented in favor of free love, premarital sex, easy divorce, same-sex
relationships, birth control, equal rights for women, equal rights for gay people,
interracial relationships and marriage, liberation of sex laws, and other aspects in
Ellis, Albert 189
favor of sexual freedom. Few others dared to talk about such topics in those years,
and he was considered a renegade, maverick, and worse by many people with con-
servative views. He wrote many articles on sex and love, which were published in
journals and popular magazines, and gave many talks and workshops on sex and
psychotherapy. His first book, The Folklore of Sex, was published in 1951, fol-
lowed by many more volumes and articles about sex and love topics.
Ellis became a renowned sexologist, clinician, and writer and often corre-
sponded with Alfred Kinsey (1894–1956) and other notables in the field. Kinsey
consulted with Ellis and interviewed him for some of his reports and studies. Oth-
ers in the field, including John Money and Harry Benjamin, were influenced by
Ellis, respected his work, and often cited him. By 1954, Ellis had published at
least forty-six articles, two books, and two anthologies and was the American edi-
tor of the pioneering journal the International Journal of Sexology. In 1957, Ellis
founded and was the first president of the Society for the Scientific Study of Sexu-
ality, and he produced more best-selling books on sex and love, making him one
of the most influential writers and speakers of the American, European, British,
and Australian sex revolution of the 1960s. His public fame flourished in the 1960s
following publications that included his best-selling books: Sex without Guilt
(1958), The Art and Science of Love (1960), The Intelligent Woman’s Guide to Dat-
ing and Mating (1963), and Sex and the Single Man (1963).
Despite being frequently invited to write for magazines and to appear on radio
and television talk shows, his views were at times censored. Some magazine edi-
tors rejected his articles, saying they were too bold or controversial. Some radio
programs on which he spoke were not rebroadcast because management deemed
his views, such as saying that masturbation and sex were desirable, too radical and
controversial. On a couple of occasions when he appeared on television programs
and espoused premarital sex relations, the Federal Communications Commission
took those programs temporarily off the air.
As the 1960s progressed, and in the decades that followed, Ellis became
known more for his revolutionary work in psychotherapy, but his reputation as a
sexologist continued, and he was often criticized for his controversial views. He
disagreed with Freud that sex problems are major causes of general emotional
problems and asserted that general human disturbance is much more likely to
lead to sex problems than vice versa. His REBT approach teaches techniques
and methods of minimizing emotional disturbance and maximizing joy in life
and significantly contributes to assisting those with sexual problems and
dysfunctions.
Ellis considered some of his main contributions to the fields of sex, love, and
marriage to be his vigorous assertions that masturbation was not harmful and
shameful but beneficial for most people; that mutual consenting premarital sex for
adults, and the use of contraception, was not immoral; and that unconventional
sexual behavior was not perverse or deviant and that “sexual abnormality” is usu-
ally a myth. Additional contributions that he considered significant included his
being a pioneering feminist, one of few mid-twentieth-century psychologists to
strongly advocate gay liberation, and his, along with Kinsey’s, disputing of the
sacredness of the so-called vaginal orgasm.
190 Ellis, Henry Havelock
Ellis was married three times: his first two marriages ended in divorce, yet
good friendships with his ex-wives endured. He was in a long-term open relation-
ship following those marriages and finally enjoyed marriage with the woman he
called the greatest love of his life, Australian psychologist Debbie Joffe Ellis, until
his passing in 2007.
Debbie Joffe Ellis
See also: Benjamin, Harry; Kinsey, Alfred; Money, John; Sexology; Sexual Revolution;
Society for the Scientific Study of Sexuality (SSSS).
Further Reading
Ellis, A. (2010). All out: An autobiography! Amherst, NY: Prometheus Books.
Ellis, A., & Ellis, D. J. (2011). Rational emotive behavior therapy. Washington, DC:
American Psychological Association.
Reiss, I. L., & Ellis, A. (2002). At the dawn of the sexual revolution. Walnut Creek, CA:
Altamira Press.
Ellis, Henry Havelock
Henry Havelock Ellis (1859–1939) was a physician, writer, and sexologist. To
some, he is considered the founding father of the psychology of sex. In his early
career as a newly qualified medical doctor in the 1880s (having graduated from St.
Thomas’ Hospital Medical School, which is now King’s College London), Ellis
found himself working as the acting midwifery clerk in the London slums on the
south side of Westminster Bridge. The job further emphasized his interests in
research and knowledge on sex and sexual behavior. Even though Ellis wrote on a
variety of topics, he is most noted for his work on sex, particularly his seven-
volume work entitled Studies in the Psychology of Sex (published from 1897 to
1928). These volumes caused an outpouring of books on similar topics in the rest
of psychology and social science (even self-help books), as the topic was clearly of
popular interest.
In his professional capacity, Ellis served as president of the Galton Institute,
joined the Fellowship of the New Life in 1983, and is credited with introducing the
concepts of narcissism and autoeroticism, which were later taken on by psycho-
analysis and further developed by Sigmund Freud. Naturally, Ellis and Freud
shared correspondence on their work on sex and psychoanalysis—even though
differences of opinion occurred.
Ellis was known for his own sexual problems throughout his life. During his
time at boarding school, around the age of fourteen, he was bullied and forced by
one particular boy to act like a horse. Pushed over and forced onto all fours, he
was mounted by the fellow pupil who rode on Ellis’s back around the dorm and
dug his heels into Ellis with homemade spurs. Apparently, Ellis put up no resis-
tance, and this resulted in Ellis experiencing associated wet dreams (seminal
emissions during sleep) far into life as a result of these “mental wounds,” as they
were described.
Later in life, once he became a doctor and an established author, Ellis was often
ridiculed by friends for being a leading authority on sex but not having had sex for
Ellis, Henry Havelock 191
the first time until the age of thirty-two. In 1891, at the age of thirty-two, he mar-
ried English writer and female rights activist Edith Lees. Together they shared
what many would consider a peculiar relationship, as Edith was openly lesbian (or
arguably bisexual) and had frequent affairs with women, of which Ellis was seem-
ingly aware. Ellis idolized Edith, and she became the central focus of his own
autobiography, entitled My Life, which many reviewers have said focused more on
Edith than Ellis and appears to end at the point of Edith’s death in 1916. For a long
time after his marriage to Edith, Ellis suffered from erectile dysfunction. It was
not until he was in his sixties that he discovered that he was still able to become
aroused when observing women urinating. This was apparently associated with
his early experiences as the acting midwifery clerk, where on one occasion of
attending a delivery, the pregnant woman concerned had apparently urinated on
Ellis during the birth. Ellis reported in his personal notes and private life that he
gained some pleasure from this act.
Having published some fifty books in his lifetime, Ellis has been credited with
being the coauthor (with J. A. Simonds) of the first medical textbook on homo-
sexuality, entitled Sexual Inversion (1897). Ellis did not consider homosexuality a
disease, unnatural, nor a crime. However, in reading this book today, there are
significant age gaps between some of the case studies of male-on-male relation-
ships, which today would be considered child abuse. Ellis even published on, and
provided some of the initial framework for, transgender psychology.
He became somewhat of a household name in his time due to his writings,
being widely known in public as the infamous sex psychologist. With sex being
somewhat of a taboo subject in England in the late nineteenth to early twentieth
century, a lot of negative reviews were received for his books. Some boasted of
having burned Ellis’s books, while others expressed feeling dirty and wrong for
having read the material. In their day, Ellis’s books would have been seen as highly
controversial. Read in the current context, Ellis’s writings on sex present nothing
more than academic observations of sexual processes and behavior. Yet, at the
time, he was seen as a purveyor of pornography.
Ellis conducted most of his research and writings in his study in his Brixton
flat, where he also saw “patients” (or clients), who came to him to discuss various
sexual problems they had, typically within marriage. Some who visited him for
such counsel reported him to be a tall, shy, and reserved man in a home office sur-
rounded by books and furniture. Much like Sigmund Freud, Ellis also corre-
sponded with his patients by post, which at one point led to a considerable number
of letters being received.
Following the death of Ellis’s wife, Edith, in 1916, he spent the last twenty years
of his life in a close relationship with Françoise Delisle. Moving from France to
England to become a schoolteacher of French, Delisle reignited some of Ellis’s
early interests in metaphysics and materialism. She notes in her autobiographies—
of which she published three—that sex dwindled in their relationship, but conver-
sations on the topic and many others were constant. Delisle noted discussions and
experiences of psychic phenomena between Ellis and herself, instances that some
would describe as telepathic, involving hallucinations of Ellis or “bilocation.” Fol-
lowing Ellis’s death in his home in Suffolk in 1939, Delisle discussed in great
192 Emergency Contraception
detail three specific instances of encountering apparitions of Ellis and sittings
with mediums, the latter after having consulted with Sir Oliver Lodge. All this is
noted in her third autobiography, The Return of Havelock Ellis, published in 1968.
Today, Ellis remains an important historical figure in sexology, especially due
to the amount of publications he produced and his establishment of some of the
solid foundations that have served as the basis for the field of sexology. However,
much like Sigmund Freud, his work on sex has not stood the test of time, with
modern thought and a vast array of research findings changing the way we view
and understand who we are and the world we live in. Several Ellis biographies
have been published with varying reviews. Certainly, one of the better pieces to
offer a full and detailed coverage of Ellis’s life was published in 1979, entitled
Havelock Ellis: Philosopher of Sex by Vincent Brome.
Callum E. Cooper
See also: Freud, Sigmund; Sexology.
Further Reading
Brome, V. (1979). Havelock Ellis: Philosopher of sex. London: Routledge & Kegan Paul.
Cooper, C. E. (2015). Havelock Ellis’ involvement in psychical research. Paper presented
at the joint 58th Annual Parapsychological Association Convention and 39th Inter-
national Conference of the Society for Psychical Research (pp. 50–51, book of
abstracts), University of Greenwich, UK.
Delisle, F. (1946). Friendship’s odyssey. London: Heinemann.
Delisle, F. (1968). The return of Havelock Ellis. London: Regency Press.
Ellis, H. (1940). My life. London: Heinemann.
Eysench, H. J., & Wilson, G. (1979). The psychology of sex. London: J. M. Dent & Sons.
Peterson, H. (1928). Havelock Ellis: Philosopher of love. London: George Allen & Unwin.
Emergency Contraception
Emergency contraception (EC) is an over-the-counter birth control that females
can take after intercourse in order to prevent a possible pregnancy. It can be used
in situations such as unprotected sex, unwanted sex, or failed birth control. The
medication is available in both pill form and as an intrauterine device (IUD). For
the pill form, women in the United States do not need a prescription to obtain it.
However, the IUD requires a physician or nurse practitioner for insertion. There
are no age restrictions or limits. EC will not terminate a preexisting pregnancy.
Some types of EC can be effective for up to 5 days, or 120 hours, after sexual
intercourse. Other types are effective for up to 3 days, or 72 hours, after sex. How-
ever, it is not as effective as other birth control methods used before sex, and
therefore it should not be used or substituted as a form of regular birth control.
Furthermore, EC only works to prevent pregnancy and does not prevent sexually
transmitted infections.
EC prevents pregnancy mainly in two ways: through synthetic hormone pills
and intrauterine devices. One of the most widely used synthetic hormones is called
levonorgestrel, a form of progesterone. This hormone prevents pregnancy by
Endometriosis 193
delaying the release of an egg or preventing fertilization or implantation of the egg
to the uterus. The level of levonorgestrel that is used in EC is higher than levels
found in daily birth control pills. These pills are typically taken in one dose and do
not have restrictions in order to purchase them. If taken within three days (sev-
enty-two hours) as directed, these pills are 89 percent effective, and they are more
effective the sooner they are taken after intercourse.
The newest one-pill form of EC contains ulipristal acetate. It works by tempo-
rarily delaying the release of an egg from the ovary and can be used for up to five
days after unprotected sex or failed birth control. Unlike the levonorgestrel pills,
ulipristal acetate’s effectiveness remains consistent throughout the entire five
days. It is currently only available by prescription and through online ordering. If
taken as directed, it is 85 percent effective.
Another type of hormonal EC is combination daily birth control pills. Combi-
nation pills contain both synthetic estrogen and progesterone. Under the instruc-
tion of a physician, women can take between two and five daily birth control pills
within three days of unprotected sex to prevent pregnancy. Different brands
require different doses, and the doses are typically taken twelve hours apart. For
this reason, consultation with a physician is often recommended to avoid overdos-
ing or painful side effects.
Finally, copper IUDs are the most effective form of EC with an effectiveness
rate of more than 99 percent. The copper causes an inflammatory reaction in the
uterus to create a hostile environment for sperm. It can be inserted by a medical
professional up to five days after sex and can remain in the uterus for up to ten
years.
Lauren Wesley
See also: Conception; Contraception; Intrauterine Device (IUD); Pregnancy; Synthetic
Hormones.
Further Reading
Bedsider. (2019). Emergency contraception. Retrieved from http://bedsider.org/methods/
emergency_contraception#details_tab
National Institutes of Health. (2019). Emergency contraception. Retrieved from http://
www.nlm.nih.gov/medlineplus/ency/article/007014.htm
Planned Parenthood. (2019). Emergency contraception. Retrieved from http://www
.plannedparenthood.org/learn/morning-after-pill-emergency-contraception
World Health Organization. (2018). Emergency contraception. Retrieved from https://
www.who.int/news-room/fact-sheets/detail/emergency-contraception
Endometriosis
Endometriosis occurs in women of reproductive age, and diagnosis occurs most
often in the thirties and forties. Endometrium tissue grows outside of the uterus
and often attaches to the reproductive organs, bladder, vagina, rectum, or perito-
neum (lining of the abdominal and pelvic cavities). Like normal endometrium
tissue, the tissue outside the uterus follows the pattern of the menstrual cycle and
thickens, builds up, and bleeds with the passing of each month. However, this
194 Endometriosis
tissue outside the uterus has nowhere to go and so builds up more and more every
month. Often during menstruation, women with endometriosis experience mild to
severe abdominal and pelvic pain that is often associated with menstrual cramps.
Women who come from families with a history of endometriosis have a higher
chance of also having the condition. Often treatment is temporary and symptoms
return.
There is no exact cause of endometriosis. Researchers believe that there is a
hereditary component to the condition because women with a family history of
endometriosis are five to seven times more likely to be diagnosed. For a while,
many doctors and researchers thought that the cause was retrograde menstruation,
which occurs when endometrial cells and tissue flow backward into the fallopian
tubes during menstruation. However, endometriosis and retrograde menstruation
are two separate conditions that could possibly be related. There is also a possibil-
ity that the condition may result from an immune system disorder in which endo-
metrial cells outside the uterus are not killed and thus build upon one another.
The most common symptom of endometriosis is mild to severe abdominal and
pelvic pain that sometimes extends into the lower back region. Pain may worsen
or become unbearable during menstruation and is often associated with and mis-
taken for heavy cramping. Women with endometriosis may experience heavy
periods and less often may experience more than one episode of menstrual bleed-
ing within a month. Other symptoms of this condition include pain either during
or after intercourse and infertility.
Laparoscopy is the most exact manner of diagnosing endometriosis. Laparos-
copy is a surgery in which a laparoscope is inserted into a small incision made in
the abdomen. The abdominal and pelvic organs are observed, and a small piece of
tissue is removed for analysis. Doctors may also complete other tests such as pel-
vic examinations and ultrasounds.
There is no cure for endometriosis. However, there are treatments to help with
severe pain and infertility. The most common treatment for younger women is
hormonal contraceptives such as birth control pills and the noncopper intrauterine
device. Other treatments include laparoscopic excision surgery. Laparoscopic
excision surgery is the most effective treatment and removes the built-up tissue.
However, more tissue may return every month following the procedure. Having a
hysterectomy may be an option, but tissue buildup can still occur.
There are no preventative techniques for endometriosis. However, during men-
struation using heating pads and taking anti-inflammatory drugs, such as ibupro-
fen, may aid with abdominal and pelvic pain.
Camilla Loggins
See also: Endometrium; Menstruation; Uterus.
Further Reading
American College of Obstetricians and Gynecologists. (2012). Endometriosis. Retrieved
from http://www.acog.org/-/media/For-Patients/faq013.pdf?dmc=1&ts=201509
30T0042200720
Endometriosis Foundation of America. (2015). What is endometriosis? Retrieved from
http://www.endofound.org/endometriosis
Endometrium 195
Mayo Clinic. (2016). Endometriosis. Retrieved from http://www.mayoclinic.org/diseases
-conditions/endometriosis/basics/definition/con-20013968
PubMed Health. (2014). Endometriosis: Overview. Retrieved from http://www.ncbi.nlm
.nih.gov/pubmedhealth/PMH0072685/
Endometrium
The endometrium, also referred to as the uterine lining, is the mucosal lining
inside a female’s uterus. It plays a pivotal role in pregnancy as the site of implanta-
tion, where a young embryo attaches itself to the lining approximately six to seven
days after fertilization. It serves as a source of nourishment for the developing
embryo through the proteins and glycogen that are secreted by the uterine glands,
which are located within the endometrium. The uterine lining also goes through
cyclical changes as it prepares for a pregnancy, or menstruation in the event that a
pregnancy does not occur.
The endometrium goes through a monthly cycle of physical changes that occur
in four phases, called the menstrual, proliferative, secretory, and ischemic phases.
During these phases, the endometrium thickens to prepare itself for implantation,
and if an embryo is not present to implant, it then sheds itself. These phases are
concurrent with the ovarian cycle when eggs are matured and released for fertil-
ization. Estrogen and progesterone contribute to the stimulation of the endome-
trium as it prepares itself to receive an embryo.
In the menstrual phase, during approximately the first five days of the cycle,
the endometrium, containing a mixture of blood and debris, sheds itself, and
this constitutes the menstrual flow. The second phase, known as the prolifera-
tive phase, occurs between days six and fourteen of the cycle. At this time, the
endometrium rebuilds after shedding from the previous phase. Proliferation
takes place as estrogen stimulates the formation of thick mucosa and uterine
glands. This phase occurs along with ovulation (typically around day fourteen),
when the egg is released from the ovary. The increase in progesterone that is
released during ovulation leads to the secretion of uterine fluid by the endome-
trial glands, which marks the beginning of the secretory phase. This phase
occurs between days fourteen and twenty-eight. The secretions released during
this phase are necessary for embryonic implantation and development. Finally,
in the absence of fertilization, the ischemic phase begins as estrogen and pro-
gesterone decline, oxygen reduces, and the endometrial blood flow diminishes,
causing the endometrium to shed. This occurs between days twenty-seven and
twenty-eight of a typical twenty-eight-day cycle.
Abnormalities of the endometrium can indicate a number of conditions that
affect thousands of women each year. One of the most common is endometriosis,
a condition where the tissues of the endometrium grow outside the uterus. In
severe cases, the endometrium can encase the surrounding organs, causing other
tissues to develop into adhesions that bind organs together. Another condition,
adenomyosis, occurs when the endometrial lining grows into the muscular wall of
the uterus, which can cause an enlarged uterus and painful menstrual cycles.
196 Epididymis
Endometrial cancer, also referred to as uterine cancer, develops when cancer cells
form in the endometrium. One of the first symptoms of endometrial cancer is
vaginal bleeding, which is why this type of cancer is often diagnosed early. In the
United States, endometrial cancer is the most common type of female reproduc-
tive cancer.
Lauren Wesley
See also: Endometriosis; Menstruation; Pregnancy; Uterine Cancer; Uterus.
Further Reading
American Cancer Society. (2015). Endometrial (uterine) cancer. Retrieved from http://
www.cancer.org/cancer/endometrialcancer/detailedguide/endometrial-uterine
-cancer-key-statistics
Aria Health. (2015). Endometrial conditions. Retrieved from https://www.ariahealth.org/
programs-and-services/centers-of-excellence/women-s-health/endometrial
-onditions
Mayo Clinic. (2015). Adenomyosis. Retrieved from http://www.mayoclinic.org/diseases
-conditions/adenomyosis/basics/definition/con-20024740
Mayo Clinic. (2015). Endometrial cancer. Retrieved from http://www.mayoclinic.org/
diseases-conditions/endometrial-cancer/basics/definition/con-20033696
WebMD. (2015). Endometrium and cervix. Retrieved from http://www.webmd.com/
women/the-endometrium-and-cervix
Epididymis
The epididymis is a structure of the male reproductive system. It is located on
each testicle and is often referred to as the housing center for sperm. The epididy-
mis is made up of tightly coiled tubes that create a pathway for sperm. It is cres-
cent shaped and has three parts: a tail, head, and body. The head is located on the
top of the testes and is considered the widest region of the epididymis. This is
where sperm are stored until they are matured and sent to the body of the epididy-
mis. The body is narrow and moves sperm from the head to the tail of the epididy-
mis. The tail of the epididymis is located on the bottom of the testes and connects
to the vas deferens. All these parts combined help ensure the safe travel of sperm
until they reach their next destination.
Prior to entering the epididymis, sperm develop in the seminiferous tubules,
which are a large set of condensed tubes inside the testicles. After sperm is pro-
duced, is it usually nonmotile and requires a large amount of liquid to be trans-
ferred to the next location—the epididymis. The immature sperm make their way
to the epididymis, where they usually spend about a week finding their way
through the largely coiled tubes. During this time, they begin to mature and
develop a slow swimming forward motion. When the matured sperm finish pass-
ing through the epididymis, they travel into the vas deferens upon sexual stimula-
tion, leading to possible ejaculation. When the sperm is transferred from the
epididymis to the vas deferens, it has a paste-like consistency. Through muscular
contractions, the vas deferens transfers the mature sperm to the ejaculatory duct.
This sperm is then combined with fluids secreted from the prostate gland, which
Epididymis 197
gives semen its texture and odor, and the seminal vesicles, which give sperm fruc-
tose for energy. Finally, this fluid travels down the ejaculatory duct and into the
urethra, where it will be propelled out of the penis.
The epididymis contains stereocilia inside each of its structures. Stereocilia are
long projections that are nonmotile. The point of stereocilia is to take 90 percent of
the fluid used to transfer the sperm to the epididymis and only leave mature mobile
sperm. The epididymis can store matured sperm for up to a month until it expires
and the stereocilia begin to absorb it completely. When this happens, expired
sperm are then replaced with younger, immature sperm.
The epididymis is very important for sperm and fertility. If something damages
the epididymis, such as trauma, sperm production and reproduction can be hin-
dered. While sperm can still be produced, they cannot be stored and, therefore,
will not be viable. A possible injury to the epididymis could come from a urinary
infection that develops due to bacteria like Escherichia coli (E. coli). This is most
common in older men because of an increase in restriction or obstruction of urine
flow. Another example of a complication would be epididymitis, which occurs
when the epididymis tube swells, resulting in testicle pain and inflammation. This
is most commonly caused by a bacterial infection or sexually transmitted infec-
tion (STI). Most of the time, epididymitis can be treated with antibiotics, ice, and
rest. However, if not properly treated, chronic epididymitis or continuous pain and
swelling in the testicles may occur, possibly requiring surgery.
In order for epididymitis to be diagnosed, doctors will examine the groin and
swollen testicles to assess for enlarged lymph nodes. Rarely doctors may perform
a rectal exam to determine if the prostate is also swollen. Some tests to diagnose
epididymitis include STI screenings, urine and blood tests, and ultrasounds.
Screenings may include a small swab that is inserted into the penis to test the dis-
charge inside of the urethra as well as urine and blood tests. Ultrasounds can be
used to assess the level of blood flow in the testicles. If there is less blood flow
than average, the pain and swelling could be due to another possible condition of
the testicles. However, if the flow of blood is higher than average, the doctor may
request further testing and possibly confirm the diagnosis of epididymitis.
It is known that temperature influences the function of the epididymis. For
sperm to be produced, the body requires the testicles to be at a specific tempera-
ture, slightly below core body temperature. If the testicles are exposed to higher or
lower temperatures for long periods of time, sperm count may decrease, possibly
leading to decreased fertility. With significant temperature changes, the life span
of the sperm being stored inside the epididymis can be shortened.
Casey T. Tobin
See also: Semen; Seminiferous Tubules; Sperm; Testicles; Vas Deferens.
Further Reading
Lehmiller, J. (2013). The psychology of human sexuality. Hoboken, NJ: John Wiley &
Sons.
Maier, T. (2009). Masters of sex. New York: Basic Books.
Sullivan, R., & Mieusset, R. (2016). The human epididymis: Its function in sperm matura-
tion. Human Reproduction, 22, 574–587.
198 Erectile Dysfunction
Erectile Dysfunction
People with penises may experience erectile dysfunction. Erectile disorder may be
diagnosed if an individual reports repeatedly being unable to have or maintain an
erection during sexual activity with a partner. People who are experiencing erec-
tile dysfunction may also experience low self-esteem, a lack or reduction in self-
confidence, depressed mood, and a decrease in their sense of masculinity. Because
of the difficulty with experiencing an erection and the associated negative feel-
ings, some people with erectile dysfunction may avoid sexual activities and may
experience less sexual satisfaction and lower sexual desire. An individual’s part-
ner or partners may also experience some of these same feelings as a result of their
partner’s erectile dysfunction.
Approximately 8 percent of men report experiencing erectile problems the first
time they have sex, and this may be related to using drugs or alcohol or to various
psychological factors, such as not wanting to have sex or feeling peer pressure.
The majority of these cases will resolve on their own. When erectile dysfunction
occurs later in life, it is often associated with medical factors such as diabetes,
cardiovascular disease, or other diseases that affect how the body functions. In
these cases, erectile dysfunction can be persistent for many people. Other psycho-
logical factors, such as neuroticism, depression, anxiety, and posttraumatic stress
disorder, can also be linked with erectile dysfunction. Other risk factors include
smoking, lack of exercise, and decreased sexual desire. There are often both medi-
cal and psychological causes for erectile dysfunction, and it can also co-occur
with other sexual disorders, including premature (early) ejaculation and male
hypoactive sexual desire disorder.
According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition (DSM-V), in order for a diagnosis of erectile disorder to be made, an indi-
vidual must experience at least one of the following symptoms during almost all
or all (75–100%) occasions of sexual activity: (1) marked difficulty in obtaining an
erection during sexual activity, (2) marked difficulty in maintaining an erection
until the completion of sexual activity, or (3) marked decrease in erectile rigidity.
To meet criteria for diagnosis, symptoms need to have occurred for a minimum of
around six months, and they need to cause clinically significant distress to the
individual. Finally, the erectile difficulties should not be better explained by a
nonsexual mental disorder or as a consequence of severe relationship distress or
other significant stressors, and they should not be a side effect of substance or
medication use or another medical condition.
In addition, the DSM-V recognizes that erectile disorder can occur in specific
identified situations or in all contexts. It can also be lifelong or acquired, meaning
that it begins after a period of relatively normal sexual function, such as in later
life. Severity of distress associated with symptoms of erectile disorder can be
mild, moderate, or severe.
Erectile dysfunction becomes more common with age, particularly over the age
of fifty years. Approximately 13–21 percent of men aged forty to eighty years
complain of occasional erectile difficulties; however, older men (ages sixty to sev-
enty years) are increasingly likely to report significant erectile problems. Only
Erectile Dysfunction Drugs 199
2 percent of men under the age of forty years report frequent erection difficulties.
Age has been shown to be associated with erectile dysfunction in both heterosex-
ual and sexual minority men.
Heather L. Armstrong
See also: Diagnostic and Statistical Manual of Mental Disorders (DSM); Erectile Dys-
function Drugs; Erection; Penis; Sexual Disorders, Male.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: Author.
Hart, T. A., Moskowitz, D., Cox, C., Li, X., Ostrow, D. G., Stall, R. D., … Plankey, M.
(2012). The cumulative effects of medication use, drug use, and smoking on erec-
tile dysfunction among men who have sex with men. Journal of Sexual Medicine,
9, 1106–1113.
Hirshfield, S., Chiasson, M. A., Wagmiller, R. L., Remien, R. H., Humberstone, M.,
Scheinmann, R., & Grov, C. (2010). Sexual dysfunction in an internet sample of
U.S. men who have sex with men. Journal of Sexual Medicine, 7, 3104–3114.
Ivanković, I., Šević, S., & Štulhofer, A. (2015). Distressing sexual difficulties in hetero-
sexual and non-heterosexual Croatian men: Assessing the role of minority stress.
Journal of Sex Research, 52(6), 647–658.
Laumann, E. O., Nicolosi, A., Glasser, D. B., Paik, A., Cingell, C., Moreira, E., & Wang,
T. (2005). Sexual problems among women and men aged 40–80 y: Prevalence and
correlated identified in the Global Study of Sexual Attitudes and Behaviors. Inter-
national Journal of Impotence Research, 17, 39–57.
Shindel, A. W., Vittinghoff, E., & Breyer, B. N. (2012). Erectile dysfunction and prema-
ture ejaculation in men who have sex with men. Journal of Sexual Medicine, 9,
576–584.
Erectile Dysfunction Drugs
Erectile dysfunction drugs (EDD) are prescription medications used to treat men
with erectile dysfunction (ED), the inability to obtain or maintain an erection.
This condition, also known as impotence, affects, to some extent, as many as
50 percent of men over age forty.
Erectile dysfunction can have any of several causes, including low levels of
testosterone, diseases affecting blood vessels, diabetes, pelvic injuries, and psy-
chological problems. Whatever the cause, the end result is that the penis is pre-
vented from growing hard and erect. For the penis to become erect, blood needs to
flow into, and fill, two sponge-like regions called corpora cavernosa, which run
the length of the penis.
Sildenafil citrate, one of the first and most common EDDs, works by relaxing
the smooth muscles that surround the blood vessels in the penis, thereby widening
the vessels and increasing blood flow into the corpora cavernosa. The drug is
taken in the form of a blue pill, preferably thirty minutes to one hour before sexual
activity, though it could remain effective as long as four hours. Dosage depends
on the precise diagnosis of the individual’s condition. The drug does not
200 Erection
automatically produce an erection. Some form of sexual stimulation must occur
for it to work, such as arousal prompted by a sex partner or by sexual images.
People with cardiovascular diseases who are using nitrate medications should
not use sildenafil citrate because the drug combination increases the risk of heart
attack and stroke during sexual activity. Consequently, the Food and Drug Admin-
istration (FDA) warns physicians to be cautious about prescribing sildenafil citrate
to men with heart disease or high blood pressure.
Some people using EDDs experience prolonged, painful erections called pria-
pism. Such erections can cause tissue damage to the penis, so medical attention is
needed if an erection lasts more than two hours. Sildenafil citrate has also been
linked to sudden vision loss in a small number of individuals. In such cases, the
drug causes an unintended increase in the flow of blood to the optic nerve. Other
adverse effects associated with EDDs include nausea, headache, dizziness, hear-
ing problems, sweating, swelling in hands or feet, and shortness of breath.
Sildenafil citrate was developed based on the work of several scientists, includ-
ing pharmacologists Robert F. Furchgott, Louis Joseph Ignarro, and Ferid Murad,
who shared the 1998 Nobel Prize in Physiology or Medicine for their research into
how a gas called nitric oxide causes muscle relaxation and blood vessel widening.
Clinical trials by pharmaceutical scientists indicated that sildenafil citrate was
effective in 70 percent of about 4,000 men in whom it was tested, leading to the
patent of their medication in 1996.
The FDA approved sildenafil citrate in March 1998. The drug soon became a
best-selling product, with 3.6 million prescriptions written in the first four months
of its availability. In 2005, the FDA approved a version of sildenafil to improve
exercise ability in adults with pulmonary arterial hypertension (high blood pres-
sure in the lungs).
Other EDDs used to treat patients with erectile dysfunction, all of which work
through mechanisms similar to those of sildenafil citrate, include tadalafil, varde-
nafil hydrochloride, and avanafil. The widespread use of these EDDs has had a
few surprising social effects. For example, they have been linked to an increase in
sexually transmitted infections among the residents of senior citizen facilities.
A. J. Smuskiewicz
See also: Arousal; Erectile Dysfunction; Erection; Male Sexuality; Penis; Priapism; Sex-
ual Disorders, Male; Sexual Dysfunction, Treatment of; Sexuality among Older Adults.
Further Reading
Loe, M. (2006). The rise of Viagra: How the little blue pill changed sex in America. New
York: New York University Press.
Morgentaler, A. (2003). The Viagra myth: The surprising impact on love and relation-
ships. San Francisco: Jossey-Bass/Wiley.
Erection
Erections occur in both penises and clitorises, although they work differently,
serve different functions, and look different. Penile erections are the result of a
complex internal system activated by erectile tissue, vascular (blood flow) and
Erection 201
cavernosal smooth muscle, brain function, complex nerve function, and neu-
rotransmitters. Similarly, the clitoris engorges and arouses but is distinguished in
that it does not become “hard” but rather full and swollen. While both penile and
clitoral erections indicate the presence of physical arousal, neither are necessary
for sexual pleasure, as pleasure is highly subjective.
The human penis is comprised of three cylindrical structures working in uni-
son, along with muscles, nerves, arteries, and veins. There are two corpora cav-
ernosa and one corpus spongiosum, which run the length of the penis. It is
helpful to remember that cavernosa are full of caverns, tiny holes that function
like cups that fill up with blood to enable the penis to engorge and create the
erection. The cavernosa are supported at the base of the penis by the penis’s
crura (legs), which reach deep inside the body. These in turn are further sup-
ported by the ischiocavernosus muscles that run underneath the bones of the
pelvis, which contract during an erection to keep the blood inside the penis. The
spongiosum is padded tissue that wraps around the urethra. It is made of squishy
tissue that swells to prevent restriction of the urethra during arousal. The ure-
thra is the tube where both urine and ejaculate leave the body, although it is rare
for urine to come out during an erection. The corpus spongiosum is surrounded
by the bulbospongiosus muscle. This muscle is responsible for increasing pres-
sure to sustain the erection as well as for contracting and providing the pulsing
sensation during ejaculation. This muscle may also be felt during urination
when squeezed to stop the flow of urine.
The three cylinders of the penis are bound together inside the skin by the tunica
albuginea (TA), which acts like a sock that wraps around them and tightens to help
keep the blood in during an erection. The TA is a dual-layered structure that wraps
both lengthwise and circularly around the cylinders. It is made of collagen fibers
to promote hardness and elastin to support flexibility.
Penile erections result from relaxation of cavernosal and vascular smooth mus-
cles, which leads to dilation of the arteries, which allows blood in, and vein com-
pression, which keeps the blood trapped inside. When the penis is flaccid, vascular
and cavernosal smooth muscles are in a contracted state.
The clitoris is a similar though not identical anatomical structure that also con-
tains erectile tissue. The clitoris is approximately four inches long and, like the
penis, consists of two joined corpora cavernosa reaching down within the body as
crura (legs). Each corpus cavernosum contains tiny blood vessels and is wrapped
by the tunica albuginea. The TA in the clitoris, however, is only a single layer,
unlike the dual structure found in the penis. As a result, there is no function for
trapping blood, which results in engorgement but not hardness. The vestibular
bulbs of the clitoris are analogous to the spongiosum in the penis except they are
separate from the urethra and the crura of the clitoris. The clitoral glans (or head)
is the part of the clitoris that protrudes from between the top of the inner labia of
the vulva and can be seen externally. However, unlike the penis, the majority of
the clitoris is internal and extends to deep within the body. Like the penis, the
crura are comprised of erectile tissue and are adjacent to the vagina and urethra.
Penile erections are often required for penetrative sex but not for receiving
pleasure. This means a penis may still enjoy touch whether erect or not. Likewise,
202 Erection
clitoral erections indicate the presence of genital arousal but alone are not an indi-
cation of sexual pleasure nor satisfaction. The only way for a person to know if
pleasure is happening is for them to talk about it with their partner(s).
Penile erections do not always happen on demand, and they are notoriously
unreliable. There is a misconception (especially in Western culture) that erections
occur readily and spontaneously, with no incentive, and that males are always
ready for sex. This is not true. While some people experience penile erections
without any sexual stimuli, others may have difficulty achieving or maintaining
an erection even in the presence of stimuli they find sexually arousing. This can
become more prominent with age.
Penile erection problems can stem from a variety of sources, including anxiety,
trauma and injury, poor dietary choices, poor general health, diabetes, aging, and
smoking, all of which can affect blood flow. Erectile dysfunction (ED) is a com-
mon experience estimated to affect 30 million people in the United States with up
to 52 percent of men aged forty to seventy years experiencing mild to complete
ED. The worldwide prevalence of ED is projected to increase to 322 million men
by the year 2025. While treatment for ED can include pharmacology (pills) and
psychosexual (talk therapy) treatment, often a simple change in routine can help if
there are no underlying physiological factors. Despite controversy in popular
media, there is no evidence that consumption of pornography alone is a direct
cause of ED. It is hypothesized that high-intensity, frequent masturbation may
reduce sexual incentive for partnered sex and potentially reduce the effectiveness
of traditional sexual incentives. In other words, a lot of masturbation may poten-
tially reduce a person’s level of sexual interest or desire, potentially making it less
likely they will get an erection on demand when they are with a partner. However,
it is hard to say what a “normal” amount of masturbation is because each person is
unique. Instead, highly frequent masturbation may become a behavioral choice
people can manage by accessing better-quality sex education and reflecting on
their sexual health values.
The same sexual function problems that cause erectile dysfunction in penises
can also cause problems in clitorises and vulvas, although they may manifest dif-
ferently. These include spinal cord injury or disease of the central or peripheral
nervous system, including diabetes and motor neuron disease.
Cyndi Darnell
See also: Arousal; Clitoris; Erectile Dysfunction; Erectile Dysfunction Drugs; Penis;
Sexual Dysfunction, Treatment of; Touching, Sexual Arousal and.
Further Reading
Berman, J. R., Berman, L. A., & Kanaly, K. A. (2003). Female sexual dysfunction: New
perspectives on anatomy, physiology, evaluation and treatment. EAU Update
Series, 1(3), 166–177.
Blechner, M. J. (2017). The clitoris: Anatomical and psychological issues. Studies in Gen-
der and Sexuality, 18(3), 190–200.
Braun-Harvey, D., & Vigorito, M. A. (2016). Treating out of control sexual behavior. New
York: Springer Publishing.
Darnell, C. (2019). The atlas of erotic anatomy and arousal. Retrieved from https://cyndi-
darnell.com/atlas-of-erotic-anatomy-arousal/
Erogenous Zones 203
Yuh, L., & Shindel, A. (2017). Anatomy of penile erection. In S. Minhas & J. Mulhall
(Eds.), Male sexual dysfunction: A clinical guide (22–29). Sacramento, CA:
Wiley-Blackwell.
Zaid, U. B., Zhang, X., & Lue, T. F. (2017). Physiology of penile erection. In S. Minhas &
J. Mulhall (Eds.), Male sexual dysfunction: A clinical guide (14–21). Sacramento,
CA: Wiley-Blackwell.
Erogenous Zones
Erogenous zones are areas of the body with concentrated nerve endings that are
highly sensitive to touch and, when stimulated through touch, allow an individual
to experience sexual arousal. Erogenous zones may be split into two categories:
nonspecific erogenous zones and specific erogenous zones. Nonspecific erogenous
zones contain the typical density of dermal nerves. These are areas of the body
that have “usual haired skin” such as the back and sides of the neck. Specific erog-
enous zones are found in mucocutaneous areas (where mucosa transitions to skin)
of the body, specifically the genitals, perineum (area between the anus and scro-
tum or vulva), lips, and nipples. In these areas, nerve concentrations are raised
higher in the dermis than in the typical haired skin mentioned above (Winkel-
mann, 1959). This nerve structure makes these areas extra sensitive to touch.
Sigmund Freud discussed erogenous zones when he theorized about the psy-
chosexual development of humans. He stated that children have specific eroge-
nous zones through which they seek and receive pleasure. During the “oral phase,”
children from birth to age 1.5 years are focused on their mouth to receive pleasure.
From age 1.5 years to age three years, children are focused on their anus during
their “anal stage.” During the “phallic stage,” which occurs between the ages of
four and five years, children focus on their genitals. From age five to puberty,
Freud believed children take a break from their sexual development to focus on
other areas of growth and, therefore, he believed that during this “latency stage,”
they do not focus on a specific erogenous zone. However, from puberty on, during
a stage called the “genital stage,” the focus of sexual pleasure returns to the geni-
tal erogenous zone.
A 2014 study conducted in Canada sought to understand how female bodies
reacted to various types of touch on various body parts. This study revealed that
not all areas of the body respond similarly to sensory experiences. Different areas
of the body were subjected to different sensory experiences: light touch, pres-
sure, and vibration. The data showed that the neck, forearm, and vaginal margin
were among the areas of the body most sensitive to light touching. The areola
was the area of the female body least sensitive to light touch. With regard to pres-
sure, the clitoris and nipples were most sensitive and the lateral breasts and abdo-
men were least sensitive to pressure. The clitoris and nipples were among the
most sensitive to vibration.
In a Finnish study in 2016, 704 volunteer participants were given pictures of
male and female bodies and were asked to indicate where on the male and female
bodies they would expect touch to elicit sexual arousal. Researchers collected this
data and created “erogenous zone maps” based on the body parts frequently
204 Erotophilia and Erotophobia
indicated by the participants as being sexually arousing when touched. While the
data showed that the entire body has the potential to be an erogenous zone, the
“hotspots” or most frequently indicated body parts consisted of the breasts, geni-
tals, and anus. On a whole, about 24 percent of the total body area was found to be
capable of producing sexual arousal when touched. After the “hotspots” men-
tioned above, the next most common areas to be indicated as erogenous zones
included the chest, neck, and mouth. Researchers were also surprised that the
back, thighs, and shins ranked highly despite the fact that these areas have low
tactile sensitivity.
Other results stemming from this study indicate that erogenous zones are per-
ceived differently depending on the type of sex being had. When discussing part-
nered sex, participants were more generous in the number of body parts they
considered to be erogenous zones. In partnered sex, the entire skin area could be
considered sensitive and arousing. However, in the context of masturbation, par-
ticipants were more selective in the body parts they considered erogenous zones,
focusing mostly on the breasts, genitals, and inner thighs.
Gender differences were also highlighted in this research. On the pictures of
female bodies, participants indicated a greater total area of erogenous zones than
on the pictures of male bodies. It is important to note that this data was driven by
participant perception and response.
Erogenous zones are frequently discussed in the media and popular culture.
However, there is not an overwhelming amount of research on erogenous zones. It
is agreed that erogenous zones are areas of the body that, when stimulated, lead to
sexual arousal. However, the specific body parts are up for discussion and are
often based on personal preference.
Amanda Manuel
See also: Arousal; Freud, Sigmund; Touching, Sexual Arousal and.
Further Reading
Cardeau, D., Belanger, M., Beaulieu-Prevost, D., & Courtois, F. (2014). The assessment of
sensory detection threshold on the perineum and breast compared with control
body sites. Journal of Sexual Medicine, 11(7), 1741–1748.
Freud, S., Strachey, J., & Richards, A. (1977). On sexuality: Three essays on the theory of
sexuality and other works. Harmondsworth: Penguin Books.
Nummenmaa, L., Suvilehto, J. T., Glerean, E., Santtila, P., & Hietanen, J. K. (2016).
Topography of human erogenous zones. Archives of Sexual Behavior, 45,
1207–1216.
Winkelmann, R. K. (1959). The erogenous zones: Their nerve supply and significance.
Mayo Clinic Proceedings, 34(2), 39–47.
Erotophilia and Erotophobia
Erotophilia and erotophobia have been involved in many aspects of psychology,
sex education, and even politics. Erotophobia can be described as an irrational
fear of anything sexual in nature and is something that can be clinically diag-
nosed. However, it is also seen as a personality trait, being on the far end of a
Erotophilia and Erotophobia 205
personality spectrum, opposite of erotophilia. Erotophilia refers to someone who
thinks of sex as a positive part of life, often having a positive attitude and positive
feelings toward sex. An erotophilic is not ashamed to discuss sex and sexuality
and believes sex is an essential part of a healthy relationship.
The words “erotophilia” and “erotophobia” come from the Greek god of erotic
love, Eros. “Eroto” means relating to eroticism, sexual arousal, or sexual excite-
ment, and “philia” means a love of a specified thing. This means that erotophilia
literally means a love of eroticism. A phobia, on the other hand, is an irrational
fear of something, so erotophobia is an irrational fear of eroticism.
Looking at erotophobia as a clinical phobia, it is the irrational fear of anything
pertaining to sex. “Erotophobia” is also an umbrella term that can include many
different, more specific phobias, such as a fear of nudity, a fear of sexual images,
a fear of sex education, a fear of sexual disclosure, and homophobia. The fear can
be related to other psychological problems, such as social anxiety or body dysmor-
phic disorder, or it can be very specific only to something related to sex. A person
with erotophobia can have a feeling of guilt about their own sexuality. Erotopho-
bia can have several causes or underlying factors, including sexual abuse, other
traumas, and religious beliefs. Symptoms of the phobia can vary from person to
person but typically include anxiety, dread, and panic when exposed to anything
that is sexual in nature. These symptoms and the phobia itself can be very debili-
tating, meaning that it can affect the person’s sex life, sexuality, and their daily life
in negative ways.
Although erotophobia is a clinical disorder, it is also seen in psychological
research as a personality trait that determines how someone responds to sexual
cues. A person can fall anywhere on the spectrum from erotophobia (negative
feelings or a fear of sexual cues) to erotophilia (positive feelings toward sexual
cues). In this sense, erotophobia is a more general aversion to sex rather than a
debilitating disorder. Erotophobes are less likely to talk about sex, and they have
more negative reactions to sexual material. They also tend to have more tradi-
tional sex roles, meaning that they may not experiment when it comes to sexual
activity or explore their sexuality. They also tend to have sex less, fewer sexual
partners, more sex guilt, and more negative feelings when it comes to masturba-
tion and homosexuality. In a general sense, erotophobic people are more tradi-
tional with sexuality and are not comfortable talking about, learning about, or
exploring their sexuality.
People on the opposite side of the spectrum are considered erotophilic and have
positive feelings toward sexual aspects of life. They are more likely to masturbate,
think about sex, and fantasize. They generally have sex for the first time earlier
than do erotophobes and have more sexual partners. They are more open to explor-
ing sexuality, less traditional, and more open to learning about sex and sexuality.
There are online tests that people can take to see where they fall on the spectrum
and if they are more erotophobic or erotophilic.
In addition to seeing how erotophilic and erotophobic people feel about sex and
sexuality, these personality measurements are also very helpful when it comes to
sexual health and relationships. For sexual health, these measurements are used to
see how sexually healthy people are. Research has found that erotophilic people
206 Erotophilia and Erotophobia
are more likely to protect against sexually transmitted infections, do breast self-
examinations, and go to regular gynecologist appointments. People who are com-
fortable talking about their sexuality and learning more about it are more likely to
use contraception. This openness to sexual aspects of life leads to having a safer
sex life and a better understanding of sexual health. Having a fear of sexuality and
a fear of learning more about how to engage in sex safely can be damaging to ero-
tophobic people. Although they have a fear of or negative feelings toward sexual
aspects of life, they are not asexual beings, meaning they still participate in sexual
intercourse, just not in the safest or most pleasurable ways. In addition to sexual
health, being an erotophobe may bring problems to relationship or marriage. Sex
is a very important aspect of many people’s relationships, so if one person has
very negative feelings toward sex while the other person doesn’t, this can cause a
disconnect in the sexual aspect of their relationship. This disconnect may not
allow for the couple to connect in other ways that are important to them, creating
significant problems for their relationship.
Finally, erotophobia has also been used by activists in the political world. These
antioppression activists use the word “erotophobia” to describe sex-negative atti-
tudes as a form of oppression. They believe that people who wish not to talk about
sex or engage in exploring their sexuality use their beliefs in a way that affects
how they feel about other people. The activists believe that being erotophobic puts
constraints on sexuality and that people use their erotophobic feelings to discrimi-
nate against those who are more open about their sexuality. Activists also believe
that erotophobia is a particularly damaging phobia, comparing it to racism, sex-
ism, homophobia, and other isms and phobias that are particularly relevant in our
society today. Some even believe that erotophobia is intertwined with social
inequality and politics, stating that overcoming the irrational fear of sexual aspects
of life is one of the first steps one can take toward a democratic society. Activists
are against erotophobia in general because they feel that this discomfort with sex
and sexuality makes the subjects taboo, meaning that society is taking a step in
the wrong direction. Activists wish for our society to become more open with sex
and sexuality as it is a normal part of life, but erotophobia gets in the way of
accomplishing that.
Casey T. Tobin
See also: Asexual; Communication, Sexual; Homophobia; Sex Guilt; Sexual Avoidance;
Sexual Health.
Further Reading
Balzarini, R. N., Shumlich, E., Kohut, T., & Campbell, L. (2018). Sexual attitudes, eroto-
phobia, and sociosexual orientation differ based on relationship orientation. Jour-
nal of Sex Research. Online ahead of print.
Fisher, W., White, L., Byrne, D., & Kelley, K. (2010). Erotophobia-erotophilia as a dimen-
sion of personality. Journal of Sex Research, 25, 123–151.
García-Vega, E., Rico, R., & Fernández, P. (2017). Sex, gender roles and sexual attitudes
in university students. Psicothema, 29(2), 178–183.
LeVay, S., Baldwin, J., & Baldwin, J. (2018). Discovering human sexuality (4th ed.). Sun-
derland, MA: Sinauer Associates.
Essure Coil 207
Essure Coil
The Essure coil was a permanent female birth control procedure and was touted as
a nonsurgical alternative to tubal ligation. The procedure was approved by the
Food and Drug Administration (FDA) in 2002 and was reported to be about
99 percent effective, with statistics showing that fewer than one out of one hundred
women who have undergone successful Essure implantation procedures experi-
ence an unplanned pregnancy. Approximately 750,000 women around the world
have been fitted with Essure coils. However, because of growing reports of serious
adverse side effects, the production and use of Essure coils was stopped in 2018.
The Essure procedure involved inserting small, flexible metal and fiber coils
inside the fallopian tubes, which carry the egg from the ovaries to the uterus. The
coils were inserted through the natural openings in the vagina and cervix, so no
surgical incision was required. Once the coils were in place, scar tissue began to
build up around them. After a period of approximately three months, the tissue
buildup created a barrier that blocked any sperm from reaching an egg, thus pre-
venting conception. As the procedure was not surgical, it typically required a one-
hour outpatient visit to a clinic, followed by one to two days of decreased physical
activity. X-rays were taken at a follow-up appointment at three months to deter-
mine whether or not enough scarring had occurred to create a viable barrier. Until
this barrier was fully formed, people were advised to use additional forms of birth
control to prevent unwanted pregnancies.
Although the Essure procedure was considered to be a highly effective means
of birth control, it was not without risk. If an accidental pregnancy occurred after
receiving the Essure coil, it was more likely to be an ectopic pregnancy, meaning
it had implanted somewhere outside the uterus (usually within the fallopian tube
itself). Additional risks involved with the procedure include infection, rash or
other allergic reaction to the nickel-titanium alloy in the coils, pain in the pelvic
region, bleeding or spotting, perforations in the uterus or fallopian tube due to
insertion of the coils, or only partial tubal blockage some six months or more after
the procedure has taken place. In addition, Essure does not provide protection
against sexually transmitted infections.
Although considered a permanent form of birth control, the Essure coil proce-
dure is reversible and, once removed, should not prevent future planned
pregnancies.
In recent years, complaints against Essure surged, with the FDA fielding some
five hundred reports of “adverse events” related to the contraception device in
2013 alone. Because of the growing number of complaints, and product recalls and
suspensions, the manufacturer of the Essure coil stopped producing and selling
them in 2018.
Tamar Burris
See also: Contraception; Fallopian Tubes; Sterilization; Tubal Ligation.
Further Reading
Bullough, V. L. (2001). Encyclopedia of birth control. Santa Barbara, CA: ABC-CLIO.
Zorea, A. W. (2012). Birth control. Westport, CT: Greenwood.
208 Estrogen
Estrogen
Estrogens are the primary female sex hormones. They are produced in the ovaries,
fat cells, and adrenal glands. Estrogens are essential for reproductive development
and regulate the menstrual cycle. They are also produced synthetically for use in
birth control medications and hormone replacement therapy.
In the female body, estrogens are instrumental in the onset of puberty and the
development of secondary sex traits. These hormones are also important for
proper functioning of the reproductive system, playing a role in triggering ovula-
tion and preparing the uterus for implantation of a fertilized egg, which will
develop into a fetus. During pregnancy, estrogen levels remain high and work
with the hormone progesterone to stop ovulation. Natural estrogens are also essen-
tial for bone formation and condition, working with vitamin D and calcium to
rebuild bone tissue. Postmenopausal women have significantly lower levels of
estrogen, leading to bone tissue being broken down more than being built up,
causing women to be more at risk of osteoporosis, a condition in which bones are
weak and brittle and break easily. Johns Hopkins Medicine reports that estrogen
also helps maintain the body’s ability to clot blood and affects the condition of
one’s skin, hair, mucus membranes, and pelvic muscles. The hormone may also
affect brain cells, with some studies finding that postmenopausal women with low
estrogen levels have reduced memory and depressed mood.
Estrogens produced synthetically are a key component in oral birth control
medicines. The synthetic hormones are identical to the ones produced in the
human body and are made in the laboratory from the plant chemicals of yams and
soybeans. The hormones work to keep estrogen levels high, essentially “tricking”
the body into thinking it is pregnant and thereby preventing ovulation from
occurring.
Hormone replacement therapy is also a major use of synthetic estrogens.
Although most often used to relieve uncomfortable symptoms during and after
menopause, they are also prescribed to younger women who do not produce
enough estrogen in the body, which causes problems with the reproductive pro-
cess. It is also given to adolescent girls who need higher estrogen levels in order to
induce puberty. Estrogen therapy may also be used by trans women during their
gender transition process.
Despite the benefits of estrogen replacement, research has shown that taking
synthetic estrogen in this form for a prolonged period can pose serious health
risks. Similar risk factors exist for those who take oral contraceptives over a long
period. Estrogen causes an increased risk of endometrial cancer, ovarian cancer,
and breast cancer and may also cause gallbladder disease. According to the
National Institute of Health, people who took estrogen, especially along with pro-
gestin (synthetic progesterone), suffered a greater incidence of heart attack, stroke,
blood clots in the lungs or legs, and dementia. For this reason, women should use
estrogen hormone therapy only for short periods and at the lowest dose possible
that will control symptoms. In addition, alternative forms of birth control may be
recommended for those who find such risks undesirable.
Christina Girod
Evolutionary Perspectives on Gender and Sexual Behavior 209
See also: Birth Control Pills, Estrogen-Progestin; Hormone Replacement Therapy; Pro-
gesterone; Puberty; Sex Hormones; Synthetic Hormones.
Further Reading
Lark, S. M. (2004). The estrogen decision: Self-help book. Berkeley, CA: Celestial Arts
Publishing.
Watkins, E. S. (2007). The estrogen elixir: A history of hormone replacement therapy in
America. Baltimore: Johns Hopkins University Press.
Evolutionary Perspectives on Gender and Sexual Behavior
Evolutionary theory is often associated with the phrase “survival of the fittest.”
According to evolutionary theory, environments are constantly changing, and
those animals that are best able to adapt to their environment are the ones most
likely to survive and reproduce. In this way, reproduction becomes the key com-
ponent; at the heart of it, evolutionary theory is concerned with the transfer of
useful (adaptive) genetic traits by parents to their offspring.
Because evolutionary theory is so biologically based, it may seem odd to con-
sider the implications for social behavior. However, evolution does affect and has
affected how animals, including humans, behave in social contexts, and an entire
branch of science, called sociobiology, is devoted to its study. Sociobiology can be
used to help explain and understand a wide variety of human behaviors, including
gender roles and sexual behavior.
Gender roles are the socially constructed ways that people are expected to
behave in any given context within a specified culture. For example, men are typi-
cally expected to be more physical and aggressive, while women are generally
seen as being more emotional. Traditionally, men have been expected to be the
providers for their families, while women have been expected to assume a care-
taking role, often staying home from work, or ceasing to work outside the home
entirely, in order to care for children. While these expectations have been shifting
in recent years, their influence is still felt.
In dating and sex, many heterosexual people still believe that men should be the
initiator—asking and then paying for a first date, leaning in for the first kiss, and
initiating sexual contact. Women, on the other hand, are often encouraged to be
more passive and let the guy “take the lead.” Many people also believe that women
should be more sexually conservative than men, and women who break this expec-
tation may be shamed, both publicly and personally. Gender roles also influence
what people find attractive. In general, tall, muscular, socially dominant, and
successful men are seen as attractive, while attractiveness in women is often
determined by slimness and breast size as well as a pleasing demeanor.
Even though gender roles are socially prescribed, male and female gender roles
have been influenced by evolution because of the different roles that men and
women play in reproduction and the subsequent strategies they have developed
because of these differences. Biologically speaking, men play only a minor role in
reproduction; they produce the necessary sperm and mate with a woman who may
then become pregnant. Their contribution could last only a few minutes. Women,
210 Evolutionary Perspectives on Gender and Sexual Behavior
on the other hand, are the ones who become pregnant, and this nine-month com-
mitment is only the beginning. Once the baby is born, the infant is entirely depen-
dent on the mother for sustenance until weaned. In many cases, the mother remains
the primary caregiver throughout the offspring’s childhood. This difference in
parental investment has been proposed as one of the primary reasons that people
have evolved to have the gender roles they do.
In addition, because of these differences in required parental investment, evolu-
tionary theorists have proposed that heterosexual men and women have developed
different sexual strategies to deal with short-term and long-term mating situations.
For men, because their parental investment is minimal, it may be in their best evo-
lutionary interest to mate with numerous women in short-term scenarios in order to
produce more offspring to carry their genetic material into the next generation.
What this means is that men may be evolutionarily predisposed to prefer having
many sexual partners and to be more inclined to engage in casual sex relationships
such as one-night stands. For women, however, because of their longer parental
investment, there is limited benefit to engage in short-term sexual relationships
with partners who will not be around to help care for any children that should
result. Therefore, it may be more evolutionary advantageous for women to find a
mate that is willing to make a long-term, monogamous commitment to provide
care and resources to the family to ensure the success of their children. Following
this logic, it should also be more advantageous for women to be more sexually
selective than men, and therefore have fewer sexual partners, since the potential
pregnancy is theoretically more costly. If these differences are truly grounded in
our evolutionary past, we would expect to find them in most cultures all over the
world. David Schmitt (2003) sought to explore this assumption in a survey of
16,288 people from fifty-two nations on six continents; as expected, he found
universal differences in the sexual strategies of men and women, suggesting that at
least in part, human sexual behavior has evolutionary roots.
Evolutionary strategies also influence what people look for in a partner. Hetero-
sexual men are more likely to seek youthful, physically attractive partners since
youth and health are signals of high fertility. Heterosexual women, on the other
hand, may be more attracted to older, well-established, and successful men who
are able to provide them with the necessary resources for raising healthy children.
Support for these “universally attractive” characteristics has also been found
across numerous studies in varied cultures.
Ultimately, people are influenced by many factors, and no one theory can
account for everything. In addition to evolutionary forces, people’s attitudes
toward gender roles, both personally and in a general sense, are influenced by
family values, peer norms, social and cultural expectations, religious beliefs, and
past experiences. Therefore, evolution is just one piece in the puzzle when it comes
to explaining why people behave the way they do, especially when it comes to
gender and sexuality.
Heather L. Armstrong
See also: Casual Sex; Gender Roles, Socialization and; Monogamy; Physical Attractive-
ness; Sexual Dimorphism; Stereotypes, Gender; Stereotypes, Sexual.
Exhibitionism 211
Further Reading
Buss, D. M. (1999). Evolutionary psychology: The new science of the mind. Boston: Allyn
& Bacon.
Buss, D. M. (2003). The evolution of desire: Strategies of human mating (Rev. ed.). New
York: Basic Books.
Buss, D. M., & Schmitt, D. P. (1993). Sexual strategies theory: An evolutionary perspec-
tive on human mating. Psychological Review, 100, 204–232.
Gangestad, S. W., & Simpson, J. A. (2000). The evolution of human mating: Trade-offs
and strategic pluralism. Behavioral and Brain Sciences, 23, 573–644.
Schmitt, D. P. (2003). Universal sex differences in the desire for sexual variety: Tests
from 52 nations, 6 continents, and 13 islands. Journal of Personality and Social
Psychology, 85, 85–104. doi: 10.1037/0022-3514.85.1.85
Trivers, R. L. (1972). Parental investment and sexual selection. In B. Campbell (Ed.),
Sexual selection and the descent of man 1871–1971 (136–179). Chicago: Aldine
Press.
Exhibitionism
Exhibitionism is considered a paraphilia and is characterized by sexual excite-
ment experienced through genital or sexual exposure, usually to an unsuspecting,
and therefore nonconsenting, person, usually a stranger. Some exhibitionists may
also experience a strong desire to be observed by others during sexual activity.
Exhibitionistic disorder is a paraphilic disorder. Exhibitionistic disorder is classi-
fied by the Diagnostic and Statistical Manual of Mental Disorders. In order for a
diagnosis to be made, the person must experience ongoing and intense sexually
arousing fantasies, urges, or sexual behaviors that involve exposing the genitals to
an unsuspecting person, and the person has to have acted on these sexual urges
with a nonconsenting person, or they must experience significant distress or dif-
ficulty in the workplace or in other social situations.
Exhibitionism involving unsuspecting, nonconsenting individuals is a sexual
crime and is punishable by jail. Prevalence of exhibitionistic disorder is not
known, although it is estimated to affect 2–4 percent of males; it is less common
among females although the exact prevalence is unknown. Perpetrators of exhibi-
tionism will often masturbate as part of their exposure to others. Many people
who engage in this behavior are never arrested either due to lack of reporting or
the ability to escape quickly before police arrive. While it is a noncontact sexual
crime, it may still have a psychological impact on victims, who often feel
violated.
Individuals who engage in exhibitionism may have difficulty controlling their
impulses. Exhibitionism, when it involves an unsuspecting other, may be a threat-
ening act as it displays a power dynamic where the perpetrator exercises control
over another by shocking them. The motivation behind exposing the genitals may
be to entice a potential sexual partner, or it may be to elicit a reaction from the
unsuspecting victim. Looks of shock, disgust, and fear are often the desired reac-
tions and may allow the exhibitionist to feel sexual arousal and pleasure. In
212 Extramarital Sex
interviews, some exhibitionists have reported feeling very disappointed if they do
not elicit the reaction of fear, disgust, or shock, as this is desired for them to feel
better emotionally and sexually.
Most exhibitionists feel a tremendous amount of guilt and shame after exposing
themselves to unsuspecting others, and they often report feeling out of control.
Many report they feel they are suffering by having to deal with this impulse-
control issue and the emotional aftermath of exposing themselves.
Many exhibitionists start to display this behavior during adolescence; however,
the causes of exhibitionism are not known. People with exhibitionistic disorder
are also more likely to have other psychological problems. Among a nonclinical
population sample, exhibitionism has been found to be associated with psycho-
logical problems, substance use, and sexual risk taking or novelty seeking.
Some people may seek treatment for exhibitionism on their own as they experi-
ence shame and distress as a result of this behavior. Others may be required to
attend treatment due to arrest. Group therapy is a very common form of treatment
for exhibitionism; individual therapy is also an option. In any therapy, the goal is
for the patient or client to learn distress tolerance skills and behavioral and impulse
control and then to implement them when confronted with emotions that would
trigger an urge to engage in exhibitionism. During the process, the patient gains
insight into their behavior and their motivation to engage in exhibitionism.
Amanda Manuel
See also: Diagnostic and Statistical Manual of Mental Disorders (DSM); Paraphilias;
Sexual Consent; Voyeurism.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.) Washington, DC: Author.
Balon, R. (2016). Exhibitionistic disorder. In R. Balon (Ed.), Practical guide to paraphilic
disorders (77–91). New York: Springer.
Hayes, R. M., & Dragiewicz, M. (2018). Unsolicited dick pics: Erotica, exhibitionism or
entitlement? Women’s Studies International Forum, 71, 114–120.
Långström, N., & Seto, M. C. (2006). Exhibitionistic and voyeuristic behavior in a Swed-
ish national population survey. Archives of Sexual Behavior, 35(4), 427–435.
Piemont, L. (2007). Fear of the empty self: The motivations for genital exhibitionism.
Modern Psychoanalysis, 32(1), 79–93.
Swindell, S., Stroebel, S. S., O’Keefe, S. L., Beard, K. W., Robinett, S. S., & Kommor, M. J.
(2011). Correlates of exhibitionism-like experiences in childhood and adolescence:
A model for development of exhibitionism in heterosexual males. Sexual Addic-
tions & Compulsivity, 18, 135–156.
Yarber, W., Sayad, B., & Strong, B. (2010). Variations in sexual behavior. In Human sexu-
ality diversity in contemporary America (7th ed.). New York: McGraw-Hill.
Extramarital Sex
Extramarital sex (EMS) occurs when either one or both partners of a marriage
engage in sexual acts with a person or people other than their spouse. The sce-
narios for what EMS looks like are widely varied and unique to every couple’s
Extramarital Sex 213
understanding of their relational boundaries. EMS can be described in terms of
behaviors that range from sexual intercourse to flirting. Other perspectives detail
who is having EMS with whom, how often, and for what purpose. Finally, EMS
within the context of the marriage can be permissive, tolerated, nonpermissive,
and even punishable depending on the laws of the geographic location.
Permissive EMS, also known as consensual nonmonogamy, is when both part-
ners agree that one or both are able to engage in sexual activities with people
outside the marriage. This consensual arrangement can take many forms, such as
an open marriage, swinging, or polyamory. In an open marriage, spouses remain
committed to each other while allowing romantic or sexual relationships with out-
side partners. In polyamory, the individual(s) may have multiple romantic partner-
ships with all parties having an awareness of the others. Swinging is when the
couple, either individually or together, engages in some form of sexual activity
with other people. With each type of relationship or lifestyle, the couple usually
creates boundaries and rules for communication, sexual behaviors, and emotional
attachments.
Adultery and infidelity are often associated with nonpermissive EMS. Adultery
addresses the legal aspect of having sex with someone who is not your spouse and
is often cited as grounds for divorce. As marriage is a legally binding contract,
adultery can have legal ramifications in many states. For example, in Massachu-
setts, an adulterer can be incarcerated for up to three years and have a fine up to
$500. Infidelity is concerned with the breaking of the marital vows, or the promise
to not have sex outside of the marriage. While many marriages in the United
States are built on monogamy (having only one romantic or sexual partner),
34 percent of men and 24 percent of women report having engaged in extramarital
sexual activities.
Though the descriptor “extramarital sex” has only been discussed in the con-
text of marriage, the sentiment of the act, permissive or not, also applies to com-
mitted couples who are not legally bound. In these cases, it may be referred to as
“extradyadic sex,” or sex outside of the couple.
Darci Shinn
See also: Adultery; Cheating and Infidelity; Monogamy; Open Marriage; Polyamory;
Swinging.
Further Reading
Edwards, J. N. (1973). Extramarital involvement: Fact and theory. Journal of Sex
Research, 9, 210–224.
Hertlein, K. M., Weeks, G. R., & Gambescia, N. (2008). Systemic sex therapy. New York:
Routledge.
Rhode, D. L. (2016). Adultery: Infidelity and the law. Cambridge, MA: Harvard Univer-
sity Press.
Tafoya, M. A., & Spitzberg, B. H. (2007). The dark side of infidelity: Its nature, preva-
lence, and communicative functions. In B. H. Spitzberg & W. R. Cupach (Eds.),
The dark side of interpersonal communication (2nd ed., 201–242). Mahwah, NJ:
Lawrence Erlbaum Associates.
Thompson, A. P. (1983). Extramarital sex: A review of the research literature. Journal of
Sex Research, 19(1), 1–22.
F
Fallopian Tubes
The fallopian tubes, also called oviducts, are a pair of four-inch-long trumpet-
shaped tubes located on each side of the uterus that connect the ovaries to the
uterus. They are responsible for the transportation of a mature ovum, or egg, from
the ovaries to the uterus. Each tube contains hairlike projections called cilia,
which propel the ovum forward toward the uterus. The fallopian tubes are also the
site where fertilization takes place when an ovum meets with sperm.
The fallopian tubes consist of four parts, including the isthmus, ampulla, infun-
dibulum, and fimbriae. Beginning at the end of the tubes that attach to the uterus,
the isthmus is the thick, walled region that constitutes the narrowest portion. The
tubes expand into the ampulla, which makes up the largest section of the tubes, to
extend beyond the isthmus and curve around to connect to the bell-shaped infun-
dibulum. At the end of the infundibulum are the fimbriae, which are the fingerlike
projections that surround the ovary to be in position to receive ova when released.
Triggered by the release of estrogen from the ovaries, the smooth muscle of the
fimbriae begins a series of contractions to move the ovum into the fallopian tubes.
Once the ovum has reached the inside of the infundibulum, the wavelike motions
of the cilia create a current to keep the ovum moving along through the ampulla
and isthmus toward the uterus. The process of ovulation typically takes three days
as the ovum moves from ovary to the uterus. Fertilization usually takes place in
the ampulla about twelve to twenty-four hours after the ovum is released.
There are several conditions that can damage the fallopian tubes, often result-
ing in scar tissue that interrupts ovulation and keeps the cilia from being able to
transport an ovum or embryo to the uterus. These conditions can include pelvic
inflammatory disease, endometriosis, uterine fibroids, and ectopic pregnancies, a
pregnancy when implantation of the embryo occurs in the fallopian tube. Tubal
blockage is a common symptom of these diseases where the fallopian tubes are
blocked by various abnormal tissues. Depending on the location and the extent of
the blockage, surgical removal of these tissues may be possible. Most surgical
procedures involve the removal of the unhealthy tissue and fusion of the two
healthy ends of the tubes to repair and re-create an unblocked tube. The success
rates vary, and the likelihood of an ectopic pregnancy increases.
The fallopian tubes can be permanently blocked or cut through with various steril-
ization procedures if an individual decides they do not want children. The cutting,
blocking, or tying of the tubes is called tubal ligation. Tubes can be cut, a small piece
can be removed, or instruments such as clips, rings, or clamps can be applied. Although
intended to be permanent, the ligation procedure can be reversed in some cases.
Lauren Wesley
216 Family Planning Clinics
See also: Conception; Endometriosis; Essure Coil; Ovaries; Pelvic Inflammatory Disease
(PID); Tubal Ligation; Uterus.
Further Reading
Barclay, T. (2018). Fallopian tube. Retrieved from http://www.innerbody.com/image
_repfov/repo03-new.html#full-description
Healthline. (2015). Uterine tube (fallopian tube). Retrieved from http://www.healthline
.com/human-body-maps/fallopian-tubes
Planned Parenthood. (2019). Sterilization. Retrieved from https://www.plannedparenthood
.org/learn/birth-control/sterilization
Rebar, R. W. (2019). Problems with the fallopian tubes and abnormalities in the pelvis.
Retrieved from https://www.msdmanuals.com/en-gb/home/women-s-health
-issues/infertility/problems-with-the-fallopian-tubes-and-abnormalities-in-the-pelvis
Family Planning Clinics
Family planning clinics are medical clinics that help people control the number of
children that they have as well as the timing of pregnancies. At full-service clin-
ics, people can obtain counseling services, birth control pills and other contracep-
tive methods, sterilization surgery, treatment for infertility, and abortions. Some
clinics do not offer all such services, but they can refer patients to other clinics or
health care providers. The services provided at family planning clinics, depending
on the type of clinic and the patient’s particular case, may be paid for by the
patients themselves, by insurance companies, or by government programs, such
as Medicaid in the United States.
Some family planning clinics offer other health care services in addition to
family planning. These services may include screenings for breast and cervical
cancer, testing for HIV and other sexually transmitted infections, counseling
regarding menopause, advice on adoption, and general checkups and physical
examinations. Many women use family planning clinics as their regular source of
health care. Although most family planning services are designed for women,
clinics also usually offer limited services for men, such as infertility treatment.
Family planning can have several benefits for women, their families, and soci-
ety at large. Wise family planning can help people achieve or maintain their eco-
nomic and social autonomy and independence. It can protect the health of
adolescents and older women whose youth or advanced age puts them and their
pregnancies at risk for problems or neonatal complications. Pregnancy prevention
options, like contraception, avoids the need for abortion.
Preventing unintended pregnancies can save society money by avoiding the
need for social services to raise children whose parents are unable to care for
them. Because many single adolescent mothers drop out of school to raise their
children, preventing those pregnancies would allow these individuals to stay in
school and eventually get better jobs, which benefits the economy in the long term.
Family planning can further benefit society by slowing population growth.
According to the U.S. Department of Health and Human Services, publicly
funded—that is, government-funded—family planning clinics in the United
States prevent about 1.94 million unintended pregnancies each year, including
Family Planning Clinics 217
400,000 teen pregnancies. These numbers do not include the hundreds of thou-
sands of unintended pregnancies prevented by services obtained in private
clinics.
African American and Hispanic women are less likely to have access to family
planning services than white women. Other population segments that are less
likely to have access to family planning are people with low incomes, without a
high school diploma, and with a cohabiting relationship (as opposed to a married
relationship). These people may not be able to afford the services because of a lack
of health insurance or an inability to get public assistance; because clinic locations
and hours are not convenient; or because they may not be aware of the services.
The services of family planning clinics have led to increased contraception use
in many regions of the world, including developing countries, though the rate of
contraception use remains low in sub-Saharan Africa. Throughout the world,
modern contraception methods are used by approximately 57 percent of women
aged fifteen to forty-nine. In Asia, this rate increased from 60.9 percent in 2008 to
61.9 percent in 2014. In Latin America, the rate rose from 66.7 percent in 2008 to
67.0 percent in 2014. During this period in Africa, the rate rose from 23.6 percent
to 27.6 percent.
According to the World Health Organization (WHO), an estimated 225 million
women in developing countries would like to delay or stop their pregnancies but
do not have the means to do so. In those poor nations, WHO family planning
advocates are working to increase access to a variety of contraception methods, to
educate the public about contraception benefits, and to remove the cultural stig-
mas associated with birth control. However, certain segments of developing
nations’ populations have especially severe unmet family planning needs, includ-
ing refugees from wars, migrants, urban slum dwellers, and adolescents.
Family planning clinics are often at the center of the abortion controversy—the
debate over whether a woman has the right to terminate an unwanted pregnancy
and, if so, under what conditions. In the United States, abortion during the first
trimester (first three months) of pregnancy has been legal under any condition
since the Supreme Court’s Roe v. Wade ruling in 1973. Also, according to that rul-
ing, individual states can regulate abortion as they deem appropriate beginning in
the second trimester.
Despite the established legal right to have an abortion, various “pro-life” (or
anti-abortion) groups that oppose abortion for religious or other reasons do not
recognize this right. Some of these groups post members outside family planning
clinics to try to prevent people from entering the clinics. Some of the more radical
antiabortion groups have even vandalized, bombed, or set fire to clinics, and oth-
ers have resorted to assassinating doctors or other people who work in the clinics.
In response to such terrorist-like acts, as well as to various restrictions placed on
abortions by some state governments, “pro-choice” groups have increased their
efforts to defend the right to have abortions at safe medical clinics.
One of the largest operators of family planning clinics is an organization called
Planned Parenthood Federation of America (PPFA), headquartered in New York
City. This group operates clinics in some one thousand communities throughout
the United States. It also helps to support family planning programs in other
218 Fantasy, Sexual and Erotic
countries. PPFA’s work—including providing abortions at some of its centers and
dispending birth control advice to adolescents—is opposed by some.
A. J. Smuskiewicz
See also: Abortion, Elective; Abortion Legislation; Contraception; Fertility; Infertility;
Planned Parenthood; Roe v. Wade; Sterilization; Teen Pregnancy.
Further Reading
Planned Parenthood Federation of America. (2019). Home page. Retrieved from http://
www.plannedparenthood.org
World Health Organization. (2018). Family planning: A global handbook for providers, 2018
edition. Geneva: WHO. Retrieved from https://www.who.int/reproductivehealth/
publications/fp-global-handbook/en/
Fantasy, Sexual and Erotic
Sexual fantasies, defined as mental images that a person finds to be sexually
arousing, are one of the most common forms of sexual expression. In fact, most
people, of all sexual orientations and gender identities, say they have fantasized
before. Fantasy content is derived from many sources and varies widely from one
person to the next, although there are some predictable gender differences in the
nature of people’s fantasies. Once thought to be revealing of psychopathology,
fantasies are now typically viewed as a normal and healthy part of one’s
sexuality.
Put simply, a sexual fantasy is a conscious thought that turns one on. The “con-
scious” aspect is an essential element here because it distinguishes a sex fantasy
from a sex dream. Within a fantasy, there is conscious control over the content and
direction of the narrative, unlike in dreams. Studies have consistently found that
almost everyone has sexual fantasies. In fact, most have reported prevalence rates
of greater than 90 percent. However, men are more likely to report having sex
fantasies, and they report having them more often than women.
Fantasies can occur at any time of day. For instance, people may fantasize while
they are at work, exercising, watching television, engaged in conversation, or even
at religious services. However, it is not uncommon for fantasies to coincide with
sexual activity. Most people say that they have previously fantasized during both
masturbation and sexual intercourse.
Given the range of settings in which fantasies can occur, it is clear that fantasies
are designed to serve multiple purposes. For instance, fantasies are sometimes
nothing more than a mental distraction or a way of relieving boredom. Other
times, fantasies are used to plan out a future sexual event. And yet other times,
fantasies might be called on during sex to enhance or maintain arousal, or perhaps
to compensate for a less-than-satisfying sexual experience.
Fantasy content is incredibly varied and idiosyncratic. This means that one per-
son’s fantasies may bear no resemblance to another’s. Further, a given fantasy
theme might lead some people to experience sexual arousal, while others might
respond to the same thought with disgust or revulsion.
Fantasy, Sexual and Erotic 219
The content of sexual fantasies is derived from multiple sources. For instance,
some fantasies are inspired by past sexual events (e.g., reliving one’s first or favor-
ite sexual experience), while others may be inspired by pornography or other
forms of media. However, while some fantasies may indeed have their roots in
sexual histories, the origin of sexual fantasies is actually far more complex. Fanta-
sies are a unique product of individual psychology (including our personality,
attachment style, and learned experiences), culture, and evolutionary history.
Survey research on sexual fantasy has revealed that the most popular themes
revolve around novelty (e.g., trying a new sexual position or having sex in a new
and exciting location, such as on a beach or under a waterfall), love and romance,
sex with someone other than one’s current partner (e.g., celebrities, acquaintances,
strangers), sex with multiple partners, as well as dominance and submission.
Fantasies about so-called paraphilic (i.e., unusual or uncommon) sexual inter-
ests were once thought to be rare but are actually more popular than previously
believed. For instance, a large number of men and women fantasize about things
like voyeurism (i.e., watching other people have sex) and sadomasochism (i.e.,
deriving sexual pleasure from giving or receiving pain). Research suggests that
very few fantasies are statistically rare. These include fantasies about sex with
animals (zoophilia) and sex with prepubescent children (pedophilia).
There are several important differences between men and women when it
comes to the nature of their sexual fantasies. For one thing, men’s fantasies tend to
be more sexually explicit and are more likely to involve themes of group sex (e.g.,
threesomes, orgies) compared to women’s. In addition, whereas men are more
likely to fantasize about dominance, women are more likely to fantasize about
submission. Finally, women’s fantasies are more likely to contain emotional and
romantic imagery than are men’s.
Few differences in fantasy content have been noted based on sexual orientation.
The primary difference for gay and lesbian persons compared to heterosexuals is
the gender of the person(s) about whom they are fantasizing. Interestingly, studies
suggest that most asexual persons have sexual fantasies too; however, research has
not yet systematically explored how the content of asexuals’ fantasies compares to
persons of other sexual orientations.
Historically, sexual fantasies were viewed as problematic, a view attributable to
none other than Sigmund Freud, who famously argued that happy people do not
fantasize and that sexual fantasies tend to reflect unresolved psychological issues.
Today, however, psychologists have largely rejected this Freudian notion and
believe that sexual fantasies are part of a healthy sex life. Indeed, research has
found that the people who have the most sexual fantasies tend to be the most sexu-
ally satisfied.
That said, specific kinds of fantasies can be problematic, such as when people
fantasize about nonconsensual sexual activities (e.g., sex with children or noncon-
senting adults). Persistent fantasies about activities that pose a serious risk of harm
to others may warrant treatment to the extent that they become personally dis-
tressing or one feels a strong urge to act on them.
Justin J. Lehmiller
220 Fausto-Sterling, Anne
See also: Arousal; Desire; Freud, Sigmund; Masturbation; Paraphilias.
Further Reading
Kahr, B. (2008). Who’s been sleeping in your head?: The secret world of sexual fantasies.
New York: Basic Books.
Joyal, C. C., Cossette, A., & Lapierre, V. (2015). What exactly is an unusual sexual fan-
tasy? The Journal of Sexual Medicine, 12, 328–340.
Lehmiller, J. J. (2018). Tell me what you want: The science of sexual desire and how it can
help you improve your sex life. Boston: Da Capo Lifelong Books.
Leitenberg, H., & Henning, K. (1995). Sexual fantasy. Psychological Bulletin, 117,
469–496.
Wilson, G. D. (2010). Measurement of sex fantasy. Sexual and Relationship Therapy, 25,
57–67.
Zurbriggen, E. L., & Yost, M. R. (2004). Power, desire, and pleasure in sexual fantasies.
Journal of Sex Research, 41, 288–300.
Fausto-Sterling, Anne
Anne Fausto-Sterling (1944–) is a scientist, researcher, and professor of biology
and gender studies at Brown University in Providence, Rhode Island. She is well
known for her research on sex, gender roles, gender identity, sexuality, intersexu-
ality, and other topics in the field of sexology. Fausto-Sterling has a bachelor’s
degree in zoology from the University of Wisconsin (1965) and a PhD in develop-
mental genetics from Brown University (1970). While she has many publications
in peer-reviewed journals, her most well-known writings are two of her earlier
books: Myths of Gender: Biological Theories about Women and Men (1992, sec-
ond edition) and Sexing the Body: Gender Politics and the Construction of Sexu-
ality (2000), as well as the article “The Five Sexes,” which appeared in The
Sciences, a peer-reviewed academic journal (1993). She has dozens of other aca-
demic publications and has given lectures around the world on topics regarding
sex, gender, intersexuality, and nature versus nurture. Her current work utilizes
dynamic systems theory to better understand how difference from a cultural per-
spective becomes bodily difference.
In approaching the fields of sexology and feminist and gender studies from a
biological perspective, Fausto-Sterling delved into the constructs of sex and gen-
der and focused on how much of these concepts are biological imperative and how
much are socially constructed. Moreover, her work suggests that there are more
than two biological sexes (commonly identified as only male and female) and that
society is doing a disservice to individuals by not recognizing the more biologi-
cally diverse variation of sexes that are present in humans. She feels doctors and
other medical professionals may be unethical in their practices of assigning a sex
to intersex infants only a few hours after birth without more information about
how those children may identify their gender in the future. An advocate for better
understanding of intersexuality, she views the concept of and need for sexing bod-
ies as a social creation and not part of our biology.
In addition to her thoughts and writings on genetics, she also engages in dia-
logue and theoretical discussion on gender roles, sexual orientation, and gender
Feinberg, Leslie 221
identity, positing that nurture of a sexual or gendered variety has a much larger
impact on gender and sexual orientation than any component of either nature or
biology. Fausto-Sterling’s research and writings encourage society to expand its
definitions of what it means to be male and female, not only from a biological
framework but also in how gender roles and activities are viewed as men’s work
and women’s work.
By working at the intersection of biology and sexuality, Fausto-Sterling brings
a unique lens to the studies of sex and gender, engaging in interdisciplinary con-
versations. While much of her work focuses on children and individuals with
intersex conditions, her theoretical frameworks for reexamining how society
views, creates, and reinforces gender have cemented her in the canon of feminist
literature and gender studies as one of the first people to approach gender diversity
from a genetic perspective.
Shanna K. Kattari
See also: Binary Gender System; Feminist Theory; Gender; Gender Diversity; Gender
Roles, Socialization and; Intersexuality; Sexology; Sexual Orientation; Stereotypes, Gen-
der; Stereotypes, Sexual; Transgender.
Further Reading
Biography. (n.d.). Anne Fausto-Sterling. Retrieved from http://www.annefaustosterling
.com/biography/
Brown University. (2017). Anne Fausto-Sterling. Retrieved from https://vivo.brown.edu
/display/afaustos
Fausto-Sterling, A. (1992). Myths of gender: Biological theories about women and men.
New York: Basic Books.
Fausto-Sterling, A. (1993). The five sexes. The Sciences, 33(2), 20–24.
Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of sexu-
ality. New York: Basic Books.
Fausto-Sterling, A. (2012). Sex/gender: Biology in a social world. New York: Routledge.
Feinberg, Leslie
Leslie Feinberg (1949–2014) was a grassroots activist and journalist who was born
September 1, 1949, in Kansas City, Missouri. Feinberg later moved to Buffalo,
New York, in the 1960s and considered hirself a young butch lesbian. Feinberg
preferred to use gender-neutral pronouns like “zie” or “ze” (pronounced like
“see”) and “hir” (pronounced like “here”). Feinberg described hirself as “an anti-
racist white, working class, secular Jewish, transgender, lesbian, female, revolu-
tionary communist.” Zie was married to Minnie Bruce Pratt, a lesbian poet-
activist.
Feinberg’s experiences with medical professionals led hir to advocate for a bet-
ter understanding of trans health issues and needs among health care providers
and medical professionals. From December 1995 to December 1996, Feinberg was
dying of endocarditis, a bacterial infection that lodges and proliferates in the
valves of the heart. Doctors refused to treat Feinberg, hospitals told hir to leave,
and zie was called a freak, troubled, and other derogatory names. Feinberg was
222 Female Ejaculation
also diagnosed with other serious infections and health disorders such as late-
stage Lyme disease; these health conditions ultimately led to hir death in 2014.
Feinberg’s novel Stone Butch Blues was published on March 1, 1993, by Fire-
brand Books. It won the prestigious American Library Association Award Gay
and Lesbian Book Award and was a finalist for the LAMBDA Literary Award.
Feinberg also wrote nonfiction work including Transgender Warriors: Making
History from Joan of Arc to RuPaul, which was the first to analyze the historical
roots of transgender oppression. Transgender Warriors won the 1996 Firecracker
Alternative Book Award for Non-Fiction. Another of hir nonfiction books, Trans
Liberation: Beyond Pink or Blue, contains speeches and essays written by the
author and other trans activists. Hir second novel, Drag King Dreams, was pub-
lished in March 2006.
Feinberg was a well-known activist in the United States and other parts of the
world who worked to help build a strong bond between the LGBT communities.
Ze was a political activist and a national leader of the Workers World Party and
was a managing editor of its newspaper, Workers World. Feinberg was a trade
unionist, antiracist, and socialist, and ze helped to build connections of unity
between these movements and others that were advocating for those oppressed by
their nationalities, sex, disabilities, and class or socioeconomic status as a whole.
For more than three decades, Feinberg advocated for the treaty rights and freedom
of Native nations and for the freedom of political prisoners in the United States.
Finally, Feinberg was also known for touring around the United States speaking at
pride rallies, protests, and on college and university campuses.
Lauren Ewaniuk
See also: Gay Rights Movement; Pronoun Usage; Transgender.
Further Reading
Feinberg, L. (1993). Stone butch blues. Ann Arbor, MI: Firebrand Books.
Feinberg, L. (1998). Transliberation: Beyond pink or blue. Boston: Beacon Press.
Transgender Warrior. (n.d.). Home page. Retrieved from http://www.transgenderwarrior
.org/
Female Ejaculation
Also known as “squirting” or “gushing,” “female ejaculation” refers to the release
of fluid from what is likely the paraurethral ducts during sexual arousal or orgasm.
These ducts, called Skene’s glands, are located on both sides of the vaginal open-
ing and seem to act in a similar manner to the prostate (which provides the fluid
for male ejaculate or semen). The expelled fluid is often described as somewhat
“milky” in appearance, sweet tasting, without odor, and ranging widely in vol-
ume. Female ejaculation is considered a normal part of sexuality and, as far as
researchers have discovered, there is nothing unhealthy about this experience.
The phenomenon of female ejaculation has actually been described for many
years, possibly dating back to the days of Aristotle. Popular cultural discussion of
female ejaculation, however, is relatively recent. The book The G Spot, and Other
Recent Discoveries about Human Sexuality is often credited with helping female
Female Ejaculation 223
ejaculation reemerge into the public consciousness as well as sparking renewed
discussion about this phenomenon within the medical community. Research on
female ejaculation, however, is still relatively sparse and quite incomplete. It
remains unclear what percentage of women experience female ejaculation, with
estimates ranging anywhere from 10 percent to 69 percent, depending on the defi-
nitions and methods utilized by researchers. The purpose of the fluid release is
also unknown, though suggestions have included an antimicrobial function to
protect females from vulvo-vaginal infections following sexual activity. In addi-
tion, the exact source and makeup of the fluid continues to be a topic of debate
among medical professionals and researchers and is related to controversy sur-
rounding the existence of the “G-spot” in women.
The term “female ejaculation” is considered a misnomer by many health care
professionals, as the fluid itself is not the same as male ejaculate (semen). That
said, however, a major controversy surrounding female ejaculation has involved
the composition of the expulsed fluid. Specifically, much of the existing research
has focused on determining whether female ejaculate is, or contains, urine. In a
recent review of the literature, researchers concluded that female ejaculation may
present as whitish secretions from the “female prostate” (i.e., Skene’s glands) or
coital incontinence in which diluted urine is released. Indeed it is argued that both
may occur simultaneously, making it difficult to parse “true” female ejaculation
from symptoms of urinary incontinence. According to researchers who have con-
ducted chemical analyses of female ejaculation, however, the fluid may be similar
but is not the same as urine. Such studies have revealed that female ejaculate
includes creatinine, prostate-specific antigen, glucose, and fructose, among other
substances. Of note, the undetermined makeup of female ejaculate has resulted in
specific social implications around censorship. For example, following the argu-
ment that female ejaculate is simply urine, the United Kingdom’s British Board of
Film Classification has banned films that allegedly show female ejaculation, as
portraying urination during sex is considered to be obscenity under U.K. law
(Rosen, 2014).
Often debates about female ejaculation are tied to the existence of the Grafen-
berg spot, or “G-spot,” a sensitive area on the anterior wall of the vagina, which,
when stimulated, is reported to variably result in orgasm and ejaculation. The
G-spot was named for Dr. Ernst Grafenberg, a German-born obstetrician and
gynecologist. In 1950, Grafenberg described that stimulation of this area of the
vagina seemed to cause the female urethra to enlarge and swell. He also noted a
fluid emerging from the urethra that he believed to be distinct from urine. It has
been argued that, due to its location, stimulation of the G-spot also involves simul-
taneous stimulation of the paraurethral tissue in which the Skene’s glands are
located and, in which, it has been argued that the ejaculate fluid is stored. As such,
many believe that having a G-spot-induced orgasm increases the likelihood of
female ejaculation.
Related to disagreements about the composition of female ejaculate and G-spot
involvement is a third controversy. Specifically, where is female ejaculate stored
prior to squirting? As noted, many point to the Skene’s glands, located in the para-
urethral tissue, as the source of female ejaculation. Others have argued that the
224 Female Genital Cutting
paraurethral tissue cannot hold the volume of fluid reportedly ejaculated by some
women and instead point to the bladder as the largest potential source of female
ejaculate located in the pelvis. Overall, health care professionals and researchers
continue to debate the major points of female ejaculation—what it is, where it
comes from, and why it exists.
Jennifer A. Vencill
See also: Arousal; Ejaculation; Grafenberg Spot (G-Spot); Orgasm; Vaginal Lubrication.
Further Reading
Grafenberg, E. (1950). The role of the urethra in female orgasm. International Journal of
Sexology, 3, 145–148.
Ladas, A. K., Whipple, B., & Perry, J. D. (1982). The G spot, and other recent discoveries
about human sexuality. New York: Holt, Rinehart, and Winston.
Pastor, Z. (2013). Female ejaculation orgasm vs. coital incontinence: A systemic review.
Journal of Sexual Medicine, 10, 1682–1691.
Rosen, R. (2014, December). No female ejaculation, please, we’re British: A history of
porn and censorship. The Independent. Retrieved from https://www.independent
.co.uk/life-style/health-and-families/features/no-female-ejaculation-please-we-re
-british-a-history-of-porn-and-censorship-9903054.html
Whipple, B. (2015). Female ejaculation, G spot, A spot, and should we be looking for
spots? Current Sexual Health Reports, 7, 59–62.
Wimpissinger, F., Stifter, K., Grin, W., & Stackl, W. (2007). The female prostate revisited:
Perineal ultrasound and biochemical studies of female ejaculate. Journal of Sex-
ual Medicine, 4, 1388–1393.
Female Genital Cutting
Female genital cutting (FGC), often referred to as female genital mutilation or
female circumcision, is a procedure that intentionally alters, injures, or removes
female genitalia or organs for nonmedical purposes. FGC can be classified into
four major categories: type 1, clitoridectomy (partial or total removal of the clito-
ris); type 2, excision (partial or total removal of the clitoris and labia minora, with
or without removal of the labia majora); type 3, infibulation (sealing the vaginal
opening with or without clitoridectomy); and type 4, all other harmful procedures
to female genitalia. More than 200 million girls and women today have undergone
FGC, and 3 million girls are at risk of undergoing FGC every year. Young girls
(younger than fifteen years of age) are most likely to experience FCC, specifically
if located in one of the thirty African, Middle Eastern, or Asian countries where
FGC is most concentrated. FGC is performed by community members (mostly
women, although in some communities it may be performed by men) who range
from non-medically trained religious leaders or circumcisers to trained health pro-
fessionals. The environment is generally unsterile, and the procedure is most often
completed without anesthetic. A variety of instruments are used in performing
FGC, such as razor blades, knives, scissors, glass, sharpened rocks, and finger-
nails. FGC has been found to provide no benefit to the health of young girls and
women and, contrarily, has been linked to several negative physical, psychologi-
cal, and psychosexual health outcomes.
Female Genital Cutting 225
The practice of FGC is deeply rooted in societal norms and cultural traditions
that have persisted for generations. FGC is traditionally a ceremonial event that
prepares girls for marriage and adulthood under the belief that FGC protects the
virginity and virtue of young girls, increases male and female sexual pleasure,
and maintains feminine hygiene and cleanliness. The ceremonies also provide
economic benefit because they are accompanied by community spending (such as
food and gifts), are a form of income for circumcisers or practitioners, and can
improve the status and worth for young girls or women when it is time for mar-
riage. In most cases, only women are present at the ceremony and, therefore,
mothers and grandmothers largely maintain the tradition of FGC. Men, however,
also contribute to upholding the tradition as they prefer to marry women who have
been “cut,” believing their virginity has been preserved and they are more suitable
for marriage.
Today, FGC is a widely condemned practice that is recognized as a human
rights violation of girls and women. The prevalence and support of FGC has
decreased in many countries over the last three decades; however, decline has
occurred more rapidly in some countries than others, with some countries experi-
encing nominal change. There are currently laws prohibiting FGC in twenty-six
African and Middle Eastern countries, in addition to thirty-three countries with
large populations that practice FGC. The legislation and penalty for violating leg-
islation varies from country to country, and it has been argued that to increase
success, legislation needs to be accompanied by programming and strategies that
influence a sociocultural shift toward ending FGC.
Nicole C. Doria and Matthew Numer
See also: Circumcision; Clitoris; Female Sexuality; Labia; Virginity; Vulva.
Further Reading
Jiménez Ruiz, I., Almansa Martínez, P., & Alcón Belchí, C. (2017). Dismantling the man-
made myths upholding female genital mutilation. Health Care for Women Interna-
tional, 38(5), 478–491.
Klein, E., Helzner, E., Shayowitz, M., Kohlhoff, S., & Smith-Norowitz, T. (2018). Female
genital mutilation: Health consequences and complications—A short literature
review. Obstetrics and Gynecology International, 2018, 1–7.
Lewnes, A., & UNICEF Innocenti Research Centre. (2005). Changing a harmful social
convention, female genital mutilation/cutting (Innocenti digest). Florence, Italy:
UNICEF Innocenti Research Center.
Odukogbe, A., Afolabi, B., Bello, O., & Adeyanju, A. (2017). Female genital mutilation/
cutting in Africa. Translational Andrology and Urology, 6(2), 138–148.
UNICEF. (2013). Female genital mutilation/cutting: A statistical overview and explora-
tion of the dynamics of change. Retrieved from https://data.unicef.org/wp-content
/uploads/2015/12/FGMC_Brochure_Lo_res_1613.pdf
UNICEF. (2016). Female genital mutilation/cutting: A global concern. Retrieved from
https://data.unicef.org/wp-content/uploads/2016/04/FGMC-2016-brochure_250
.pdf
World Health Organization. (2018). Female genital mutilation. Retrieved from http://www
.who.int/news-room/fact-sheets/detail/female-genital-mutilation
226 Female Sexuality
Female Sexuality
“Female sexuality” refers to everything that distinguishes an individual as female
rather than male or another gender. It may also be thought of as femaleness or
being female. “Female sexuality” can refer to biological factors, such as physical
sexual characteristics and reproductive organs; psychological factors, such as atti-
tudes, emotions, and ideas; and cultural factors, such as the ways in which social
expectations influence dressing styles and other behaviors.
The biological factors that distinguish a female from a male are present at
birth in the form of female genitals. These include a clitoris, vulva, vagina,
uterus, and ovaries. A female is born with each of her ovaries containing
approximately 400,000 immature eggs. Only about 400 of these eggs will even-
tually mature.
At puberty, which usually begins between the ages of ten and twelve in females,
the ovaries start producing increased amounts of estrogen—the hormone that trig-
gers body changes that characterize a sexually mature female. The breasts grow,
hips become wider, and the monthly menstrual cycle begins. In a menstrual cycle,
an egg matures and is released by an ovary, and the uterine wall develops a special
lining. If the egg is fertilized by sperm, it will implant itself in the uterine wall,
resulting in pregnancy. If the egg is not fertilized, the uterine lining is shed and
passes out of the vagina in menstrual bleeding. Usually, the ovaries decline in
functioning between the ages of forty-five and fifty-five, a period known as
perimenopause.
Sexual pleasure for many woman is associated with physical stimulation of the
clitoris, which is filled with sensitive nerve endings. Stimulation of the clitoris by
a penis, sex toy, fingers, tongue, or other means can feel very pleasurable and may
lead to orgasm. Some people can experience multiple orgasms in a brief period of
time if pleasurable stimulation, often involving the clitoris, is continued. How-
ever, others may have difficulty experiencing orgasm. If experiencing orgasm is
difficult, this may be related to improper or insufficient clitoral or other sexual
stimulation, stress, the use of certain medications, or other physical or psychologi-
cal conditions. Lack of awareness of the important role the clitoris plays in sexual
pleasure, as well as a general lack of awareness of the body and sexuality, are also
associated with difficulties with orgasm. Fortunately, in most cases, exploration
and communication, both on one’s own and with a partner, can help increase the
likelihood of orgasm.
There are numerous psychological factors associated with female sexuality.
A woman has certain attitudes, emotions, ideas, and behaviors that constitute her
self-identity as a female. These may consist of the ways in which she walks, talks,
dresses, and wears her hair and makeup. They may also include her concepts of
what it means to have a good job or to be a good wife or mother.
According to many biologists, psychologists, and sociologists, some of these
“female” attitudes and ideas are the result of complex genetic and hormonal
influences—the biological aspects of being female. However, others are the result
of cultural influences regarding expectations of what a woman should act like in
any given society.
Femininity 227
Not all people conform in their sexuality to their biological sex. Some people
who are born with male bodies have a psychological sexuality or gender identity
that is female. Conversely, some people who are born with female bodies have a
psychological sexuality or gender identity that is male.
Much of a female’s concept of her sexuality is derived from the diverse experi-
ences she has while growing up as a girl and while living as a woman. Influencing
her ideas of her own femininity and sexuality are such things as the types of toys,
clothes, and chores given to her by her parents; the ways in which her peers act
regarding their sexuality; the ways in which prominent women are portrayed by
teachers in school; and the ways in which women in popular culture are portrayed
on television shows, in movies, and in the music industry.
For example, one girl might be exposed to experiences that lead her to believe
that an essential part of being female is focusing on an ideal outer beauty, involv-
ing constant dieting to stay slim, spending money on expensive clothes, and wear-
ing elaborate makeup. Another girl’s experiences might lead her to believe that
such concerns are frivolous and that it is much more important to get a good edu-
cation and to have a successful career. Yet another girl might come to expect that
her main role as a female is to be a good wife and mother.
Since the sexual revolution of the 1960s and 1970s, liberal cultural influences
have allowed many women in the United States and other Western nations to pur-
sue their dreams of accomplishing anything they choose to accomplish. By con-
trast, many conservative, traditional cultures, such as those in Islamic nations of
the Middle East, enforce extremely limited roles for women in society. Despite the
improved opportunities for women in modern society, a frequent criticism of pop-
ular portrayals of women in the United States is that too much emphasis is placed
on the overtly sexual aspects of being female, giving girls a shallow concept of
their own sexuality.
A. J. Smuskiewicz
See also: Black Sexuality; Gender Identity; Gender Roles, Socialization and; Male Sexu-
ality; Media and Sexuality; Puberty; Religion, Diversity of Human Sexuality and; Social
Learning Theory, Gender and.
Further Reading
Bergner, D. (2014). What do women want? Adventures in the science of female desire.
New York: Ecco Press.
Eckert, K. G. (2014). Things your mother never told you: A woman’s guide to sexuality.
Downers Grove, IL: IVP Books.
Hite, S. (1976). The Hite report: A national study of female sexuality. New York: Seven
Stories Press.
Femininity
Femininity is the set of attributes, behaviors, roles, expectations, social norms,
and qualities associated with the female sex. Femininity is both biologically and
socially constructed based on biological factors (i.e., being born with a vagina).
228 Femininity
Some traits often associated with femininity include being gentle, empathetic,
caring, conflict and anger avoidant, tolerant, submissive, relationship focused,
meeting expectations of beauty, and being sexually passive or uninterested. Femi-
ninity as a concept is inherently white and includes “traditional” Western beauty
standards (e.g., height, body size, breast size, weight, hair color). Media portrayal
of the “ideal” woman can lead to poor self and body image, which can in turn lead
to the acceptance and practice of more traditionally gendered roles. Just being
born female is not enough to be considered feminine; one also needs to show oth-
ers that they are feminine through their behavior, their appearance, and other
aspects related to the traditional gender role.
Judith Butler defined gender as “an identity instituted through a stylized repeti-
tion of acts . . . instituted through stylization of the body . . . [in] which the body
gestures, movements, and enactments . . . constitute the illusion of . . . a gendered
self” (Butler, 1998). Like the description of femininity above, this definition of
gender also describes how one must not only look the part of female but also act
feminine in order to maintain the idea of one’s femininity through a repeated per-
formance. Media also plays a role in how femininity and masculinity are per-
formed by not only repeating what is socially acceptable but also by creating
caricatures of sexualized responsibility, which can lead to hyperfemininity and
hypermasculinity, which can create problems for individuals as well as societies.
The idea of how to be feminine and how to be a woman has been historically
performed and repeated, a lifelong “project” or “strategy” defined and shaped by
social norms that can change across time and across cultures. Women who do not
conform to these social norms can be subject to bullying and other forms of nega-
tive social consequences. Because of the importance of social interactions in peo-
ple’s lives, if people face prejudice and discrimination from others because of
their gender, or the way they present themselves as female through, for example,
their behavior, speech, and clothing, this can lead to feeling bad about oneself and
can cause lower self-esteem and self-worth. Likewise, those who do conform to
these norms of femininity are often seen as “beautiful” and may be socially
rewarded. This can be problematic as it may lead some women to engage in
“beauty practices” like dieting, coloring their hair, or having plastic surgery that
they would otherwise not want to do in order to seem “attractive.”
Femininity is also racialized. Because social norms of femininity and mascu-
linity are traditionally based on Western ideals, typically white characteristics
(e.g., white skin, blonde hair, blue eyes) are often seen as the most beautiful and
the most feminine. Black women, for example, are at an intersection of being both
the minority sex and race. Physically, black women often do not meet the Euro-
centric ideals of beauty, simply by being born with different skin color and hair
texture. While the “right” body frame can sometimes be achieved, there are still
supposed “black sexual characteristics” that would need to be overcome to meet
white femininity standards. Black women’s sexuality, which is often portrayed
and viewed in stereotypical ways, does not lend itself to traditional notions of
femininity. Different stereotypes of black female sexuality lend themselves to
masculine traits by way of being the head of a household, not being docile and
compliant, and being considered overly sexual or having too many sexual
Feminist Theory 229
partners. Many women manipulate features that can be changed to meet the stan-
dard of white feminine beauty. Women of color, both inside and outside the United
States, use bleaching creams to lighten their skin as a way to achieve whiteness.
Many women also use chemicals in their hair to achieve either the correct texture
or color in order to conform to these beauty ideals. Cosmetic surgery has also
been a way, for those with financial means, to achieve the “ideal” female form of
larger busts and smaller waists. Worldwide, eyelid surgery, foot binding, girdles,
and the other aforementioned means are also used to achieve the purported “ideal”
look.
Donna Oriowo
See also: Black Sexuality; Double Standards, Sexual; Female Sexuality; Gender Roles,
Socialization and; Masculinity.
Further Reading
Butler, J. (1998). Performative acts and gender constitution: An essay in phenomenology
and feminist theory. Theatre Journal, 40(4), 519–531.
Collins, P. H. (2005). Black sexual politics: African Americans, gender, and the new rac-
ism. New York: Routledge.
Deliovsky, K. (2008). Normative white femininity: Race, gender, and the politics of
beauty. Atlantis, 33, 49–59.
Dittmar, J. (2009). How do “body perfect” ideals in the media have a negative impact on
body image and behaviors? Factors and processes related to self and identity.
Journal of Social and Clinical Psychology, 28(1), 1–8.
Oriowo, D. O. (2016). Is it easier for her? Afro-textured hair and its effects on black
female sexuality: A mixed methods approach (Order No. 10120152). Retrieved
from Dissertations & Theses @ Widener University; ProQuest Dissertations &
Theses A&I. (1805610606).
Stephens, D., & Few, A. L. (2007). The effects of images of African American in hip hop
on early adolescents’ attitudes toward physical attractiveness and interpersonal
relationships. Sex Roles, 56, 251–264.
Feminist Theory
Feminist theory is the system of ideas used to study, analyze, and understand gen-
der inequality and consists of academic principles used to illustrate feminism. Col-
loquially, feminism represents the belief that individuals of all genders should have
equal political, economic, social, and basic rights. According to bell hooks (2015),
feminism is “a movement to end sexism, sexist exploitation, and oppression.” This
definition directly indicates that sexism, inequality, and oppression underlie gender
inequity and addresses the misconception that feminism is “antimale.” The femi-
nism definition offered by bell hooks acknowledges that sexist thinking and behav-
ior can be perpetuated by people of any gender and age and, thus, conceptualizing
feminism as “anti-male . . . reflects the reality that most folks learn about feminism
from patriarchal mass media” (hooks, 2015). That is, the misconception that femi-
nism is “antimale” is, in and of itself, a result of inequity and is not in line with
feminist theory. Adopting a feminist perspective is relevant to persons of all gen-
ders and, thus, many cisgender (those whose birth-assigned sex and gender identity
230 Fertility
align) men advocate for feminist theory and identify as feminists. Moreover,
individuals of all genders who work within feminism and feminist theory often
share the common goal of shifting attention from exclusively focusing on the per-
spective of cisgender men to focusing on how systems of power and oppression
interact to maintain inequality, oppression, and injustice.
Feminist theory posits that power and oppression maintain imbalances in equity
and opportunity that affect all areas of existence, including economics (e.g., unequal
pay), politics (e.g., leaders are typically cisgender men), religion and family systems
(e.g., traditional gender roles), and psychology (individuals’ beliefs about what one
is capable of achieving). To understand how power and oppression lead to gender
inequity, feminist theory focuses on various gender-related constructs, such as gen-
der roles and stereotypes, media depictions of gender and sex, social hierarchies,
and sexual objectification. In particular, feminist theory aims to understand the
nature of gender inequity and argues that societal gender roles play a large part in
how we come to think about others, the larger community, and ourselves.
Importantly, many disciplines of feminist thought inform and shape feminist
theory. For example, intersectionality is one discipline that provides critical per-
spectives on how social identities like gender, race, and class interconnect and
inform, disrupt, and expand our understanding of behavior and culture. Feminist
theory considers the myriad biases shaped by sociocultural contexts. As such,
feminist theory has critiqued “objective” methods of data collection and interpre-
tation by calling into question an “objective truth” to human behavior that can be
observed outside of its sociocultural context. Nonetheless, feminist theory has
garnered subjective and empirical support. Moreover, the principles underlying
gender inequity (i.e., feminist theory) explain many sexual and gender-related
phenomenon, including, but not limited to, sexual violence, sexual consent, dis-
crimination against women and the LGBTQ+ community, the lack of women in
science, and economic injustice. Ultimately, the goal of feminism and feminist
theory is to promote and strive for equity and justice.
G. Nic Rider and Janna A. Dickenson
See also: Female Sexuality; Gender; Gender Roles, Socialization and; Sexism; Stereo-
types, Gender; Stereotypes, Sexual.
Further Reading
Allen, A. (2018). The power of feminist theory. New York: Routledge.
hooks, b. (2015). Feminism is for everybody: Passionate politics. New York: Routledge.
Tolman, D. L. (2012). Female adolescents, sexual empowerment and desire: A missing
discourse of gender inequity. Sex Roles, 66(11–12), 746–757.
Fertility
Fertility is the quality or state of being fertile, where being fertile is the natural
ability to produce offspring, not including stillbirths. Like all body systems, the
reproductive tract does not exist in isolation and can change in response to other
events in the body. Thus, fertility is dependent not only on reproductive organs but
also on the brain, hormones, adipose tissue (fat cells), and glands. The human
body is very complex, so it is important to be mindful that, while not necessarily
Fertility 231
discussed here, other body systems potentially affect fertility as well. Other fac-
tors that influence fertility for both partners are age, weight, diet, history of infec-
tion, exposure to environmental toxins, genetics, exercise, and consumption of
alcohol, tobacco, and other substances.
Female fertility is rooted in the menstrual cycle. At birth, the ovaries contain
approximately one million oocytes (eggs) in an immature state. Over time, some
of the oocytes die due to lack of stimulation in a normal process called atresia.
During puberty, which usually occurs between the ages of nine and fourteen years,
an egg begins to mature in its follicle. At maturity, it bursts out and is picked up by
the fallopian tube in a process called ovulation. If there are no sperm to fertilize
the egg, it is expelled from the body, along with the uterine lining, in a process
called menstruation. The whole cycle is called the menstrual cycle (period) and
typically runs twenty-five to thirty days. It is important to note that the onset of
menstruation, also called menarche, does not mean a female is fertile. Oftentimes
a female’s first ovulation occurs several months to two years after menarche.
The fertility window (FW) is the time during a female’s cycle when pregnancy
is possible and is based on when ovulation occurs, usually fourteen days before
the start of menstruation. The FW is different for every woman and includes the
five days before ovulation, since sperm can survive for up to five days in the
female body, and the day of ovulation itself. Fertility drops off sharply twelve to
twenty-four hours after the oocyte is released, since the oocyte is only viable for
about twenty-four hours.
Many women use fertility calendars to track their cycles and then calculate
their FW. Day one is the first day of menstruation, while the last day is the day
before the next period starts. For individuals with inconsistent cycles and who are
trying to conceive, it is recommended that they have sexual intercourse every two
to three days to optimize chances of pregnancy.
If, during the ovulation phase, a sperm is available to fertilize the egg and fer-
tilization occurs, the resulting zygote will float from the fallopian tube into the
uterus. Approximately five to six days after fertilization, the zygote has become a
blastocyst and is now ready for implantation into the uterine wall. Roughly 50
percent of fertilized blastocysts do not implant or stop developing; if this occurs,
the female will menstruate as usual. However, if successful implantation and
development occur, a woman may experience a missed period and become aware
that she is pregnant.
Sometimes the menstrual cycle can be irregular, meaning it arrives sooner than
twenty-five days, later than thirty days, or not at all, despite not being pregnant.
Having an occasional irregular cycle may be caused by stress, illness, diet, exer-
cise, or variance in routine. Consistently irregular periods can be indicative of
larger problems with the reproductive system. For example, periods occurring too
closely together may mean that the eggs are not reaching maturity before ovula-
tion. Periods that are too far apart can mean that ovulation is not regular, which
could be caused by polycystic ovarian syndrome.
The quality and quantity of fertilizable eggs are also dependent on the female’s
age. Women ages nineteen to twenty-six years are typically the most fertile and
have a 50 percent chance of conceiving during the peak of the FW. Chances of
conceiving decline by 10 percent from ages twenty-seven to thirty-four and then
232 Fertility
decline more rapidly from age thirty-five to thirty-nine. According to the Ameri-
can Society for Reproductive Medicine, a woman’s chance of becoming pregnant
is less than 5 percent per month at age forty.
Oocyte quality is synonymous with its ability to implant into the uterus once it
has been fertilized. One explanation for this is that energy-producing mechanisms
within the egg do not function as well as they did when they were younger and
therefore are unable to sustain the energy needed to keep growing until implanta-
tion. In addition, research shows that between the ages of thirty and thirty-five
years, the rate of chromosomal abnormalities increases from 1 in 526 (under thirty
years) to 1 in 385. By age forty-five, the rate of chromosomal abnormalities jumps
to 1 in 66.
Males generally become fertile between ages twelve and sixteen years with the
onset of puberty. In the seminiferous tubules located in the testes, many new
sperm cells are generated daily, roughly one thousand per second. However, the
full process of creating sperm (spermatogenesis and spermiogenesis) takes sixty-
five to seventy-five days.
Male fertility is dependent on the characteristics of the semen, which includes
ejaculate volume, total number and concentration of sperm present, sperm mor-
phology (normal shape), percentage and total motility (progressive and nonpro-
gressive movement), presence of antibodies, and viability. Fertility in males is
often evaluated using a semen analysis. Some conditions that can alter semen and
sperm quality are the presence of varicoceles (enlarged veins that cause testicles
to overheat), diabetes, paralysis, cystic fibrosis, infection, testicular failure, expo-
sure to environmental toxins like pesticides and lead, and substance use.
By contrast, infertility is the inability to conceive offspring. Medically, infertil-
ity in women under thirty-five years old is described as the desire to have a baby
with the inability to become pregnant after one year of sex without contraception
with the same partner, or the inability to carry a pregnancy to term. If a woman is
age thirty-five or older, the time criteria to be diagnosed with infertility is reduced
to six months. Between 10 percent and 15 percent of couples living in the United
States are affected by infertility. In roughly a third of cases, infertility can be
traced to male causes, and likewise, in an additional third of cases, infertility can
be traced to female causes. For the remaining third, the infertility is either linked
to both male and female factors or considered unexplained. Infertility may be
treated in several ways, including medication, surgery, intrauterine insemination,
or assisted reproductive technology (ART).
Although infertility is a medical condition, it can cause high levels of psycho-
logical distress. Some people grow up with the expectation that they will become
parents and that it is a biological imperative as well as significant life role. One
study found that women feel guilt, blame themselves, and wonder what they may
have done to deserve having trouble with fertility. Sometimes women have a hid-
den and prolonged sense of loss and may feel that they are missing out on the
pregnancy and birth experiences, passing on of their genetics, and fulfilling their
ideal of family; they may also feel as though they are disappointing others and
may experience diminished self-worth and self-esteem. Reactions to infertility
Fertility 233
are similar to any loss and include shock, grief, depression, anger, frustration, and
a feeling of having no control over one’s future.
Sterility, which is relatively rare, is the complete inability to conceive offspring.
Some conditions that cause sterility are Klinefelter syndrome (a chromosomal pat-
tern of XXY), androgen insensitivity syndrome (being unable to process male
hormones), hypogonadism (inadequate production of testosterone), and Turner
syndrome (genetic disorder in females). Other causes of infertility include radia-
tion therapy, trauma to the reproductive tract, repeated incidence of sexually trans-
mitted infections, or exposure to some diseases (e.g., mumps), among others.
People may also choose to become sterile as a means of birth control. Males
may undergo a vasectomy, a procedure that purposefully blocks the sperm cells
from mixing with the seminal fluid and inhibits them from becoming part of the
ejaculate. Females may choose to have a tubal ligation, which blocks sperm from
entering the fallopian tubes, preventing it from fertilizing the oocyte.
While some choose to suspend fertility via contraception, others attempt to
prolong it. Many people are choosing to delay having children until they are older,
possibly because of education, career, or prioritizing other life goals. Over 20 per-
cent of new mothers are over thirty-five years, and one in seven children are born
to them. Technology has proposed a solution to the aging gamete factor as cryo-
preservation (freezing eggs or sperm) is increasingly used for a variety of situa-
tions. Like many decisions in life, it is important to weigh the pros and cons before
making a decision. Gamete freezing does not guarantee that a baby will result as
there are the general risks involved when using ART procedures as well as other
overall risks involved in the freezing process.
Darci Shinn
See also: Assisted Reproductive Technology; Conception; Contraception; Fertility
Awareness Methods of Contraception; Fertility Drugs; Infertility; Menarche; Menstrua-
tion; Ovulation; Pregnancy; Puberty; Sperm.
Further Reading
Alter, C. (2015, July 27). Buying time. Time, 41–45.
American Society for Reproductive Medicine. (2012). Optimizing natural fertility.
Retrieved from https://www.reproductivefacts.org/news-and-publications/patient
-fact-sheets-and-booklets/documents/fact-sheets-and-info-booklets/optimizing
-natural-fertility/
Centers for Disease Control and Prevention. (2019). Infertility FAQs. Retrieved from
http://www.cdc.gov/reproductivehealth/infertility/index.htm
Chandra, A., Copen, C. E., & Stephen, E. H. (2013). Infertility and impaired fecundity in
the United States, 1982–2010: Data from the National Survey of Family Growth.
Centers for Disease Control: National Health Statistics Reports, 62, 571–577.
Fertility Coalition (2019). Getting the timing right. Retrieved from http://yourfertility.org
.au/for-women/timing-and-conception
Jones, R. E., & Lopez, K. (2006). Human reproductive biology (3rd ed.). New York: Aca-
demic Press.
Levine, H. (2016). 9 things every woman must know about her fertility. Retrieved from
http://www.health.com/health/gallery/0,,20987648,00.html
234 Fertility Awareness Methods of Contraception
Lindsey, R., & Driskill, C. (2013). The psychology of infertility. International Journal of
Childbirth Education, 28(3), 41–47.
Mneimneh, A. S., Boulet, S. L., Sunderam, S., Zhang, Y., Jamieson, D. J., ... Kissin, D. M.
(2013). States monitoring assisted reproductive technology (SMART) collabora-
tive: Data collection, linkage, dissemination, and use. Journal of Women’s Health,
22(7), 571–577.
Perkins, S., & Meyers-Thompson, J. (2007). Infertility for dummies. Indianapolis: Wiley
Publishing.
Resolve. (2016). What is infertility? Retrieved from http://www.resolve.org/about
-infertility/what-is-infertility/
USC Fertility. (2016). Female egg quality is synonymous with the probability of embryo
implantation. Retrieved from http://uscfertility.org/fertility-treatments/female
-egg-quality/
Fertility Awareness Methods of Contraception
Although they may be derided as old-fashioned in industrialized countries, fertil-
ity awareness methods (FAMs) of birth control can meet the needs of many indi-
viduals. Some people use FAMs because they limit the risk of pregnancy while
respecting cultural and religious norms. Others like the fact that no hormones or
other chemical agents are involved, or that they are low-cost, ecological solutions.
FAMs, also called “natural family planning” or “the rhythm method,” have the
advantage of allowing a better understanding of the menstrual cycle and the repro-
ductive system. However, it should be noted that these methods have limited effec-
tiveness and require considerable discipline to be put into practice. Furthermore,
both partners must commit to abstain from penile-vaginal intercourse on the
“unsafe” days. This restriction of sexual activity for fear of unwanted pregnancy
means that sexual relations are associated with procreation, which has followed a
downward trend as more “modern” contraceptive methods become available.
FAMs are ways to identify the fertile days of the menstrual cycle by monitoring
the signs and symptoms of ovulation or by tracking the fertile days. They include
the calendar method, the temperature method, the cervical mucus method, and the
symptothermal method (i.e., the previous three methods combined), among oth-
ers. A recent advance is the personal fertility monitor, which allows tracking the
menstrual cycle via an app on a smartphone. FAMs generally require the partners
to collaborate and to exercise discipline. Partners must commit to abstain from
penile-vaginal sex during fertile days, or they must use an alternative contracep-
tive method during this time. In addition, determining the fertile period requires
knowledge, an adjustment period, and daily attention. Therefore, users of these
methods should be well informed beforehand, for instance, by reading pamphlets
and other publications. This helps them make informed decisions about the poten-
tial risks of these methods.
The methods based on tracking the fertile days are not the most effective. The
effectiveness varies across individuals and depends greatly on the partners’ moti-
vation to prevent pregnancy. Several additional factors may come into play, such
as the health care provider’s knowledge and the quality of the information that is
provided, the frequency of penile-vaginal sex, the contraceptive method used
Fertility Drugs 235
during the fertility window (e.g., abstinence versus withdrawal method versus
barrier methods), as well as origin from a country where FAMs are more wide-
spread. With typical use, the limited data available indicate that FAMs have about
a 75 percent effectiveness rate overall. With perfect use, the effectiveness rates are
91 percent for the calendar method, 97 percent for the cervical mucus method, and
98 percent for the symptothermal method.
Like other contraceptive methods, FAMs come with both advantages and dis-
advantages. Notably, there are no side effects or health risks. FAMs also help indi-
viduals to understand their body and menstrual cycle better, and they are very
useful for identifying the fertile days if an individual wishes to get pregnant.
Moreover, FAMs allow individuals to respect certain religious and cultural norms
concerning contraception. In addition, FAMs require both partners to collaborate,
which means that both partners have to participate in decisions about contracep-
tion. On the other hand, FAMs require good knowledge of the menstrual cycle and
the different birth control strategies available to use on fertile days as well as an
adjustment period that can last several months. Abstinence from penile-vaginal
sex is required on certain days, and users must be alert to the signs and symptoms
of fertility on a daily basis. Numerous factors, including stress, illness, medica-
tions, vaginal infections, adolescence, and perimenopause, can modify the men-
strual cycle, making it harder to accurately observe and interpret fertility signals.
FAMs are also less suitable for those who are uncomfortable about exploring their
body or who find it difficult to negotiate conception issues (e.g., in an intimate
relationship where domestic violence is present). Furthermore, FAMs provide no
protection from sexually transmitted infections.
Sylvie Lévesque
See also: Cervical Mucus Method; Contraception; Fertility; Ovulation.
Further Reading
Black, A., Guilbert, E., Costescu, D., Dunn, S., Fisher, W., Kives, S., . . . Todd, N. (2015).
Canadian contraception consensus (Part 2 of 4). Journal of Obstetrics and Gynae-
cology Canada, 37(11), 1036–1039.
Glasier, A., & Gebbie, A. E. (2008). Handbook of family planning and reproductive
healthcare (5th ed.). London: Churchill Livingstone.
McVeigh, E., Guillebaud, J., & Homburg, R. (2013). Oxford handbook of reproductive
medicine and family planning. Oxford: Oxford University Press.
Planned Parenthood. (2019). Fertility awareness. Retrieved from https://www
.plannedparenthood.org/learn/birth-control/fertility-awareness
Serena. (2019). Home page. Retrieved from www.serena.ca
World Health Organization. (2018). Family planning: A global handbook for providers.
Retrieved from https://www.who.int/reproductivehealth/publications/fp-global
-handbook/en/
Fertility Drugs
Fertility drugs are prescribed medications used to treat infertility in women due to
a variety of causes. The majority of fertility drugs are used to stimulate or regu-
late ovulation in women who do not ovulate regularly each month. Although about
236 Fertility Drugs
50 percent of women who use fertility drugs achieve pregnancy, certain risks are
present with many of these medical treatments.
The most common fertility drug used by women is clomiphene citrate. Clomi-
phene is a synthetic hormone that is used to induce ovulation or to help the body
maintain a regular ovulation cycle. It works by stimulating the pituitary gland to
release follicle-stimulating hormone (FSH), which directs the ovaries to develop
egg-producing follicles. Clomiphene is taken orally in fifty-milligram tablets for
three to five days at the beginning of a menstrual cycle. It is estimated that
85 percent of women treated with clomiphene will ovulate, and of these about half
will become pregnant within four to five cycles.
Although it has been used for over thirty years, there remain some side effects
and risks from the use of clomiphene. The American Society for Reproductive
Medicine recommends that clomiphene be used for no more than three to six
cycles based on preliminary studies that show there may be an increased risk of
ovarian cancer in women who use it for more than twelve cycles. However, this
risk has yet to be proven. Common side effects from the use of clomiphene include
hot flashes, anxiety, headaches, nausea, and ovarian cysts.
In the case that clomiphene is not successful in inducing ovulation, alternative
drugs may be tried. Letrozole is an aromatase inhibitor that stimulates the release
of FSH by suppressing the body’s production of estrogen. Although it has fewer
side effects than clomiphene, its success in stimulating ovulation appears to be
slightly lower. Metformin works by lowering the body’s insulin level in order to
improve ovulation in women with polycystic ovary syndrome. Side effects from
metformin use include nausea, abdominal pain, and allergic reactions.
Other fertility drug treatments that are used in the event clomiphene is unsuc-
cessful include injections of FSH, luteinizing hormone (LH), and human meno-
pausal gonadotropin. Each bypasses the pituitary gland to directly stimulate the
ovaries to produce multiple eggs. Once follicles are matured, a woman may be
given an injection of human chorionic gonadotropin hormone in order to trigger
release of the eggs. A serious complication that sometimes occurs with these
drugs is known as ovarian hyperstimulation syndrome (OHSS), in which the ova-
ries become enlarged and fluid builds up in the abdomen, resulting in a swollen
stomach, nausea and vomiting, and severe abdominal pain. Women who experi-
ence symptoms of OHSS should seek emergency treatment as the condition can be
life-threatening.
In some women, the pituitary gland produces excess amounts of the hormone
prolactin. This overproduction causes problems with the release of FSH and LH,
which interfere with normal ovulation. Two oral medications that reduce prolactin
levels are bromocriptine and cabergoline. Side effects with these drugs include
nausea, dizziness, headache, and decreased blood pressure.
Once the ovaries develop follicles, ovulation must be regulated to control the
release of eggs in preparation for assisted reproductive technology procedures
such as in vitro fertilization. Leuprorelin and nafarelin are gonadotropin-releasing
hormone agonists that hyperstimulate the ovaries to produce multiple eggs.
Certain drugs are used to enhance other fertility treatments. Methylpredniso-
lone is a steroid that is taken to improve the uterine lining in preparation for
Fetishism 237
embryo implantation. Progesterone is a natural hormone injected once ovulation
has occurred that also improves the uterine lining to increase the chances of a suc-
cessful embryo implantation following fertilization of the egg or eggs.
With all fertility drug use, the greatest risk is increased incidence of multiple
births. With clomiphene use, the chance of having twins is 10 percent, while the
chance of having triplets is only 1 percent; higher-order multiples are very rare.
According to a study published in the American Journal of Epidemiology, 22.8
percent of multiples are conceived using fertility drugs. Health risks to infants
include increased chance of premature birth and low birth weight. Some 60 per-
cent of twins and more than 90 percent of all other multiples are born prematurely.
Premature birth carries the risk of intellectual disability, cerebral palsy, develop-
mental delays, vision and hearing problems, and death.
For many women, fertility drugs have made the possibility of becoming pregnant
a reality. Although the drugs do carry certain side effects and risks, the success rate
of fertility drugs is sufficient for many women to attempt these treatments. In all,
over 190,000 infants are conceived each year with the intervention of fertility drugs.
Christina Girod
See also: Artificial Insemination; Assisted Reproductive Technology; Fertility; Follicle-
Stimulating Hormone; Infertility; Ovulation; Pregnancy.
Further Reading
Aboulghar, M., & Rizk, B. (Eds.). (2011). Ovarian stimulation. Cambridge: Cambridge
University Press.
March of Dimes Foundation. (2010, January). Fertility drugs contribute heavily to multi-
ple births. ScienceDaily. Retrieved from www.sciencedaily.com/releases/2010/01
/100120104002.htm
Fetishism
“Fetishism” refers to an obsessive fascination with, and sexual arousal from, inan-
imate objects or body parts not normally associated with sex. Objects might
include high-heeled shoes, skirts, pantyhose, panties, or purses. Body parts might
include feet, armpits, hair, or other nongenital parts. Most people have some
degree of sexual fetishism, and that is considered a normal, healthy part of human
sexuality. However, if the sexual fetish is ongoing and interferes with normal
social functioning and conventional sexual practices, causes significant distress,
or if sexual arousal is impossible without the fetish object, it may be diagnosed as
fetishistic disorder, as specified by the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-5).
Fetishistic disorder is classified as a type of paraphilic disorder, a group of con-
ditions that involve atypical sexual desires and extreme behaviors. In fetishistic
disorder, the affected individual must look at, hold, rub, smell, taste, or wear the
fetish object, or have their partner do so, in order to achieve sexual arousal
and orgasm. In most cases, the individual performs these acts alone while mastur-
bating. Men who practice fetishism by wearing women’s clothes, typically
masturbating while wearing the clothes, are said to have transvestic fetishism.
238 Fetishism
Psychologists classify fetish objects as form fetishes or media fetishes. Form
fetishes prompt arousal primarily by their perceived-to-be-appealing shapes, such
as a stiletto-heel shoe, a strappy purse, or a delicate bracelet. Media fetishes
prompt arousal by their perceived sensual feel and texture, such as lacy panties
and bras, silky nylons, leather skirts, and fur coats. In some cases, it is mainly the
smell or sound of an object or body part that causes arousal, such as the odor of an
armpit or foot, the sound of heels on the floor while walking, or the sound of a zip-
per on a dress. For some people, merely looking at photographs of the fetish
objects is enough to arouse them, though they are likely to prefer possessing the
objects.
Fetishists typically make collections of their preferred fetish objects. Some peo-
ple with fetishistic disorder may even resort to stealing these objects from stores
or homes or assaulting other people to get the objects. Compulsive thoughts of the
object and powerful urges regarding the object can become so psychologically
dominant that the individual becomes unable to focus on anything else, including
work, family relationships, and other personal responsibilities. It is not uncommon
for people with fetishistic disorder to take a job at a particular business to facilitate
their fetish behavior, such as a clothing or shoe store.
Although individuals with fetishistic disorder may experience intense sexual
excitement and pleasure while engaged in the practice, afterward they may have
feelings of mental anguish, distress, shame, or guilt regarding the behavior.
Fetishistic disorder is much more common in men than women. In fact, clinical
data suggest that it is extremely rare in women and is almost exclusively a male
condition. However, the prevalence of this condition within the general population
cannot be stated with certainty. That is because the distinction between “normal”
fetishism and fetishistic disorder is not always clear. Furthermore, many individu-
als who engage in fetishistic behavior do so in private and do not seek treatment.
Thus, they are never tabulated in medical statistics.
Psychologists do not fully understand the causes of sexual fetishism, and most
studies on the topic have focused on males. This research suggests that fetishistic
behavior is associated with certain social experiences. Men who are socially iso-
lated, lack confidence in their masculinity and sexual attractiveness, and fear
rejection from women are more likely to report sexual fetishes, although it is
impossible to determine if their social experiences contribute to, or are the result
of, their fetish. It may be that their feelings of sexual inadequacy and their inabili-
ties to develop intimacy with other people are compensated for by exercising con-
trol over the fetish objects and by other fetishistic practices.
Research also indicates that the roots of fetishism may begin in childhood and
adolescence, when certain objects become mentally associated with feelings of
sexual excitement or gratification, especially during masturbation. Such associa-
tions tend to develop through an unconscious learning process called condition-
ing, in which the mind forms new associations between certain stimuli and
certain responses that were not previously associated. For example, and adoles-
cent male may see an attractive woman in high-heeled shoes and become aroused
and experience sexual urges, leading him to masturbate so that he experiences
sexual gratification. In the future, if the shoes have become paired with arousal,
5-Alpha-Reductase Deficiency 239
they will be arousing on their own, even without the presence of the attractive
woman.
Most experiences of fetishism do not require treatment. However, if the fetish is
significantly impairing social or sexual functioning or causing significant distress,
the individual may seek treatment to decrease their compulsive thoughts and
urges. Treatment typically involves a combination of psychotherapy or other forms
of counseling and drug therapy. To be successful, these therapies usually have to
be performed on a continuous, long-term basis.
One of the main forms of psychotherapy used to treat fetishistic disorder is
cognitive behavioral therapy, which seeks to change destructive conditioned
thoughts into useful productive thoughts and, consequently, into useful productive
behaviors. Thought stopping is an example of a technique used in cognitive behav-
ioral therapy. In this technique, the individual learns to stop any developing
thoughts related to the fetish and immediately substitute other thoughts about less
harmful fantasies. Biofeedback is another technique that might be useful for help-
ing the individual control harmful thoughts.
Among the drugs that are commonly used in treatment are antiandrogens,
which temporarily reduce testosterone levels and the frequency of sexually arous-
ing mental imagery and sexual fantasies in men. Other drugs that may be incorpo-
rated into treatment are antidepressants, such as selective serotonin reuptake
inhibitors, which help to decrease sex drive.
While some types of fetish objects are fairly common (e.g., shoes, feet, leather,
latex), there are many other—though much more rare—forms of sexual fetishes
and arousal. These include agalmatophilia (arousal from statues), apotemnophilia
(arousal from thoughts of oneself as an amputee), coprophilia (arousal from feces),
psychrophilia (arousal from being cold or watching others who are cold), and
xylophila (arousal from wood or bark).
A. J. Smuskiewicz
See also: Arousal; Kink; Paraphilias.
Further Reading
Bering, J. (2014). Perv: The sexual deviant in all of us. New York: Doubleday.
Bressert, S. (2019). Fetishistic disorder symptoms. Retrieved from http://psychcentral
.com/disorders/fetishism-symptoms
Huffington Post. (2013). 46 sexual fetishes you’ve never heard of. Retrieved from https://
www.huffpost.com/entry/sexual-fetish_n_4144418
Scorolli, C., Ghirlanda, S., Enquist, M., Zattoni, S., & Jannini, E. A. (2007). Relative
prevalence of different fetishes. International Journal of Impotence Research, 19,
432–437.
5-Alpha-Reductase Deficiency
5-alpha-reductase deficiency is one of a group of congenital disorders character-
ized as causing disorders or differences of sexual development (DSDs). Indi-
viduals with 5-alpha-reductase deficiency have X and Y chromosomes, but at
240 5-Alpha-Reductase Deficiency
the time of birth they appear to have female or ambiguous genitalia. This is
because 5-alpha-reductase is an enzyme that converts testosterone into dihy-
drotestosterone or DHT. A lack of DHT during gestation means that the external
genitalia of these XY infants develop more like they would in an XX or typical
female child.
Although testosterone is often described as the main hormone responsible for
masculinization, dihydrotestosterone is a more active version of testosterone
that causes many of the physiological changes associated with a male-typed
body. DHT is particularly important in the development of the external repro-
ductive structures of the body prior to birth. When DHT is absent in an XY
fetus, several structures follow stereotypical female instead of male develop-
ment. Specifically, the clitoris is formed instead of the penile glans, the labia
minora instead of the shaft of the penis, and the labia majora instead of the
scrotum.
Without surgical intervention to remove the testes, individuals with 5-alpha-
reductase deficiency will make normal male amounts of testosterone at the time of
puberty. At this time, their bodies may suddenly masculinize. Their clitoris can
lengthen into a penis, their testicles descend into the scrotum, and they can have
other male pattern physical development. The degree to which this happens
depends on the specific mutations that have caused their 5-alpha-reductase
deficiency.
5-alpha-reductase deficiency has been documented around the world. However,
because it is a genetic condition, it is more common in certain populations, includ-
ing in the Dominican Republic, Papua New Guinea, Turkey, and Egypt. In the
Dominican Republic, 5-alpha-reductase deficiency is common enough in certain
villages that individuals with this condition are known as guevedoces, which
means “penis at twelve.” These individuals are generally encouraged to embrace
their male gender identity. The response to the sudden masculinization of 5-alpha-
reductase deficiency children at puberty has been met with different responses in
other cultures.
Gender assignment for infants born with 5-alpha-reductase deficiency is
challenging—medically, ethically, and culturally. Research suggests that, regard-
less of the appearance of their genitals at the time of birth, a slight majority of
these children will go on to develop a male gender identity. This is thought to be
because, unlike individuals with complete androgen insensitivity syndrome, chil-
dren with 5-alpha-reductase are exposed to normal levels of testosterone during
fetal development. Prenatal testosterone exposure has been linked to gender iden-
tity formation in several conditions characterized as DSDs. The formation of a
male gender identity may also be because of the changes in their bodies that these
individuals experience at the time of puberty, if their testes are not removed dur-
ing childhood.
Historically, many parents have chosen to assign children with 5-alpha-
reductase deficiency as female because of the appearance of their genitalia. This
choice has become more controversial over time, in part because of data suggest-
ing that many children with 5-alpha-reductase deficiency will develop a male
gender identity. As such, a growing percentage of these children are now being
assigned male at birth rather than female.
Fluidity, Gender 241
There are some parents who still choose to assign children with 5-alpha-
reductase deficiency as female at birth. In the United States and in states where
doing so is legal, these parents may also choose to remove the child’s testes with
the goal of trying to maintain the child’s female identity rather than risking that
exposure to increased levels of testosterone at puberty could encourage male
gender identity development. It is possible that removal of the testes can be benefi-
cial to those individuals who maintain a female gender identity at puberty, who
might be harmed by masculinization of their bodies. However, gonadectomy can
be traumatic or problematic for individuals with a male gender identity.
A growing number of activists and medical professionals have begun to
argue against genital “normalization” surgeries for infants with differences of
sexual development, including 5-alpha-reductase deficiency, except in cases
where those surgeries have a clear benefit for the child’s health. They advocate
for surgery to be postponed until children are old enough to make their own
decisions about what they want to happen to their bodies. In contrast, propo-
nents of genital surgery during childhood argue that asking a young person to
make this decision is beyond their emotional or intellectual capacity and that
therefore it is more appropriate for the choice to be made by parents and
professionals.
Elizabeth R. Boskey
See also: Androgen Insensitivity Syndrome; Androgens; Chromosomal Sex; Congenital
Adrenal Hyperplasia; Gender Identity Development; Intersexuality; Sex Reassignment
Surgery; X Chromosome; Y Chromosome.
Further Reading
Byers, H. M., Mohnach, L. H., Fechner, P. Y., Chen, M., Thomas, I. H., Ramsdell, L. A.,
… Keegan, C. E. (2017). Unexpected ethical dilemmas in sex assignment in
46,XY DSD due to 5-alpha reductase type 2 deficiency. American Journal of Med-
ical Genetics Part C: Seminars in Medical Genetics, 175(2), 260–267.
Cohen-Kettenis, P. T. (2005). Gender change in 46,XY persons with 5alpha-reductase-2
deficiency and 17beta-hydroxysteroid dehydrogenase-3 deficiency. Archives of
Sexual Behavior, 34(4), 399–410.
Imperato-McGinley, J., Guerrero, L., Gautier, T., & Peterson, R. E. (1974). Steroid 5alpha-
reductase deficiency in man: An inherited form of male pseudohermaphroditism.
Science, 186(4170), 1213–1215.
Kolesinska, Z., Ahmed, S. F., Niedziela, M., Bryce, J., Molinska-Glura, M., Rodie, M., …
Weintrob N. (2014). Changes over time in sex assignment for disorders of sex
development. Pediatrics, 134(3), e710–e715.
Reis-Dennis, S., & Reis, E. (2017). Are physicians blameworthy for iatrogenic harm
resulting from unnecessary genital surgeries? American Medical Association
Journal of Ethics, 19(8), 825–833.
Fluidity, Gender
“Gender fluidity,” sometimes also known as “multigender,” “pangender,” and
“gender flexible,” is a term describing an individual whose gender identity or gen-
der expression fluctuates over time or in different situational contexts. The term
“fluidity” suggests the tendency to change shape and form. This term was initially
242 Fluidity, Gender
applied to sexuality to describe sexual fluidity—the notion that sexual attractions,
desires, and behaviors can change over time and across situations and may lead to
a shift in sexual identity. Thus, gender fluidity is the idea that gender identities and
expressions may shift across contexts, situations, and over time. As such, gender
fluidity suggests that some people can feel that they are in between, neither, out-
side of, or both man and woman, and that self and social perceptions can and do
shift.
Gender fluidity challenges the idea that people must have a single, stable gender
identity. Cisgender individuals experience their gender as congruent with their sex
assigned at birth, and some transgender individuals may endorse a singular, stable
gender that differs from their sex assigned at birth. Gender fluidity, on the other
hand, suggests a tendency to oscillate between and combine attributes of mascu-
linity and femininity. People who identify as gender fluid may describe their gen-
der identity as changing from mood to mood, day to day, or situation to situation.
Also, gender-fluid people may identify with others of all different genders along a
spectrum of gender identity and expression. For example, one study found that
gender-fluid participants described the ability to “understand people better” as a
result of experiencing both masculine and feminine socialization.
Sometimes gender fluidity can be frustrating or confusing to gender-fluid indi-
viduals and others. Gender-fluid people may feel like their gender identity is
unpredictable. The ambiguity and instability of gender identity may lead to per-
sonal and social distress due to transgressing social forces that regulate gender
identity and expression. For example, Wilchins (2002) said, “Looking gender nor-
mative is vital to social acceptance . . . few things are more uncomfortable than
seeing someone whose gender you can’t discern,” meaning that appearing in a
way that is consistent with masculine and feminine gender norms is generally
more socially accepted than gender presentations that deviate from gender ideals.
However, many people find their gender fluidity to be a source of strength and
positivity. When they understand and accept the validity of their experience, peo-
ple often feel that gender fluidity empowers them to self-identify or “disidentify”
in whatever way is appropriate. For instance, author and activist Jeffery Marsh
(2015) said gender fluidity means “you don’t need to decide your gender.” Indi-
viduals who are gender fluid have described their ability to deconstruct gender
binaries, the authority to self-define, and the aptitude to identify as and empathize
with a broad spectrum of genders.
Jory M. Catalpa, Nova J. Bradford, Janna A. Dickenson, and G. Nic Rider
See also: Agender; Bigender; Binary Gender System; Fluidity, Sexual; Gender; Gender
Diversity; Gender Expression; Gender Identity; Gender Roles, Socialization and; Gender
Transition; Genderqueer; Nonbinary Gender Identities.
Further Reading
Bauman, Z. (2000). Liquid modernity. Malden, MA: Polity Press.
Bradford, N. J., Rider, G. N., Catalpa, J. M., Morrow, Q. J., Berg, D. R., Spencer, K. G., &
McGuire, J. K. (2018). Creating gender: A thematic analysis of genderqueer narra-
tives. International Journal of Transgenderism, 20(2–3), 155–168.
Butler, J. (1990). Gender trouble. London: Routledge.
Fluidity, Sexual 243
Diamond, L., & Butterworth, M. (2008). Questioning gender and sexual identity:
Dynamic links over time. Sex Roles, 59, 365–376.
Diamond, L. M., Pardo, S. T., & Butterworth, M. R. (2011). Transgender experience and
identity. In S. J. Schwartz, K. Luyckx, & V. L. Vignoles (Eds.), Handbook of iden-
tity theory and research (629–647). New York: Springer.
Marsh, J. (2015, August 19). What is gender fluid? Retrieved from https://www.youtube
.com/watch?v=3Hj1Dm4sob4
Muñoz, J. E. (1999). Disidentifications: Queers of color and the performance of politics.
Minneapolis: University of Minnesota Press.
Wilchins, R. (2002). Deconstructing trans. In J. Nestle, C. Howell, & R. A. Wilchins
(Eds.), GenderQueer: Voices from beyond the sexual binary (56). Los Angeles,
CA: Alyson Books.
Fluidity, Sexual
Historically, sexual orientation has been defined as an enduring pattern of sexual
attractions, desires, fantasies, and behaviors for people of a specific gender or sex
that differs and/or is similar to their own. Whereas this definition characterizes
the experiences of many individuals, unexpected changes in sexual attractions,
identities, and behaviors can also occur. Over the past several decades, Lisa Dia-
mond, PhD, and other researchers have shown that some individuals experience
changes in their same-sex (or same-gender, hereafter denoted same-sex/gender)
and other-sex (or other-gender, hereafter denoted other-sex/gender) desires. Such
shifts may be transient or lead to a lasting change in their overall pattern of attrac-
tions, desires, fantasies, and behaviors.
Sexual fluidity is defined as the capacity for one’s attractions, desires, fantasies,
and behaviors to be flexible and change across time, situations, and contexts. Like
sexual orientation, sexual fluidity is a trait that varies from person to person. Some
individuals tend to show stable patterns of sexual attractions, desires, and behav-
iors, whereas others show variation in their overall pattern of attractions, desires,
and behaviors. For example, some gay men and lesbians may experience occa-
sional other-sex/gender attractions whereas others do not, just as some heterosex-
uals experience occasional same-sex/gender attractions whereas others do not.
Furthermore, sexual fluidity differs from bisexuality and other nonexclusive
sexual orientations. One difference is that sexual fluidity does not denote the
direction of your attractions, nor does it imply sexual orientation, whereas bisexu-
ality does. Bisexuality and other nonexclusive sexual orientations imply stable,
enduring predispositions toward a pattern of mixed sexual attractions, desires,
and behaviors. In contrast, sexual fluidity represents a situation-dependent capac-
ity for change in attractions, desires, and behaviors and does not specify the direc-
tion of this change (you can be a fluid lesbian, a fluid heterosexual, etc.). Because
both fluidity and bisexuality may look similar (both show a nonexclusive pattern
of attractions), it is difficult for researchers to know whether nonexclusive patterns
of attractions, desires, and behaviors arise from a nonexclusive sexual orientation
or sexual fluidity. Nonetheless, research has repeatedly demonstrated that indi-
viduals have the capacity to have flexible erotic responses over time.
244 Fluidity, Sexual
Researchers believe that female sexuality is more fluid than male sexuality.
Several studies have shown that more cisgender (individuals whose gender iden-
tity and birth-assigned sex align) women than cisgender men show patterns of
nonexclusive sexual attractions. In fact, many studies examining the percentage of
exclusive and nonexclusive attractions among lesbian, gay, bisexual, and other
nonheterosexual sexual orientations (LGB+) individuals demonstrate that more
than half of cisgender LGB+ men show an exclusive pattern of same-sex sexual
attractions. Yet, the majority of cisgender LGB+ women show nonexclusive pat-
terns of attractions. In addition, cisgender women are more likely than cisgender
men to show change in their desires, attractions, and behaviors over time (from
year to year). This pattern is also evident at the population level. For example, the
percentage of people reporting same-sex/gender sexual behavior across the past
several decades has been relatively stable for men, whereas the percentage of
women reporting same-sex/gender sexuality has increased linearly over the past
several decades.
The reasons as to why female sexuality is more likely to be fluid than male
sexuality are unclear. However, some researchers believe that social factors are
relevant. For example, one study examining the percentage of people reporting
same-sex/gender sexual behavior in the United States demonstrated that the
changes in same-sex/gender sexuality across the population years were driven by
increases in bisexual patterns of behavior. That is, rates of nonexclusive same-sex/
gender sexual behavior changed, whereas exclusive same-sex/gender sexual
behavior did not change. This study also found that such population-wide increases
in same-sex/gender behavior were partially attributable to increases in social
acceptance of same-sex/gender sexuality.
Some researchers suggest that social and cultural factors may explain gender
differences in sexual fluidity. It is well documented that female sexuality is more
strongly shaped by social factors than is the case for male sexuality. One possibil-
ity is related to a historical context in the United States, in which female sexuality
has been subjected to far greater control than male sexuality. As this social control
lessens, perhaps there is an increase in women’s willingness to act on predisposi-
tions for bisexuality that went unexpressed in previous (and more restrictive)
decades. Another possibility that some have posited is that there may be more
cultural homophobia directed toward men’s same-sex/gender sexuality than wom-
en’s same-sex/gender sexuality. If social acceptance of same-sex/gender sexuality
continues to increase, might men eventually be just as fluid as women? Although
the answer to this question is as of yet unknown, more research will likely illumi-
nate a greater understanding of these potential gender differences. Like all forms
of human behavior, multiple factors (genetic, endocrinological, biological, social,
cultural, emotional, cognitive) likely influence sexual fluidity.
Finally, capacity for a flexible erotic response does not mean that individuals
who are sexually fluid can choose their sexual responsiveness. Research has dem-
onstrated that effortful attempts to change one’s sexual attractions, desires, and
behaviors are not effective and are potentially harmful. Rather, sexual fluidity
denotes unintentional, noneffortful change. As Lisa Diamond has eloquently
stated in a recent article, “Whereas observational studies of ‘naturally occurring’
Follicle-Stimulating Hormone 245
change can reveal important information about the expression of sexuality of the
life course, studies on effortful therapeutic change are primarily relevant for
understanding the psychological consequences of the social privileging of hetero-
sexuality over same-sex sexuality.”
Janna A. Dickenson and G. Nic Rider
See also: Bisexuality; Fluidity, Gender; Same-Sex Attraction and Behavior; Sexual Iden-
tity; Sexual Orientation.
Further Reading
Baumeister, R. F., & Twenge, J. M. (2002). Cultural suppression of female sexuality.
Review of General Psychology, 6(2), 166.
Diamond, L. M. (2008). Sexual fluidity: Understanding women’s love and desire. Cam-
bridge, MA: Harvard University Press.
Diamond, L. M. (2016). Sexual fluidity in male and females. Current Sexual Health
Reports, 8(4), 249–256.
Twenge, J. M., Sherman, R. A., & Wells, B. E. (2016). Changes in American adults’
reported same-sex sexual experiences and attitudes, 1973–2014. Archives of Sex-
ual Behavior, 45(7), 1713–1730.
Follicle-Stimulating Hormone
Follicle-stimulating hormone (FSH) is a hormone produced by the pituitary gland
that plays an essential role in regulating the menstrual cycle by helping to trigger
ovulation. It is also present in males and is essential to the production of sperm.
In the female body, the level of FSH changes according to the phase of the men-
strual cycle. FSH peaks right before ovulation, as the hormone plays a role in
selecting the most mature follicle in the ovaries for releasing an egg. Once ovula-
tion occurs, the level of FSH decreases. If pregnancy does not occur, FSH begins
to build up again after the menstruation period ends as the female body prepares
for the next cycle of ovulation. It is also responsible for the onset of puberty regard-
ing the maturation of the ovaries.
In the male body, FSH levels remain mostly constant because there is no cyclic
process to the male reproductive system. FSH works with other hormones to
maintain healthy sperm cell production. The hormone also plays a role in the onset
of puberty and the development of testicular function.
Monitoring of FSH levels can help to diagnose and often resolve problems with
infertility. In women, measuring the amount of FSH in the blood can tell doctors
if a woman is ovulating normally and, if she is not, to determine what may be the
problem. An FSH blood test can indicate the presence of ovarian cysts (benign
fluid-filled growths on the ovaries) or polycystic ovary syndrome, in which a hor-
mone imbalance causes follicles to fail to release eggs and to develop into small
cysts instead.
Higher FSH levels can also indicate the onset or completion of menopause (the
ending of monthly menstrual periods) and is especially helpful in diagnosing pre-
mature menopause. Abnormally high FSH levels can also indicate the presence of
a tumor in the pituitary gland. Finally, high levels of FSH can also be a sign of
246 Foreplay
Turner syndrome, in which an individual has only one X chromosome (a normal
female chromosome pair is XX). Low amounts of the hormone may also be caused
by abnormally low body weight and malfunction of the pituitary gland.
In men, the FSH test can determine if the testicles are producing sperm of nor-
mal quantity and quality. Higher than normal FSH levels in men may be caused by
advanced age; genetic abnormalities such as Klinefelter syndrome, in which a
man has an extra X chromosome resulting in an XXY genotype (normal males
have an XY chromosome pair); and damage to testicles due to alcohol abuse, che-
motherapy, or radiation. It may also indicate a tumor in the pituitary gland.
In children, the FSH test is given to determine if higher or lower levels of the
hormone than normal are present. Higher than normal amounts of FSH can result
in the early development (younger than age ten) of secondary sex characteristics,
while lower than normal amounts can tell doctors why some adolescents have a
delay in the onset of puberty (later than age fifteen).
Synthetic FSH is sometimes given to women in combination with luteinizing
hormone to treat infertility. This combination is called menotropins and is most
often used when other types of fertility treatments have failed, such as clomi-
phene. It is administered as a subcutaneous injection immediately prior to ovula-
tion. It may also be given to men to promote better sperm production. However,
menotropins are usually used to stimulate a greater number of follicles to ovulate
in preparation for intrauterine insemination, gamete intrafallopian transfer, or in
vitro fertilization.
Although menotropins can successfully result in pregnancy, there are several
risk factors involved in their use. Due to the fact that more than one follicle is
being developed, the risk of ovarian hyperstimulation syndrome (OHSS) is higher.
It is a painful condition and can be life-threatening if not treated. Symptoms of
OHSS include severe abdominal pain, nausea and vomiting, weight gain, diar-
rhea, shortness of breath, and decreased urine output. The maturation of more
than one follicle also increases the chance of becoming pregnant with multiple
babies. Using menotropins is also associated with increased risk of blood clots,
stroke, or heart attack, as well as a higher incidence of ovarian cancer.
Christina Girod
See also: Fertility Drugs; Infertility; Menstruation; Ovulation; Sex Hormones.
Further Reading
Goldberg, J., & Krause, L. (2016). What is a follicle-stimulating hormone level test?
Retrieved from https://www.healthline.com/health/fsh
National Institutes of Health. (2019). Follicle-stimulating hormone (FSH) levels test.
Retrieved from https://medlineplus.gov/lab-tests/follicle-stimulating-hormone-fsh
-levels-test/
Stewart, S. C. (1996). The American Medical Women’s Association guide to fertility and
reproductive health. New York: Dell Publishing.
Foreplay
“Foreplay” usually refers to various intimate activities that people engage in
before sexual intercourse or before some other sexual act. Foreplay activities, such
Foreplay 247
as kissing and caressing, typically have the effects of increasing sexual desire and
arousal in both partners and often lead to some form of sexual act in which one or
both partners experience orgasm.
Importantly, however, foreplay does not have to lead to an orgasmic sexual act.
People also sometimes engage in foreplay activities just to enjoy the pleasurable
feelings generated by those activities. Foreplay is important if all participants are
to thoroughly enjoy the sexual experience, including both the physical sensations
and the emotional feelings. Foreplay helps ensure that partners are in a similar
sensual and erotic mood and that they want the same thing—to share sexual plea-
sure with each other.
It is commonly believed that women enjoy foreplay more than men. However,
foreplay “works” as a result of biochemical reactions that all people experience.
Foreplay helps all people obtain more enjoyment out of the sexual experience by
increasing levels of oxytocin, dopamine, and other biochemical hormones that
lead to feelings of pleasure in the brain. Foreplay further increases blood flow to
the skin, which makes nerves in the skin more sensitive to touch. The nerves relay
sensations to the brain, which interprets them as pleasurable.
Any act meant to increase sexual interest, desire, or arousal can be considered
foreplay. Verbal aspects of foreplay may include flirtatious chatting or teasing,
suggestive whispering, compliments, or even an intelligent conversation that
engages both individuals. Text messaging or phone calls with flirtatious com-
ments might also be considered verbal foreplay. Visual aspects of foreplay may
include the wearing of sexy clothes in front of an intended partner, such as a
woman showing off her legs in a miniskirt and stiletto heels to a man in whom she
is interested. The gradual removal of clothes—either by the person wearing them
or by that person’s partner—can also be an effective form of foreplay. Certain
body postures, such as a suggestive crossing of the legs, may be considered fore-
play. Visual foreplay can be as simple as the wink of an eye or a prolonged gaze.
Atmospheric aspects of foreplay may involve dim lights, candles, and romantic
music. Some people consider an entire date, such as a movie and dinner, an
extended form of foreplay if it leads to sexual intercourse.
When most people think of foreplay, however, they think of intimate acts that
involve physical contact, usually in the privacy of a bedroom, living room, or
other place away from other people. Physical foreplay might begin with a soft kiss
on the neck, an intermingling of fingers, or a gentle stroke of an arm or leg. This
may progress to more passionate kissing and the removal of clothing. Foreplay
usually reaches its height with various forms of touching, rubbing, caressing, hug-
ging, kissing, licking, nibbling, or sucking of body parts that have extra nerve
sensitivity or special sensual connotations—so-called erogenous zones. These
parts include the breasts and nipples, the shoulders, the stomach, the inner thighs,
the buttocks, and the genitals. Any part of the body may be touched in foreplay to
help elicit erotic feelings.
Some people engage in certain kinds of “games” as part of foreplay. They might
enjoy role-playing or fantasy games in which they dress in erotic, sexually stimu-
lating clothing. For example, a man might cross-dress in women’s lingerie, or a
woman might dress like a leather-clad dominatrix, playfully enforcing acts of dis-
cipline on her partner. Some partners get excited by playing bondage games,
248 Foreskin
involving such equipment as handcuffs, chains, and ropes. Other partners may get
“turned on” by watching pornographic videos as part of foreplay. Sex toys, such
as vibrators and dildos, are common objects used in foreplay, though they may
also be used in the sexual act itself. Foreplay games are limited only by the imagi-
nation of the people involved as well as by whatever the partners find acceptable.
Some people use alcohol, cannabis, or other mind-altering substances to
enhance the sensual feelings of foreplay. Whatever acts, games, or substances are
used in foreplay, it is ethically important that both partners feel comfortable and
safe in using them. If one partner objects to any form of foreplay, the other partner
should respect that objection.
A. J. Smuskiewicz
See also: Afterplay; Arousal; Erogenous Zones; Kissing; Oxytocin; Touching, Sexual
Arousal and.
Further Reading
Ross, L. (2010). The secrets to sensational foreplay: The hottest ways to touch your lover
for incredible pleasure, stronger orgasms, and longer, better sex. Minneapolis:
Quiver/Quarto Publishing.
Spurr, P. (2008). Fabulous foreplay: The sex doctor’s guide to teasing and pleasing your
lover. New York: St. Martin’s Griffin.
Foreskin
In the human male, the foreskin is a double-layered fold of skin, smooth muscle,
and nerves that covers the glans and the urinary meatus at the tip of the penis. The
role of the foreskin remains somewhat unclear. Some believe it protects the glans
and increases the pleasure of sexual intercourse by increasing sensitivity. The
foreskin also provides natural lubricant for the glans, making intercourse more
enjoyable for both partners. For others, the role of the foreskin is minor. Its removal
through circumcision is a method of improving hygiene and preventing medical
issues with the penis. Circumcision also plays an important religious role in cer-
tain faiths, such as Judaism.
The foreskin is also sometimes referred to as the “prepuce,” which is a broader
technical term that includes the clitoral hood in women. The outer skin of the fore-
skin is an extension of the penis’s skin and covers almost, if not all, of the penis
when in a flaccid state. However, when the penis is erect, the foreskin is drawn back.
The tip of the foreskin includes a band of skin with many nerve endings that respond
to fine touch. The inner skin is also exposed, and it includes many nerve endings.
During intercourse or masturbation, the sensitivity of these areas increases the
pleasurable experience of the male. The foreskin also keeps the glans moist, acting
as a natural lubricant. Some research indicates that the loss of the foreskin decreases
the sensitivity of the glans. It may also reduce the likelihood of ejaculation.
The foreskin normally cannot be retracted until males reach a certain age. Forc-
ing it can cause pain and injury. Other medical conditions related to the foreskin
include phimosis, in which the foreskin cannot be pulled back from the glans. The
resulting inability to make sure the area under the foreskin is kept clean may lead
Foucault, Michel 249
to a painful infection called balanitis. A more serious problem is paraphimosis. In
this case, the foreskin is pulled back but swells and cannot return to its position
covering the glans. This situation is a medical emergency and requires quick
action to prevent the loss of blood flow to the glans. Paraphimosis may require
immediate circumcision in some cases.
Tim J. Watts
See also: Circumcision; Penis; Phimosis; Religion, Diversity of Human Sexuality and.
Further Reading
Better Health Channel. (2014). Foreskin care. Retrieved from https://www.betterhealth
.vic.gov.au/health/conditionsandtreatments/foreskin-care
NHS. (2018). Tight foreskin (phimosis and paraphimosis). Retrieved from https://www
.nhs.uk/conditions/phimosis/
Foucault, Michel
Significantly challenging contemporary assumptions surrounding the concept of
sexuality, Michel Foucault (1926–1984) was a renowned French philosopher of the
late twentieth century. Most famous in the realm of sexology for his innovative
assertion that the overall concept of “sexuality” is not only subject to the influence
of cultural relevance but is actually a social construct in and of itself has revolu-
tionized many areas in the field of study. His deconstructive analyses comparing
modern and historical contexts of sexual behavior support the notion of present-
day sexuality as a venture only as recent as the eighteenth century. More specifi-
cally, he argued that the tendency to classify people according to categories based
on particular sexual behaviors, such as the operations of sexual orientation, is
uniquely modern in that sexual behaviors had been previously understood as
descriptive components of a person and are now essentially fashioned into pre-
scriptive models to claim as one’s sexual identity (Clark, 2008).
While recognizing the obvious advantages to organizing in the name of civil
liberties, Foucault did not agree with invalidating the whole of our personhood by
sexualizing ourselves and commodifying our interests. Foucault hoped society, as
a whole, could ultimately surpass the need to advance sexual minority politics by
developing a more universalized understanding of queerness that might assume a
multifaceted spectrum of diversity as the new norm. He saw transgression of
established mores as sanctioning them the default, thus fundamentally depending
on them. For this, and various other social commentaries, Foucault has had a tre-
mendous influence on queer and feminist theory, especially in regard to sexual
identity politics. While often critiqued for an overall lack of consideration for the
female experience in his social analyses, his suggested alternatives were ulti-
mately inclusive substitutions for the current alienating systems.
Educated in Paris at the elite École Normale Supérieure, Foucault had the lux-
ury of studying with distinguished existential-phenomenologist Maurice Merleau-
Ponty. This is where he also met philosopher historian George Canguilhem, who
would later assist with his doctoral thesis Folie et déraison: Histoire de la folie à
l’âge classique (Madness and Insanity: History of Madness in the Classical Age).
250 Foucault, Michel
With degrees in philosophy, psychology, and eventually a diploma from the Insti-
tut de Psychologie at Paris for psychopathology, Foucault went on to teach in Paris,
Sweden, Tunisia, and Germany in the 1950s and 1960s. His first major publication
Folie et déraison: Histoire de la folie à l’âge classique (Madness and Civilization:
A History of Insanity in the Age of Reason, 1961), was quickly followed by Nais-
sance de la clinique: Une archéologie du regard médical (The Birth of the Clinic:
An Archaeology of Medical Perception, 1963), and Les mots et les choses: Une
archéologie des sciences humaines (The Order of Things: An Archeology of the
Human Sciences, 1966). In 1968, he was sought out to establish a philosophy
department at Le Centre Expérimental de Vincennes outside of Paris. He left there
soon after, in 1969, when he was elected to join Collège de France as the newly
named chair, “history of systems of thought.”
As a very involved political advocate in the 1960s and 1970s, Foucault worked
closely with antiracist campaigns and efforts toward institutional penal reform,
among others, while he lectured at various universities and worked on his publica-
tions. The first of his Histoire de la sexualité (History of Sexuality) series, La
volonté de savoir (The Will to Knowledge), was released in 1976. His original
plans to compose a six-volume series would never come to fruition, as he would
only publish another two before his death: L’usage des plaisirs (The Use of Plea-
sure) and the unfinished Le souci de soi (The Care of the Self).
In the time Foucault directed toward sexuality and sexual identity, he took par-
ticular interest scrutinizing the influence of Western medicine and the Roman
Catholic Church. His perspective of institutionalized sexuality as a means to con-
trol a given culture was refreshingly contrary to that of his colleagues. Adamantly
refusing the notion that the twentieth century had “liberated” the modern world
from the confines of the Victorian era, he proposed that stringent religious prohi-
bitions of sex did not necessarily indicate a lack of its presence. Coining the term
“repressive hypothesis,” Foucault did not believe such a theory realistically
accounted for the lived experience of sex as part of human socialization. He was
less concerned with any allowances afforded and more focused on what new form
sexual regulation had espoused. When dictated solely by Christian traditions and
sexuality beliefs, acceptable sexual behavior was simply a matter of refraining
from condemned acts. With the introduction of the pathological model, medical
recognition of same-sex attraction shifted public opinion from what is “evil” to
who may be “sick,” removing the action of choice. When further exploration of
homosexuality as an ailment exposed it simply as a natural inclination, Foucault
remarked that such validation of “homosexuality” essentially alienated the homo-
sexual as another species. Historically used for matters of convenience, he now
saw classification reducing many to their sexual orientation, subsequently dis-
counting all other attributes as secondary to this main aspect of identity. Foucault
found this incredibly limiting in the shaping of one’s self and the surrounding
discourse. For this, he praised the ancient Greeks in their concern for themselves
as works of art. To “know thyself” outside of any preconceived archetypes would
be the inspiration for his last published work before dying of AIDS-related com-
plications in 1984.
Ilyssa Boseski
Freud, Sigmund 251
See also: Homosexuality; Queer; Religion, Diversity of Human Sexuality and; Sexual
Identity; Sexual Orientation; Sexual Revolution; Sexualization; Stereotypes, Sexual; Vic-
torian Era.
Further Reading
Bullough, V. L., & Brundage, J. A. (1996). Handbook of medieval sexuality. New York:
Routledge Taylor & Francis Group.
Clark, A. (2008). Desire: A history of European sexuality. New York: Routledge Taylor &
Francis Group.
Foucault, M. (1978). The history of sexuality (Vols. 1–3, R. Hurley, Trans.). New York:
Random House. (Original work published 1976)
Karras, R. M. (2005). Sexuality in medieval Europe: Doing unto others (2nd ed.). New
York: Routledge Taylor & Francis Group.
Siedman, S., Fischer, N., & Meeks, C. (2011). Introducing the new sexuality studies (2nd
ed.). New York: Routledge Taylor & Francis Group.
Freud, Sigmund
Sigmund Freud was a doctor in Austria who specialized in treating mental illnesses
during the late 1800s and early 1900s. He developed a treatment method called
psychoanalysis that is still used today. This “talking treatment” involves getting
patients to talk openly about their feelings and personal history. Freud believed that
many anxieties and emotional problems stem from traumatic events, unresolved
conflicts, or unfulfilled wishes from a person’s past, particularly childhood. He
wrote and lectured about his theories concerning the conscious and unconscious
mind, the importance of dreams, and sex-based desires. His ideas about sexuality
were considered shockingly indecent at the time and remain controversial.
Sigismund Schlomo Freud was born on May 6, 1856, in Freiberg, Moravia, later
part of the Czech Republic. Because of their Jewish heritage, his family endured
anti-Semitic sentiments. They moved to Vienna, Austria, in 1860. Freud was
extremely smart and learned multiple languages before he was a teenager. He
wanted to become a research scientist but was not allowed by authorities to do so
because of his Jewish background. Instead he went to medical school at the Uni-
versity of Vienna and studied neurology. He graduated in 1881.
Following graduation, Freud worked at a psychiatric clinic and became a pro-
ponent of a new drug called cocaine. He used it recreationally and enthusiastically
recommended it to others. In that era, doctors did not know that cocaine was
addictive. Freud did not become addicted to the drug, but this did happen to some
of his colleagues. He did become a habitual cigar smoker, eventually smoking up
to twenty-four cigars daily.
Freud focused on a condition called hysteria. It was characterized by anxiety or
personality disorders along with physical symptoms with no apparent biological
cause. Freud’s friend, Dr. Josef Breuer, treated a young woman who had fits of
confusion and delirium and episodes of muscle paralysis and other physical prob-
lems. Breuer encouraged her to talk openly about her past. He found that she tem-
porarily felt better when she recalled her experiences around the time her
symptoms first began. Freud became convinced that hysteria develops in people
252 Freud, Sigmund
who have suffered some traumatic event in the past and then deeply buried their
memories of it. The idea of repressed memories would become a cornerstone of
psychoanalysis.
In 1895, Breuer and Freud published their findings in Studies in Hysteria. By
this time, Freud had a thriving private practice. He had his patients recline on a
couch in a soothing environment while they talked about their personal histories.
Freud counseled them to remember and acknowledge forgotten traumas or unre-
solved problems from the past. Then these issues were examined and discussed
openly in an attempt to relieve the anxiety they had caused.
Freud considered dreams as peeks into the unconscious mind. His book The
Interpretation of Dreams (1900) explained his early theories on this subject. It was
followed by The Psychopathology of Everyday Life (1901), in which Freud said
that slips of the tongue can have hidden meanings. For example, accidentally say-
ing goodbye rather than hello when meeting a person could indicate buried
unfriendly feelings about that person. Such slips of the tongue became known as
“Freudian slips.”
During Freud’s lifetime, sexuality was not discussed openly. He broke this
taboo with publication in 1905 of Three Essays on the Theory of Sexuality. Freud
argued that the sex drive plays a huge role in human behaviors, not only for adults
but also for children. His theories on childhood psychosexual development were
considered scandalous and are still controversial today. For example, he theorized
that young boys go through a stage in which they develop a sexual attraction to
their mothers and hate-tinged jealousy of their fathers. This became known as the
Oedipus complex, named after a character in an ancient Greek play.
In 1923, Freud published The Ego and the Id, which describes the three parts of
the psyche (the mental processes, emotions, and drivers of behaviors). The id
encompasses deeply selfish desires and is present at birth. As a child develops so
does another part of the psyche called the ego. It functions both in the unconscious
and conscious mind and creates realistic strategies to satisfy id-based desires. Last
to develop is the superego. It consciously considers the social limits on behavior
and the ramifications for violating them. Freud’s theory is considered a revolution-
ary way of looking at the competing needs that drive human emotions and
behavior.
Also in 1923, Freud was diagnosed with oral cancer, a consequence of his long
addiction to cigar smoking. He underwent dozens of surgeries and painful proce-
dures even as he continued to see patients. In 1938, Nazi Germany invaded Aus-
tria. Freud’s Jewish background put him in danger; however, he was allowed to
flee the country. His cancer worsened and caused him great pain. Finally, he asked
his physician to administer him a lethal dose of morphine. He died on September
23, 1939, in London. He was eighty-three years old.
Although many of Freud’s theories—particularly those relating to dreams and
sexuality—have been heavily criticized and are no longer considered part of
mainstream psychology, he has nevertheless made a lasting contribution to the
fields of both psychology and sexology.
Kim Masters Evans
See also: Ellis, Henry Havelock; Oedipus Complex; Psychosexual Therapy.
Friends with Benefits 253
Further Reading
Jacobs, M. (2003). Sigmund Freud. London: SAGE.
Loftus, E. F. (1993). The reality of repressed memories. American Psychologist, 48,
518–537.
PBS. (1998). Sigmund Freud. Retrieved from http://www.pbs.org/wgbh/aso/databank/entries/
bhfreu.html
Friends with Benefits
Friends with benefits (FWB) relationships are a type of ongoing casual sex rela-
tionship in which two (or more) people agree to have sex with each other without
the expectation of a committed romantic relationship. FWB relationships combine
characteristics of friendship relationships with aspects of sexual relationships, and
they are very common; around half of first-year university students report having
had at least one FWB relationship.
While casual sex is not a new phenomenon, the way people describe and expe-
rience casual sex varies by time and by culture. In Western culture, social norms
have shifted so that there is greater acceptance of premarital sex than in past
decades. In addition, many people are waiting until they are older to get married,
as compared to previous generations. There are many factors that contribute to
this, including more acceptance of casual sex, as mentioned, but also because of
advances in contraception and because more people are attending university or
other postsecondary education. As a result of prolonged education, many young
adults incur debt or live with minimal income; consequently, many choose to live
at home longer and may delay marriage until they are more stable, both financially
and in their careers. Prior to having a long-term committed relationship or mar-
riage, some people may choose to engage in casual sexual relationships, including
having one or more FWB relationship(s).
FWB relationships have been defined as “sex between two people who have an
existing friendship, these two may or may not engage in sexual activity when they
hang out with each other, they are usually not under the influence of alcohol or
drugs, these two engage in sex with each other regularly” (Wentland & Reissing,
2014). Research suggests that FWB relationships differ from other types of casual
sex relationships because FWB relationships include formal discussions about
engaging in sexual activity, whether or not the relationship is exclusive or monog-
amous, and when to end sexual activity. People who engage in an FWB are also
more likely to continue to have contact with each other after the sexual component
of the relationship has ended. The increased level of communication between peo-
ple in an FWB relationship is unique to this type of casual sex relationship. Fur-
ther, research indicates that people in an FWB relationship have higher levels of
respect and care for their FWB, and it is important to them that all partners agree
to their negotiated rules about the relationship.
People begin FWB relationships for a variety of reasons. Among a sample of
people in an FWB relationship, sex was the most commonly reported motivation
for beginning the relationship, and wanting an emotional connection was second.
Other motivations for FWB relationships included relationship avoidance and
254 Frotteurism
relationship simplicity as well as simply wanting an FWB relationship. Finally,
some participants in this study also noted that sometimes there was no specific
motivation to begin the relationship and that it spontaneously developed. FWB
relationships are typically ongoing and usually end when one of the partners
enters into a new dating relationship with another person.
Heather L. Armstrong
See also: Casual Sex; Dating; Hookup Culture; Online Dating.
Further Reading
Bisson, M. A., & Levine, T. R. (2009). Negotiating a friends with benefits relationship.
Archives of Sexual Behavior, 38(1), 66–73.
Mongeau, P. A., Knight, K., Williams, J., Eden, J., & Shaw, C. (2013). Identifying and
explicating variation among friends with benefits relationships. Journal of Sex
Research, 50(1), 37–47.
Stein, J. B., Mongeau, P., Posteher, K., & Veluscek, A. (2019). Netflix and chill?: Explor-
ing and refining differing motivations in friends with benefits relationships. Cana-
dian Journal of Human Sexuality, 28(3), 317–327.
Wentland, J. J., & Reissing, E. D. (2011). Taking casual sex not too casually: Exploring
definitions of casual sexual relationships. Canadian Journal of Human Sexuality,
20(3), 75–91.
Wentland, J. J., & Reissing, E. D. (2014). Casual sexual relationships: Identifying defini-
tions for one night stands, booty calls, fuck buddies, and friends with benefits.
Canadian Journal of Human Sexuality, 23(3), 167–177.
Frotteurism
Frotteurism involves a person gaining arousal from rubbing a body part against
someone else without consent. A person who engages in frotteurism is a “frotteur.”
Academics reference the behavior as “frottage,” a French word meaning “rubbing.”
The first scholar on record to explore the behavior is Richard Freiherr von Krafft-
Ebing, who wrote about it in Psychopathia Sexualis (1886). Frotteurism first
appeared as a paraphilia in the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM) in 1980. In the current version of
the DSM, frotteurism involves repetitive, intense sexual arousal from nonconsent-
ing touching or rubbing that impairs social functioning and lasts at least six months.
Frotteurs are typically middle-class young males with high IQs. They target
women in crowded public places, where the likelihood of bodily contact is great.
Research implies this includes locations such as elevators, buses, subways, con-
certs, and churches. The goal involves deliberately bringing a clothed part of the
body into contact with the target. Some frotteurs desire contact involving any part
of the body, but the height of frotteurism involves areas directly related to sexual
arousal. This includes the genitals but also the buttocks and breasts. Traditionally
interpreted as a voluntary action, researchers are now considering the likelihood
of impulsive frotteurism, which involves a hypersexual person with severe psychi-
atric illness. Research shows as many as 10 percent of males have engaged in frot-
teurism. Samples of males who claim to have coerced a female into sex have
frotteurism participation rates up to 77 percent.
FTMInternational 255
Victims are typically attractive to the frotteur, wear tight clothing, and fail to
recognize victimization. Female college students self-report high rates of victim-
ization. People are often unsure if they are victims with cultural norms typically
allowing a limited amount of touching in crowded environments. Some frotteurs
target multiple victims in one situation. Others target one person, who is typically
the object of their sexual fantasies. After contact, some frotteurs retreat to a pri-
vate location to masturbate. The occurrence of an orgasm may take place when
contact occurs if the frotteur is extremely aroused.
Consensual-based behaviors associated with frotteurism may unintentionally
support actions associated with it. This includes lap dances given by exotic danc-
ers, dancing while using themes of sex simulation, and abstinence-related “dry
humping.”
There is limited literature on frotteurism. What does exist typically uses small
samples derived from convenience. Moreover, previous research inconsistently
applies diagnostic criteria cited in the literature. More studies to legitimize exist-
ing research, and generate new information, are necessary.
Jason S. Ulsperger
See also: Arousal; Diagnostic and Statistical Manual of Mental Disorders (DSM); Krafft-
Ebing, Richard von; Paraphilias.
Further Reading
Clark, S. K., Jeglic, E. L., Calkins, C., & Tater, J. R. (2016). More than a nuisance: The
prevalence and consequences of frotteurism and exhibitionism. Sex Abuse:
A Journal of Research and Treatment, 28(1), 3–19.
Johnson, R. S., Ostermeyer, B., Sikes, K. A., Nelsen, A. J., & Coverdale, J. H. (2014).
Presence and treatment of frotteurism in the community: A systematic review.
Journal of the American Academy of Psychiatric Law, 42(4), 478–483.
Langstrom, N. (2010). The DSM diagnostic criteria for exhibitionism, voyeurism, and
frotteurism. Archives of Sexual Behavior, 39(2), 317–324.
FTMInternational
Female to Male International (FTMI), also known as FTMInternational, was
founded in 1986 by Lou Sullivan in San Francisco, California. With the mission
“FTMInternational builds and strengthens FTM lives,” FTMI is the first known
organization specifically to support and connect transgender men worldwide.
FTMInternational has provided hundreds of educational presentations, panels,
and workshops and has been featured in numerous documentaries on television,
film, and radio as well as in major magazines and newspapers. FTMI also pro-
vides extensive public education on the transgender community.
Sullivan began holding support group meetings in December 1986 and started
publishing the FTMI quarterly newsletter in 1987. He got the idea for FTMI from
a Los Angeles group known as Under Construction, founded in 1983 by Jeff
Shevlowitz.
In 1992, FTMI published the first edition of The FTMI Yellow Pages, a resource
guide for transgender men. As the community grew, it became too time-consuming
256 FTMInternational
to continue updating the resource guide. The eighth and final printed edition in
2005 was 108 pages in length.
FTMI has a long list of accomplishments and community “firsts,” such as orga-
nizing one of the first conventions specifically for transgender men. A Vision of
Community: The First All-FTM Conference of the Americas was held August
1–20, 1995, in San Francisco and continued annually for three years. FTMI also
provided support for other FTM gatherings in North America in the early 2000s,
including True Spirit, FORGE Forward, and the Malibu Men’s Retreat, among
others. A popular fund-raising project titled Calendar: The Men of FTMI was
published in 2005 and featured photos of transgender men in classic “beefcake”
poses.
Another important service provided by FTMI was developing and maintaining
a network of support groups for transgender men to connect with each other and
share experiences and resources. During the most active period in the 2000s,
FTMI had about 5,000 members around the world, with chapters or affiliated
groups in more than a dozen U.S. cities as well as other countries.
In addition to his community-building work, founder Lou Sullivan was also a
writer and researcher who published several books and papers about the transgen-
der experience. He was one of the first FTMs to openly identify as a gay man.
Like a number of other young gay men of his generation, Sullivan became HIV-
positive and died in 1991 of complications from AIDS. FTMI developed the Lou
Sullivan Award in his name; it has been awarded to approximately fifteen trans
men since its inception, beginning with Jamison Green, who became president of
FTMI after Lou’s death.
FTMI received designation as a 501(c)(3) nonprofit organization in 1996. Chap-
ters continue operations around the globe. The quarterly newsletter is available
via email subscription, and a listing of professionals and clinics for gender dys-
phoria is available online at www.ftmi.org or by phone at (877) 267-1440.
C. Michael Woodward
See also: Gender Expression; Gender Identity; Gender Transition; Green, Jamison; Trans-
gender; Transsexual.
Further Reading
FTMInternational. (2019). Home page. Retrieved from www.ftmi.org
Smith, B. D. (2017). Lou Sullivan: Daring to be a man among men. Oakland, CA: Trans-
gress Press.
G
Galactorrhea
Galactorrhea is a spontaneous discharge of milky fluid from the nipples. It is not
related to breastfeeding and can occur in adults of any gender, as well as in infants,
although it is most commonly seen in women. Galactorrhea itself is not a disease
but rather is a symptom of an underlying condition. Research suggests that some-
where between 5 percent and 32 percent of all women are affected by this issue.
There are many possible causes of galactorrhea, including chronic kidney dis-
ease, hypothyroidism (an underactive thyroid), an injured spinal cord, use of seda-
tives or other medications, chronic emotional stress, and use of birth control pills.
The most common cause has been identified as overproduction of prolactin, which
is the hormone that stimulates milk production after giving birth. As the pituitary
gland is in charge of producing prolactin, prolactin-secreting tumors in the pitu-
itary gland are largely to blame for this problem. In males, galactorrhea is also
typically associated with decreased testosterone levels. When the condition occurs
in infants, it is usually a result of high estrogen levels in the mother, which cross
the placenta and create enlarged breast tissue and a possible milky discharge in
the baby. At times, however, galactorrhea presents without any known cause.
When this happens, it is usually attributed to prolactin sensitivity, meaning that
even normal levels of prolactin in the body can trigger nipple discharge.
In addition to a milky secretion, galactorrhea may also have other symptoms,
including an abnormal menstrual cycle, increase or decrease in appetite or body
weight, loss of sex drive, headaches, vision problems, and abnormal hair growth.
In order to test for the condition, a medical professional will conduct a physical
exam and run laboratory tests on a fluid sample from the discharge. Blood tests to
check for hormone levels, a pregnancy test, and imaging tests to check for tumors
and suspicious breast tissue are also usually required. After a diagnosis is made, a
course of treatment will be decided. In very mild cases, it is not unusual to recom-
mend no medical treatment and allow the condition to clear on its own. When
treatment is required, it is usually focused on the underlying cause of the problem.
For example, if a pituitary tumor is found to be the cause, medication may be pre-
scribed to shrink the tumor, or surgery may be performed to remove it. In addi-
tion, in the case of hypothyroidism, medication to counteract the low thyroid
activity will most likely be prescribed.
Reports suggest that the earliest known cases of galactorrhea occurred in the
mid-1800s, but correlation between the condition and problems with the pituitary
gland was not made until the 1950s. The development of computed tomography
and magnetic resonance imaging in the 1970s helped to confirm this connection
by allowing doctors to readily identify pituitary tumors. Since this time, much
258 Gay Affirmative Therapy
research related to galactorrhea has been devoted to determining how prolactin
secretion is regulated and developing medications that can help control this func-
tion as well as the growth of pituitary tumors.
Tamar Burris
See also: Breast, Female; Breastfeeding.
Further Reading
Javadpour, N. (1987). Tumor markers: Biology and clinical applications. Westport, CT:
Praeger.
Mayo Clinic. (2019). Galactorrhea. Retrieved from https://www.mayoclinic.org/diseases
-conditions/galactorrhea/symptoms-causes/syc-20350431
Gay Affirmative Therapy
Gay affirmative therapy is a form of psychotherapy for people who experience
same-sex attraction that encourages them to accept their sexual orientation. This
is in contrast to other unethical forms of therapy that try to diminish same-sex
sexual behaviors or to “convert” these behaviors to heterosexual (so-called gay
conversion therapy). Many therapists who practice gay affirmative therapy expand
the coverage of such therapy to bisexual, transgender, and “queer” (challenging
traditional norms of sexuality and gender) or “questioning” (exploring different
sexualities and genders) patients, in which case it is referred to as LGBTQ+ (les-
bian, gay, bisexual, transgender, queer/questioning, and more) therapy. To sim-
plify the present discussion, this article refers to “gay affirmative therapy,” though
the principles discussed could also apply to other LGBTQ+ individuals.
The main guiding principle of gay affirmative therapy is that the patient needs
to feel comfortable, happy, and proud about their sexuality—not ashamed or wor-
ried about it. Patients are helped to embrace their sexuality in a positive (affirma-
tive) way, despite whatever negative reactions they may encounter from other
people.
Several guidelines for gay affirmative therapy are provided by the American
Psychological Association (APA), the American Association for Marriage and
Family Therapy (AAMFT), and other professional associations of therapists.
Many guidelines seek to overcome previous ideas about homosexuality being a
mental illness. Many guidelines also seek to educate professional therapists about
how to help patients successfully deal with antigay stigmas that remain in some
segments of society as well as antigay teachings that remain in some religions.
Therapists are encouraged to educate themselves as much as possible about
LGBTQ+ issues and to become involved with the LGBTQ+ community—even to
become advocates on behalf of the community.
The APA and AAMFT guidelines note that many people with same-sex attrac-
tion encounter opposition not only from society in general but also specifically
from family members and friends who do not understand their sexuality. For
many people, that kind of personal opposition is the most difficult, complex aspect
of their sexual orientation. In some cases, it may be possible for the family or
friends to eventually learn about and accept the individual’s sexual orientation.
Gay Rights Movement 259
Therapy may be able to help the patient talk openly to family and friends about the
issue, and family members might even participate in the therapy sessions. In other
cases, however, overcoming rejection from family or friends is not possible, and
the patient might be encouraged to find emotional support elsewhere, such as with
LGBTQ+ support groups, both in the local community (if available) and online.
Some mental health professionals who provide gay affirmative therapy are clin-
ical psychologists with PhD degrees. Others are licensed clinical professional
counselors. Still others may have other academic credentials. Some may special-
ize in LGBTQ+ issues, while others may have more generalist backgrounds.
When looking for an affirmative therapist, the patient should be sure to feel com-
fortable with, and confident in, the therapist of their choice.
Not all therapists who perform gay affirmative therapy agree with or follow all
the AAMFT or APA guidelines. Nevertheless, their therapy may still be effective
for their clients. Scientific research suggests that, as a whole, gay affirmative ther-
apy can be effective at helping patients live happy, fulfilled lives.
A. J. Smuskiewicz
See also: Heterosexism; Homophobia, Internalized; Homosexuality; Psychosexual Ther-
apy; Same-Sex Attraction and Behavior; Sexual Orientation.
Further Reading
Johnson, S. D. (2012). Gay affirmative psychotherapy with lesbian, gay, and bisexual indi-
viduals: Implications for contemporary psychotherapy research. American Jour-
nal of Orthopsychiatry, 82(4), 516–522.
Kort, J. (2008). Gay affirmative therapy for the straight clinician: The essential guide.
New York: W. W. Norton & Company.
Gay Rights Movement
The gay rights movement refers to the social, legal, and political activities con-
ducted to advance the civil rights of gay and lesbian people. The U.S. movement
dates to the 1950s, when homosexuality was illegal and considered to be a psycho-
logical disorder and dangerously immoral. Gay people regularly faced harassment
from police and discrimination in employment and other areas of their lives. Over
the decades, gay rights advocates have worked to change laws and social attitudes
toward gay and lesbian individuals. Significant reforms have occurred. Homo-
sexuality is no longer illegal or branded a psychological disorder. Many laws and
policies have been amended to prohibit discrimination based on sexual orienta-
tion. For example, gay and lesbian individuals can now openly serve in the U.S.
military and legally marry in all states.
The roots of the U.S. gay rights movement lie in the early 1950s. Many gay
people of that era referred to themselves as homophiles. The prefix “homo-“
means “same,” and the suffix “–philes” means “lovers of.” All states had long-
standing sodomy laws that prohibited oral and anal sex, even between consenting
adults in private. Thus, sexual activities between homophiles were illegal by defi-
nition. The American Psychiatric Association (APA) publishes the Diagnostic and
Statistical Manual of Mental Disorders (DSM), a listing of mental disorders. The
260 Gay Rights Movement
1952 DSM classified homosexuality as a “sociopathic personality disturbance.” A
sociopath is someone who disregards social moral conventions for selfish reasons
and can be so antisocial as to be violent.
The criminality, immorality, and psychological sickness associated with homo-
sexuality were used to justify all kinds of discriminatory practices. People known
or suspected of being gay were refused housing and employment and fired from
their jobs. This was particularly true in occupations that involved children, such
as teaching, and in government and military positions. As a result, many gay pro-
fessionals tried to “stay in the closet”—that is, to keep their sexual orientation a
secret.
A subculture is a group of people with shared beliefs or interests that are differ-
ent from the larger society to which they belong. By the early 1950s, gay subcul-
tures had emerged, particularly in large cities. Homophiles began forming local
organizations to provide a forum to discuss and tackle various civil rights con-
cerns. For example, the Mattachine Foundation (later the Mattachine Society) was
founded by Henry Hay in Los Angeles. Numerous chapters eventually sprang up
around the country.
Within gay subcultures, there were neighborhood restaurants, bars, and clubs
that became favorite hangouts. These establishments were often targeted by local
officials, who viewed them as hotbeds of immoral behavior. Police raids on so-
called gay bars were common during the 1950s and 1960s. Numerous people were
arrested on charges such as public indecency and disorderly conduct; however,
few convictions resulted. The purpose seemed to be harassment. Newspapers of
that era typically listed the names, addresses, and occupations of arrested
individuals.
By the mid-1960s, local homophile groups had banded together under umbrella
organizations such as the East Coast Homophile Organizations and the North
American Conference of Homophile Organizations. Activists staged protests and
picketed in major cities to draw attention to discrimination against gay people. On
June 28, 1969, a popular gay bar called the Stonewall Inn was raided by police in
New York City. The crowd grew angry and began throwing bricks and bottles at
police. The incident sparked several days of protest that attracted thousands of
people.
The Stonewall riot garnered little public attention at the time. It was a tumultu-
ous era with protests raging across the country over the Vietnam War and various
social causes. However, on the one-year anniversary of the Stonewall riot, thou-
sands of gay activists met and marched through New York City. It was likely the
first gay pride parade. In 1973, the APA decided to remove homosexuality from
the DSM. The decision followed intense lobbying by gay rights groups and pro-
tests at APA conventions and meetings. By this time, activists were much more
vocal and public than in the past. Many referred to their cause as the gay liberation
movement.
Gay individuals began making inroads in political circles. A handful of openly
gay men and women were elected to local public office. Perhaps the best known of
them was Harvey Milk, who won a seat on the San Francisco Board of Supervi-
sors in 1977. He was murdered a year later by a former colleague on the board. In
Gay Rights Movement 261
1979, gay activists staged a national march in Washington, D.C., and rallied for
federal laws to protect the civil rights of gay people. Such protections were slowly
being implemented on the local and state level. For example, some cities modified
their housing codes and other ordinances to prohibit discrimination based on sex-
ual orientation. In 1982, Wisconsin became the first state to do likewise.
The gay rights movement faced considerable challenges during the 1980s. Con-
servative politicians, such as President Ronald Reagan, were elected to office with
strong backing from the religious right (chiefly Christian groups favoring tradi-
tional moral values). There was strong resistance and outright resentment against
gay rights activists and causes. Meanwhile, a new and deadly virus emerged that
spread rapidly among men who had sex with men. First called gay-related immune
deficiency disorder, its name was soon changed to acquired immune deficiency
syndrome (AIDS). It was found to be caused by the human immunodeficiency
virus, which is transmitted via bodily fluids, such as semen and blood. Initially,
gay men were the chief victims of AIDS, and thousands of them became sick and
died from it. However, it was soon detected in nongay people and became a public
health priority.
Politicians and religious leaders who thought homosexuality immoral expressed
little to no sympathy for the gay victims of AIDS. A 1987 march on Washington,
D.C., included hundreds of thousands of gay activists demanding action from the
federal government. Although the disease could not be transmitted through casual
contact, public paranoia resulted in harassment and discrimination against gay
and nongay sufferers. By the mid-1990s, the number of new AIDS cases was
down, as was the death rate. The improvement came due to safer sex practices—
for example, greater use of condoms—and powerful new AIDS treatments.
Throughout U.S. history, many tens of thousands of men (and some women)
have been ousted from the military for being (or suspected of being) gay. It is an
issue that has long occupied the gay rights movement. In 1993, the Pentagon
implemented a new “Don’t Ask, Don’t Tell” policy. This provided some level of
employment security for gay service members. However, it still meant that homo-
sexuality had to be kept secret. The policy was finally repealed in 2010. Since that
time, openly gay people have been allowed to serve in the U.S. military.
In the early years of the twenty-first century, the gay rights movement achieved
two major milestones. In 2003, the U.S. Supreme Court ruled in Lawrence v. Texas
that the handful of state laws that still prohibited sodomy were unconstitutional. A
year later, Massachusetts became the first state to allow same-sex couples to legally
marry. More states followed suit, but others resisted, even passing laws specifically
banning gay marriage. In 2015, the U.S. Supreme Court ruled in Obergefell v.
Hodges that laws banning same-sex marriage were unconstitutional.
Kim Masters Evans
See also: Don’t Ask, Don’t Tell; Homosexuality; LGBTQ+; Mattachine Society; Same-
Sex Marriage; Sexual Orientation; Sexual Rights; Sodomy Laws; Stonewall Riots.
Further Reading
Clendinen, D., & Nagourney, A. (2013). Out for good: The struggle to build a gay rights
movement in America. New York: Touchstone/Simon and Schuster.
262 Gay-Straight Alliance (GSA)
Heredia, C. (2002, October). Henry “Harry” Hay—gay rights pioneer. San Francisco
Chronicle.
PBS. (2019). Stonewall Inn: Through the years. Retrieved from http://www.pbs.org/wgbh/
americanexperience/features/stonewall-inn-through-years/
Philipps, D. (2015, September). Ousted as gay, aging veterans are battling again for hon-
orable discharges. New York Times.
Gay-Straight Alliance (GSA)
A gay-straight alliance (GSA) is any of numerous student-led clubs in high schools,
colleges, and universities designed to make the schools safe, supportive learning
and social environments for lesbian, gay, bisexual, transgender, and queer/ques-
tioning (LGBTQ+) students. (“Queer” refers to individuals who challenge tradi-
tional norms of sexuality and gender. “Questioning” refers to individuals who are
exploring different sexualities and genders.) GSA groups are more common and
widespread in the United States than in any other country, though they exist in
several other nations.
The thousands of GSA groups in the United States can maintain connections
with each other and with similar groups through the Gay-Straight Alliance Net-
work, a national youth leadership organization based in San Francisco, California,
and the Gay, Lesbian, and Straight Education Network (GLSEN), an organization
of students, parents, and teachers based in New York City. Some GSA groups use
alternative names to better reflect their particular membership or ideas, such as
Gender-Sexuality Alliance, Queer-Straight Alliance, Pride Alliance, and Project
Rainbow.
Many LGBTQ+ students suffer harassment, bullying, and violence at school,
making school not only a dangerous place for them but also a difficult place to
learn their academic material and to form friendships. Because of these serious
problems, the main focus of most GSAs is raising student awareness of LGBTQ+
issues and enhancing the safety and acceptance of LGBTQ+ students.
GSA groups organize awareness-raising events at their schools and in their
communities. They also usually take part in national LGBTQ+ campaigns, such
as National Coming Out Day, Transgender Day of Remembrance, and GSA Day.
Typical activities at a GSA event, such as National Coming Out Day (October 11),
include meetings in which participants share their personal stories, panel discus-
sions, painting of murals, writing workshops, poetry presentations, concerts, wine
and cheese receptions, and other opportunities for expanding social contacts. For
some events, these activities are spread out over several days.
After their origin in Massachusetts in the late 1980s, GSAs began to spread
throughout the United States in the 1990s. The spread of these organizations
accelerated after the October 1999 federal court ruling in Utah—East High Gay/
Straight Alliance v. Board of Education of Salt Lake City School District. That
case began in 1996, when the Salt Lake City School District tried to prevent a
GSA at East High School from meeting. The American Civil Liberties Union and
other organizations filed a lawsuit on behalf of the East High GSA. U.S. district
Gay-Straight Alliance (GSA) 263
judge Bruce Jenkins ruled that the school district violated the Equal Access Act,
which gives all students the right to use school facilities for extracurricular activi-
ties at any school that receives public funds. That ruling removed all legal obsta-
cles to the establishment of GSAs.
GSAs are proud of their accomplishments in both raising public awareness of
LGBTQ+ issues and in improving the safety of schools for LGBTQ+ students. A
report issued in 2007 by the GLSEN, titled Gay-Straight Alliances: Creating Safer
Schools for LGBT Students and Their Allies, described several findings regarding
GSAs and their accomplishments up to that time. The following are some of these
findings, as they are worded in the report:
• Students in schools with GSAs are less likely to hear homophobic remarks in
school on a daily basis than students in schools without a GSA (57% com-
pared to 75%).
• LGBT students who attend schools with a GSA are less likely than those at
schools without a GSA to report feeling unsafe in school because of their
sexual orientation (61% vs. 68%) or because of the way in which they express
their gender (38% vs. 43%).
• Sexual minority youth (youth who identify as lesbian, gay, or bisexual as well
as youth who have same-sex romantic attractions or engage in same-sex sex-
ual behavior) in Massachusetts schools with GSAs were half as likely as those
in schools without a GSA to report experiencing dating violence, being threat-
ened or injured at school, or missing school because they were afraid to go.
• LGBT students in schools with GSAs are less likely to miss school because
they feel unsafe compared to other students: a quarter (26%) of students in
schools with GSAs missed school in the past month because they felt unsafe
compared to a third (32%) of students at schools without GSAs.
• Students in schools with GSAs or similar student clubs are two times more
likely than students without such clubs to say they hear teachers at their school
make supportive or positive remarks about lesbian and gay people (24% com-
pared to 12%).
• LGBT students in schools with a GSA are significantly more likely than stu-
dents in schools without a GSA to be aware of a supportive adult at school
(84% compared to 56%). LGBT students who report having supportive fac-
ulty and other school staff report higher grade point averages and are more
likely to say they plan to pursue post-secondary education than LGBT stu-
dents who do not have supportive school staff.
• LGBT students in schools with a GSA have a greater sense of belonging to
their school community than students without a GSA.
Since the release of this detailed report by the GLSEN, academic, safety, and
social conditions have continued to improve for LGBTQ+ students in the United
States, according to most GSA leaders. Nevertheless, incidents of intolerance and
violence against LGBTQ+ students still occur at many schools.
A. J. Smuskiewicz
264 Gender
See also: Adolescent Sexuality; Antigay Prejudice; GLSEN (Gay, Lesbian and Straight
Education Network); LGBTQ+.
Further Reading
Gay, Lesbian & Straight Education Network. (2007). Gay-straight alliances: Creating
safer schools for LGBT students and their allies. New York: Gay, Lesbian &
Straight Education Network.
Gay, Lesbian & Straight Education Network. (2019). 10 steps to start your GSA. Retrieved
from https://www.glsen.org/activity/10-steps-start-your-gsa
Gay-Straight Alliance Network. (2019). Home page. Retrieved from http://www
.gsanetwork.org
Gender
Gender is the assigned, assumed, or chosen social category encompassing the
social and cultural characteristics representative of one’s gender identity. “Gen-
der” is a socially constructed word, where the meaning of gender is ever changing
with research and growth in social, emotional, and developmental views. The def-
inition of gender is often confused with sex. Sex is biologically determined from
birth and is a representation of the combination of one’s genetics, chromosomes,
and hormones. An individual’s sex is typically labeled and addressed as male,
female, or intersex. The sex of a body does not bear any necessary or determinis-
tic relationship to the social category, or gender, of that body.
Most individuals identify with their gender assigned at birth, typically boy or
man or girl or woman. Other individuals (intersex) may be born with varied geni-
tals or chromosomal mutations that make gender difficult to assign at birth. There
is currently a heated debate on the appropriate standards of care for intersex
infants. However, not all individuals may identify with the preconceived notions
of their gender identity. Some individuals may identify as a gender other than the
one assigned at birth, which may include, but is not limited to, man, woman, trans-
gender, gender nonconforming, genderqueer, and agender. Gender can be broken
down further to evaluate physical differences between genders, presentation,
expression, and socialization. These aspects of gender are highlighted dependent
on the theoretical lens that people use to look at and discuss gender.
The assumption of gender is typically associated with particular characteristics
of a body associated with maleness or femaleness. These characteristics are asso-
ciated with specific body morphology, or the shape and structure of one’s body, or
secondary sex characteristics. One of the physical qualifiers of gender is based on
a hip to waist ratio; women typically have a smaller hip to waist ratio, while men
have a more equal ratio. Another differential morphological assumption between
men and women is the breadth of shoulders relative to height. Men have broader
shoulders in relationship to their height, while women have a smaller shoulder
breadth. Lastly, men and women tend to have differences between the thickness of
limbs, with men typically having denser limbs than women.
Gender can also be assumed by secondary sex characteristics, which are physi-
cal traits associated with genetic sex or reproductive potential. Some of these
Gender 265
secondary sex characteristics may include skin texture, body fat distribution, and
patterns of hair growth. Based on these secondary sexual characteristics, indi-
viduals are typically assumed into certain gender categories. Men typically have a
rougher skin texture, even body fat distribution, and thicker hair on legs, arms,
and face. Women typically have a softer skin texture, body fat distribution toward
the waist and hips, and thinner hair on legs, arms, and face.
Gender comportment is defined as the performance or presentation of one’s
gender, often based on gender assigned at birth. The performance of gender is a
subtlety taught to children and youth both through direct observation as well as
the redirection of gender-incongruent behaviors. Direct observation could be see-
ing a gender-typical behavior, such as a little girl watching her mom put on
makeup, and interpreting this as a gender-typical behavior. That same little girl
could be redirected toward more gender-congruent behaviors when she is yelled at
for playing in the dirt with other children. Children can get these messages from
family, friends, teachers, the media, or from people in any social situation. Gender
and youth can be taught gender-typical bodily actions such as the ways that one is
supposed to speak, tone of voice, ways of holding their body, and desirable ways
of dressing.
Gender expression is the way that people communicate gender to others via
clothing, mannerisms, hairstyle, and ways of speaking. Gender expression is not
necessarily synonymous with one’s gender assigned at birth or gender identity but
is the way one presents their gender to others. People can express their gender as
feminine, masculine, androgynous, or queer, among others. Gender expression is
fluid and can change and develop across one’s life span. Other people typically
misinterpret one’s gender expression as equivalent to their gender identity, which
can cause problems for those whose gender is fluid or undefined.
Gender roles are the prescribed thoughts, actions, and feelings that one is sup-
posed to experience, typically thought to be congruent with their gender assigned
at birth. Children learn gender roles from family, friends, school, and teachers
through modeling, observing, or redirection from someone else verbally or non-
verbally to more gender-stereotypical behavior. Gender roles can be present from
youth through adulthood, which can often become convoluted when that person is
not interested in fitting that prescribed gender role. Some gender roles can be
assumed, especially in the functioning and allocating of responsibility in
relationships.
Gender theories critically analyze the development and makeup of gender
through a multitude of lenses. Gender theories consider the biological, social, and
cultural aspects of gender.
Biological theory focuses on the influences of genes and hormones on the
development and expression of gender. Biological theory proposes no distinction
between sex and gender but instead focuses on the creation of gendered behavior
through biological sex. This theory is supported by research on brain hemisphere
usage for language tasks. This research has indicated a difference between men’s
and women’s use of their brain for language tasks. Men tend to use the left side
of their brain independently in carrying out language tasks, while women tend
to use both hemispheres of their brain. This difference between brain usage
266 Gender Diversity
between genders was found to be facilitated by the higher levels of testosterone
found in men.
Biosocial theory is an intersectional viewpoint of gender whereby nature and
nurture have roles in gender development. In biosocial theory, people are born as
a male or a female; however, social labeling, interaction, and treatment of boys
and girls interact with their biological factors. Prenatally, infants are exposed to
levels of hormones determined by chromosomes that develop the infant into their
biological sex. Postnatal parents react and label their children based on their geni-
tals and socialize the child to the gender they are assigned at birth.
Another more recently developed theory of gender is the enculturated lens the-
ory, combining all former theories of gender and examining gender through the
lenses of gender polarization androcentrism and biological essentialism. There are
two key enculturation processes that are constantly linked and work together. The
first process of enculturation focuses on the historical and institutional prepro-
gramming of gender based on biology, era, and culture. The second process of
enculturated lens theory focuses on the transmission of implicit lessons, or
metamessages, about the present culture’s lenses organizing social reality.
Metamessages can be gathered culturally or socially based on one’s interactions
with the world.
Kimberly A. Fuller
See also: Agender; Androgyny; Bigender; Binary Gender System; Biological Sex; Child-
hood Gender Nonconformity; Cisgender; Evolutionary Perspectives on Gender and Sex-
ual Behavior; Fluidity, Gender; Gender Diversity; Gender Dysphoria; Gender Expression;
Gender Identity; Gender Identity Development; Gender Roles, Socialization and; Gender
Transition; Genderqueer; Intersexuality; Nonbinary Gender Identities; Sexual Identity;
Social Learning Theory, Gender and; Stereotypes, Gender; Transgender.
Further Reading
Feder, H. H., Phoenix, C. H., & Young, W. C. (1966). Suppression of feminine behaviour
by administration of testosterone propionate to neonatal rats. Journal of Endocri-
nology, 34(1), 131–132.
Money, J., & Ehrhardt, A. A. (1972). Man and woman, boy and girl: Differentiation and
dimorphism of gender identity from conception to maturity. Baltimore: Johns
Hopkins University Press.
Quadagno, D. M., Briscoe, R., & Quadagno, J. S. (1977). Effect of perinatal gonadal hor-
mones on selected nonsexual behavior patterns: A critical assessment of the non-
human and human literature. Psychological Bulletin, 84(1), 62.
Shaywitz, B. A., Shaywltz, S. E., Pugh, K. R., Constable, R. T., Skudlarski, P., Fulbright,
R. K., ... Gore, J. C. (1995). Sex differences in the functional organization of the
brain for language. Nature, 373(6516), 607.
Gender Diversity
As gender is being deconstructed and expanded, the labels used to describe the
diversity of gender identities are also growing and evolving. Historically, “trans-
gender” has been an umbrella term for all gender identities that do not align with
the assigned sex at birth; however, some gender minorities do not identify as
Gender Diversity 267
transgender, feeling it reinforces the gender binary (a conceptualization of gender
as only exclusively male or female). Alternatively, some individuals who do not
identify on the gender binary prefer nonbinary or genderqueer labels. Previous
terms for gender diversity include gender variant and gender deviant, both of
which have received criticisms for othering (treating anything or anyone outside
of the status quo as alien) and are used less frequently. Currently, “gender diverse”
is a broad term that encompasses transgender and nonbinary identities. According
to current national estimates, between 0.6 percent and 5.0 percent of Americans
identify as transgender. When gender diversity is conceptualized more broadly
(e.g., including nonbinary identities), it is anticipated that these numbers will
increase notably. Growth in prevalence has been attributed to expanding gender
identity language, availability of information about gender identity, online com-
munity support, and increased representation and acceptance.
“Gender diverse” encompasses an extensive collection of gender identities
without one representation of gender diversity; however, gender-diverse individu-
als may have shared experiences of stigma, marginalization, and discrimination
based on their gender identity. In particular, nonconforming gender expression
including physical appearance and interpersonal factors (e.g., voice, pronouns,
chosen name) can be a risk factor for discrimination. A series of bathroom bills
that began with the North Carolina HB2 in March 2016 restricted the use of bath-
rooms to those that align with an individual’s sex assigned at birth, with individu-
als singled out by appearance. A national study on discrimination found that
gender-diverse individuals reported facing suspicion and hostility in bathrooms
on a daily basis, including being verbally harassed, physically attacked, and
denied access to facilities. In addition, some individuals reported that fear of these
negative experiences contributing to limiting their food and water intake to mini-
mize the need to use the bathroom, with these actions sometimes leading to health
issues such as urinary tract infections.
Access to health care is another shared challenge for many gender-diverse indi-
viduals despite the fact that the 2010 Affordable Care Act provided gender-diverse
individuals increased access to services and protections against gender-based dis-
crimination. Gender-diverse individuals have reported experiences of gatekeep-
ing (e.g., required professional letters to access gender-affirming treatment) and
mistreatment by health care providers ranging from rough handling to refusal of
services. For many gender-diverse individuals, chosen names and pronouns are an
essential part of gender expression but can also be a source of frequent microag-
gressions. Using the correct pronoun for gender-diverse individuals can be as
important as using a correct name. Misgendering (identifying someone by the
wrong gender through incorrect pronouns) is a microaggression that can occur
frequently and be a stigmatizing experience. Additional microaggressions include
others’ use of former names rather than chosen names, lack of representation on
forms and identification, being tokenized (e.g., being expected to represent their
gender), and being asked to explain their gender.
Gender diversity has been argued to be the next human rights movement. Cis-
normativity (the general assumption that most people are cisgender and that cis-
gender is “normal”) can create an environment where gender-diverse individuals
268 Gender Diversity
experience microaggressions and barriers to basic needs. Despite these challenges,
gender-diverse individuals demonstrate resilience, which can be bolstered when
individuals feel free to explore their gender identity and expression and when they
see themselves positively represented in others and their environment. In addition
to personal resilience, social support is one of the strongest predictors of health
outcomes for gender-diverse individuals, supporting the need for creating spaces
that welcome and represent gender diversity.
M. Killian Kinney
See also: Agender; Bigender; Binary Gender System; Fluidity, Gender; Gender; Gender
Expression; Gender Identity; Gender Identity Development; International Foundation for
Gender Education (IFGE); Nonbinary Gender Identities; Queer; Questioning;
Transgender.
Further Reading
Barker, M.-J. (2014, February 15). 57 genders (and none for me)? Reflections on the new
Facebook gender categories. Rewriting the rules. Retrieved from https://www
.rewriting-the-rules.com/gender/57-genders-and-none-for-me-reflections-on-the
-new-facebook-gender-categories/
Brown, M. E., & Burill, D. (2018). Challenging genders: Non-binary experiences of those
assigned female at birth. Miami, FL: Boundless Endeavors.
Budge, S. L., Rossman, H. K., & Howard, K. A. (2014). Coping and psychological distress
among genderqueer individuals: The moderating effect of social support. Journal
of LGBT Issues in Counseling, 8(1), 95–117.
Collazo, A., Austin, A., & Craig, S. L. (2013). Facilitating transition among transgender
clients: Components of effective clinical practice. Clinical Social Work Journal,
41(3), 228–237.
Flores, A. R., Herman, J. L., Gates, G. J., & Brown, T. N. T. (2016, June). How many
adults identify as transgender in the United States? Los Angeles, CA: The Wil-
liams Institute.
Grossman, A. H., Park, J. Y., & Russell, S. T. (2016). Transgender youth and suicidal
behaviors: Applying the interpersonal psychological theory of suicide. Journal of
Gay & Lesbian Mental Health, 20(4), 329–349.
Herman, J. L., Flores, A. R., Brown, T. N. T., Wilson, B. D. M., & Conron, K. J. (2017).
Age of individuals who identify as transgender in the United States. Los Angeles,
CA: The Williams Institute.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The
report of the 2015 U.S. transgender survey. Washington, DC: National Center for
Transgender Equality.
Lewis, J. (2008). Resilience among transgender adults who identify as genderqueer:
Implications for health and mental health treatment (Doctoral dissertation).
Retrieved from ProQuest Information & Learning. (Accession number 57395)
McLemore, K. A. (2015). Experiences with misgendering: Identity misclassification of
transgender spectrum individuals. Self and Identity, 14(1), 51–74.
Poteat, V. P., Sinclair, K. O., DiGiovanni, C. D., Koenig, B. W., & Russell, S. T. (2013b).
Gay-straight alliances are associated with student health: A multischool compari-
son of LGBTQ and heterosexual youth. Journal of Research on Adolescence,
23(2), 319–330.
Richards, C., Bouman, W. P., Seal, L., Barker, M. J., Nieder, T. O., & T’Sjoen, G. (2016).
Non-binary or genderqueer genders. International Review of Psychiatry, 28(1),
95–102.
Gender Dysphoria 269
Singh, A. A., Meng, S. E., & Hansen, A. W. (2014). “I am my own gender”: Resilience
strategies of trans youth. Journal of Counseling & Development, 92(2), 208–218.
Transgender Law and Policy Institute. (n.d.). Transgender issues: A fact sheet. Retrieved
from http://www.transgenderlaw.org/resources/transfactsheet.pdf
Gender Dysphoria
Gender dysphoria is classified in the fifth edition of the Diagnostic and Statistical
Manual published by the American Psychiatric Association. The diagnosis of gen-
der dysphoria is used to indicate that individuals are experiencing dysphoria, or
unease or dissatisfaction, with the sex they were assigned at birth because they
identify with a different gender. In common language, individuals with gender dys-
phoria are often referred to as transgender, though individuals meeting the diagnos-
tic criteria for gender dysphoria may identify with any gender identity and do not
necessarily identify as transgender. Further, it is not necessary for individuals to be
diagnosed as having gender dysphoria to consider themselves transgender.
Symptoms of gender dysphoria vary but often involve individuals feeling as if
their body does not represent their true gender, feelings of unease or disgust
toward their genitalia or bodily representations of their sex assigned at birth (sec-
ondary sex characteristics such as body hair, breast development, Adam’s apple,
wide hips, etc.), anger or unease when others refer to them using pronouns used to
represent their sex assigned at birth, anger or unease when feeling pressured to
wear clothing generally worn by individuals of the sex they were assigned at birth,
and general discomfort regarding their physical body presentation. Individuals
with gender dysphoria often struggle socially due to being bullied, harassed,
assaulted, or ostracized. These situations may occur within family, school,
employment, and other social environments and often lead to depression, anxiety,
low self-esteem, social isolation, and, if severe, suicidal thoughts or attempts. It
should be noted that in many cases, the dysphoria experienced as well as mental
and social effects are more related to social responses to the individuals’ gender
identities rather than a direct consequence of those gender identities.
Among youth with gender dysphoria there is generally a stated desire to be of
the gender with which they identify, a desire to present socially as the gender with
which they identify, preferences for types of activities that are stereotypically
associated with the gender with which they identify, and a taking on of the gender
role with which they identify within role-plays. Post puberty, while the aforemen-
tioned continue, individuals’ focus often turns more directly toward desiring to
remove or modify physical characteristics of their sex assigned at birth and to
obtain those of the gender with which they identify. For those who were assigned
male at birth, this could include a desire to have body hair removed, breast aug-
mentation, reduction of their Adam’s apple, hip augmentation, and, in some cases,
removal of their penis. Among those assigned female at birth, there may be a
desire for stopping menses, removal of breast tissue, growth of body hair, and, for
some, the surgical construction of a penis.
Per the World Professional Association for Transgender Health’s Standard of
Care Version 7, a diagnosis of gender dysphoria is required before individuals
receive medical treatment such as gender-affirming hormones or gender-affirming
270 Gender Dysphoria
surgeries. Treatment of gender dysphoria encompasses two areas: one social or
emotional and the other physical. Within the social and emotional realm, treatment
focuses on resolving internal concerns regarding the individual’s gender identity;
reducing depression, anxiety, substance use, and other mental health concerns;
using family therapy to address conflicts related to the individual’s gender identity
and help others within their family understand them and their identity; and increas-
ing the individual’s ability to cope with negative social messaging related to their
gender identity. Psychotropic medications are not used to treat gender dysphoria but
may be used to treat accompanying depression, anxiety, or other psychosocial
concerns.
Physical treatment involves the introduction of gender-affirming hormones or
surgical procedures designed to produce the desired physical changes. For those
assigned female at birth, treatment can include menses suppression or introduc-
tion of testosterone via injection or topical application. Testosterone supplementa-
tion will produce many male secondary sex characteristics, such as hair growth,
lowering of the voice, and redistribution of body fat. Among those assigned male
at birth, an antiandrogen may be used to reduce the impact of naturally occurring
testosterone, and estrogen may be introduced. Supplementation of estrogen will
result in breast growth, fat redistribution, thinning of body hair, and feminization
of the facial structure. Various surgical procedures are also available to remove or
recreate both male and female genitalia. Desires regarding physical changes are
highly individualized, with some individuals with gender dysphoria wanting little
to no changes to their bodies and others wanting to undergo extensive gender-
affirming surgical procedures.
In previous editions of the Diagnostic and Statistical Manual, gender dyspho-
ria was known as gender identity disorder and was classified within the section of
sexual and gender identity disorders. This classification raised concerns that it
conflated gender and sexuality, pathologized identifying as transgender or as a
gender other than that which corresponds to the sex assigned at birth, and rein-
forced beliefs that people whose gender does not match their sex assigned at birth
are mentally ill. Within the fifth edition of the Diagnostic and Statistical Manual,
gender identity disorder was moved into its own chapter and the name changed to
gender dysphoria to emphasize the dysphoria associated with individuals’
experiences.
In the new edition, the diagnostic criteria were also divided into two sections––
one for children and the other for adolescents and adults. This separation was done
to reflect the aforementioned age-based differences in how gender dysphoria is
experienced. While the diagnosis of gender dysphoria is still controversial among
mental health professionals due to concerns about people receiving a mental health
diagnosis based on their identities, the current diagnostic criteria represent a more
positive understanding of how individuals experience conflicts between their gen-
der identity and their sex assigned at birth.
Richard A. Brandon-Friedman
See also: Binary Gender System; Childhood Gender Nonconformity; Diagnostic and Sta-
tistical Manual of Mental Disorders (DSM); Gender; Gender Diversity; Gender Expres-
sion; Gender Identity; Gender Identity Development; Gender Transition; Nonbinary
Gender Identities; Pronoun Usage; Testosterone Replacement Therapy; Transgender.
Gender Expression 271
Further Reading
American Psychiatric Association. (2013). Gender dysphoria. In American Psychiatric
Association, Diagnostic and statistical manual of mental disorders (5th ed., 451–
460). Arlington, VA: American Psychiatric Publishing.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman,
J., … Lev, A. I. (2011–2012). Standards of care for the health of transsexual, trans-
gender, and gender-nonconforming people, version 7. International Journal of
Transgenderism, 13(4), 165–232.
Curtis, R., Levy, A., Martin, J., Playdon, Z.-J., Wylie, K., Reed, T., & Reed, B. (2007).
A guide to hormone therapy for trans people. London: Department of Health.
Dhejne, C., Van Vlerken, R., Heylens, G., & Arcelus, J. (2016). Mental health and gender
dysphoria: A review of the literature. International Review of Psychiatry, 28(1),
44–57.
Moolchaem, P., Liamputtong, P., O’Halloran, P., & Muhamad, R. (2015). The lived expe-
riences of transgender persons: A meta-synthesis. Journal of Gay & Lesbian
Social Services, 27(2), 143–171.
Orr, A., Baum, J., Brown, J., Gill, E., Kahn, E., & Salem, A. (n.d.) Schools in transition:
A guide for supporting transgender students in K–12 schools. San Francisco, CA:
National Center for Lesbian Rights.
Wylie, K., Knudson, G., Khan, S. I., Bonierbale, M., Watanyusakul, S., & Baral, S. (2016).
Serving transgender people: Clinical care considerations and service delivery
models in transgender health. The Lancet, 388(10042), 401–411.
Gender Expression
Gender expression is the way in which someone demonstrates or communicates
their gender identity. This may be through a variety of outlets, including clothing,
speech, posture, nonverbal communication, interests, and self-reference (pro-
nouns that are used). Various forms of expression may present on a masculine or
feminine spectrum. Often, gender expression is influenced by one’s culture. Some
people may also express their gender outside of masculine and feminine spec-
trums that are defined by their culture, and expression can fluctuate. In addition,
gender expression may not necessarily fit in with cultural expectations or norms,
which may lead to potential discrimination and stigma. Gender expression may or
may not reflect someone’s gender identity.
Rachel Snedecor
See also: Binary Gender System; Femininity; Fluidity, Gender; Gender; Gender Diver-
sity; Gender Identity; Gender Transition; Masculinity; Pronoun Usage.
Further Reading
APA Task Force on Gender Identity and Gender Variance. (2008). Report of the Task
Force on Gender Identity and Gender Variance. Washington, DC: American Psy-
chological Association.
Gutierrez, N. (2004). Resisting fragmentation, living whole: Four female transgender stu-
dents of color speak about school. Journal of Gay & Lesbian Social Services,
16(3–4), 69–79.
Hidalgo, M. A., Kuhns, L. M., Kwon, S., Mustanski, B., & Garofalo, R. (2015). The impact
of childhood gender expression on childhood sexual abuse and psychopathology
among young men who have sex with men. Child Abuse & Neglect, 46, 103–112.
272 Gender Identity
Leibowitz, S., & de Vries, A. L. C. (2016). Gender dysphoria in adolescence. Interna-
tional Review of Psychiatry, 28(1), 21–35.
Masequesmay, G. (2003). Negotiating multiple identities in a queer Vietnamese support
group. Journal of Homosexuality, 45(2–4), 193–215.
Mathy, R. M. (2001). A nonclinical comparison of transgender identity and sexual orien-
tation: A framework for multicultural competence. Journal of Psychology and
Human Sexuality, 13(1), 21–54.
Gender Identity
Gender identity cannot be adequately understood without a fundamental discus-
sion of gender and gender norms. Gender is an abstract concept of masculinity,
femininity, and, more recently, additional genders that are each constructed by
society and reinforced through social systems (e.g., gender norms). While the
terms “gender” and “sex” are often used interchangeably, this is inaccurate, as sex
is a biological category based on chromosomes and physical attributes rather than
a social construct, and conflating the two excludes a diverse range of gender iden-
tities. Gender identity is an individual’s internal sense of their gender and may be
static or fluid. Unlike social constructions of gender, gender identity is self-
identified. In other words, one’s gender identity can only be identified by the indi-
vidual. The term “cisgender” refers to those whose gender identity is congruent
with their sex assigned at birth (i.e., assigned female at birth and identifies as
female). “Transgender” refers to someone whose gender identity is different from
their sex assigned at birth (i.e., assigned male at birth and identifies as female). In
the last decade, recognition of additional genders continues to increase including
nonbinary identities, which refer to genders that are not exclusively male or female
(e.g., genderqueer, genderfluid, trigender).
Conceptualizations of gender change with shifts in culture, which influence the
concepts and language used to describe gender identity. Cultural expectations of
gender such as gender norms of roles and expression are based on expectations of
femininity, masculinity, and androgyny as it is currently socially constructed. The
color pink, for example, was associated with masculinity and worn by boys until
the 1950s, when the current blue for boys and pink for girls became dominant. In
Western society, the dominant conceptualization of gender is grounded in the gen-
der binary or an understanding of gender as either male or female and no other
genders. This gender binary is evidenced by checkboxes in formal documents,
gender markers on government identification, and men’s or women’s bathrooms.
Recent social and legal changes have indicated a shift in the conceptualization of
gender with fill-in gender options on forms, a third-gender marker on birth certifi-
cates and driver’s licenses, and all-gender bathrooms.
Gender conceptualization has undergone several iterations and continues to
evolve. Starting with the gender binary, gender then began to be understood on a
single spectrum with some individuals fitting at some degree between entirely
masculine and entirely feminine. Multiple spectrums followed that allowed for an
individual’s gender to be conceptualized as a degree of masculinity and degree of
Gender Identity 273
femininity from none to entirely. Then, gender-expansive models were created
with multifaceted continuums of biological sex, gender identity, gender expres-
sion, and sexual orientation, including the Genderbread Person versions, then the
Gender Unicorn. Finally, a multidimensional nonlinear galaxy of numerous pos-
sibilities (gender galaxy) is considered to be the most inclusive conceptualization
of gender.
Gender has been described as performativity or an ongoing process of creating
and re-creating gender through exchanges such as language and expression. While
influenced by gender norms, how one expresses their gender identity can be as
unique as their gender identity. An individual’s gender expression may or may not
align with expectations of gender norms. In addition to physical appearance, some
individuals may express their gender identity through a chosen name or pronouns.
For some, activism toward gender equality and representation of gender diversity
is a part of gender identity. Gender expression plays a significant role in how one’s
gender identity is seen and, consequently, how one is gendered by those around
them.
As understanding and acceptance of gender diversity increases, a growing
number of people are openly identifying as transgender and nonbinary. This
trend is especially evident among youth, particularly those in progressive coun-
tries and regions where many youth describe their gender expression as noncon-
forming or androgynous. As such, gender identities and related language continue
to expand to represent this community. In addition to increasing awareness of
gender diversity, language for gender identities can provide validation of indi-
viduals’ gender identity as well as create a common label to unite people with
shared experiences.
M. Killian Kinney
See also: Agender; Bigender; Binary Gender System; Cisgender; Fluidity, Gender; Gen-
der; Gender Diversity; Gender Dysphoria; Gender Expression; Gender Identity Develop-
ment; Gender Roles, Socialization and; Gender Transition; Genderqueer; Nonbinary
Gender Identities; Queer; Transgender.
Further Reading
Beemyn, G., & Rankin, S. (2011). The lives of transgender people. New York: Columbia
University Press.
Butler, J. (1990). Gender trouble: Feminism and the subversion of identity. New York:
Routledge.
Kinney, M. K. (2018). Carving your own path: Exploring non-binary identities. Manu-
script in preparation.
Paoletti, J. B. (2012). Pink and blue: Telling the boys from the girls in America. Blooming-
ton: Indiana University Press.
Russel, E. B., & Viggiani, P. A. (2018). Understanding differences and definitions: From
oppression to sexual health and practice. In M. P. Dentato (Ed.), Social work prac-
tice with the LGBTQ community (26–48). New York: Oxford University Press.
Vade, D. (2005). Expanding gender and expanding the law: Toward a social and legal
conceptualization of gender that is more inclusive of transgender people. Michi-
gan Journal of Gender & Law, 11(2), 253–316.
274 Gender Identity Development
Wilson, B. D. M., Choi, S. K., Herman, J. L., Becker, R., & Conron, K. J. (2017). Charac-
teristics and mental health of gender nonconforming adolescents in California:
Findings from the 2015–2016 California health interview survey. Los Angeles,
CA: The Williams Institute and UCLA Center for Health Policy Research.
Gender Identity Development
Gender identity is an internal sense of self that develops as an ongoing process
and is influenced by the social construction of gender. As the social construction
of gender changes, so too can the conceptualization of one’s gender identity and
expression change in comparison to social norms and expectations. Furthermore,
gender identity is unique to each person whether their gender aligns with their sex
assigned at birth (cisgender) or whether they are gender diverse. While gender
norms can facilitate gender identity development for many individuals, transgen-
der and nonbinary individuals are not typically represented in cultural norms of
gender. Several models for sexual orientation identity development exist; how-
ever, gender identity development has received less attention. Currently, a model
for cisgender identity development has not been created, but several models for
gender identity development have been proposed.
The most frequently used gender identity model is Devor’s (2004) stages of
transgender identity formation. Devor’s model included fourteen stages:
1. Abiding anxiety
2. Identity confusion about originally assigned gender and sex
3. Identity comparison about originally assigned gender and sex
4. Discovery of transgenderism
5. Identity confusion about transgenderism
6. Identity comparisons about transgenderism
7. Tolerance of transgender identity
8. Delay before acceptance of transgender identity
9. Acceptance of transgender identity
10. Delay before transition
11. Transition
12. Acceptance of posttransition gender and sex identities
13. Integration
14. Pride
As described by Devor in 2004, transitioning can vary among individuals from
social transitioning (e.g., chosen name, pronouns) to physical transitioning (e.g.,
hormone replacement therapy, gender-affirming surgeries). Similar to other mod-
els, integration of gender identity and pride are the goals of identity development.
In 2018, Kinney introduced a nonbinary gender identity development model. This
model consists of eight stages:
Gender Identity Development 275
1. Early freedom
2. Gender identity confusion
3. Language acquisition
4. Reconciling repression
5. Gender experimentation
6. Envisioning an ideal self
7. Disclosing gender identity
8. Gender identity integration
The importance of language acquisition is noteworthy in that language for nonbi-
nary identities in Western culture has only recently emerged over the last decade.
Similarly, envisioning an ideal self presents a challenge stage as nonbinary expres-
sion can vary broadly with little modeling in mainstream media.
Several key elements across gender identity development models include social-
ization about gender, isolation, language acquisition, and eventual acceptance of
gender identity. Gender is a social construction and, as such, is taught and rein-
forced through interpersonal exchanges and social systems, including education,
media, and policy. Throughout their lives, individuals are taught different gender
norms for boys, men, girls, and women from toys to clothing to careers. Even before
birth, gender norms begin with gender reveal parties for fetuses in utero with color-
coded balloons and cakes (blue for boy and pink for girl). These subtle and not-so-
subtle reinforcements of gender norms may not be as apparent to individuals whose
gender aligns with such norms. However, gender-diverse individuals who do not see
themselves represented or affirmed in gender norms can feel misunderstood and
isolated. Acquiring language about gender can be a pivotal point in gender identity
development marked by validation of gender. Language can also be a means to
facilitate community building through shared gender identities and experiences,
which may reduce feelings of isolation. Even once an individual understands their
gender identity, cisnormativity (the assumption that most people are cisgender and
that is “normal”) and internalized stigma (e.g., accepted negative messages about
gender-diverse individuals) may inhibit an individual from accepting their gender
identity. Due to hostile environments, some individuals may repress or choose to
conceal their gender identity as a strategic coping mechanism. An accumulative
effect of invalidating experiences can lead to a deterioration of mental health among
transgender and nonbinary individuals. Conversely, representation and affirmation
of gender have been shown to ameliorate negative health implications for gender-
diverse individuals, stressing the importance of building resilience among trans-
gender and nonbinary individuals. Increasing the understanding of how gender is
created, learned, self-identified, and affirmed can aid in learning ways to support
healthy gender identity development across gender identities.
M. Killian Kinney
See also: Cisgender; Gender; Gender Diversity; Gender Dysphoria; Gender Expression;
Gender Identity; Gender Roles, Socialization and; Gender Transition; Nonbinary Gender
Identities; Questioning; Transgender.
276 Gender Roles, Socialization and
Further Reading
Beemyn, G., & Rankin, S. (2011). The lives of transgender people. New York: Columbia
University Press.
Cass, V. C. (1984). Homosexual identity formation: Testing a theoretical model. Journal
of Sex Research, 20, 143–167.
Davis, C. (2009). Introduction to practice with transgender and gender variant youth. In
G. P. Mallon (Ed.), Social work practice with transgender and gender variant
youth (2nd ed., 15–35). London: Routledge.
Devor, A. H. (2004). Witnessing and mirroring: A fourteen stage model of transsexual
identity formation. Journal of Gay and Lesbian Psychiatry, 8(1–2), 41–67.
Eliason, M. J. (1996). An inclusive model of lesbian identity assumption. Journal of Gay
Lesbian and Bisexual Identity, 1(1), 3–19.
Fox, R. C. (1995). Bisexual identities. In A. R. D’Augelli & C. J. Patterson (Eds.), Lesbian,
gay, and bisexual identities over the lifespan: Psychological perspectives (48–86).
New York: Oxford University Press.
Kinney, M. K. (2018). Carving your own path: A nonbinary gender identity development
model. Manuscript in preparation.
Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: The experience of transgender
identity development. Journal of Homosexuality, 61(12), 1727–1758.
Troiden, R. R. (1988). Gay and lesbian identity: A sociological analysis. Dix Hills, NY:
General Hall.
Gender Roles, Socialization and
Gender roles are the beliefs, rights, attitudes, and behaviors that are associated
with a particular sex and gender. Expectations of a person’s gender role are
assigned to people even before birth, for example, when someone asks a person
who is pregnant if they are having a boy or a girl. Physical, emotional, and psycho-
logical aspects of how a child should act depend on societal standards. For exam-
ple, in Western culture, the color pink, gentleness, and fragility are associated
with girls, while the color blue, being tough, and having no tolerance for showing
emotion is associated with boys. These ideas are typically based on female-
identified or male-identified genitals, and there is a social expectation of appropri-
ate associated behavior. It is important to note that these binary gender roles
usually leave out people who are born with genitalia that is not typically male or
female, and consequently, many parents of babies born with intersex conditions
feel the need to raise their children as either boys or girls, and some may seek sur-
gery for their infants in order to change the appearance of their genitals.
According to Longres (2000), socialization is “the process through which indi-
vidual participation is defined and refined as individuals learn to function as a
system member. Included are the processes by which people become aware of the
expectations of others and learn the attitudes, knowledge, and abilities necessary
to comply with those expectations.” In order for infants and children to function
within a certain system, there are roles that need to be met in the dichotomy of
male and female. This is usually regardless of how those individual people feel
about themselves. Two theories that are instrumental in explaining socialization’s
influence on gender roles are social learning theory and cognitive developmental
Gender Transition 277
theory. Social learning theory was developed by Albert Bandura in the 1970s. He
theorized that through cognition, we have the ability to “use language, anticipate
consequences, and make observations” through the socialization of our environ-
ment. For example, if a girl observes that only boys are allowed to speak in loud
volumes without being reprimanded by adults and that girls who speak too loudly
are punished, she will model her behavior in order to avoid the consequences.
Cognitive developmental theory, on the other hand, takes notice of how chil-
dren correct their behaviors within the environment according to what other chil-
dren and adults are doing. By taking the cues from the environment and paying
close attention to what other girls and boys do, it informs the behavior of the indi-
vidual. This gives a particular boy or girl the opportunity to “independently strive
to act like proper girls or boys” (Yarber et al., 2010).
Larger societal institutions also play a part in shaping children’s behavior.
Teachers in school play an important role in reinforcing societal, cultural, and
gender expectations among the students they teach. For example, boys may be
encouraged to participate in more aggressive sports such as football, whereas girls
may be steered away from football and encouraged into sports with less contact
like gymnastics due to them being seen as fragile or unable to take care of them-
selves. Religious teachings and traditions are also ways to further perpetuate gen-
der roles within the households and communities that practice them. If the religion
of the family pushes for the dominance of females by males, and if all the people
in leadership roles in that institution are also male, then it again reinforces the
stereotype that girls are not granted top spots in these structured settings. Finally,
the messages taken in by children through cartoons, advertisements, and TV
shows give various favored examples of how girls and boys should behave in soci-
ety. It is also important to note that as time goes along and systems change, the
expectations for genders change as well.
Shane’a Thomas
See also: Binary Gender System; Gender; Gender Identity; Gender Identity Development;
Sexual Learning; Social Learning Theory, Gender and; Stereotypes, Gender; Stereo-
types, Sexual.
Further Reading
Lehmiller, J. J. (2014). The psychology of human sexuality. Hoboken, NJ:
Wiley-Blackwell.
Longres, J. (2000). Human behavior in the social environment (3rd ed.). Belmont, CA:
Wadsworth/Thomson Learning.
Yarber, W. L., Sayad, B. W., & Strong, B. (2010). Human sexuality: Diversity in contem-
porary America (7th ed.). New York: McGraw Hill.
Gender Transition
“Sex” and “gender” are often conflated into one idea in mainstream culture; that
is, they are used interchangeably to mean the same thing. However, feminist
scholarship over the past four decades has shown how sex and gender are two dif-
ferent constructs. Gender is here defined as the set of social, cultural, and linguis-
tic norms that can be attributed to someone’s identity, expression, or role as
278 Gender Transition
masculine, feminine, androgynous, or nonbinary. Whereas someone’s sex is
assigned at birth by medical professionals based on the appearance of genitalia,
and related assumptions about chromosomal makeup, gender identity, expres-
sions, and roles emerge over the life span, sometimes changing over time.
“Gender transition” can refer to some of those change processes. This term is
generally used to indicate changes undergone by transgender people in relation to
their identities. There are different forms of gender transition that people might
undertake. Legal gender transition refers to the process of changing gender mark-
ers on legal documentations, which might include birth certificates, school tran-
scripts, identification documents, marriage certificates, social security information,
and so on. People who change their gender marker legally usually also change
their name at the same time to ensure coherence between their name, appearance,
and legal documentations. Requirements for changing gender markers legally
vary from country to country and, within the United States, from state to state.
Some states and countries require transgender people to have undergone some
form of surgical intervention to modify their bodies to reflect the legal gender
marker change sought, whereas others only require proof that the person is socially
aligned with the change they are seeking.
Some people seek body modification through medical intervention and surgery
as part of their process of gender transition. This could take the form of hormonal
treatment to masculinize or feminize their bodies, or, in the case of prepubescent
and pubescent transgender youth, it could mean seeking hormone blockers to stop
physical changes that increase distress and gender dysphoria for the person under-
going treatment. As well as hormone treatment, some people seek surgical inter-
ventions, such as chest, genital, and facial reconstruction. The types and extent of
those interventions depend on the person’s identity and expression as well as the
level of dysphoria—that is, incongruence between their bodies and identities—
that they might experience. The surgical interventions chosen can also be depen-
dent on physical limitations, financial access, and available medical techniques.
For example, trans feminine people tend to seek genital reconstruction more fre-
quently than trans masculine people given that this is more successful, and medi-
cally advanced, for the former than the latter group. These interventions are often
referred to as being part of someone’s medical gender transition process.
Finally, most transgender people undertake a process of social gender transi-
tion, which can include name and pronoun changes among family, friends,
coworkers, or social networks, as well as changes in clothing, appearance, and
sometimes mannerisms. Transgender people seeking legal and medical transition
usually need to be supported by health providers in their transition efforts. Deci-
sions made by health providers in relation to supporting people’s gender transition
decisions are usually based on the latest standards of care issued by the World
Professional Association for Transgender Health.
Alex Iantaffi
See also: Gender; Gender Diversity; Gender Dysphoria; Gender Expression; Gender
Identity; Hormone Replacement Therapy; Pronoun Usage; Sex Reassignment Surgery;
Testosterone Replacement Therapy; Transgender; World Professional Association for
Transgender Health (WPATH).
GenderPAC 279
Further Reading
Brill, S., & Pepper, R. (2013). The transgender child: A handbook for families and profes-
sionals. San Francisco, CA: Cleis Press.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J.,
… Monstrey, S. (2012). Standards of care for the health of transsexual, transgen-
der, and gender-nonconforming people, version 7. International Journal of Trans-
genderism, 13(4), 165–232.
Guss, C., Shumer, D., & Katz-Wise, S. L. (2015). Transgender and gender nonconforming
adolescent care: Psychosocial and medical considerations. Current Opinion in
Pediatrics, 26(4), 421–426.
Iantaffi, A. (2015). Gender and sexual legitimacy. Current Sexual Health Reports, 7(2),
103–107.
Iantaffi, A., & Barker, M. J. (2017). How to understand your gender: A practical guide for
exploring who you are. London: Jessica Kingsley Publishers.
Lev, A. I. (2013). Transgender emergence: Therapeutic guidelines for working with
gender-variant people and their families. London: Routledge.
Richards, C., & Barker, M. J. (Eds.). (2015). The Palgrave handbook of the psychology of
sexuality and gender. New York: Palgrave Macmillan.
GenderPAC
GenderPAC (Gender Public Advocacy Coalition) was a political advocacy organi-
zation that worked to further the rights of lesbian, gay, bisexual, and transgender
(LGBT) people. It was headquartered in Washington, D.C. Like other political
action committees (PACs), it lobbied Congress on behalf of legislation it sup-
ported, and it contributed money to candidates whom it supported. The organiza-
tion was active from 1995 to 2009.
Transgender people (people who identify with a gender other than their sex or
gender at birth or who express another gender by the way they dress and behave)
constituted the primary focus of GenderPAC. However, it also dealt with matters
of concern to other people with other diverse forms of gender or sexual orienta-
tion. The organization maintained a number of programs intended to educate the
public and politicians about gender identity and expression and to promote its
positions on these and other LGBT issues. The primary matters addressed by
these programs were discrimination and violence against LGBT people in the
workplace, schools, and communities. GenderPAC also developed networks to
help LGBT youth and parents of these youth find support and assistance.
Transgender activist Riki Anne Wilchins founded GenderPAC in 1995 to fill
the gap left by existing gay and lesbian organizations, which failed to address
transgender issues in any substantial way. She continued to lead the group through-
out its existence.
GenderPAC achieved a number of important accomplishments in its relatively
brief existence. It developed the Congressional Non-Discrimination Pledge, in
which approximately 200 members of Congress promised to support nondiscrimi-
nation against transgender people in their own offices. Besides lobbying Congress
on such issues, GenderPAC also worked with several private corporations to
280 Genderqueer
convince them to protect gender identity and expression as part of their employ-
ment nondiscrimination policies.
GenderPAC’s GenderYOUTH program was designed to assist college students
in organizing chapters on campus to work for transgender rights. Schools were
ranked according to their nondiscrimination policies regarding transgender stu-
dents in GenderPAC’s Gender Equality National Index for Universities and
Schools. The organization also published the National Survey of TransViolence
and 50 under 30: Masculinity and the War on America’s Youth, both of which fea-
tured reports of violent attacks against transgender people. Most of the docu-
mented attacks were against young African American or Hispanic trans women.
These reports helped lead to congressional passage of the Matthew Shepard Act,
which, among other things, extended federal hate crimes protections to transgen-
der people. President Barack Obama signed the act into law in 2009.
Certain other transgender organizations criticized GenderPAC for not focusing
exclusively on issues concerning transgender individuals. For example, Gender-
PAC worked to publicize violence and discrimination against some “gender-
variant” individuals who were not transgender, such as a self-identified “butch
lesbian” who was harassed at her workplace and later fired for appearing “too
masculine.” Wilchins defended the group against such criticism by stating that
GenderPAC’s mission was to move beyond the strict “identity form of organizing”
and work toward true diversity.
In 2009, GenderPAC ceased to exist when its board determined that it had
achieved many of its goals and that other organizations now existed to carry on
advocacy for gender-related issues.
A. J. Smuskiewicz
See also: Gender; Gender Diversity; Gender Expression; Gender Identity; LGBTQ+;
Shepard, Matthew; Transgender.
Further Reading
Theophano, T. (2015). Gender public advocacy coalition (GenderPAC). GLBTQ Archives.
Retrieved from http://www.glbtqarchive.com/ssh/gender_public_advocacy_S.pdf
TrueChild. (2017). Home page. Retrieved from https://www.truechild.org
Genderqueer
Arguments against binary models of gender—those that understand male and
female or man and woman, as exclusive and exhaustive possibilities—have
increased over time as binary models fail to accommodate the diversity and fluid-
ity of all gender identities. Binary views of gender exclude and erase individuals
who identify as genderqueer, an identity that can be understood as neither exclu-
sively male nor female. Genderqueer individuals often hold such gender identities
as “bigender,” “trigender,” “pangender,” “agender,” “gender neutral,” “nongen-
dered,” “genderless,” “neuter,” or “neutrois.” The term “nonbinary” is often used
interchangeably with “genderqueer,” though some individuals may identify with
one term and not the other. Many gender-fluid individuals, whose gender identity
or gender expression fluctuates over time or in different situational contexts,
Genderqueer 281
identify as genderqueer or nonbinary. However, not all genderqueer individuals
identify as gender fluid and thus experience a sense of consistency in their gender-
queer identity across time and context.
The experience of genderqueer individuals is extremely diverse; some may
identify as neither male nor female, whereas others may identify as both male and
female. Some people may identify as genderqueer but do not consider themselves
transgender, whereas other genderqueer individuals do identify as members of the
transgender community. In fact, 29 percent of respondents to the 2015 United States
Transgender Survey used the term “genderqueer” to describe their gender identity.
Furthermore, genderqueer individuals may hold multiple gender identities simultane-
ously. Some genderqueer individuals, for example, also hold identities of “trans man”
or “trans woman.” However, many trans men and trans women identify exclusively
as men and women, respectively, and thus do not consider themselves genderqueer.
Some genderqueer individuals will choose to pursue medical interventions for
gender transition, including hormone therapy and surgical interventions. On the
other hand, a subset of genderqueer individuals consider themselves “nontransi-
tioning” (i.e., they do not pursue medical interventions and may not even pursue
social transition options such as changing their name or appearance). It is impor-
tant to keep in mind the distinctions between gender identity and gender expres-
sion, such that genderqueer individuals may or may not be gender nonconforming
in their physical appearance. Genderqueer individuals may pursue certain options
for gender transition that are appropriate for their own desires and experiences,
and thus their choices in this area are very diverse.
Though sometimes misunderstood, genderqueer identities represent a normal
and natural manifestation of human diversity and can provide an important source
of strength and positivity when individuals accept the validity of their experience.
Many individuals describe a sense of freedom from the constraints of the gender
binary after adopting a genderqueer identity because they are able to define the
meaning and significance of their gender for themselves.
Nova J. Bradford, Jory M. Catalpa, and G. Nic Rider
See also: Agender; Bigender; Binary Gender System; Fluidity, Gender; Gender; Gender
Diversity; Gender Expression; Gender Identity; Gender Transition; Nonbinary Gender
Identities; Queer; Transgender.
Further Reading
American Psychological Association & National Association of School Psychologists.
(2015). Resolution on gender and sexual orientation diversity in children and ado-
lescents in schools. Retrieved from http://www.apa.org/about/policy/orientation
-diversity
Bilodeau, B. L. (2005). Beyond the gender binary: A case study of two transgender stu-
dents at a midwestern research university. Journal of Gay & Lesbian Issues in
Education, 3(1), 29–44.
Bornstein, K. (1994). Gender outlaw: On men, women, and the rest of us. New York:
Vintage.
Bradford, N. J., Rider, G. N., Catalpa, J. M., Morrow, Q. J., Berg, D. R., Spencer, K. G., &
McGuire, J. K. (2018). Creating gender: A thematic analysis of genderqueer narra-
tives. International Journal of Transgenderism, 20(2–3), 155–168.
282 Genital Dysphoria
Gates, T. G. (2010). Combating problem and pathology: A genderqueer primer for the
human service educator. Journal of Human Services, 30(1), 54–64.
James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The
report of the 2015 US Transgender Survey. Washington, DC: National Center for
Transgender Equality. Retrieved from http://www.transequality.org/sites/default/
files/docs/USTS-Full-Report-FINAL.PDF
Muñoz, J. E. (1999). Disidentifications: Queers of color and the performance of politics.
Minneapolis: University of Minnesota Press.
Puckett, J. A., Cleary, P., Rossman, K., Mustanski, B., & Newcomb, M. E. (2018). Barriers
to gender-affirming care for transgender and gender nonconforming individuals.
Sexuality Research and Social Policy, 15(1), 48–59.
Richards, C., Bouman, W. P., Seal, L., Barker, M. J., Nieder, T. O., & Tsjoen, G. (2016).
Non-binary or genderqueer genders. International Review of Psychiatry, 28(1),
95–102.
Roen, K. (2002). “Either/Or” and “Both/Neither”: Discursive tensions in transgender pol-
itics. Signs: Journal of Women in Culture and Society, 27(2), 501–522.
Genital Dysphoria
“Genital dysphoria” is a relatively new term with no comprehensive scientific def-
inition. “Genital” refers to the sexual organs one has. “Dysphoria” is defined as a
state of unease, unhappiness, or dissatisfaction. Combined, the term “genital dys-
phoria” describes a person who is very unhappy or uncomfortable with the geni-
tals they have. The basic idea of this term is confusion or discomfort with the
genital region, which can also include misconception of the genitals. Feeling as
though you are not in the body you feel you belong in can cause severe stress,
anxiety, and depression. Symptoms can cause a disruption in a person’s everyday
life, from work to school or engaging in social activities.
Genital dysphoria is extreme discomfort with one’s genital region, often lead-
ing to feelings of being ashamed or embarrassed by their genitalia. Those with
genital dysphoria may also have dysphoria for certain parts of their genitals, an
example being their testicles. A lack of sexual desire could be associated with
genital dysphoria, as individuals often do not want anyone to be sexually attracted
to their genitals or to use them during sex. Masturbation fits into this realm, as
those who experience genital dysphoria and masturbate may experience a sense of
disconnect with their body and pleasure. In addition, many who do experience
genital dysphoria may not masturbate due to their own disgust with their genitals,
and this could be detrimental to one’s healthy sexuality.
Genital dysphoria is associated with gender dysphoria and a transgender iden-
tity. Unlike genital dysphoria, gender dysphoria does have a concrete definition: it
is when a person has a conflict with the sex they were born with and the gender
they identify as, which causes distress. Gender dysphoria is labeled as a mental
health condition and appears in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition, whereas genital dysphoria does not. Transgender people
identify as a different gender from the gender assigned at birth, and it is important
to note that transgender people may suffer from gender dysphoria, but not all do.
Though people with gender dysphoria may not particularly like the body they
Genital Dysphoria 283
have, it does not always mean they are distressed by their genitals. Those with
gender dysphoria may not hate their genitals but would choose the other set of
genitals if possible. In addition, those with gender dysphoria may experience other
dysphorias as well, such as their shoulders being too broad, their voice being too
high, or not having enough curvature to their body. Considering the lack of
research on the topic, it is hard to say how many people experiencing gender dys-
phoria also experience genital dysphoria.
Depression and anxiety can result from genital dysphoria, which can have neg-
ative mental and physical health consequences. Everyone who experiences genital
dysphoria handles it uniquely. Some individuals experiencing genital dysphoria
may employ a technique termed “tucking.” Tucking is when a male puts their
genitals between or behind their legs so that they are not visible. This process
often involves taping the penis back between the legs toward the anus and then
taping everything up, so there is no sign of a penis or testicles. This allows for the
wearing of tight-fitting or more feminine clothes without revealing male genitalia.
There are health concerns with tucking, though. First, it does not permit urinating.
This could increase the risk for urinary tract infections if one holds their urine for
an extended amount of time. Ripping off the tape could also irritate the skin over
time. Along with that, where people tuck is typically a warm and moist area,
which could result in fungal infections. Regardless, tucking is a method by which
people make themselves feel more secure with the body they were born with.
Some individuals have also reported the feeling of a “phantom” genital. People
may see their genitals as being of the opposite sex, or they may describe their
genitals differently. This could include people labeling their penis as a clitoris, or
a clitoris as a penis. Again, research in this area is extremely lacking, although
this seems to occur more in individuals who are transitioning.
While genital dysphoria may not be currently recognized by the psychiatric
society, given all the discussion about it, it seems likely that it will soon be classi-
fied and defined. This term clearly needs to be researched more in order to further
understanding and knowledge on how to support those experiencing this dyspho-
ria. Genital dysphoria can be incredibly distressing to some, so the more support
they have, the greater the chance of improving their mental health.
Casey T. Tobin
See also: Gender Dysphoria; Gender Transition.
Further Reading
Blakeslee, S. (2008, April 13). Gender identity and phantom genital. San Francisco
Chronicle. Retrieved from https://www.sfgate.com/opinion/article/GENDER
-IDENTITY-AND-PHANTOM-GENITALIA-3219560.php
Drescher, J., & Pula, J. (2013). Expert Q & A: Gender dysphoria. Retrieved from https://
www.psychiatry.org/patients-families/gender-dysphoria/expert-qa
Merriam-Webster. (2019). Dysphoria. Retrieved from https://www.merriam-webster.com
/dictionary/dysphoria
Ramachandran, V., & McGeogh, P. (2007). Occurrence of phantom genitalia after gender
reassignment surgery. Medical Hypotheses, 69(5), 1001–1003.
Samantharz. (2012, August 23). Gender dysphoria and genital dysphoria. Retrieved from
http://transcoward.blogspot.com/2012/08/gender-dysphoria.html
284 Genital Warts
Genital Warts
Genital warts (also commonly referred to as condyloma, condylomata acumi-
nata, and venereal warts) are soft wart-like growths that occur along the external
genitalia, including the penis, vulva, urethra, vagina, cervix, and around the
anus. Genital warts are caused by the sexually transmitted virus known as the
human papillomavirus (HPV). Currently there are more than 100 types of HPV,
with approximately 40 types that can infect the genital tract. Genital HPV is the
most common sexually transmitted infection (STI), with HPV types 6 and 11
now known to be the cause of more than 90 percent of genital warts. HPV is
commonly passed via sexual contact, and therefore genital warts are considered
to be an STI.
Almost all cases of genital warts are caused by HPV. Genital warts are spread
through direct skin-to-skin contact, and this can occur during oral, vaginal, or
anal sex. The majority of genital warts are caused by two specific types of HPV—
HPV types 6 and 11. The virus can penetrate the skin or mucosal membranes (the
lining of certain organs, such as the vagina, mouth, and anus) through micro-
scopic abrasions in the genital area, which primarily occur during sexual
activity.
HPV types 6 and 11 are considered to be low risk, which means that although
they can cause a growth along the external genitalia, these growths tend to be
benign and have a low risk of causing cancer. There are other HPV types, most
commonly types 16 and 18, which are known as high-risk types because this sub-
set causes cancer of the cervix, anus, and oropharynx (mouth). Fortunately, the
majority of people infected with HPV have no symptoms because the body’s
immune system is able to suppress the virus, so there is no outward sign of infec-
tion. However, being asymptomatic can often be misleading because a person
infected with the virus may not know they are infected and unknowingly pass the
virus to a partner.
Following infection with HPV, it may take weeks, months, or even years before
the warts can be detected, and not everyone who comes in contact with the virus
will develop them. It is also possible (and common) to be infected by more than
one type of HPV at the same time, so a person could get genital warts and have a
low-risk HPV type and yet still be exposed to a high-risk HPV type that can cause
cancer. If a person has genital warts or may have been exposed to genital warts, it
is extremely important to let their health care provider know so that regular exams
and Pap smears can be performed. There are certain risk factors that make it more
likely to get genital warts or to spread them, including having unprotected sex,
having multiple sexual partners, becoming sexually active at an early age, using
alcohol and tobacco, being pregnant, and having a weakened immune system
because of illness (such as HIV) or medication (such as immunosuppressants that
are taken following an organ transplant).
Not all types of HPV cause genital warts. Several types of HPV have been
found to be the cause of warts that occur on other parts of the skin, including the
hands and feet. The warts that occur on the hands are commonly referred to as
common warts, while those that occur on the feet are referred to as plantar warts.
Genital Warts 285
Genital warts tend to be flesh-colored soft growths that occur along the surface
of the genital tract. This includes the penis, scrotum, vagina, cervix, rectum, and
anus; they can also occur in and around the mouth. These growths commonly look
like a tiny cauliflower and can grow as a single wart or in clusters and range in
size from very small to a large mass. Genital warts are typically asymptomatic,
but depending on their size and location, they can cause pain or itching. They can
also cause an increase in vaginal discharge or dampness in the genital area near
the warts or vaginal bleeding either during or after sex.
The diagnosis of genital warts is typically a clinical diagnosis made at the time
of a physical exam by a health care provider. The warts can be directly visualized
with the naked eye but oftentimes are so small or flat in appearance that magnifi-
cation is required. The magnification is done using a special scope, called a colpo-
scope, which resembles a pair of binoculars. A dilute solution of vinegar, known
as acetic acid, can be applied to the affected area to aid in better visualization of
the warts. If HPV changes are present, the infected area will turn a whitish color.
The colposcope is also used to look for any of these abnormal changes in the vagi-
nal canal or on the cervix. A medical provider may not feel confident regarding
the diagnosis of genital warts if the lesions do not have a classic appearance. At
times the lesions may take on a different shape, color, or texture than is typical. If
there is any clinical doubt as to whether or not a growth in the genital area is
indeed a genital wart, the lesion should be biopsied (removed by the clinician) and
sent to a lab so a pathologist can do the diagnosis with certainty.
Genital warts tend to grow for about six months, and then the growth of the
wart stabilizes. Since the warts can still be emerging during this time, immediate
treatment is not recommended since additional treatment may be required. Geni-
tal warts may also go away spontaneously without any treatment. When treat-
ment is indicated, there are several options available, including medicines,
freezing, laser, or surgery. Medical treatment options include a prescription
cream applied by the patient at home. These creams tend to work either by
destroying the wart tissue or by boosting the body’s immune system so it is able
to suppress the virus.
Other treatment options include those done by the health care provider and can
be done in either the doctor’s office or in an operating room. Treatment options
done in an office setting include cryotherapy or freezing of the wart with liquid
nitrogen, and application of a chemical called trichloroacetic acid, which is applied
directly to the surface of the wart. Medicines applied by the health care provider
are those that tend to have a greater risk of damaging the skin surrounding the
wart and must be applied with caution. Surgical treatment options include exci-
sion of the warts using a scalpel (surgical knife); electrocautery, which burns off
the wart using an electric current; or laser, which is a light amplified by the stimu-
lated emission of photons that is used to vaporize or excise the warts. In general,
smaller warts tend to respond more favorably to treatment than larger warts, and
warts that are on a moist surface respond better to topical treatments when com-
pared with warts on a drier surface. If the warts have not resolved after three treat-
ments by a health care provider or after six prescription treatments, then treatment
286 GLAAD
options should be reevaluated and surgical options for the treatment of the warts
considered.
It is easier to prevent an STI than to treat an infection after it has occurred. To
reduce the risk of becoming infected with HPV, it is important to practice safer
sex and communicate with a partner about any STIs or potential exposure to one
before beginning a sexual relationship. To help reduce the risk of becoming
infected with HPV, condom use is recommended. It is important that condoms are
used consistently and correctly before any sexual contact. Accurate condom use
can significantly decrease the transmission of HPV. However, because HPV can
be spread outside of the area covered by a condom, even perfect condom use is not
a guaranteed way to prevent catching or spreading genital warts.
There is a vaccine currently available to prevent infection by the most common
strains of HPV, including several of the high-risk types that cause cancer and sev-
eral of the most common low-risk types that can cause warts. The vaccine is typi-
cally given as a series of shots over a period of about six months. HPV vaccination
is recommended for all people, especially those age nine to twenty-six. Ideally, the
vaccine should be given before the commencement of sexual activity due to poten-
tial exposure to HPV which can occur during any sexual act. However, even if
individuals have previously had sexual experience, the vaccine is still recom-
mended as it can help prevent future infection.
Lori Apffel Smith
See also: Cervical Cancer; Human Papillomavirus (HPV); Pap Smear; Sexually Trans-
mitted Infections (STIs).
Further Reading
Grimes, J. A., Smith, L. A., & Fagerberg, K. (2013). Sexually transmitted disease: An
encyclopedia of diseases, prevention, treatment, and issues. Santa Barbara, CA:
Greenwood.
McAnulty, R. D., & Burnette, M. M. (Eds.). (2006). Sex and sexuality. Santa Barbara, CA:
Praeger.
Newton, D. E. (2009). Sexual health: A reference handbook. Santa Barbara, CA:
ABC-CLIO.
GLAAD
GLAAD is a nonprofit organization that advocates for more accurate portrayals of
lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) people in the
U.S. media, as well as greater inclusion of the LGBTQ community in general.
Formerly known as the Gay and Lesbian Alliance Against Defamation, the group
dropped this name in 2013 and began to use only its acronym, GLAAD—a move
meant to emphasize the expansion of its mission to include bisexual, transgender,
and queer/questioning people.
Gay and lesbian advocates founded GLAAD in 1985 in response to what
GLAAD now deems “defamatory and sensationalized” media coverage of gays
and lesbians at the beginning of the HIV/AIDS epidemic. The group initially
GLAAD 287
targeted the New York Post and the New York Times for reporting seen by the gay
and lesbian community as discriminatory. Soon, however, it was actively monitor-
ing all media outlets for any misrepresentation of gays and lesbians.
During the 1980s and 1990s, GLAAD convinced the New York Times, the
Associated Press, and other prominent news outlets to officially change the terms
they use to refer to gays and lesbians; it also pressured television networks to
increase positive representations of gays and lesbians in their programming.
GLAAD’s efforts began to expand with the 1998 murder of Matthew Shepard,
when the group not only led a media outreach campaign but also became part of a
nationwide dialogue on antigay hate crimes.
GLAAD widened its mission in the early 2000s, first to include bisexual and
transgender people and later when it reached out to Spanish-language television
networks to encourage them to include the LGBTQ community in their program-
ming. In 2006, GLAAD launched the “Be an Ally and a Friend” campaign, which
asked straight people to work for positive LGBTQ representation as well.
As part of its work, GLAAD created an annual media awards program, meant
to highlight positive portrayals of the LGBTQ community, and an annual Spirit
Day, in which LGBTQ supporters wear purple to show support for LGBTQ youth
and to denounce bullying. More recently, GLAAD has worked with the National
Basketball Association, Boy Scouts of America, Facebook, and other social media
to reduce discrimination against LGBTQ people within these forums.
Over the course of GLAAD’s existence, positive portrayals of LGBTQ people
in the media and elsewhere have skyrocketed, leading some media observers to
question whether GLAAD may have rendered itself obsolete. Journalist James
Kirchick, a fellow with the Foundation for Defense of Democracies, wrote in 2013,
“The best thing the organization could do is dissolve—not because it is actively
harmful, but rather because it is a victim of its own success.” Others have made
similar statements, criticizing GLAAD for being hypersensitive and too “politi-
cally correct” for an age of growing LGBTQ mainstreaming.
Some GLAAD critics also argue that the organization has moved too far away
from its original mission and has instead developed a liberal bias. They point out
that the organization has heavily criticized Fox News for discriminatory com-
ments made about LGBTQ people on its shows but has failed to do so when the
more liberal MSNBC has aired similar statements. GLAAD also was criticized
after its former president Jarrett Barrios wrote a letter to the Federal Communica-
tions Commission in support of AT&T’s purchase of rival T-Mobile—after AT&T
had donated large sums of money to GLAAD.
Barrios was forced to resign from GLAAD in 2011, and the organization has
since worked to improve its image across the political spectrum, working with
religious leaders and other traditionally conservative groups. GLAAD leaders and
supporters maintain that the organization remains relevant and important, espe-
cially in the areas of bisexual and transgender rights and representation, which lag
behind those of gays and lesbians.
Terri Nichols
See also: Gay Rights Movement; LGBTQ+; Media and Sexuality; Shepard, Matthew.
288 GLMA: Health Professionals Advancing LGBTQ Equality
Further Reading
GLAAD. (n.d.). Home page. Retrieved from http://www.glaad.org/
Kirchick, J. (2013, May). How GLAAD won the culture war and lost its reason to exist.
The Atlantic. Retrieved from https://www.theatlantic.com/politics/archive/2013/05/
how-glaad-won-the-culture-war-and-lost-its-reason-to-exist/275533/
GLMA: Health Professionals Advancing LGBTQ Equality
GLMA: Health Professionals Advancing LGBTQ Equality, or simply GLMA, is
the newest name of the “world’s largest and oldest association of lesbian, gay,
bisexual, transgender, and queer (LGBTQ) healthcare professionals.” Their mis-
sion is “ensuring health equity for lesbian, gay, bisexual, transgender, queer
(LGBTQ) and all sexual and gender minority (SGM) individuals, and equality for
LGBTQ/SGM health professionals in their work and learning environments. To
achieve this mission, GLMA utilizes the scientific expertise of its diverse multi-
disciplinary membership to inform and drive advocacy, education, and research”
(GLMA, 2018).
GLMA was founded in 1981, a time when community organizations’ names
tended to be less obvious about their mission in order to avoid harassment. The
group was originally known as American Association of Physicians for Human
Rights. Membership was initially open only to physicians, residents, and medical
students. As the LGBTQIA+ movement has matured and become more visible and
inclusive, the organization’s identity and scope has evolved accordingly. The orga-
nization “came out” in 1994 and changed its name to Gay and Lesbian Medical
Association (GLMA). In the years that followed, the group struggled between
maintaining their established brand identity as GLMA and the perception as an
organization exclusive of anyone not gay and lesbian. In 2012, the official name of
the organization became GLMA: Health Professionals Advancing LGBT Equal-
ity. In 2018, the Q was added in LGBTQ to further broaden the outreach to queer-
identified providers and individuals.
Despite the many shifts in name, GLMA has had a significant impact on public
policy, clinical practice, and social perspective regarding sexual orientation and
gender identity and expression, both for patients and providers.
A few examples of GLMA’s accomplishments:
• Since 1982, GLMA’s Annual Conference on LGBT Health has been the larg-
est of its kind in the world.
• In 2007, GLMA codeveloped the Healthcare Equality Index with the Human
Rights Campaign.
• In 2008, GLMS supported the quest for marriage equality by publishing a
landmark research report, “Same-Sex Marriage and Health,” which showed
significant health disparities among families denied the right to marry.
• In 2010, GLMA initiated what became federal joint commission policy
changes on hospital visitation and nondiscrimination.
• In 2012, GLMA filed an amicus brief supporting successful defense of the
Affordable Care Act.
GLSEN (Gay, Lesbian, and Straight Education Network) 289
• In 2012, GLMA submitted a letter to Centers for Medicare and Medicaid in
support of including sexual orientation and gender identity in electronic health
records.
GLMA also provides several important resources for LGBTQ patients and provid-
ers, including an online directory to help patients locate LGBTQ-friendly provid-
ers in their area; an educational webinar series; and the biweekly LGBT Health
Digest, which serves more than 6,000 subscribers. GLMA is also the parent orga-
nization to the Lesbian Health Fund (LHF), which supports research aimed at
“improving the health of lesbians and other sexual minority women and their fam-
ilies” (GLMA, 2018). The total amount of funding LHF has awarded since its
founding in 1992 is nearly $1 million.
C. Michael Woodward
See also: Gay Rights Movement; LGBTQ+; Same-Sex Marriage; World Professional
Association for Transgender Health (WPATH).
Further Reading
GLMA. (2018). About GLMA. Retrieved from http://www.glma.org
GLMA. (n.d.). GLMA’s impact. Retrieved from glma.org: http://www.glma.org/_data/
n_0001/resources/live/Our%20Impact.pdf
GLSEN (Gay, Lesbian, and Straight Education Network)
GLSEN (Gay, Lesbian, and Straight Education Network) was formed in 1990 by
teachers from Massachusetts who recognized that their LGBTQ+ students were
often bullied and discriminated against, and so they wanted to improve the educa-
tion system to make it better for those students. Since 1999, GLSEN has also been
conducting research on LGBTQ+ issues in primary, middle, and high school.
GLSEN’s research staff are recognized throughout the country as trusted experts.
Their research has been used to improve legislation and policy for LGBTQ+ stu-
dents and has advocated for the presence of gay-straight alliances and other poli-
cies and resources in schools to build safe and respectful spaces. In addition, they
also educate students and school staff about bullying and harassment, and they
help to develop best practices and resources in order to create safe and affirming
schools. Today, GLSEN is the leading national educational organization focused
on ensuring safe schools for all students.
GLSEN works to change the pervasive problem of LGBTQ+ students being
harassed at school because of who they are. One of the goals of GLSEN is to
ensure that every student is valued and treated with respect in school, regardless
of their sexual orientation, gender identity, or gender expression. They believe that
a safe and positive school environment can help support and develop a positive
sense of self, which in turn can lead to education achievement and personal
growth. In order to accomplish this, GLSEN works with government, including
Congress and the Department of Education, individual schools, and school dis-
tricts to improve school environments and advocate for LGBTQ+ student issues,
especially highlighting the negative effects that homophobia and heterosexism
can have on students and schools. They also advocate for government funding to
290 Gonorrhea
support all students in K-12 public school, including support for antiharassment
policies, factual and evidence-based inclusive learning, and inclusive cocurricular
and extracurricular activities.
GLSEN also creates school programs to help support the LGBTQ+ community.
One example, the National Day of Silence, is a day when students from all across
the country call attention to LGBT bullying and harassment in schools and the
effects that this has on LGBTQ+ students. Another program, No Name-Calling
Week, was inspired by The Misfits, a novel where students created a No Name-
Calling Day at their school. GLSEN created this program to celebrate and pro-
mote kindness to create safe schools without name-calling, bullying, and
discrimination. There are lessons and activities for grades K-12. Finally, Ally
Week is a week for students of all sexual orientations to discuss and plan for how
to become better allies to LGBTQ+ youth.
GLSEN welcomes all individuals who are committed to improving school cli-
mates and who value diversity within schools as members, regardless of sexual
orientation, gender identity, gender expression, or occupation. GLSEN is governed
by a national board of directors that establishes their mission, strategic aims, and
public policy platform. The executive director and other delegates work together to
develop and implement programs in line with the goals and mission of GLSEN.
Lauren Ewaniuk
See also: Gay-Straight Alliance (GSA); Sex Education.
Further Reading
GLSEN. (2017). Championing LGBTQ issues in K–12 education since 1990. Retrieved
from https://www.glsen.org/
True Tolerance. (2017). Backgrounder: What parents should know about GLSEN.
Retrieved from http://www.truetolerance.org/2011/what-parents-should-know
-about-glsen/
Welcoming Schools. (2017). Creating safe and welcoming schools for all children & fami-
lies. Retrieved from http://www.welcomingschools.org/
Gonorrhea
Gonorrhea is a sexually transmitted infection (STI) caused by the gram-negative
bacterium Neisseria gonorrhoeae. It is a very common multistrain bacterial infec-
tion that can infect the penis, vagina, uterus, cervix, anus, urethra, eyes, or throat.
The Centers for Disease Control and Prevention (CDC) estimate that nearly
820,000 new gonorrheal infections occur in the United States each year. The
infection may be referred to colloquially as “the clap” or “the drip.”
Gonorrhea bacteria live in the moist membranes of the urogenital tract as well
as in the mouth and throat, eyes, and anus. It is typically transmitted through
sexual contact by an infected partner. On rare occasions, touching the eye after
touching an infected body part can cause transmission.
Ejaculation does not have to occur for the infection to be transmitted or con-
tracted. Once a person has been infected by the bacteria, the typical incubation
period is between two and five days, but the full range can be anywhere between
Gonorrhea 291
one and eight days. It is also possible for gonorrhea to be passed from an infected
pregnant female to the fetus during a vaginal birth. This can result in blindness,
joint infection, or a blood infection in the newborn.
Many people with gonorrhea do not experience symptoms. Males with the
infection are more likely to experience symptoms than females. Even when people
do exhibit symptoms associated with gonorrhea, they are often mild and may be
easily confused for a different vaginal or bladder infection.
Females with symptoms may experience painful or frequent urination,
increased discharge that might turn yellow or green in color, vaginal bleeding
between menstrual periods, painful intercourse, fever, vomiting, urethritis, and
swelling of the vulva. Left untreated, the infection may cause cervicitis, and if the
bacteria reach the bladder, it can cause cystitis.
Most males infected with gonorrhea develop symptoms, but they are typically
mild. Initial symptoms often include a pus-like discharge from the urethra, red-
dening of the glans of the penis, and painful or frequent urination. Other common
symptoms include painful erections, swelling and pain in the scrotum, and a low
fever. If left untreated, the infection can spread to the urinary bladder, prostate
gland, and epididymis.
People with an oral infection may experience a sore throat and itchiness. Anal
infections can cause anal discharge, itching, soreness, bleeding, painful bowel
movements, and potentially proctitis. If left untreated, the bacteria can enter the
bloodstream, potentially inflaming the heart, brain, eyes, skin, spinal cord mem-
branes, and joints.
Gonorrhea can be diagnosed by a health care professional in several ways. Dis-
charge produced from the urethra, vagina, or anus may be tested, or cell samples
collected from swabs may be taken from the penis, cervix, urethra, anus, or throat.
These tests usually take about twenty-four to forty-eight hours. It is also possible
to detect the infection through a urine test.
It is important to treat gonorrhea, as it can result in severe complications. In
females, untreated gonorrhea can lead to pelvic inflammatory disease, which can
affect a person’s ability to get pregnant. In males, untreated gonorrhea can lead to
epididymitis, which may cause infertility. In rare cases, people with untreated
gonorrhea may develop disseminated gonococcal infection, which can cause
arthritis and skin sores and potentially permanently damage joints.
Treatment for gonorrhea has changed as different strains of the infection have
combatted commonly used antibiotics. For example, penicillin was the standard
treatment until resistant forms dubbed “super gonorrhea” appeared in the 1990s.
Fluoroquinolones may also be used, but a fluoroquinolone-resistant gonorrhea
was discovered in Asia, the Pacific Islands, and California in the early 2000s.
More recently, the CDC has recommended cephalosporin antibiotics; however,
cephalosporin-resistant strains of gonorrhea have now also been found. Often,
people with gonorrhea may also be infected with chlamydia, so many doctors
prescribe dual antibiotics. Persons treated for gonorrhea should also be retested in
six months.
Several measures can be taken to prevent contracting or transmitting gonor-
rhea. Abstaining from sexual intercourse will ensure no spread of the infection.
292 Grafenberg Spot (G-Spot)
For sexually active individuals, using condoms and other barriers can greatly
reduce the risk of transmission. Getting regularly tested for STIs can also help
prevent the spread of the infection.
If someone has gonorrhea, treatment and partner notification can help prevent
complications from the infection as well as transmission to others. Also, abstain-
ing from sexual intercourse during treatment will ensure no spread of the infec-
tion or risk reinfection. According to the CDC, persons diagnosed or being treated
with gonorrhea should tell all sexual partners within sixty days of the diagnosis or
onset of symptoms.
Sarah Gannon
See also: Pelvic Inflammatory Disease (PID); Safer Sex; Sexually Transmitted Infections
(STIs); Testing, STI.
Further Reading
Centers for Disease Control and Prevention. (2019). Gonorrhea: CDC fact sheet (detailed
version). Retrieved from http://www.cdc.gov/std/gonorrhea/stdfact-gonorrhea
-detailed.htm
Jones, R. E., & Lopez, K. H. (2014). Human reproductive biology (4th ed.). San Diego,
CA: Academic Press.
Mayo Clinic. (2019). Gonorrhea. Retrieved from https://www.mayoclinic.org/diseases
-conditions/gonorrhea/symptoms-causes/syc-20351774
Planned Parenthood. (2019). Gonorrhea. Retrieved from https://www.plannedparenthood
.org/learn/stds-hiv-safer-sex/gonorrhea
Grafenberg Spot (G-Spot)
The G-spot, or Grafenberg spot, was named after Dr. Ernest Grafenberg (1881–
1957), a gynecologist who described the “sensual potential” of this part of the
anatomy during the 1950s. The G-spot was named in the 1980s and popularized by
Beverly Whipple and John Perry in their book The G Spot and Other Discoveries
about Human Sexuality. The G-spot is a very sensitive, erotic spot, located on the
front wall of the vagina. It may be better described as a general area rather than as
a specific spot. There is a lot of controversy over the existence of the G-spot.
The G-spot is located on the front wall of the vagina about one to three inches
inside the vagina. It is a small, textured area that may be felt by the fingers and
stimulated by fingers utilizing a “come hither” motion. Researchers hypothesize
that this area is sensitive because the internal parts of the clitoris and the erectile
tissue that surrounds the urethra meet in this area.
Another theory in regards to what makes this spot sensitive is that when the
female body is aroused, the clitoris rises. This changes the angle of the stems of
the clitoris inside the body, which may expose more nerve endings. Another the-
ory offered is that the area is actually the area corresponding to the trigone of the
bladder. Support for this theory comes from the fact that many people experience
greater sensation in this area when the bladder is full. Many sex toys have been
created specifically for the G-spot. While many people enjoy having this area
stimulated, many others do not.
Green, Jamison 293
There is not a great deal of research on the G-spot in general, however, Beverly
Whipple is most closely associated with researching this area. Many researchers
question the existence of such a spot. In fact, in 2009, there was a Journal of Sex-
ual Medicine debate on the topic held during the International Society for the
Study of Women’s Sexual Health Congress. During this debate, experts in the
field of female sexuality were asked by researchers to form an opinion on the topic
of the G-spot after given data to review. Some experts agreed the G-spot exists but
note that it is not a consistent spot and may vary from person to person. Other
scholars note the G-spot shows dynamic changes during stimulation and even
allude to this spot being the source of stimulation that leads to female ejaculation,
or “squirting.” However, other scholars argue against the G-spot by discussing
many contrasting findings on the topic.
In the past, most research about the G-spot was done on cadavers. Newer tech-
nology allows more thorough research to be done on living people; however, much
more research is needed in order to understand more about this sometimes elusive
spot.
Amanda Manuel
See also: Arousal; Clitoris; Erogenous Zones; Female Ejaculation; Orgasm; Sex Toys;
Vagina.
Further Reading
Herbenick, D. (2012). Sex made easy. Philadelphia: Running Press Book Publishers.
Herbenick, D., & Stoddard, G. (2012). Great in bed. New York: DK Publishing.
Jannini, E. A., Whipple, B., Kingsberg, S. A., Buisson, O., Foldes, P., & Vardi, Y. (2010).
Who’s afraid of the G-spot? Journal of Sexual Medicine, 7(1), 25–34.
Joannides, P. (2012). What’s inside a girl? Guide to Getting It On (6th ed., 77–105). Wald-
port, OR: Goofy Foot Press.
Whipple, B. (2015). Female ejaculation, G spot, A spot, and should we be looking for
spots? Current Sexual Health Reports, 7, 59–62.
Green, Jamison
Jamison Green, PhD, is a well-known leader in the transgender rights movement.
Since the early 1990s, Green has been an influential advocate for the transgender
community through his publications, speaking engagements, consultation ser-
vices, and membership on the board of multiple transgender and LGBT organiza-
tions of national and international renown. For nearly three decades, Green, who
himself identifies as a transgender man, has made significant contributions to the
field of transgender health and LGBTQ workplace equality.
Jamison Green was born female-bodied on November 8, 1948, in Oakland,
California. He was adopted at one month old by a couple who wanted to raise a
daughter, but he began showing signs of atypical gender development early in his
life. In his website, Green recalled that he started refusing typical young girls’
clothing before age two and, by the time he reached grade school, it became clear
to him that he was different than other girls and boys. As a baby, Green was given
female first and middle names, but in 1964, at the age of fifteen, he adopted the
294 Green, Jamison
name Jamison and started going by the gender-neutral nickname Jamie. Although
Green knew by his early twenties that he was transsexual, the social climate and
stigma surrounding gender variance in the early 1970s prevented him from seek-
ing out care from gender specialists and from pursuing legal gender change. It was
then in his late twenties that he began living openly as lesbian and began a long-
term relationship with a woman who would later become the mother of his two
children. Although not legally male at the time, Green was listed as the father on
both children’s birth certificates. Green’s romantic relationship with the mother of
his children ended in 1989, but they remained close, as coparents, until her death
in 2008. Other significant events in Green’s life were his legal name change in
1991 and his marriage to Heidi A. Bruins (now Heidi B. Green), an instructional
design consultant and political activist, in 2003.
Green received a bachelor degree in English in 1970 and a master of fine arts in
English/creative writing in 1972, both from the University of Oregon, Eugene. He
went on to pursue a career in technical writing, whereby he managed publications
for various technology manufacturing companies and ultimately worked his way
up to the level of vice president at a publicly held software publishing firm. His
accomplishments as a professional writer extended to the fields of medical and
legal writing as well—an experience that equipped him with valuable knowledge
and skills he later applied to his work as an advocate for transgender people’s
rights. It was not until the early 1990s that Green began his earliest advocacy
efforts, working with attorneys, legislators, and other policy makers to develop
language regarding gender identity and expression as it relates to employment,
housing, and public accommodation laws. In the 1990s, among other distinctions,
he served as leader of FTMInternational—the world’s largest advocacy organiza-
tion for female-to-male individuals and their families—for eight years (1991–
1999) and was influential in the establishment of the Transgender Protection
Ordinance in San Francisco. In 1994, working alongside the San Francisco Human
Rights Commission, he authored the Report on Discrimination against Transgen-
dered People, which provided a comprehensive public evaluation of the experi-
ences of transsexual and transgender individuals living in San Francisco. This
report helped motivate city supervisors to pass legislation that added gender iden-
tity to the list of protected classes and led the Human Rights Commission to orga-
nize a group of volunteers from the transgender community to assist in providing
sensitivity training to various social service agencies. Expanding his reach beyond
social services, Green eventually became known as an expert on workplace gen-
der nondiscrimination policies and practices and provided consultation services to
various organizations, including major corporations and governmental agencies
seeking to ensure compliance with state and local laws concerning gender
identity.
The 2000s and beyond helped consolidate Green’s visibility and influence as an
advocate for transgender people’s rights. His efforts helped establish new models
for transinclusive workplace benefits and policies, which ultimately had effects on
a national level, becoming adopted in 2002 as benchmarks by the Corporate
Equality Index—a tool used to rate workplaces on LGBTQ equality. In 2004,
Green published Becoming a Visible Man, an autobiographical analysis of the
Gynecomastia 295
emerging transgender community, describing his own transition from living as a
lesbian woman to affirming his identity as a bisexual trans man; and that same
year, his book received the Sylvia Rivera Award for best book in Transgender
Studies from the Center for Lesbian and Gay Studies and was a finalist for the
Lambda Literary Award. In 2011, Green earned his doctorate (PhD) in equalities
law from the Manchester Metropolitan University in England and became
president-elect of the World Professional Association for Transgender Health
(WPATH), an international and interdisciplinary professional organization that he
had served as an elected board member since 2003. From June 2016 to the time of
this writing, Green has served as president of the WPATH Executive Committee
as well as chairperson and board of directors liaison of their ethics committee. He
has also served on the boards of various other organizations, including Gender
Education and Advocacy, the Transgender Law and Policy Institute, the Equality
Project, and Trans Youth Family Allies.
Cristina L. Magalhães and Marissa A. Worth
See also: FTMInternational; Gender Identity; LGBTQ+; Transgender; Transsexual;
World Professional Association for Transgender Health (WPATH).
Further Reading
Denny, D. (Ed.). (1998). Current concepts in transgender identity. New York: Garland
Publishing.
FTMInternational. (2009). FTMInternational facts. Retrieved from https://www.ftmi.org
GLSEN. (2018). Jamison Green: Transgender activist. Retrieved from https://www.glsen
.org/sites/default/files/Jamison%20Green%20Backgrounder.pdf
Green, J. (2004). Becoming a visible man. Nashville, TN: Vanderbilt University Press.
Green, J. (2008). Jamison Green & associates: Education and policy consulting on trans-
gender and transsexual issues. Retrieved from http://jamisongreen.com
World Professional Association for Transgender Health. (2013). Home page. Retrieved
from https://www.wpath.org/about/EC-BOD
Gynecomastia
Gynecomastia is an endocrine disorder that creates abnormal male breast tissue
growth. It can affect one or both breasts and typically is seen in pubescent boys
and older adult men as they undergo hormonal changes. Statistics show that the
benign condition is quite common—some 50–60 percent of boys experience
gynecomastia, and around 70 percent of men age fifty and older are also affected
by this disorder. In addition, an estimated 60–90 percent of all male infants are
born with gynecomastia; however, many of these children will never present any
symptoms.
Although gynecomastia is typically more of an uncomfortable or embarrassing
problem than a truly dangerous one, in some cases it can signal a more serious
underlying issue. Some of these issues include kidney failure, liver failure, or mal-
nutrition. More commonly, gynecomastia is caused by natural hormone changes
that decrease the amount of testosterone in the system while at the same time
increasing estrogen levels. In other instances, factors such as illicit drug and
296 Gynecomastia
alcohol use, anabolic steroid use, and side effects from certain medications can
trigger gynecomastia. Tumors in the pituitary or adrenal glands, or an overactive
thyroid, may also cause the condition. And, in about 2 percent of gynecomastia
cases, the disorder is caused by a testicular tumor.
A person affected by gynecomastia may be wholly asymptomatic, or they may
experience swelling and tenderness in the breasts. Some people may notice that
one breast is larger than the other. To diagnose the condition, a medical practitio-
ner will conduct a physical exam and may recommend certain laboratory tests,
including tissue biopsies or a magnetic resonance imaging exam. In some cases,
blood tests will be conducted to check the blood hormone levels, or a doctor will
advise studies of the liver and kidneys to look for underlying problems creating
the gynecomastia. If the condition is caused by natural hormone changes, the
body will most likely return to normal without medical intervention, and treat-
ment is usually contained to ice packs and over-the-counter pain medications to
relieve tenderness and swelling. Gynecomastia caused by puberty usually disap-
pears within six months to two years without treatment, and gynecomastia in
infants (due to higher estrogen levels in the mother) will generally go away in one
to two weeks. If the condition does not improve on its own or if another underly-
ing cause is determined, there may be further treatment required. Possible courses
of action include hormone treatment to reduce estrogen levels, medication or sur-
gery to shrink or remove a tumor, and surgery to remove excess breast tissue.
Gynecomastia has been a recognized disorder since the time of ancient Greece.
It is thought that Galen of Pergamon, a second-century Greek physician and phi-
losopher, was the first to introduce the term “gynecomastia” in medical refer-
ences. Several different medical and surgical treatments of the condition were
recorded throughout the 1800s, and treatment continues to evolve as new advances
in medicine are made.
Tamar Burris
See also: Breast, Female; Estrogen; Testosterone.
Further Reading
Meletis, C. D., & Woods, S. G. (2009). His change of life: Male menopause and healthy
aging with testosterone. Westport, CT: Praeger.
Watson, S., & Miller, K. (2004). The endocrine system. Westport, CT: Greenwood.
H
Hepatitis
Hepatitis is a virus that infects the liver. There are three common types: hepatitis
A (HAV), hepatitis B (HBV), and hepatitis C (HCV). According to the Centers for
Disease Control and Prevention (CDC), although the different strains may cause
similar symptoms, they can affect the liver differently and have different modes of
transmission. HBV is most likely to be transmitted through sexual contact and is
the focus of this article. While HAV and HCV can be transmitted through sexual
contact, it is rare, especially for HCV. According to the CDC, there are nearly
20,000 new HBV infections reported in the United States each year, but the actual
number of infected individuals is expected to be much higher.
The virus lives in semen, vaginal fluid, blood, and urine and can be transmitted
during sexual intercourse. It can also be spread by an infected pregnant person to
their infant at birth. According to the CDC, nearly two-thirds of HBV cases are
acquired through unprotected sexual intercourse. HBV can also be transmitted by
sharing needles or syringes.
There are two types of HBV infection: acute and chronic. Acute HBV lasts less
than six months. When it lasts longer, it becomes chronic. Chronic HBV can lead
to severe liver infections. According to the Mayo Clinic, adults are more likely to
develop acute HBV, while infants and children are more likely to develop chronic
HBV. The CDC estimates that between 700,000 and 1.4 million individuals have
chronic HBV in the United States. Globally, the number of persons infected with
HBV is estimated to be approximately 240 million.
According to the CDC, approximately 70 percent of adults develop symptoms
from HBV. Symptoms of acute HBV may appear between six weeks and six
months after exposure. These symptoms typically last for a few weeks, but some
people may have them for up to six months. Symptoms include extreme fatigue,
fever, nausea, vomiting, loss of appetite, abdominal pain, headache, jaundice, joint
pain, and dark urine or feces.
Individuals infected with chronic HBV may experience long-term health issues
such as liver damage, liver failure, or liver cancer. The CDC estimates that 15– 20
percent of people with chronic HBV develop serious liver conditions. They also
estimate that approximately 2,000–4,000 people die each year from a HBV-related
liver disease in the United States. Globally, this number is estimated to be about
786,000 deaths each year.
According to the CDC, there are different blood tests to diagnose HBV, and
they may be ordered as a single test or multiple tests. These tests are designed to
find antibodies or antigens in the body and may determine whether or not a person
has an acute or chronic infection, has recovered from the infection, is immune to
298 Herpes
HBV, is currently a carrier of the virus, or if they would be a good candidate for a
vaccination.
The Mayo Clinic states that a doctor might also test samples from the liver to
assess whether or not there is liver damage. This test involves the insertion of a
thin needle under the skin and into the liver to remove a tissue sample. The sample
is then taken to a laboratory for analysis.
There is no cure for HBV. However, most adults’ immune systems clear the
virus and develop immunity to it. When someone is diagnosed with acute HBV,
rest, healthy nutrition, and fluids are often recommended. For those diagnosed
with chronic HBV, there are several medications that have been developed to treat
the virus and help slow down the process of liver damage.
For those who want to prevent contracting HBV, a vaccine for the virus has
been available since 1981. It usually involves three to five shots over six months.
The vaccination is more than 90 percent effective in all persons immunized before
exposure to HBV. If a pregnant person has HBV, they can prevent passing the
infection to the infant at birth through a series of vaccinations and hepatitis B
immune globulin (HBIG) injections.
According to the Mayo Clinic, if someone thinks they have been exposed to the
virus and have not been vaccinated, they can receive an injection of HBIG within
twelve hours of exposure. This can help prevent development of HBV. For those
who are not vaccinated, either abstaining from or using condoms during sexual
intercourse can reduce the risk of transmission. Individuals should also refrain
from using or sharing unclean needles or syringes. Partner notification can con-
tain the spread of the virus.
Sarah Gannon
See also: Pregnancy; Safer Sex; Sexual Health; Sexually Transmitted Infections (STIs);
Testing, STI.
Further Reading
Centers for Disease Control. (2019). Viral hepatitis: Hepatitis B information. Retrieved
from http://www.cdc.gov/hepatitis/hbv/index.htm
Jones, R. E., & Lopez, K. H. (2014). Human reproductive biology (4th ed.) San Diego,
CA: Academic Press.
Mayo Clinic. (2019). Hepatitis B. Retrieved from https://www.mayoclinic.org/diseases
-conditions/hepatitis-b/symptoms-causes/syc-20366802
Planned Parenthood. (2019). Hepatitis B. Retrieved from https://www.plannedparenthood
.org/learn/stds-hiv-safer-sex/hepatitis-b
Herpes
The human herpes virus (HHV) is commonly associated with sores or blisters on
the lips and genitals. When these sores appear on the lips, they are generally
called cold sores. There are eight types of herpes viruses: herpes simplex viruses
(HSV) 1 and 2, HHV 3 (chicken pox/shingles), HHV 4 (mononucleosis or mono),
HHV 5 (cytomegalo virus), HHV 6 (roseola virus), HHV 7, and HHV 8
Herpes 299
(Karposi’s sarcoma-associated herpes virus). HSV 1 and 2 are most commonly
noted in sexual health classes as sexually transmitted infections because they can
infect the mucoepithelial tissue (tender skin that is not mucus membrane). Herpes
sores can appear on the lips and around the mouth, genitals, anus, and buttocks.
It is commonly said that HSV 1 is oral herpes and HSV 2 is genital. However,
either HSV strain can infect either area.
HSV 1 and 2 are contracted through skin-to-skin contact or contact with moist
areas that may contain the virus (e.g., saliva or lip balm). When the virus comes in
contact with mucoepithelial tissue, the virus travels down the nerve endings to the
bundle of nerves called a ganglion. Oral herpes infections live in the trigeminal
ganglia (by the temple on either side of the head), and genital herpes infections
reside in the sacral ganglia (at the sacrum or base of the spine). It is possible to
transmit the herpes virus through oral-genital or genital-genital contact when one
of the partners is infected with the herpes virus.
During an outbreak, sores appear on or around the mouth, genitals, anus, or
buttocks. Outbreaks can be caused by sunlight, trauma (being hit), irritation,
stress, illness, hormones, or menstruation. The likelihood of an outbreak increases
during illness because herpes is an opportunistic infection—it takes the opportu-
nity to break out when the immune system is suppressed. The virus is able to be
transmitted from a herpes sore during an outbreak. Transmission can also occur
before a sore is present, when the skin feels tingly or a dull pain is present with no
visible sore. Only about 10 percent of outbreaks are severe blisters. The majority
of herpes sores are classified as small, itchy ulcers.
Many people have some form of the herpes virus. One estimate from 1999–
2004 suggests that 60 percent of people have HSV 1, and about 20 percent of
people have HSV 2. It is common for oral herpes infections to be transmitted in
childhood. Family members with oral herpetic sores may kiss younger family
members and transmit the virus unknowingly.
Because herpes is a chronic condition, herpes outbreaks are usually treated
with suppressive drug therapy. Acyclovir, valacyclovir, and famciclovir are antivi-
ral drugs that suppress the virus and prevent outbreaks. These drugs can be taken
proactively (before an outbreak) or reactively (at the onset of pain or a sore). Tak-
ing the drugs proactively is the best way to limit transmission.
Despite the common prevalence of herpes and the relative ease of treatment,
stigma about herpes still persists. The common belief that an individual’s sex life
is over once they contract herpes in the genitals can contribute to strong negative
feelings upon diagnosis. The false belief that herpes ends a person’s sex life is
perpetuated by the lack of knowledge around how herpes works and treatment
efficacy. As a reaction to herpes stigma, people who have been diagnosed with
herpes have formed support groups and dating sites. Confronting social stigma
with little-known facts about herpes can contribute to a better understanding of
how herpes exists in our society and end harmful narratives that contribute to
herpes misinformation.
Mark A. Levand
See also: Sexual Health; Sexually Transmitted Infections (STIs); Testing, STI.
300 Heterosexism
Further Reading
Bradley, H., Markowitz, L. E., Gibson, T., & McQuillan, G. M. (2014). Seroprevalence of
herpes simplex virus types 1 and 2—United States, 1999–2010. Journal of Infec-
tious Diseases, 209(3), 325–333.
Hunt, R. (2005). Herpes viruses. In P. R. Murray, K. S. Rosenthal, & M. A. Pfaller (Eds.),
Medical microbiology (5th ed.) New York: Elsevier Mosby.
Jones, R. E., & Lopez, K. H. (2006). Human reproductive biology (3rd ed.) Burlington,
MA: Academic Press.
Margolis, T. P., Imai, Y., Yang, L., Vallas, V., & Krause, P. R. (2007). Herpes simplex
virus type 2 (HSV-2) establishes latent infection in a different population of gan-
glionic neurons than HSV-1: Role of latency-associated transcripts. Journal of
Virology, 81(4), 1872–1878.
Mertz, G. J. (2008). Asymptomatic shedding of herpes simplex virus 1 and 2: Implica-
tions for prevention of transmission. Journal of Infectious Diseases, 198(8), 1098–
1100. doi: 10.1086/591914
Heterosexism
Heterosexism describes a behavioral system that denies, denigrates, and stigma-
tizes any nonheterosexual form of behavior, identity, relationship, or community.
Heterosexism is often misused as synonymous with homophobia. However, het-
erosexism is the systemic display of homophobia within societal institutions, cre-
ated through the assumption that the world is heterosexual and that heterosexuality
is superior and normative. In the 1990s, queer scholars began referring to this as
normative heterosexuality or heteronormativity. Heteronormativity illustrates the
cultural dichotomy that exists between heterosexuality and homosexuality.
Heterosexism is analogous to sexism and racism, with similar parallels in the
way it approaches issues in mainstream culture. Heterosexism uses the invisibility
of homosexuality to minimize its existence while attacking it personally and insti-
tutionally when it becomes more visible. Historically, heterosexism has been
found in large societal institutions like religion and law.
While sexuality has been a topic of conversation for centuries, terms such as
“homosexuality” and “heterosexuality” are more recent. The term “heterosexism”
was coined around 1972, coinciding with the publication of Society and the
Healthy Homosexual. Two separate letters to the editor in the July 10 edition of an
Atlanta newspaper, The Grey Speckled Bird, used the term to parallel the treat-
ment and denigration of lesbian and gay individuals as similar to the treatments of
other individuals based on their gender and race.
Development of this term continued throughout the 1970s and 1980s through
lesbian-feminist writers who often focused on the layers of homophobic oppres-
sion through the prevalence of patriarchy, gender roles, and power relations. The
original analysis of homosexuality derived through the lens of psychopathology,
focused on homophobia as an attitude instead of focusing on systems’ and institu-
tions’ treatment of LGBTQ+ people. Three of the most significant institutions that
have exemplified heterosexism throughout history are (1) religion, (2) law, and (3)
psychology and psychiatry.
Religion was one of the first institutions that perpetuated heterosexism through
its views and teachings on sexuality. Throughout history, Christianity has long
Heterosexism 301
been one of the most dominant religions, and it has been verbal about its teaching
on sexuality. Christian law has expressed antipathy toward three major aspects of
sexuality: (1) nonprocreative sexual conduct (e.g., masturbation, contraception
use), (2) marital sex only for sensual gratification (e.g., all intercourse positions
beyond missionary), (3) and sex not sanctioned by (heterosexual) marriage (e.g.,
adultery, premarital sex). Sex that gay men engage in, historically known as sod-
omy, can be categorized underneath all three of these problematic areas.
Historically, Christianity commonly focused on the differences between being
homosexual versus acting on homosexual desires. An individual could identify as
homosexual, but acting on these desires or engaging in a relationship with a per-
son of the same gender would be considered a sin. This viewpoint on homosexual-
ity falls within the view of “love the sinner, hate the sin.” Certain groups, such as
white American Evangelical Protestant Christians, believe that those who openly
identify as LGBTQ+ need to be helped to reach salvation or risk deprivation of
civil liberties. Some white Evangelical Protestant Christians may participate in
extreme antigay activist groups that attempt to disallow LGBTQ+ individuals
from adopting, fostering, and working in certain child-centered careers.
The second major heterosexist institution is within law and criminalization. For
centuries, many aspects of sexual deviance were considered a crime, including
participation in homosexual behaviors. Originally, there were three forms of
stigma surrounding sexuality-related concerns: laws prohibiting or restricting pri-
vate sexual acts between consenting adults, laws specifically denying civil liber-
ties to gay and lesbian individuals, and laws that reinforce power differentials (i.e.,
adult-child relationships). Laws prosecuting sodomy can be found as far back as
the thirteenth century in France and Spain. After the colonization of the United
States, legislation across the United States was created in the 1700s and 1800s and
existed until 2003 in some parts of the country; some of these laws still remain on
the books in some states. Statutes on sodomy were often written in Latin or
described using phrases such as “the unmentionable vice” or “wickedness not to
be named,” insinuating the negative stigma associated with homosexuality.
Laws about sodomy have typically applied exclusively to men. Historically, if
people were assumed or found to be participating in homosexual acts, they were
imprisoned until cured, resulting in a loss of employment and ostracization from
their families. Some exceptions to the poor treatment of homosexual men were
allowed when it would benefit the country, as in American drafts for World War I.
In the initial onset of World War I, homosexual men were allowed to participate as
service men but were often asked not to share their sexual orientation. However,
during World War II, stigma toward homosexuality increased, and, as the war
dwindled and fewer people were needed for active duty, the country’s view of
homosexuality shifted from criminal or sinner to more of sexual deviant or psy-
chopath. Homosexuality became an acceptable medical rationale for exclusion
from service.
Heterosexism still exists within the U.S. legal system but to a lesser degree than
before. Marriage equality was voted on in the United States Supreme Court in
June 2015 and was approved with a 5–4 vote. Other legislation is still ongoing,
especially legislation about workplace discrimination, rights for transgender indi-
viduals, and helping LGBTQ+ youth homelessness. There is still a lot of
302 Heterosexuality
development that needs to happen to further assist LGBTQ+ individuals on a legal
front. However, with views shifting away from criminality and illness, there has
been a plethora of progress in passing new LGBTQ+-positive legislation.
During the nineteenth and early twentieth century, views of homosexuality
changed from homosexuality as criminal activity to homosexuality as a pathol-
ogy. Homosexuality was defined through the actions of the person, or “the homo-
sexual,” and was created to describe the opposition of normalcy. The focus of
homosexuality as a pathology did not become solidified until the twentieth cen-
tury. Researchers such as Havelock Ellis and Richard Krafft-Ebing were instru-
mental in making homosexuality a diagnosis in the Diagnostic and Statistical
Manual, which reduced the amount of imprisonment of homosexuals but resulted
in increased stigma around homosexuality as an illness. A comparison study
between heterosexual and homosexual men, which found that there were no sig-
nificant differences in the mental health status between the two groups, conducted
by Evelyn Hooker in 1971, led to the removal of homosexuality as a clinical diag-
nosis in the DSM-III in 1973. Some level of heterosexism still exists among some
therapists who attempt to perform conversion therapy, a type of therapy that seeks
to change the sexual orientation of lesbian, gay, and bisexual people. Most thera-
peutic practices ban this type of treatment.
Kimberly A. Fuller
See also: Gay Rights Movement; Heterosexuality; Homophobia; Homosexuality; Reli-
gion, Diversity of Human Sexuality and; Sodomy Laws.
Future Reading
Herek, G. M. (2004). Beyond “homophobia”: Thinking about sexual prejudice and stigma
in the twenty-first century. Sexuality Research & Social Policy, 1(2), 6–24.
Herek, G. M., Chopp, R., & Strohl, D. (2007). Sexual stigma: Putting sexual minority
health issues in context. In The health of sexual minorities (171–208). New York:
Springer.
Heterosexuality
Heterosexuality is one of several sexual orientation categories used in popular
media, mainstream culture, medicine, health, and research. The term “heterosex-
ual” often refers to persons who report sexual attraction and affection toward per-
sons belonging to “the other biological sex” or gender. Often used synonymously
with the term “straight,” heterosexuality denotes a sexual orientation identity in
which a man is attracted to a woman or a woman is attracted to a man. Hetero-
sexuality is an encompassing term that includes identity, identity management,
sexual behavior, physiological arousal, and fantasies that one has toward a mem-
ber of a different gender or biological sex. Given the various facets that construct
heterosexuality, identifying exclusively as heterosexual does not preclude some-
one from having a same-sex experience or encounter. Relatedly, having a same-
sex encounter does not necessarily mean someone identifies as gay, lesbian,
bisexual, or queer. Recent research indicates that heterosexuality is typically a
stable sexual orientation identity and tends to be more stable over time for
Heterosexuality 303
heterosexual-identified men than for heterosexual-identified women. Heterosexual-
identified individuals might also engage in heterosexual identity management
practices, including conforming to gender norms and public displays of affection
with members of the other sex.
Heterosexuality has been conceptualized using various philosophical para-
digms, including essentialism, social constructivism, poststructuralism, and femi-
nism, but the term “heterosexual” only entered into popular mainstream arenas
during the late nineteenth and early twentieth century. Prior to the writings of
Richard von Krafft-Ebing, Albert von Schrenk-Notzing, and Sigmund Freud, the
term “heterosexuality” was not part of modern everyday vernacular, especially
not as an identifying characteristic of one’s sexual orientation. Furthermore, in
Katz’s (1995) historical review of the construct, heterosexuality was initially used
to denote perverse and deviant sexual behaviors (i.e., sex for pleasure) versus
behavior exclusively for procreative purposes. It was not until Freud normalized
sexual identity development, and helped influence the ideology, that heterosexual-
ity became the sociocultural and sexual “norm.” To date, the “norm of heterosexu-
ality” has been challenged, and many scholars agree that sexual orientation is
fluid and resides more on a continuum than as a binary.
Similar to lesbian, gay, and bisexual identity development models, there have
been recent attempts to articulate a model of heterosexual identity development.
One such model contends that heterosexual identity is made up of both individ-
ual and social identity development processes. Both processes occur within the
context of biology, gender norm socialization, culture, religion, sexual prejudice
and stigma, privilege, and microsocial mandates (e.g., family, church). This
model of heterosexual identity development also consists of five statuses: unex-
plored commitment (social mandates for acceptable gender and sexual roles),
active exploration (intentional examination of one’s own sexual needs, values,
expression), diffusion (absence of examining one’s own sexuality), deepening
and commitment (entrusting to one’s sexual needs, values, and expression), and
synthesis (coming to a state of congruence). The model has yet to be empirically
validated.
Franco Dispenza
See also: Biological Theories of Sexual Orientation; Fluidity, Sexual; Heterosexism; Kin-
sey’s Continuum of Sexual Orientation; Sexual Identity; Sexual Orientation; Storms’s
Model of Sexual Orientation.
Further Reading
Davis-Delano, L. R., & Morgan, E. M. (2016). Heterosexual identity management: How
social context affects heterosexual marking practices. Identity, 16(4), 299–318.
Katz, J. N. (1995). The invention of heterosexuality. Chicago: University of Chicago Press.
Mock, S. E., & Eibach, R. P. (2012). Stability and change in sexual orientation identity
over a 10-year period in adulthood. Archives of Sexual Behavior, 41, 641–648.
Worthington, R. L., & Mohr, J. J. (2002). Theorizing heterosexual identity development.
The Counseling Psychologist, 30, 491–495.
Worthington, R. L., Savoy, H. B., Dillon, F. R., & Vernaglia, E. R. (2002). Heterosexual
identity development: A multidimensional model of individual and social identity.
The Counseling Psychologist, 30, 496–531.
304 Hirschfeld, Magnus
Hirschfeld, Magnus
Known fondly as the “Einstein of sex,” Magnus Hirschfeld (1868–1935) was one
of the most revolutionary sexologists of the early twentieth century. Alongside
Havelock Ellis and Sigmund Freud, Hirschfeld paved the way for modern scien-
tific sexuality studies. While most notable for his overabundant data collections,
Hirschfeld contributed to the field in a plethora of ways. Prior to his work, most
sexual research was essentially theoretical or based on considerably limited case
samples. In an attempt to substantiate homosexuality as a natural variance of
human behavior, his scientific explorations and social politics fashioned him the
founding father of modern LGBTQ+ advocacy. As a gay cross-dressing man him-
self, his empirical research on LGBTQ+ prevalence afforded remarkably accurate
statistics and pioneered Western interest in cross-gender behavior. Albeit mod-
ernly controversial, his original contrivance of the word “transvestite” was tai-
lored to differentiate between cross-dressing persons and persons who were
homosexual, as these concepts were widely misinterpreted as one and the same.
Regardless of contemporary interpretation or notoriety, Magnus Hirschfeld’s con-
tributions to the field of sexology were undeniably revolutionary.
Having studied medicine at distinguished universities across Germany,
Hirschfeld began his career in human sexuality by opening his very own medical
practice for obstetrician sciences in Magdeburg, Germany, in 1894. Releasing
activist publications under the pen name Ramien Hirschfeld, his earlier writings
include a thirty-four-page pamphlet entitled Sappho und Sokrates, Wie erklärt
sich die Liebe der Mannër und Frauen zu Personen des eigenen Geschlechts?
(Sappho and Socrates, How Can One Explain the Love of Men and Women for
Individuals of Their Own Sex?). He went on to publish a variety of influential
materials and founded numerous renowned academic journals, conferences, and
committees, including the world’s first homosexual rights organization,
Wissenschaftlich-Humanitäre Komitee (The Scientific-Humanitarian Commit-
tee), 1897; the first scholarly journal for scientific sexology, Zeitschrift für Sexual-
wissenschaft (Journal of Sexology), 1908; the provocative book unveiling his
innovative terminology, Die Transvestiten (The Transvestite), 1910; his first com-
prehensive sexological work, Naturgesetze der Liebe (Natural Laws of Love),
1912; the compelling text Die Homosexualität des Mannes und des Weibes (Male
and Female Homosexuality), 1914; the brilliant but prejudicially invalidated
medical resource, Sexualpathologie (Sexual Pathology), 1917–1920 (Vol. 1–3); the
illustrious Institut für Sexualwissenschaft (Institute for Sexual Research), 1919;
and the wholly progressive and substantiating contribution of The International
Conference of Sexual Reform Based on Sexual Science, 1921.
As a politically minded scientist, Hirschfeld worked endlessly to publicly vali-
date sexuality as innate and not a deliberate choice. His introduction of the word
“transvestite” sought to outline the essential differences between cross-dressing,
homosexuality, and fetishism for uninformed outsiders, attributing diversity to the
inspirational focus of each and not simply any observed comparable behaviors.
Today, the word “transgender” would best represent the conceptual framework the
term attempted to illustrate. Regardless, the word itself was quite ineffectual as it
was not used again for decades until the works of Harry Benjamin, who is often
Homophobia 305
mistaken as the original author. While Hirschfeld’s theories expanded for years,
he initially proposed homosexuals as a “third sex” (sexual intermediaries) in a
way that might be better understood today as a form of transgender expression
combined with same-sex attraction. He himself also believed that all persons were
originally born bisexual, eventually losing interest in either sex over the course of
one’s life experiences. His efforts to depathologize atypical sexual behavior broad-
ened to other prominent objections of natural expression, such as childhood sexu-
ality and the curious explorations of adolescence. Hirschfeld reproached the
condemnation of masturbation, believing the irrational fear of it to be far more
dangerous than the act itself.
Although faulted with his own biases, such as a general lack of inherent objec-
tivity in the conviction that homosexual persons were fundamentally more altru-
istic than their heterosexual counterparts, Hirschfeld dedicated his life to sexual
reform in the name of equality. His Institute for Sexual Research alone was home
to over 20,000 sexological books and journals; over 35,000 images and artifacts;
and the first contraceptive clinic of Berlin, Germany. Ultimately, Nazi rioters
destroyed the renowned institute in May 1933 when Hirschfeld was traveling to
Paris for the latest newsreel. It was there that he watched the ghastly footage.
Stripping the walls of his legacy bare, Nazi book burnings erased much of
Hirschfeld’s work. Seen as a “Jewish science,” the Nazi party sought to prevent
the corruption of a new Aryan nation from the “perverted” ideals of sexology.
Such opposition would halt European sexological research for two decades, never
salvaging lost chronicles. Fleeing for his life, Hirschfeld spent the next two years
in France before he died at the age of sixty-seven on his birthday, May 14, 1935.
Ilyssa Boseski
See also: Antigay Prejudice; Benjamin, Harry; Bisexuality; Ellis, Henry Havelock; Freud,
Sigmund; Gender; Gender Diversity; Heterosexuality; Homosexuality; LGBTQ+; Mas-
turbation; Sexology; Sexual Orientation; Transgender; Transsexual; Transvestite.
Further Reading
Bullough, V. L. (1994). Science in the bedroom: A history of sex research. New York:
BasicBooks.
Dose, R. (2014). Magnus Hirschfeld: The origins of the gay liberation movement. New
York: Monthly Review Press.
Hooper, A., & Holford, J. (2004). Anne Hooper’s Sexology 101: From Victorian transves-
tites to ‘70’s swingers and Internet Viagra. Berkeley, CA: Ulysses Press.
Mancini, E. (2010). Magnus Hirschfeld and the quest for sexual freedom: A history of the
First International Sexual Freedom Movement. London: Palgrave Macmillan.
Wolff, C. (1986). Magnus Hirschfeld: A portrait of a pioneer in sexology. London: Quar-
tet Books.
Homophobia
Homophobia is considered to be the fear of gay, lesbian, bisexual, or queer people
or same-gender sexual behaviors. Homophobia is believed to result from learning
and reinforcement over the life span; tolerance and acceptance of sexual minori-
ties are also considered learned behaviors. The development of negative attitudes
306 Homophobia
is often the result of both explicit teachings in an individual’s family, educational,
or social setting (including some cultural and religious teachings) and implicit
messages about the worth or characteristics of sexual minorities. Silence about
sexual minorities’ experiences and the invisibility of sexual minority role models
may also contribute to the development of homophobia.
Homophobia may be externalized in the forms of negative words or actions
expressed toward others or internalized by sexual minorities, primarily in the
form of negative thoughts about one’s identity or sexual behaviors. Homophobia
has historically been considered one of the causes of antigay prejudice, and it has
sometimes been assumed that those who express the highest levels of homophobia
may be compensating for same-gender attractions. However, there is little empiri-
cal evidence to substantiate this assertion.
The study of homophobia is closely related to the study of antigay prejudice and
discrimination. Over time, many researchers have shifted their paradigms and
language from the concept of homophobia to that of homonegativity, negative atti-
tudes toward sexual minorities that may or may not arise from fear. Thus, a person
may experience or express homonegativity without experiencing a sense of fear
(phobia), anxiety, or threat from sexual minorities. Emerging research on
homophobia or homonegativity has also made distinctions among types of homo-
negativity. In traditional or classical homonegativity, individuals tend to express
more explicitly negative sentiments or misperceptions of sexual minorities (e.g.,
“gay men can’t be trusted around children”). Modern measures of homonegativity
are designed to measure more subtle forms of negativity, such as the belief that
sexual minorities make unreasonable demands on society (Morrison & Morrison,
2003).
Homophobia and homonegativity are often based on inaccurate or incorrect
assumptions about sexual minorities, such as the misconception that sexual
minorities may try to recruit others to same-sex behaviors, or a faulty assumption
that sexual minorities are more likely than heterosexual-identified individuals to
sexually abuse children. Neither of these assumptions is supported by research.
Researchers measure homophobia or homonegativity in the forms of attitude
statements (e.g., “gay men are sick”), behaviors such as discrimination in employ-
ment and housing, or desire for social distance from sexual minorities (a prefer-
ence to have a lesbian friend or family member or to have sexual minorities live
outside one’s community, for example). Homophobia and homonegativity are,
however, difficult for social scientists to measure accurately, as researchers must
often rely on self-report. Participants’ responses to measures of homophobia often
vary by the context in which the research is conducted (e.g., a conservative reli-
gious environment rather than a gay and lesbian community center), and research
participants often respond in socially desirable ways to studies of this type. Fur-
ther, it is difficult to rely on observational studies of homophobia, as it may be
impossible to discern the motivations behind an individual’s actions.
Overall, studies of homophobia and homonegativity show some cultural differ-
ences in attitudes, with several studies noting higher levels of homonegativity
among African American adults than their European American peers. However,
the two groups report similar levels of intent to discriminate (or to refrain from
Homophobia, Internalized 307
discrimination) against sexual minorities. Many studies have also reported gender
differences in this area, with men reporting higher levels of homonegativity, par-
ticularly against gay men, than their female peers.
Very little research exists on the impact on heterosexual individuals in main-
taining homophobic or homonegative attitudes. However, research on sexual
minorities indicates that both homonegative statements and actions received from
others and internalized homophobia can be damaging to mental health and
increase the risk of depression, anxiety, substance abuse, sexual compulsivity, and
partner violence.
Over time, homophobic and homonegative attitudes are becoming less com-
mon and less socially acceptable in many communities. Generational differences
are often evident in studies of homonegativity, with adolescents and younger
adults reporting more neutral or favorable attitudes toward sexual minorities than
older adults.
Elizabeth A. Maynard
See also: Antigay Prejudice; Biphobia; Bisexuality; Heterosexism; Homophobia, Inter-
nalized; Homosexuality; Queer; Transgender; Transphobia.
Further Reading
Bieschke, K. J., Perez, R. M., & DeBord, K. A. (Eds.). (2007). Handbook of counseling
and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed.)
Washington, DC: American Psychological Association.
Dworkin, S. H., & Pope, M. (Eds.). (2012). Casebook for counseling lesbian, gay, bisex-
ual, and transgender persons and their families. Alexandria, VA: American
Counseling Association.
Morrison, M. A., & Morrison, T. G. (2003). Development and validation of a scale mea-
suring modern prejudice toward gay men and lesbian women. Journal of Homo-
sexuality, 43(2), 15–37.
Homophobia, Internalized
Homophobia is considered to be a fear of lesbian, gay, bisexual, and queer people
or same-sex sexual behaviors. Internalized homophobia is the experience of this
fear by a sexual minority person. The term suggests that the individual has taken
in (internalized) a fear of sexual minorities from their environment, and they may
hold negative beliefs and sentiments both toward the self and toward other sexual
minorities. Mental health professionals have noted that internalized homophobia
is widespread and may be a significant contributor to mental health problems
among sexual minority clients.
Internalized homophobia is generally assumed to be the product of learning,
both in childhood and across the life span. Homonegative statements and formal
teachings are common across many cultural and religious groups, and most chil-
dren and adolescents are exposed to these negative messages. Further, homonega-
tivity may be reinforced by stereotyped portrayals of gay, lesbian, bisexual, and
queer individuals; silence about sexual minorities in many communities; and an
absence of positive role models. Misinformation about sexual minorities may also
308 Homophobia, Internalized
contribute to internalized homophobia/homonegativity. For example, generaliza-
tions of gay men as promiscuous, flamboyant, or pedophilic may increase an indi-
vidual’s negative sentiments.
While the term “homophobia” has been used for several decades to describe
negative attitudes toward sexual minorities, the concept of homonegativity has
been gaining wider acceptance among researchers and mental health profession-
als. While homophobia assumes that a person’s negative sentiments or attitudes
are based in fear, homonegativity describes negative sentiments and attitudes that
may arise from any source. Thus, a person may be homonegative but not
homophobic.
Research on internalized homophobia and homonegativity is less extensive
than research on externalized homonegativity. This is due in part to difficulties
creating reliable and valid measures of internalized homophobia. Further, most
early studies of homonegativity focused on the attitudes and behaviors of partici-
pants who were presumed to be heterosexual. Thus, these studies measured atti-
tudes toward members of a group perceived to be different from the self. Other
studies have focused more on sexual minorities’ experiences responding to others’
prejudice and/or negative statements rather than on the phenomenon of negativity
toward oneself.
Internalized homophobia/homonegativity may be difficult to detect. At the
most explicit level, individuals may express disgust, unhappiness, or rejection of
themselves due to their sexual orientation or sexual behaviors. Internalized
homophobia may also be present in more subtle forms, such as not caring well for
one’s general or sexual health or not advocating for one’s needs or rights in rela-
tionships. Some studies have noted correlations between internalized homopho-
bia/homonegativity and depression, anxiety, substance abuse, partner violence,
and compulsive sexuality. These studies suggest that sexual minorities who hold
more positive and accepting views of themselves may be at lower risk for these
and related mental health concerns.
Interventions to reduce or eliminate internalized homophobia/homonegativity
may occur at both the individual and systems level. Many individuals find that
individual or group counseling may promote greater levels of self-acceptance and
self-care. Further, seeking out positive role models and critiquing stereotyped pre-
sentations of sexual minorities may also reduce internalized homophobia. Both
sexual minority and majority members may engage in advocacy to address homo-
negative language and discriminatory policies and practices.
Recent research suggests generational differences in antigay prejudice,
homophobia, and homonegativity, with adolescents and young adults expressing
lower levels of homonegativity than older adults. Further, over the last thirty
years, many cultural and religious groups have demonstrated increasing tolerance,
acceptance, or celebration of sexual minorities and same-gender romantic and
sexual relationships. Thus, more positive messages and welcoming communities
are available than in the past. As overall levels of homonegativity decline in the
United States and many other countries, internalized homophobia and homonega-
tivity may also be expected to decline.
Elizabeth A. Maynard
Homosexuality 309
See also: Antigay Prejudice; Biphobia; Bisexuality; Gay Affirmative Therapy; Heterosex-
ism; Homophobia; Queer; Transphobia.
Further Reading
Bieschke, K. J., Perez, R. M., & DeBord, K. A. (Eds.). (2007). Handbook of counseling
and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed.)
Washington, DC: American Psychological Association.
Dworkin, S. H., & Pope, M. (Eds.). (2012). Casebook for counseling lesbian, gay, bisex-
ual, and transgender persons and their families. Alexandria, VA: American
Counseling Association.
Homosexuality
Homosexuality refers to a sexual orientation in which the individual is sexually
attracted to other individuals of the same sex. The word “homosexuality” has a
history of pathologization, and, as such, many people with a homosexual sexual
orientation prefer to be referred to as gay or lesbian. Individuals who are sexually
attracted to both people of the same sex and people of the other sex are referred to
as bisexual.
Estimates of the prevalence of gay and lesbian sexual orientations generally
range from about 2–15 percent of the population. The estimates vary widely,
partly because surveys may use different criteria for describing same-sex behav-
ior, attraction, or identity and partly because respondents may think of their own
sexuality in different ways.
Many people have occasional sexual experiences with other individuals of the
same sex—or they previously had such experiences—but they do not consider
themselves to be gay or lesbian. For example, it is common for teenagers to exper-
iment with same-sex activities, though most of these people are primarily or
exclusively heterosexual as adults. In another example, some prison inmates
report engaging in same-sex behavior because their preferred partners of the other
sex are unavailable. However, when they are released from prison, many return to
their previous heterosexual lifestyle.
Such facts about human behavior reveal that sexuality consists of an extremely
complex and dynamic set of behaviors. A large U.S. survey (consisting of 13,500
men and women) published by the National Center for Health Statistics in March
2011 attempted to distinguish between various homosexual and bisexual behav-
iors and identities. According to the survey results, 2–4 percent of men and 1–2
percent of women reported their sexual identity as gay or lesbian. A bisexual sex-
ual identity was reported by 1–3 percent of men and 2–5 percent of women. From
4–6 percent of men and 4–12 percent of women reported that they have had some
same-sex sexual contact. (The ranges in percentages are due to the different ways
in which the researchers classified the data, such as by age, race, year of response,
and other factors.)
Although the causes of homosexuality are not fully understood, the general
scientific consensus is that it is primarily congenital—people are born that way. A
team of American and British researchers reported in 2014, based on their genetic
analysis of 409 pairs of homosexual brothers, that sexual orientation may be
310 Homosexuality
influenced by certain kinds of genetic mutations (changes) on two chromosomes—
chromosome 8 and the X chromosome. Exactly how these genetic factors may
influence sexual orientation is not known.
Other research has indicated that part of a brain region called the hypothalamus
is smaller in gay men than in straight men. This part, called the sexually dimor-
phic nucleus, seems to be a similarly small size in gay men and in women com-
pared with its relatively larger size in straight men.
Among the most important functions of the hypothalamus is to receive sig-
nals from the nervous system that prompt it to secrete substances called neuro-
hormones, which, in turn, regulate the secretion of hormones by the pituitary
gland. Thus, if the hypothalamus is associated with sexual orientation, it is pos-
sible that the brains of gay people may regulate hormone activity differently
than the brains of straight people. The physical development of the hypothala-
mus itself is affected by hormonal chemical reactions as the fetus grows inside
the womb. However, much more research is needed to understand how (and if)
this process occurs.
Some psychologists believe that an individual’s social experiences, upbringing,
and other environmental factors may influence sexual orientation or expression. If
true, that could mean that complex combinations of both environmental and bio-
logical processes influence an individual’s sexual orientation.
When considering the causes of homosexuality, it is important to keep in mind
that same-sex behavior is not exclusive to the human species. Same-sex behavior
has also been observed in a wide array of animal species, including apes, mon-
keys, dolphins, sheep, albatrosses, geese, and certain insects.
The gay and lesbian populations have certain health care issues that are of spe-
cial concern compared with the heterosexual population. Gay and lesbian people
often experience social and political violence and discrimination, which can con-
tribute to symptoms of anxiety and depression. They may also be more likely to
have problems with substances. A major health concern among gay, bisexual, and
other men who have sex with men is the human immunodeficiency virus (HIV),
which, if left untreated, can progress to acquired immunodeficiency syndrome
(AIDS). When first discovered in the 1980s, HIV/AIDS was almost always fatal.
However, since then, much progress has been made in treatment and prevention,
and many individuals living with HIV today live long and happy lives with the use
of highly active antiretroviral medications.
In the past, homosexuality has been viewed as a form of mental illness, both by
the public and by mental health experts. That view began to change during the
early twentieth century as psychiatric experts, including Sigmund Freud and
Havelock Ellis, argued that homosexual people did not have a pathological condi-
tion. (Freud actually proposed that all people were innately bisexual.) In the 1940s
and 1950s, the pioneering sexuality researcher Alfred Kinsey revealed that homo-
sexual and bisexual activities were much more common than previously thought—
including among supposedly heterosexual people.
Despite the advances in scientific and medical knowledge, the idea of homo-
sexuality as an illness to be cured remains ingrained in more conservative and
traditional parts of society. In so-called gay conversion therapy, people unethi-
cally attempt to convert the homosexual orientation of a patient to a heterosexual
Homosexuality 311
orientation. Some individuals claim that this therapy helped them to become
“straight.” However, most psychiatric experts condemn this type of therapy as
useless and dangerous to the mental health of patients. Instead of trying to convert
gay and lesbian people, most therapists try to help those struggling to accept their
sexual orientation through gay affirmative therapy.
Throughout world history, different cultures have held varying views on homo-
sexuality. In ancient Greece, male same-sex relations, particularly between a
young man and an older man, were apparently favored over heterosexual
relations—though they did not supplant heterosexual relations. Similar attitudes
existed in ancient Rome, where many older men had younger male lovers. These
men, however, were not strictly “homosexual.” Most were married to women and
had children. Rather, ancient societies simply accepted same-sex activities along
with heterosexual activities as part of the spectrum of human sexuality. In addi-
tion to Greece and Rome, a number of other ancient “pagan” societies also either
encouraged, or at least widely accepted, same-sex behavior.
In Western societies, those liberal, broad-minded sexual attitudes changed as
Christianity cemented its power throughout Europe during the Middle Ages. Tra-
ditional Judeo-Christian teachings condemn homosexuality as immoral, sinful,
and unnatural, as do traditional Islamic teachings. In those intolerant times,
homosexuals had to hide their sexual orientation or be subject to severe punish-
ment, even death. Such antigay attitudes persisted for many centuries and became
institutionalized into laws.
Although social attitudes and laws were harsh, those ideas could not eliminate
same-sex behavior and orientations. Homosexuality is simply a part of the mosaic
of human nature—it always has been, and it always will be. Over time, gay and
lesbian people became more forceful in fighting for their rights through various
political and advocacy organizations—and eventually a cultural shift was affected.
During the late twentieth and early twenty-first century, homosexuality became
increasingly accepted into the “social mainstream” in most developed nations in
Europe, parts of Asia, and the Americas, including the United States. This cul-
tural shift can be attributed partly to continued advances in scientific knowledge
about human sexuality. It can further be attributed to the widespread recognition
of gay rights as a form of civil rights, somewhat akin to the U.S. civil rights move-
ment for African Americans in the 1950s and 1960s and the women’s liberation
movement in the 1960s and 1970s.
In the United States, Canada, many European and South American countries,
as well as other socioeconomically advanced nations, laws have been passed to
ban discrimination against gay and lesbian people in employment, housing, and
other activities. Furthermore, in many of these countries, same-sex marriages or
civil unions (with legal rights similar to marriage) have been legalized. Sadly, gay
and lesbian people continue to be subject to social discrimination and legal pun-
ishment, and in some extreme countries, this can still include the death penalty.
A. J. Smuskiewicz
See also: Antigay Prejudice; Asexuality; Bisexuality; Ellis, Henry Havelock; Freud, Sig-
mund; Gay Affirmative Therapy; Gay Rights Movement; Heterosexuality; Homophobia;
Homophobia, Internalized; Kinsey, Alfred; LGBTQ+; Same-Sex Attraction and Behav-
ior; Sexual Orientation; Ulrichs, Karl.
312 Hooker, Evelyn
Further Reading
American Psychological Association. (2019). Sexual orientation & homosexuality.
Retrieved from https://www.apa.org/topics/lgbt/orientation
Chandra, A., Mosher, W. D., Copen, C., & Sionean, C. (2011). Sexual behavior, sexual
attraction, and sexual identity in the United States: Data from the 2006–2008
National Survey of Family Growth. National Health Statistics Reports, 36, 1–36.
Retrieved from http://www.cdc.gov/nchs/data/nhsr/nhsr036.pdf
Herek, G. M. (2012). Facts about homosexuality and mental health. Retrieved from https://
psychology.ucdavis.edu/rainbow/html/facts_mental_health.html
LeVay, S. (2011). Gay, straight, and the reason why: The science of sexual orientation.
New York: Oxford University Press.
Norton, E. (2012). Homosexuality may start in the womb. Science. Retrieved from http://
news.sciencemag.org/evolution/2012/12/homosexuality-may-start-womb
Hooker, Evelyn
Evelyn Gentry Hooker (1907–1996) was a psychologist who overcame many
obstacles to earn a doctorate in psychology and work in the field when women
were not welcomed in academia. Evelyn was one of nine children born into a poor
Nebraskan family. She grew up in Colorado, and her mother encouraged her to get
an education, as she had not been able to do so herself. Evelyn did well in school,
despite some social ostracism due to her nearly six-foot height, and earned a schol-
arship to the University of Colorado Boulder. In 1924, she began her studies there
and earned a living by working as a maid. She majored in psychology and became
passionate about her study of the subject.
After completing her undergraduate degree, she was offered an instructorship
at the university, which enabled her to continue her studies and earn a master’s
degree. When she completed her degree, her mentor, Karl Muenzinger, encour-
aged her to apply for a doctoral program at an eastern university. The psychology
department at Yale turned her down, as they did not want a woman in the pro-
gram. Instead, she attended Johns Hopkins University in Baltimore, where she
earned her doctorate in 1932. After which, she was offered a teaching position at a
small women’s college near Baltimore and worked there for two years. At that
point, she contracted tuberculosis, and friends supported her to recuperate at a
sanitarium in California. As she recovered, she took a part-time position teaching
psychology at Whittier College. She then received an anonymous fellowship to
study clinical psychology in Europe. This was just before World War II, and Eve-
lyn witnessed some of the extreme forms of oppression coming from totalitarian
regimes in Germany and Russia. The experience in Europe deepened her concern
to work for social justice.
After her return to California, she applied for a position at UCLA. They turned
her down because, as the chairman of the psychology department said, they
already had three women who were “cordially disliked.” Instead, she was offered
a job as research associate in the psychology department of the extension division
at UCLA. She remained there doing research until 1970. Of special significance is
the groundbreaking work she did with gay males. In 1945, one of her students,
Hooker, Evelyn 313
Sam From, met with her after class and told her that he was homosexual and that
he very much enjoyed her class. Over time, Evelyn and her first husband social-
ized with Sam and his friends. Evelyn spent time with more homosexual people in
social settings, enjoying conversations and discussing world events. After some
time, Sam challenged her to scientifically study “people like him.”
At the time, homosexuality was classified as a mental illness in the Diagnostic
and Statistical Manual (DSM) of the American Psychiatric Association. Gay men
were not allowed to work in government jobs or in the military, and homosexual
behavior was illegal. Most research on gay men was based on those who had been
in treatment with a mental health professional, not on gay men who were living
their lives without mental illness. Sam’s challenge to Evelyn was to find out if
homosexuality really was an illness. She was intrigued by the question and felt
compelled by her experience witnessing the effects of persecution in Europe in
the 1930s and discrimination in her own personal and professional life. Her pro-
posed research program was especially risky as she applied in 1953 for the
National Institute of Mental Health (NIMH) grant during the height of the
extremely conservative McCarthy era. There were simply no scientific data about
nonimprisoned, nonpatient homosexuals. By this time, Evelyn had divorced her
first husband and married Edward Hooker, a professor of English at UCLA, and
taken his surname.
Against the odds, Evelyn was given the six-month NIMH grant, and to ensure
confidentiality, she conducted the research out of her home. She found thirty gay
men through the network of Sam’s friends and through the Mattachine Society,
one of the first organizations of gay men in the United States. She also recruited
thirty heterosexual men for comparison. The groups were matched in age and IQ
and were equal in educational levels. Evelyn administered three standard person-
ality tests to the two groups. She took all the identifying information off each
participant’s score sheets and had three expert clinicians examine her results.
Unaware of the subjects’ sexual orientation, the three men could not distinguish
between the two groups based on the test results. And they found no apparent
pathology among the gay participants.
Her research, “The Adjustment of the Male Overt Homosexual,” was published
in 1957. This landmark study showed that homosexuals were not inherently abnor-
mal and that there was no difference between the pathologies of homosexual and
heterosexual men. When it was published, it was controversial, but it was vali-
dated soon thereafter by other investigators. She continued to study homosexual-
ity through the 1960s and was asked to lead the NIMH Task Force on
Homosexuality. The Task Force produced a report in 1969 that said that homo-
sexuality should be considered neither pathological nor criminal. The report and
her earlier studies became a crucial element in the decision to have homosexuality
removed from the DSM-III in 1973. This meant that homosexuality was no longer
classified a mental illness.
At the age of sixty-three, Evelyn retired from research and started a private
practice in Santa Monica. Most of her clients were gay men and lesbian women. In
her later life, she would be awarded the Distinguished Contribution in the Public
Interest Award by the American Psychological Association. The University of
314 Hookup Culture
Chicago opened the Evelyn Hooker Center for Gay and Lesbian Studies in her
honor. She died at her home in Santa Monica, California, in 1996, at the age of
eighty-nine.
Michael J. McGee
See also: Diagnostic and Statistical Manual of Mental Disorders (DSM); Homosexuality;
Mattachine Society; Sexology.
Futher Reading
Floyd, J. Q., & Szymanski, L. A. (2007). Evelyn Gentry Hooker: The “hopelessly hetero-
sexual” psychologist who normalized homosexuality. In E. A. Gavin, A. Clamar,
& M. A. Siderits (Eds.), Women of vision: Their psychology, circumstances, and
success (177–188). New York: Springer.
Kimmel, D. C., & Garnets, L. D. (2000). What a light it shed: The life of Evelyn Hooker.
In G. Kimble & M. Wertheimer (Eds.), Portraits of pioneers in psychology (Vol. 4,
252–267). Washington, DC: American Psychological Association.
Sears, B., Hunter, N., & Mallory, C. (2009). Documenting discrimination on the basis of
sexual orientation & gender identity in state employment. Los Angeles: The Wil-
liams Institute.
Hookup Culture
Hooking up is a form of noncommitted sexual activity, prominent in sexuality
literature since 2000, with much research characterizing it as confined to young
adulthood. The college atmosphere fosters hooking up, establishing a “hookup
culture” where hooking up is the dominant way people experience intimacy. Not
only are hookups a common way to establish intimate relationships but students
are unlikely to recognize other alternatives, which powerfully underlies the com-
monness of hooking up.
Describing the ubiquity of the hookup culture, researchers Wade and Heldman
(2012) refer to hooking up as hegemonic, which means that the practice of hooking
up seems inescapable: many individuals will partake because they see no alterna-
tive, even though hooking up may not be their personal preference. Wade and
Heldman also describe elements of the hookup scene that have become normal-
ized, such as the expectation of college as a place to seek out sexual exploration
and the anticipation of male partners putting pressure on females. The popularity
of these beliefs among college students makes these behaviors seem common and
unproblematic, which encourages hooking up. Situating this within larger cultural
changes, such as more liberal university policies regarding dormitories as well as
the “pornification” of the culture and its resulting increase in self-objectification,
it can be seen that these elements combine to promote hooking up.
Hookups have been defined differently throughout both the academic litera-
ture and mainstream publications, yet most characterize hookups as noncommit-
ted intimate interactions. Some scholars refer to hookups as a casual sexual
encounter that occurs only one time, between strangers, without the expectation
of a long-term relationship. Others define hookups more broadly, as a sexual
experience ranging from kissing to intercourse between people not in a commit-
ted relationship.
Hormone Replacement Therapy 315
In college, gendered expectations frame choices for males and females differ-
ently. Modern women are expected to want and enjoy sex, but the sexual double
standard persists and shapes the enactment of sexuality for young women. The
vagueness of the term “hooking up” can thus protect the woman’s reputation. The
“strategic ambiguity” of the term allows men to earn status by emulating hege-
monic masculinity and women to perform emphasized femininity as a way of
living up to gender ideals.
Within hookup culture, men have a wider range of behaviors that are consid-
ered appropriate. Women are assumed to be more relationship-oriented and emo-
tional, they are often seen as the object of pleasure, and they are judged more
harshly for their sexual choices. Notions of masculinity, especially in college, tell
men that they are expected to want sex, seek sex, and engage in it without emo-
tional consequence. These views characterize women as a vehicle for male plea-
sure devoid of subjectivity. This complicates things for young men who seek an
emotional connection to a sex partner or who desire a committed relationship and
for women, who may doubt the sincerity of a young man’s desire for a relationship.
Perceptions that “all men” want sex and “all women” want relationships shape the
sexual double standard and may operate in hookup culture.
Hookup culture research centers on heterosexual college students. Future stud-
ies should include bisexual, gay, and transgender voices. In addition, investiga-
tions of sexuality outside college and among older adults are needed to gain a full
understanding of the extent of hookup culture.
Rachel Kalish
See also: Casual Sex; Dating; Double Standards, Sexual; Friends with Benefits; Intimacy,
Sexual and Relational; Online Dating.
Further Reading
Bogle, K. A. (2008). Hooking up: Sex, dating and relationships on campus. New York:
New York University Press.
Crawford, M., & Popp, D. (2003). Sexual double standards: A review and methodological
critique of two decades of research. Journal of Sex Research, 40, 13–27.
Currier, D. M. (2013). Protecting emphasized femininity and hegemonic masculinity in
the hookup culture. Gender & Society, 27, 704–727.
Heldman, C., & Wade, L. (2010). Hookup culture: Setting a new research agenda. Sex
Research and Social Policy, 7, 323–333.
Wade, L., & Heldman, C. (2012). Hooking up and opting out: Negotiating sex in the first
year of college. In L. M. Carpenter & J. DeLamater (Eds.), Sex for life: From vir-
ginity to Viagra, how sexuality changes throughout our lives. New York: New
York University Press.
Hormone Replacement Therapy
Hormone replacement therapy (HRT), sometimes called hormone treatment, usu-
ally refers to the restoration of the female sex hormones estrogen and progesterone
in women whose ovaries have stopped producing these chemical substances. In
most cases, the therapy is meant to relieve unpleasant symptoms that many
316 Hormone Replacement Therapy
middle-aged women experience before, during, and after menopause, the time
when menstrual periods stop and the natural production of these hormones less-
ens. The final menstrual period typically happens sometime between age forty-
five and fifty-five.
In the years leading up to menopause, levels of estrogen start to decrease in the
body. In approximately 75 percent of women, the falling estrogen levels lead to
recurring hot flashes, characterized by feelings of heat spreading over the face and
body and by sweating. Sudden chills may follow the hot flashes. These feelings
often occur at night, making it difficult to sleep. Falling estrogen levels also com-
monly lead to dryness and irritation of the vagina, causing much discomfort,
especially during sexual intercourse. The dryness makes the vagina more prone to
infection. Still other changes that commonly occur during and after menopause
are frequent shifts in mood, weakening of the bones (known as osteoporosis), and
increased risk for cardiovascular disease.
The gradual changes associated with menopause typically happen over a period
of seven to ten years. Some women are able to deal with these changes on their
own, considering them to be a natural part of the aging process, and they do not
seek HRT. However, other women find the changes so unpleasant that they seek
HRT to help relieve the symptoms.
Estrogen is the main hormone that needs to be replaced to relieve the worst
symptoms of menopause. However, studies have shown that the use of estrogen
alone in HRT increases the risk of uterine cancer. The addition of progesterone or
progestin, a synthetic form of progesterone, reduces this risk, so women who still
have their uterus are usually prescribed both hormones. Women who have had a
hysterectomy (surgical removal of the uterus) may receive only estrogen in HRT.
The hormones used in HRT can be administered in different ways, including pills,
skin patches, gels and sprays applied to the skin, vaginal rings (devices inserted
into the vagina), and intrauterine devices (which are inserted into the uterus).
Many physicians had previously believed that long-term HRT could help pre-
vent several diseases in postmenopausal women, including osteoporosis, heart
disease, Alzheimer disease and other forms of dementia, and certain cancers.
Those beliefs were contradicted in 2002 by a comprehensive study reported by the
U.S. National Institutes of Health (NIH), which found that neither estrogen-only
HRT nor estrogen-and-progesterone HRT were effective at preventing most of
these diseases—except for osteoporosis, colon cancer, and (with estrogen-only
HRT) breast cancer. The NIH study further revealed that HRT might actually
raise the risks of gallbladder disease, liver disease, blood clots, stroke, heart attack,
and (with combined HRT) breast cancer—especially if the therapy is extended
over several years. Risks were found to be greatest the later in life that women
started HRT.
Because of these health risks, many physicians now discourage the use of HRT
or urge only limited, short-term use of HRT for managing hot flashes and other
menopausal symptoms. These doctors recommend limiting HRT to the lowest
possible doses for the shortest possible time period—a few months to a few years.
Any woman taking HRT should receive regular checkups and screenings for
breast cancer and other potential diseases associated with the therapy.
Hot Flashes 317
There are a number of alternatives to HRT for managing the symptoms of
menopause. Antidepressant medications can help reduce the severity and fre-
quency of hot flashes. Lubricants can relieve vaginal dryness. Medications called
bisphosphonates, together with a regular exercise regimen, can reduce the bone-
loss effects of osteoporosis.
Some people believe that certain kinds of phytoestrogens (estrogen-like com-
pounds derived from plants) and synthetic estrogen-like compounds may offer
some of the advantages of HRT without the disadvantages of real estrogen. These
estrogen-like compounds are often referred to as bioidentical hormones. However,
there is little scientific evidence to support the effectiveness or safety of these
products.
In addition to HRT given to women to counter the effects of menopause, HRT
may also be used by transgender people during their gender transition process.
Trans women are given forms of estrogen to make their bodies develop female
characteristics, such as breasts and smooth, hairless skin. By contrast, trans men
are given testosterone, the male sex hormone, to make their bodies develop male
characteristics, such as facial hair. Various forms of hormone treatments are also
used to treat people with certain types of cancer. For example, some people with
prostate cancer are given both estrogen- and testosterone-blocking hormones as
part of their treatment.
A. J. Smuskiewicz
See also: Estrogen; Gender Transition; Menopause; Progesterone; Sex Hormones; Syn-
thetic Hormones; Testosterone; Testosterone Replacement Therapy.
Further Reading
American College of Obstetricians and Gynecologists. (2018). The menopause years.
Retrieved from https://www.acog.org/-/media/For-Patients/faq047.pdf?dmc=1&ts
=20191114T1611432976
Hormone replacement therapy. (2019). Retrieved from https://www.nhs.uk/conditions
/hormone-replacement-therapy-hrt/alternatives/
Mayo Clinic. (2018). Hormone therapy: Is it right for you? Retrieved from http://www
.mayoclinic.org/diseases-conditions/menopause/in-depth/hormone-therapy/art
-20046372
Hot Flashes
Hot flashes are brief feelings of intense warmth in the body. They can also be
accompanied by redness or blotching of the skin, perspiration, and increased heart
rate. On their own, hot flashes are not an illness. Rather, they are typically a symp-
tom of hormonal conditions and are most commonly due to menopause, the time
in a female’s life when levels of estrogen decrease and menstrual periods stop.
Around 70 percent of menopausal women experience hot flashes.
The exact cause of hot flashes is not yet understood, but it is believed that they
occur due to combined factors that include changes in the reproductive hormonal
system along with increased sensitivity in the hypothalamus, which regulates the
temperature of the body. Hot flashes can last anywhere from a few seconds to
318 Hot Flashes
several minutes and usually begin with an uncomfortable warmth that spreads
from the head or chest area throughout the rest of the body. They are most com-
mon at night but can occur at any time of day. Some people experience up to ten or
more hot flashes in a twenty-four-hour period.
Although they are often viewed as a hallmark characteristic of menopause, hot
flashes can also occur in males. In older men, the decline in reproductive hor-
mones (testosterone) is more gradual than in women, which prevents many from
experiencing hot flashes. However, some men, particularly those with prostate
cancer, are more susceptible to hormonal imbalances and hot flashes. Research
conducted at Harvard University showed that 70–80 percent of men with prostate
cancer who have received a specific type of treatment called androgen deprivation
therapy suffer from hot flashes. Hot flashes can also be a side effect of certain
medications and other illnesses, such as tumors in the endocrine system.
Hot flashes are typically diagnosed through a physical exam and discussion
with a medical practitioner. If there are other symptoms along with the hot flashes
or the cause seems unclear, a doctor may recommend blood tests to check for hor-
monal imbalances and other conditions. There are a wide variety of treatments for
hot flashes, including taking estrogen through hormone replacement therapy
(HRT), acupuncture, and supplementing with botanical herbal remedies like black
cohosh. For many years, different derivatives of HRT were the only treatments
approved by the Food and Drug Administration (FDA); however, in June 2013, the
FDA approved the first nonhormonal treatment in the form of paroxetine, a phar-
maceutical antidepressant. Around the same time, findings in a new study sug-
gested that scientists think they have pinpointed the exact locations in the brain
where menopausal hot flashes begin, which may lead to more advanced treatment
down the road. At this time, none of the known treatments cure hot flashes, but
they can be useful in diminishing the frequency and intensity of the warm spells.
Most who experience menopausal hot flashes will see this symptom gradually
disappear after a few years even without medication or treatment; in males, the
symptom takes longer to subside.
Tamar Burris
See also: Estrogen; Hormone Replacement Therapy; Menopause; Perimenopause; Sex
Hormones.
Further Reading
Gannon, L. R. (1985). Menstrual disorders and menopause: Biological, psychological,
and cultural research. Westport, CT: Praeger.
Gillespie, C. (1989). Hormones, hot flashes, and mood swings: Living through the ups and
downs of menopause. New York: Harper Perennial.
Lerner-Geva, L., Boyko, V., Blumstein, T., & Benyamini, Y. (2010). The impact of educa-
tion, cultural background, and lifestyle on symptoms of the menopausal transi-
tion: The Woman’s Health at Midlife study. The Journal of Women’s Health, 19,
975–985.
McCain, M. V. E. (1991). Transformation through menopause. Westport, CT: Praeger.
National Institutes of Health. (2016). Menopausal hormone therapy information.
Retrieved from www.nih.gov/health-information/menopausal-hormone-therapy
-information
Human Immunodeficiency Virus (HIV) 319
North American Menopause Society. (2019). Menopause 101: A primer for the perimeno-
pausal. Retrieved from https://www.menopause.org/for-women/menopauseflashes
/menopause-symptoms-and-treatments/menopause-101-a-primer-for-the
-perimenopausal
Human Immunodeficiency Virus (HIV)
The human immunodeficiency virus (HIV) is a virus that attacks and weakens the
body’s immune system, making it difficult for people to fight everyday infections
and diseases. If left untreated, HIV can progress to acquired immune deficiency
syndrome (AIDS); however, it is important to distinguish that HIV is not AIDS
and that most people living with HIV who have access to HIV medication will
never develop AIDS.
Globally, HIV is a serious public health epidemic. In 2018, there were approxi-
mately 38 million people living with HIV, and approximately 1.7 million new
cases were diagnosed. Anyone can get HIV regardless of age, sex, gender, or sex-
ual orientation. HIV can be passed through contact with bodily fluids that contain
the virus, including blood, semen and preejaculate fluid, rectal fluid, vaginal fluid,
and breast milk. As such, HIV can be sexually transmitted. It can also be trans-
mitted through sharing needles or other substance use equipment used to inject
drugs; sharing needles used for tattooing, body piercing, or acupuncture; or dur-
ing pregnancy, birth, or breastfeeding. HIV cannot be passed by shaking hands,
hugging or kissing, coughing or sneezing, or by using swimming pools, toilet
seats, or water fountains.
There is currently no cure for HIV; however, there are very effective medica-
tions called highly active antiretroviral therapy (HAART) that allow people living
with HIV to live long and healthy lives and prevent the virus from being passed to
others. In order to best treat HIV, early diagnosis is important. Everyone should
have an HIV test performed, and those who engage in behaviors that may expose
them to HIV, such as having new or multiple sexual partners or sharing substance
use equipment, should test more regularly.
There are several ways to prevent passing or acquiring HIV sexually. Condoms
remain an important tool as they prevent the transmission of the virus. A new
condom must be used for every new sexual experience. In addition, people who
are living with HIV and who take their medication as prescribed cannot pass on
the virus. New research has shown that when people living with HIV take their
medication, the virus becomes undetectable in their blood and so cannot be passed
on to anyone else (Undetectable=Untransmittable, U=U).
New medications have also been developed for people who are not living with
HIV to take in order to protect themselves from acquiring the virus. Preexposure
prophylaxis (PrEP) is a medication that when taken daily, or for several days ahead
of a potential exposure to HIV (for example before having condomless anal sex
with an unknown sexual partner), is highly effective at preventing HIV acquisi-
tion. Unfortunately, this mediation is not yet available in all areas, and if it is avail-
able, it may be very expensive. Because of the potential for this new medication to
eliminate the spread of HIV, public health agencies are calling on governments
320 Human Papillomavirus (HPV)
and other organizations to make this medication freely and widely available to
everyone who may be at risk for HIV.
In addition, if someone is not taking PrEP and they suspect that they may have
been exposed to the virus, they should go immediately to their doctor in order to
begin a course of postexposure prophylaxis. This involves taking an HIV medica-
tion every day for twenty-eight days in order to help prevent HIV acquisition.
Given advances in HIV treatment and prevention, the end of the global HIV
epidemic should be in sight. However, essential medications and prevention tech-
niques are not available in all places and, if available, can be very expensive. Also,
because of HIV stigma and discrimination, many people fear being tested and so
may unknowingly be living with HIV. This is problematic for the individual as
they will not be receiving treatment that can improve their health and well-being,
and it is problematic for any of their sexual partners who may be unknowingly
exposed to the virus. Using condoms, taking HIV medication as prescribed if liv-
ing with HIV, and using prevention techniques like PrEP are the key to eliminat-
ing HIV around the world.
Heather L. Armstrong
See also: Acquired Immunodeficiency Syndrome (AIDS); Safer Sex; Sexually Transmit-
ted Infections (STIs); Testing, STI.
Further Reading
CATIE. (2019). The basics. Retrieved from https://www.catie.ca/en/basics
Centers for Disease Control and Prevention. (2019). HIV. Retrieved from https://www.cdc
.gov/hiv/default.html
Eisinger, R. W., Dieffenbach, C. W., & Fauci, A. S. (2019). HIV viral load and transmis-
sibility of HIV infection: Undetectable equals untransmittable. Journal of the
American Medical Association, 321(5), 451–452.
National Health Service. (2018). Overview: HIV and AIDS. Retrieved from https://www
.nhs.uk/conditions/hiv-and-aids/
UNAIDS. (2019). 90-90-90: Treatment for all. Retrieved from https://www.unaids.org/en
/resources/909090
Human Papillomavirus (HPV)
Human papillomavirus (HPV) is the most common sexually transmitted infection
(STI) in the United States. Approximately 20 million Americans are currently
infected with HPV, and there are six million new cases diagnosed each year. HPV
is so common that at least 50 percent of sexually active people will be infected
with the virus during their lifetime, with some estimates as high as 75–80 percent,
or three out of every four people.
HPV is a virus that belongs to the papillomavirus family. There are almost two
hundred known types of HPV, with the majority causing no symptoms in most
people. However, several types can cause warty growths on the surface of the skin
known as common warts, which tend to occur on the hands, or plantar warts,
which occur most often on the feet. In addition to these types of HPV, there are
approximately forty HPV types, known as genital HPV, that can be passed through
Human Papillomavirus (HPV) 321
sexual contact and infect the genital areas, which includes the vulva, vagina, cer-
vix, rectum, anus, penis, or scrotum. Fortunately, in up to 90 percent of cases of
HPV infection, the body’s immune system is able to naturally clear the HPV
infection within two years, and as a result, most people infected with HPV are
asymptomatic and never know they were infected. It is the HPV infections that are
persistent and not able to be cleared that are the ones that typically can lead to
problems, including genital warts and cervical, penile, anal, or oropharyngeal
(mouth and throat) cancer, depending on the type and location of the virus.
Genital HPV infections are often classified as either low risk or high risk,
depending on their ability to cause cancer. The low-risk HPV types can cause
genital warts, which are also known as condyloma, and include types 6 and 11.
Genital warts can grow inside and around the opening of the vagina, the vulva,
cervix, penis, scrotum, thigh or groin, and in or around the anus. Rarely, these
warts can grow in the mouth or throat of a person who has had oral sex with an
infected partner or in a child exposed to the virus in the birth canal at the time of
delivery. The size of the warts may vary from being so small that they are not vis-
ible with the naked eye and are often flat and flesh colored, to large clusters or
groups of bumpy, raised, cauliflower-like growths. Symptoms may include itch-
ing, burning, and discomfort.
The high-risk HPV types are the ones that cause cancer, most commonly cervi-
cal cancer. The types of virus that most commonly cause cervical cancer in the
United States include types 16 and 18, which cause 70 percent of the cases of cer-
vical cancer each year. HPV types 31 and 45 also cause cervical cancer but are
much less common. It is important to understand that having high-risk HPV does
not mean that an individual has cancer but rather that it can lead to cancer. This is
why it is so important to have regular follow-up visits with a doctor (usually a
gynecologist or urologist), so any changes on the cervix, or anus, can be detected
on a Papanicolaou (Pap) smear, which is used to screen for cervical and anal can-
cer in developed countries.
Other types of HPV that are considered to be high risk include those types
linked to other types of cancer, including cancers of the penis, vulva, vagina,
anus, and throat and mouth cancers (known as oropharyngeal cancer, which
includes the back of the throat, tonsils, and base of the tongue). Those who smoke
are at a higher risk of developing cervical cancer.
Of the two hundred types of HPV that are known, approximately forty are
transmitted through the anogenital tract (the vulva, vagina, cervix, anus, and
penis). The virus is normally transmitted through sexual activity, including
genital-genital contact (intercourse), oral-genital contact (oral sex), and anal-
genital contact (anal sex). Transmission by routes other than sexual intercourse is
much less common for genital HPV (such as finger-genital contact) but is a possi-
ble source of transmission. Sharing contaminated objects, like sex toys, may also
be another source of transmission, as the virus is capable of living on an inert
object for extended periods of time.
In order to understand how HPV causes infection, it is important to understand
the types of cells the HPV virus infects. These cells are called keratinocytes, and
they make up 95 percent of the cells located on the epidermis, or outer layer of the
322 Human Papillomavirus (HPV)
skin. The major function of the epidermis is to act as a barrier against environ-
mental damage from things like bacteria, viruses, fungi, parasites, heat, ultravio-
let radiation, and loss of water. If a pathogen does invade the outer layers of the
epidermis, the keratinocytes react by producing various substances that help the
immune system fight the offending pathogen. Keratin, which is a protein that is
produced by the keratinocytes, helps to thicken the keratinocyte, forming more of
a physical barrier. This process is known as cornification, and once the keratino-
cytes become fully cornified, they are shed and replaced by new cells. The aver-
age turnover time for this to occur is twenty-one days.
Keratinocytes are also located along the surface of certain mucous membranes,
which are responsible for absorbing various nutrients and secreting certain chemi-
cals. These keratinocytes occur along the outermost layer of these mucous mem-
branes, which is known as the squamous layer, and are found in the mucosa of the
mouth, throat, esophagus, and anus of the digestive tract; the cornea and conjunc-
tiva of the eye; the cervix and vagina of the genital tract; and the urethra of the
urinary tract.
Because genital HPV is passed by skin-to-skin and genital contact, it is most
often spread during vaginal and anal sex. The virus cannot bind to live tissue,
instead infecting epithelial tissues through microabrasions (tiny cuts or tears in
the skin) or other skin trauma. The infectious process can take as long as twelve to
twenty-four hours, and it can take weeks, months, or even years following the ini-
tial contact with a person who has HPV to develop warts or abnormal changes of
the cervix. The virus can survive for many months and at low temperatures with-
out a host, making it even more difficult to determine when the exposure occurred.
It is possible to be infected with more than one strain of HPV, and this risk
increases with a greater number of sexual partners.
Perhaps the most challenging aspect of HPV infection is that the vast majority
is silent, meaning there are no symptoms. Most people have no idea they are
infected with HPV until they develop warts or cancerous changes, and even these
signs are often noticed only by a clinician performing an exam. Cervical cancer
frequently has no symptoms but may cause an abnormal vaginal discharge or
bleeding after intercourse. This is one reason the regular Pap smear is so impor-
tant. The primary screening tool for detecting cervical HPV infection is done in
conjunction with the Pap smear. People who have receptive anal sex should also
have regular anal Pap smears. Certain changes occur in the outer layer of the cells
of the cervix and anus (known as squamous epithelial cells) when these cells are
infected by HPV, and they become known as koilocytes. Cellular changes include
things like a large nucleus that stains darker and a halo or light area around the
nucleus.
In addition to these microscopic changes, there is also an FDA-approved test
that can be done to test for HPV DNA and is known as a hybrid-capture test. This
test can be done at the same time as a Pap smear using a liquid-based cytology,
where, instead of smearing the cervical or anal cells directly onto a slide at the
time of collection, the cells are placed in a liquid-based medium and then trans-
ported to the lab where they are processed and then placed onto the slide for
review. This allows the person reviewing the slide, known as a cytologist, a better,
Human Papillomavirus (HPV) 323
clearer view of the cells and also allows for HPV testing to be done. HPV testing
can detect the DNA of the eighteen HPV types that most commonly affect the
genitals and can distinguish between the low-risk and high-risk HPV types but is
unable to determine the specific HPV type. HPV testing is recommended for those
patients who are aged thirty and older and for those patients needing a follow-up
to an abnormal Pap smear to help determine who is considered to be at greatest
risk for developing cancer before there are any visible changes to the cells. Those
patients who have a negative HPV test and a negative Pap smear are at very low
risk of developing cancer and therefore can have less frequent screenings. HPV
testing is currently not recommended for those younger than thirty since HPV
infection is so common and usually resolves on its own. This helps to prevent any
unnecessary procedures from being done to the patient that may lead to problems
later in life, including pregnancy-related complications due to cervical incompe-
tence and possible miscarriage or preterm delivery.
HPV cannot be directly treated with antiviral medicines. However, conditions
caused by HPV can be treated. Treatment depends on which subset of HPV dis-
ease is present—genital warts or precancerous (or cancerous) changes.
For genital warts, there are two broad types of treatment: self-applied creams
or gels and physician-based treatment. Treatments done by a physician include
cryotherapy, or freezing off the wart; application of an acid that helps to burn off
the wart; electrocautery, which destroys the wart using an electrical current; laser
therapy, which vaporizes the wart; and surgical removal.
Treatment of cervical or anal dysplasia (abnormal cell growth) depends on the
type of dysplasia present. An abnormal Pap result does not mean the patient has
cancer but only that some abnormal cells have been found. It often takes years
before abnormal cells can become cancer, and cells that are only mildly abnormal
may go away on their own. Additional testing is usually necessary to follow an
abnormal Pap smear, which may include a repeat Pap smear in six to twelve
months, an HPV test, or a more detailed exam of the cervix, called a colposcopy,
with or without a biopsy. If the follow-up results confirm the presence of high-risk
HPV, whether through HPV testing or if moderate to severe dysplasia or greater is
confirmed on biopsy, then treatment may be necessary. This involves removing
the abnormal cells, either by ablation (vaporizing the abnormal cells with either
laser therapy or cryotherapy, which freezes the abnormal cells) or excision (cut-
ting out the abnormal cells using either a scalpel or cold knife, using a laser or a
hot knife, or a procedure known as a loop electrosurgical excision procedure,
which uses a fine wire loop with an electrical current to excise the abnormal por-
tion of the cells.
As there is no medical cure for HPV, it is best to prevent the infection. There
are currently HPV vaccines available to protect against the types of HPV that are
the cause of most cancer and warts. The vaccines are made up of virus particles,
not live or attenuated, so it is not possible to acquire any HPV-related infections at
the time of vaccination. The HPV vaccines are recommended for all people ages
nine to twenty-six, as the vaccine is most effective if it is given before any sexual
activity, and consequently potential HPV exposure, has occurred. The vaccine
can also be given in later adulthood to prevent future infection. The vaccines are
324 Hyde Amendment
typically given as a series of shots over approximately six months. Vaccine side
effects are minimal and include pain and redness at the injection site, nausea,
headache, and dizziness. It is important to know that the vaccine does not replace
the need to wear condoms to lower the risk of getting another type of HPV that is
not included in the vaccination or another STI. Condoms cannot fully protect
against HPV infection, as a condom may not cover all of the infected area. The
vaccine has not been proven to be effective against HPV infections that are already
present from past exposure. It is important to know that those who receive
the HPV vaccine should continue to have routine cervical or rectal screenings,
since 30 percent of HPV-related cancers are caused by HPV types other than type
16 or 18.
During pregnancy, genital warts may grow in number and size due to the sup-
pression of the immune system, which naturally occurs during pregnancy. Treat-
ment is usually delayed until after childbirth to see if the warts will go away on
their own. The majority of the time, the warts do not become problematic during
pregnancy and thus do not tend to cause any complications. Most children born to
someone with an HPV infection also tend not to have any complications due to
HPV. Rarely, warty growths occur in an infant’s throat following an exposure to a
large amount of the virus, so a C-section might be recommended in the event that
there is a very large amount of the virus present due to an extreme number or size
of warts. This is done both to help minimize exposure to the baby and to help
minimize trauma to the birth canal, as this tissue can be very difficult to repair in
the event of a cut or tear, which can occur at the time of delivery.
Lori Apffel Smith
See also: Cervical Cancer; Genital Warts; Penile Cancer; Sexually Transmitted Infections
(STIs); Testing, STI.
Further Reading
The American College of Obstetricians and Gynecologists. (2019). Pap smear (Pap test):
Resource overview. Retrieved from https://www.acog.org/Womens-Health/Pap
-Smear-Pap-Test
The Anal Cancer Foundation. (2019). About HPV/HPV & cancer. Retrieved from https://
www.analcancerfoundation.org/about-hpv/hpv-cancer/
Centers for Disease Control and Prevention. (2019). Human papillomavirus (HPV).
Retrieved from https://www.cdc.gov/hpv/
Centers for Disease Control and Prevention. (2019). HPV vaccine schedule and dosing.
Retrieved from https://www.cdc.gov/hpv/hcp/schedules-recommendations.html
Office on Women’s Health. (2019). Human papillomavirus. Retrieved from https://www
.womenshealth.gov/a-z-topics/human-papillomavirus
Hyde Amendment
The Hyde Amendment banned the use of certain federal funds to pay for abortion.
Currently, the only exceptions to the rule are if the pregnancy is the result of rape
or incest or if the mother’s life is in danger. The Hyde Amendment is a provisional
Hyde Amendment 325
“rider” rather than a permanent law, meaning that it must be renewed yearly as
part of the annual Department of Labor or Department of Health and Human Ser-
vices appropriations bill. With that, the language of the amendment is liable to
change each time it is adopted, and there have been several years in which the
amendment has either failed to pass or has gotten close to failing.
Antiabortion advocate Rep. Henry Hyde (R–Ill.) sponsored the original Hyde
Amendment in response to the landmark 1973 Roe v. Wade decision legalizing
abortion. It passed the House of Representatives with a vote of 207–167 on Sep-
tember 30, 1976, but due to controversy surrounding the constitutionality of such
a ban, the Hyde Amendment did not actually go into effect until 1980. Although
the language in the original amendment did not allow for any exceptions, argu-
ments in Congress eventually led to a compromise and the possibility of funding
in cases of rape, incest, and life-threatening situations was added to the provision
in the late 1970s; however, between 1981 and 1989, the exceptions of rape and
incest were temporarily removed from the legislation. With the possibility of
changes annually, these exceptions were then reinstated in the 1990s with the
understanding that they may once again be vetoed in any annual review.
Because the Hyde Amendment mostly affects abortions funded by Medicaid
and is thought to be the only such medical procedure ever to have been fully
banned from the comprehensive health care program, opponents of the provision
argue that it unfairly targets low-income people who are unable to pay for abor-
tions out of pocket. As a result of the legislation, it has been stated that one in four
low-income women who would choose abortion are forced to carry a baby to term
due to their financial situation. The lack of federal funding for abortions created
by the amendment has also resulted in many state governments allocating pre-
cious state resources to abortion services instead of other services, either volun-
tarily or through court-ordered requirements.
Although the Hyde Amendment itself affects only funding through the Depart-
ment of Health and Human Services, by the 1980s it had become a model for
other, similar amendments to legislation governing funding through several gov-
ernment programs. For example, health programs through the U.S. Armed Forces
no longer fund abortions, and programs for Peace Corps volunteers and Native
American health care services also do not fund abortion services.
Tamar Burris
See also: Abortion Legislation; Roe v. Wade.
Further Reading
Haney, J. (2009). The abortion debate: Understanding the issues. Berkeley Heights, NJ:
Enslow Publishing, LLC.
McBride, D. E., & Keys, J. L. (2018). Abortion in the United States: A reference hand-
book. Santa Barbara, CA: ABC-CLIO.
Rubin, E. R. (1998). The abortion controversy: A documentary history. Westport, CT:
Praeger.
Yarnold, B. M. (1995). Abortion politics in the federal courts: Right versus right. West-
port, CT: Praeger.
326 Hymen
Hymen
The hymen is a thin membrane that partially covers the opening of the vagina. It
is present in most—but not all—human females at birth. If it is present, it might be
torn during the first sexual intercourse. However, the hymen can also be torn prior
to sexual intercourse. Thus, contrary to popular belief, the presence or absence of
a hymen is not necessarily associated with virginity.
The hymen, which is named after the ancient Greek god of marriage, has no
known biological function. It varies in size, shape, and thickness between people.
One common shape is the form of a half-moon along the rear edges of the vagina,
leaving a vaginal opening about the width of a finger—wide enough for the monthly
menstrual fluids to leave the body. Other hymens may be attached to the front or
side edges of the vagina in ways that form other shapes. As long as the opening is
sufficiently large to allow menstrual bleeding and tampon use, the hymen is consid-
ered “normal.”
If the hymen is present during the first sexual intercourse, it typically separates
from the vaginal walls and is torn during insertion of fingers, penis, or sex toy into
the vagina. The tearing of tissue may lead to temporary minor pain and bleeding,
which is no cause for concern. The hymen can also separate from the vaginal
walls as a result of strenuous physical exercise that causes the tissue to stretch
excessively, such as riding a bicycle or horse. Other ways in which the tissue can
be perforated include the insertion of a tampon and masturbation. In some cases,
the hymen tears for unknown reasons.
As the absence of a hymen is not proof of the lack of virginity, the presence of
a hymen is not necessarily evidence of virginity. Some women have a hymen that
is so flexible or small that it remains intact after sexual intercourse. An intact
hymen may need to be surgically removed if still present during pregnancy so that
it does not block the passage of the baby through the vagina.
Some people have hymens with excess tissue that causes problems with insert-
ing or removing tampons or may obstruct menstrual bleeding. For example, an
imperforate hymen completely covers the vaginal opening, blocking the release of
menstrual fluid. The blocked fluid builds up inside the vagina, leading to the
development of an abnormal mass and pain in the abdomen or back. Individuals
with this condition may also experience pain or discomfort when they urinate or
defecate.
A microperforate hymen has only one, or perhaps a few, tiny openings in its
tissue. The openings may not be large enough to allow normal menstrual bleed-
ing. An individual with this condition may be unable to insert a tampon, or, if it
can inserted, it may be difficult to remove. A septate hymen has one or more
bands of tissue running across the vagina to create two or more small vaginal
openings rather than one. Such conditions also make it difficult to insert and
remove a tampon.
Minor surgery can correct all these problematic conditions by removing the
excess tissue to create a larger vaginal opening.
The mistaken belief that the absence of a hymen is proof of sexual intercourse
can have serious social consequences for a woman. In cultures that place a high
Hymenoplasty 327
value on female virginity prior to marriage, such as those in strict Islamic coun-
tries, the discovery that a woman who is expected to be a virgin lacks a hymen
could lead to divorce, public humiliation, or even execution. To avoid such conse-
quences, some women resort to a surgical procedure called hymenoplasty, in
which hymen tissue is restored or created.
A. J. Smuskiewicz
See also: Hymenoplasty; Vagina; Virginity.
Further Reading
Center for Young Women’s Health. (2019). Types of hymens. Retrieved from http://
youngwomenshealth.org/2013/07/10/hymens
Roye, C. (2008, December). Hymen mystique remains intact in bare-all culture. Wom-
en’s eNews. Retrieved from http://womensenews.org/story/media-stories/081203/
hymen-mystique-remains-intact-in-bare-all-culture#.VAiUXl6Viu4
Hymenoplasty
Hymenoplasty, also known as hymenorrhaphy, is a cosmetic, surgical repair of the
hymen, otherwise known as reconstruction surgery for the hymen. The hymen is
a layer of tissue that covers the vagina. The membrane typically has one or more
openings that allow for the use of tampons and for menstrual blood to flow. This
opening will get larger during sexual intercourse or childbirth; however, the
hymen can also tear or rip during intense physical activity, masturbation, or tam-
pon use. Some women are also born without a hymen. The hymenoplasty proce-
dure involves repair and reconstruction of the hymen so that it appears to be back
to a pretorn, “virgin-like” state. There is minimal recovery time where a woman
must refrain from certain activities that might interfere with the healing process.
Such activities include riding a bike, swimming, and engaging in intercourse.
There are many different motivations why a woman would elect to have this sur-
gery. Some women might want to have a hymenoplasty in order to appear as a
virgin with a partner, to help recover from sexual abuse or trauma, or to enhance
sex with a partner. Despite the reasoning for the surgery, it is elective and not cov-
ered by insurance, meaning the cost would have to come out of pocket.
The actual hymenoplasty procedure is fairly simple, and patients should experi-
ence little to no surgical complications. To begin the process to see if a patient is a
potential candidate for the procedure, consultations and gynecological exams are
required. Potential hymenoplasty patients must be at least eighteen years old and
cannot have any sexually transmitted infections or genital cancers. Before surgery
begins, the patient is given a local anesthesia. During surgery, a plastic surgeon
sews up torn skin from the hymen to appear as though it is still intact. The proce-
dure takes less than an hour to complete. Some common side effects are swelling,
bruising, pain, bleeding, or numbness. The recovery time is minimal, and a typi-
cal patient is able to return to normal activities within a few days; however, it is
not recommended to engage in strenuous activities while the incision is healing.
Strenuous activities include things like riding a bike or intense cardio. Dissolvable
328 Hymenoplasty
stitches are commonly used when undergoing a hymenoplasty, and there should
be little to no scarring from the procedure if there are no complications. A patient
may engage in sexual intercourse eight weeks after the surgery.
Even though a hymenoplasty may seem like an unnecessary or superficial pro-
cedure, there are a few reasons why the procedure can help ensure a woman’s
safety and improve self-image. One reason why a woman may wish to undergo a
hymenoplasty is because she is required to be a virgin until her wedding night,
often because of religious or family beliefs. In many cultures, the viability of
the hymen determines whether the woman is a virgin prior to being wed. After the
consummation of the marriage, the mother of the bride will check to see if the
sheets have blood on them, to prove that the bride has refrained from sexual activ-
ities prior to the wedding night. If it is determined that the tissue was previously
torn and not intact prior to the night of the wedding, many cultures will shame the
bride and consider her impure. Because of this disgrace, an individual may seek
out the assistance of a doctor to surgically repair her hymen. Normal pain and
bleeding will occur once the hymen is torn again during intercourse, so her part-
ner will not know that she is not a virgin. If a woman is not a virgin on her wed-
ding night in some cultures she might be isolated, beaten, exiled, or killed. In
these cases, having a hymenoplasty can be life-saving. In countries where it is
widely believed that a woman must be a virgin until her wedding night, there are
many plastic surgeons that specialize in doing hymenoplasty procedures. There is
debate about whether hymenoplasty procedures are considered ethical when
deception is involved, such as if a woman is having the surgery to deceive a part-
ner into thinking she is still a virgin. Whether someone thinks that this intent is
wrong or not, it is still ultimately the woman’s and the doctor’s decision whether
the procedure will happen. Feminist activists have spoken publicly about the need
for hymenoplasty procedures because of the safety and sexual freedom aspects.
There is a need for this type of surgery in many cultures for a multitude of situa-
tions that range from safety to trust.
It is also important to note that bleeding or lack thereof does not mean that the
hymen is or is not intact. As individuals are becoming more educated on the
hymen, the views on virginity and hymens are changing. Although it is difficult to
change traditions, many have expressed that using the hymen as an indicator of
virginity should be a thing of the past.
There have also been testimonials from women who have undergone a hymeno-
plasty to spice up the relationship with their significant other. The procedure can
make a woman feel “revirginized,” which can add a layer of excitement to a rela-
tionship. Some women have expressed that they get this procedure because they
want to lose their virginity to their current partner instead of the person they orig-
inally lost it to, or because their hymen was previously torn by vigorous exercise,
masturbation, or even tampon use. Finally, this procedure can be done to increase
sexual pleasure. By tightening the hymen, many have claimed that the sexual
experience is much more enjoyable than prior to the surgery.
Another reason why a woman may choose to have a hymenoplasty is because
of rape or abuse. If a woman’s hymen is torn from being raped or abused, it can be
very traumatic and a constant reminder of the trauma. Having a hymenoplasty
Hypersexuality 329
after experiencing such trauma can help a woman during the healing process,
which can help when recovering from the abuse. Sexual abuse survivors who have
their hymens repaired may feel as though they have a fresh start to sexual inde-
pendence and freedom.
There are other alternatives to a hymenoplasty. Those who cannot afford the
high price of this procedure can buy an artificial hymen. This cheaper alternative
comes with fake blood within a prosthetic membrane. The membrane is inserted
into the vagina twenty minutes before sexual intercourse, and when it is pene-
trated it will start to bleed, giving the illusion that the original hymen has been
broken. This mock hymen can be purchased online and discretely shipped. If one
is looking to improve sexual experiences, there are other surgeries that tighten
vaginal muscles. Laser vaginal rejuvenation is a treatment that uses lasers to heat
the inside of the vaginal walls, thus tightening the entire vaginal cavity, including
the hymen. It is important to note that the hymen will not return to its virgin-like
state; however, it appears to tighten up. Another alternative is vaginoplasy, plastic
surgery of the vagina. During a vaginoplasty, the surgeon will tighten the vaginal
muscles, which also brings in the hymen. Similar to laser vaginal rejuvenation, the
vaginoplasty will not completely repair the hymen, only bring it closer together,
which may help to improve the overall sex life of an individual.
Casey T. Tobin
See also: Double Standards, Sexual; Hymen; Vagina; Virginity.
Further Reading
Aquirre Specialty Care. (2019). Hymenoplasty. Retrieved from https://www.ascdenver
.com/aguirre-specialty-care-services/cosmetic-gynecology/hymenoplasty/
Center for Young Women’s Health. (2013). What can make the hymen break? Retrieved
from https://youngwomenshealth.org/2013/07/31/hymenbreak/
Chozick, A. (2015, December 15). Virgin territory: U.S. women seek a second first time.
The Wall Street Journal.
Lybrate. (2019). Hymenoplasty: Procedure, cost, risk, recovery and hymenoplasty sur-
gery side effects. Retrieved from https://www.lybrate.com/topic/hymenoplasty
Zikalala, Z. (2018, April 21). Why women are opting to get their virginity restored through
hymenoplasty. Health 24. Retrieved from https://www.health24.com/Lifestyle/
Woman/Your-body/why-women-are-opting-to-get-their-virginity-restored
-through-hymenoplasty-20180416
Hypersexuality
Hypersexuality may also be referred to as compulsive sexual behavior, out-of-
control sexual behavior, hypersexual disorder, sexual addiction, or historically
when applied to women, nymphomania. It is characterized by an often distressing
obsession with sexual thoughts, urges, or behaviors. The obsession may be so con-
suming that it causes much distress for the individual and can adversely affect
their self-esteem, health, relationships, career, and other aspects of life.
Various types of thoughts and acts may be part of hypersexuality, including
masturbation, looking at pornographic photos and videos, having affairs or
330 Hypersexuality
engaging in sexual relationships outside of a primary monogamous partnership,
and paying for sex. For many people, some of these thoughts and acts are very
enjoyable, and they may not pose a serious problem. However, for the individual
with hypersexual disorder, the thoughts and acts become highly disruptive and
harmful to themselves and, in some cases, to others.
Knowing the difference between “normal,” unproblematic sexual urges and
acts and those that constitute a serious, compulsive disorder means recognizing
certain symptoms. Symptoms that suggest a disorder include the following:
• feeling that the sexual impulses are so intense that they are beyond control
• feeling strongly compelled to do certain sexual activities even if they do not
bring pleasure or satisfaction
• engaging in sexual behaviors as an escape from problems such as stress, bore-
dom, depression, and loneliness
• continuing to engage in the behaviors despite the risk of serious consequences,
such as the loss of a job, the loss of a spouse or partner, legal problems, and
sexually transmitted infections
• having a compulsive state of mind that causes trouble establishing or main-
taining close, emotional relationships with people
If these symptoms are present, it is best to seek help from a sexual therapist, doc-
tor, psychiatrist, or other mental health professional as soon as possible. Compul-
sive sexual behaviors tend to escalate and expand over time—similar to drug
use—as the individual seeks to maintain the “high.” Although feelings of guilt,
shame, and low self-esteem may haunt the individual, the compulsive behaviors
continue, often leading to financial debt (if paying for sex or pornography), drug
and alcohol abuse, serious mental health concerns, and arrests for sexual or sub-
stance abuse offenses.
The causes of hypersexuality are not fully understood, but experts believe that
several factors may play a role. One factor may be abnormally high levels of neu-
rotransmitters in the brain. These chemicals, such as serotonin, dopamine, and
norepinephrine, transmit biochemical signals among the neurons (nerve cells) of
the brain, leading to rewarding feelings of pleasure, desires to seek more pleasure,
and other altered moods. High levels of testosterone, the male sex hormone,
prompt some men to become unusually sexually obsessive and aggressive.
For some individuals, a tendency toward hypersexuality has been related to
certain other diseases, including epilepsy, dementia, Huntington disease, and Par-
kinson disease. In addition, some people with histories of physical or sexual abuse;
addictions to alcohol, drugs, or gambling; or bipolar disorder or other mental
health disorders may develop hypersexuality. However, doctors warn that hyper-
sexuality can affect anyone.
The first step in getting treatment is to be professionally evaluated for hyper-
sexuality or compulsive sexual behavior disorder. To make a diagnosis of this
condition, a mental health professional may conduct examinations of both physi-
cal and mental health. Part of this examination may include asking the patient
numerous questions about their health; emotions, thoughts, and behaviors related
to sex; relationships with family and friends; and use of drugs and alcohol.
Hypersexuality 331
Different doctors and other health professionals may diagnose hypersexuality
according to different criteria. Diagnosis is complicated by the fact that the Amer-
ican Psychiatric Association’s Diagnostic and Statistical Manual of Mental
Disorders—the main guide for diagnosis of mental disorders—does not include a
specific category for hypersexuality or compulsive sexual behavior. Thus, a
patient’s condition may be diagnosed as a form of impulse control disorder or
some other disorder, like paraphilic disorder. However, in its newest edition, the
World Health Organization’s International Classification of Diseases, Eleventh
Revision, included compulsive sexual behavior disorder as an impulse control
disorder.
Once a diagnosis is made, typical treatment for a patient struggling with hyper-
sexuality includes a combination of psychotherapy, medications, and participation
in “self-help” groups (such as Sexaholics Anonymous, similar to Alcoholics
Anonymous). The treatment is designed to help the patient control and limit their
excessive sexual urges and behaviors while maintaining a healthy level of sexual
activity. Some patients may need to receive treatment for additional, associated
disorders, such as drug or alcohol addictions, obsessive-compulsive behaviors,
anxiety, or depression.
Psychotherapy involves talking with a therapist, who ideally helps the patient
learn how to better manage compulsions and urges. A patient undergoing psycho-
therapy should become increasingly aware of unconscious thoughts and develop
insights into factors responsible for problematic urges and motivations. The patient
should also learn how to replace unhealthy thoughts and acts with healthy ones.
Depending on the patient’s particular case, some psychotherapy sessions may
include spouses or other family members. A strong support system of family and
friends can be crucial to successful treatment.
A variety of medications are available to help treat patients with hypersexual-
ity. Many of the available medications act on neurotransmitters to reduce the feel-
ings of reward and pleasure derived from the compulsive, problematic acts,
thereby reducing the urges that lead to the acts. Such drugs include lithium and
naltrexone. Other medications reduce the depression that leads to the need to find
escape, such as fluoxetine and sertraline. Still other medications reduce the effects
of testosterone, such as medroxyprogesterone and luteinizing hormone–releasing
hormone agonists.
A. J. Smuskiewicz
See also: Compulsivity, Sexual; International Classification of Diseases, Eleventh Revi-
sion (ICD-11); Out-of-Control Sexual Behavior; Pornography Addiction; Sexaholics
Anonymous.
Further Reading
Mayo Clinic. (2019). Compulsive sexual disorder. Retrieved from http://www.mayoclinic
.org/diseases-conditions/compulsive-sexual-behavior/basics/definition/con
-20020126
Weiss, R. (2014). Nymphomaniac—A realistic look at female hypersexuality? Retrieved
from http://www.psychologytoday.com/blog/love-and-sex-in-the-digital-age/201404/
nymphomaniac-realistic-look-female-hypersexuality
Weiss, R. (2018). Hypersexuality: Symptoms of sexual addiction. Retrieved from http://
psychcentral.com/lib/hypersexuality-symptoms-of-sexual-addiction/00011488
332 Hypogonadism
Hypogonadism
Hypogonadism is a medical condition that produces insufficient levels of sex hor-
mones in both males and females. There are two types of hypogonadism, primary
and secondary, that are characterized by the causes of the lack of hormone produc-
tion. Primary means the gonads (i.e., testes and ovaries) cannot make enough sex
hormones. The gonads still receive messages from the brain to produce the hor-
mones but are simply unable to respond accurately. Secondary hypogonadism occurs
when one’s brain cannot send messages to the gonads to produce sex hormones.
There are many diseases and syndromes that are linked to causing secondary hypo-
gonadism, such as cancer treatments, hereditary diseases, medications, or injury.
The symptoms of hypogonadism vary slightly between males and females,
with the list of possible symptoms for males being longer than that of females.
Males can experience loss of body hair, muscle loss, abnormal breast growth,
reduced growth of the penis and/or testicles, erectile dysfunction, a low or absent
sex drive, infertility, osteoporosis, fatigue, hot flashes, and difficulty concentrat-
ing. Symptoms of secondary hypogonadism do not usually present until after
puberty. According to some, a poor sense of smell is also a symptom in the case of
secondary hypogonadism in males. Although hypogonadism is generally less
common in females, symptoms in females include low or absent sex drive, slow or
absent breast growth, difficulty conceiving, an abnormal menstrual cycle, hot
flashes, and milky discharge from the breasts.
Predominately affecting men, hypogonadism results in decreased sperm and
testosterone production. Men who have a decrease in testosterone levels may
experience less sexual desire. In most cases, this can be treated with testosterone
replacement therapy. Hypogonadism can be caused by Klinefelter syndrome,
where an individual has one Y chromosome and more than one X chromosome.
This extra X chromosome disturbs the development of the testicles, which in turn
obstructs the proper production of hormones. Male hypogonadism can also be
caused by undescended testicles—when the testicles stay inside the abdominal
cavity instead of dropping down into the scrotum. This normally occurs after
birth and can be corrected with surgery but if left untreated can cause damage to
the testicles and interrupt hormone production. Hypogonadism can also be caused
by too much iron, which affects both the testicles themselves and the pituitary
gland, meaning both the signal to produce hormones and the actual production of
hormones is dysfunctional. Other possible causes include infections such as the
mumps, traumatic injury, and aging.
In women, hypogonadism can be caused by Turner syndrome, which is charac-
terized by only having one X chromosome. Turner syndrome leads to abnormal
development of the ovaries and therefore the abnormal releasing of sex hormones.
Female hypogonadism may also be due to ovarian cysts or polycystic ovarian syn-
drome, as cysts on the ovaries prevent the release of hormones. Other possible
causes of hypogonadism among females include trauma, drug interactions, radia-
tion, tumors, and excess iron.
For both sexes, hormone production associated with the brain can be affected in
many ways. Genetically, an abnormal development of the hypothalamus known as
Kallmann syndrome (delayed or absent puberty) can affect the release of
Hypogonadism 333
hormones from the gonads. The hypothalamus controls the pituitary gland, which
tells the gonads when to release hormones. Diseases such as tuberculosis or sar-
coidosis are inflammatory to the hypothalamus and pituitary and consequently
can disrupt communication. Lower release of hormones is also associated with
opioid medications, hormone therapy, and obesity. Stress and recurring illnesses
can also affect the brain’s ability to send signals to the gonads to release
hormones.
Symptoms of hypogonadism are seen in the secondary sex characteristics first.
In men, this includes decreased muscle growth, decreased body hair production,
low libido, and breast enlargement. In females, this includes either failing to start
menstruation or stopping menstruation, decrease in breast development, hot
flashes, mood changes, low libido, and abnormal hair growth.
To diagnose hypogonadism, one must test the levels of hormones, including
luteinizing hormone and follicle-stimulating hormone. In addition, in women the
test will examine estrogen levels, and in men testosterone levels will be assessed.
Besides hormones, other tests will include iron level, sperm count in men, and
thyroid tests. An ultrasound of the ovaries can be done to determine if there are
cysts. Other scans that may be needed include brain scans to find tumors or abnor-
malities in the hypothalamus or pituitary gland.
Treatment for hypogonadism depends on the cause of the problem. The most
likely course of action will be hormone therapy. In women, this usually includes
estrogen and progesterone. In men, this is testosterone therapy. Women may also
be prescribed testosterone to help with low libido, which is a common symptom.
These hormones can be delivered in a patch or pill form for women, or through
injection, patch, gel, or solution for men. If the problem is in the hypothalamus or
pituitary, surgery to remove growths may be necessary, as well as radiation ther-
apy or other interventions. If the problem is genetic, then hypogonadism cannot be
cured and must just be managed. Other causes, like cysts or tumors, can be
removed and may return the gonads to their normal functioning.
Hypogonadism can lead to many complications besides the visible side effects
like abnormal body hair or loss of muscle growth. It can lead to infertility and
early menopause in women. Estrogen therapy can lead to blood clots, endometrial
cancer, and breast cancer. In men, hypogonadism can cause osteoporosis, infertil-
ity, and weakness. The complications from treatment include the risks of radiation
and the possibility of excess testosterone.
Casey T. Tobin
See also: Androgen Insensitivity Syndrome; Androgens; Congenital Adrenal Hyperpla-
sia; 5-Alpha-Reductase Deficiency; Hormone Replacement Therapy; Klinefelter Syn-
drome; Polycystic Ovary Syndrome (PCOS); Sex Hormones; Turner Syndrome.
Further Reading
Hyde, J., & Delamater, J. (2017). Understanding human sexuality (13th ed.) New York:
McGraw-Hill.
Lehmiller, J. (2013). The psychology of human sexuality. Hoboken, NJ: John Wiley &
Sons.
Mayo Clinic. (2019). Male hypogonadism. Retrieved from https://www.mayoclinic.org/
diseases-conditions/malehypogonadism/symptoms-causes/syc-20354881
334 Hysterectomy
Hysterectomy
Hysterectomy is the surgical removal of the uterus, the organ in which fetal devel-
opment takes place. Thus, after undergoing a hysterectomy, a person no longer has
the ability to become pregnant.
Hysterectomies are performed for several different reasons. The most common
reason is the removal of large fibroids, which are abnormal, noncancerous growths
of muscle and connective tissue in the wall of the uterus. Fibroids often cause a
great deal of pain as well as excessively heavy menstrual bleeding. If the fibroids
are small enough, physicians might be able to eliminate them with hormone-based
treatments or remove each of them individually in surgery. However, large fibroids,
in most cases, can be removed only by removing the entire uterus.
Hysterectomies may also be performed as treatment for cancers of the female
reproductive organs (mainly the uterus, cervix, or ovaries), treatment for endome-
triosis (a condition in which cells from the uterine lining grow outside the uterus,
such as on the ovaries or in the abdominal cavity), and treatment for pelvic inflam-
matory disease (an infection of the reproductive organs). Some people have a
uterus that slides into an abnormal position within the vaginal canal—a condition
called uterine prolapse—requiring hysterectomy. Still other conditions that may
require hysterectomy are adenomyosis (thickening of the uterine wall) and abnor-
mal vaginal bleeding or chronic pain in the pelvic region not necessarily related to
fibroids. Finally, hysterectomy may also be performed as part of the gender transi-
tion process for trans men.
Depending on the goal of treatment, the type of hysterectomy may vary. In a
total hysterectomy, the entire uterus, including the cervix, is removed. In a subto-
tal, or supracervical, hysterectomy, all of the uterus except the cervix is removed.
In a radical hysterectomy, the uterus and cervix, the upper part of the vagina, and
surrounding lymphatic tissue and ligaments are removed. One or both of the fal-
lopian tubes and ovaries may also be removed in some hysterectomies. The more
radical and extensive forms of surgery are usually associated with cancer
treatments.
Different surgical techniques can be used to perform a hysterectomy. The sur-
geon may remove the uterus and associated organs through a large open incision
in the abdominal wall or in any of various minimally invasive procedures (MIPs).
Abdominal hysterectomies, in which the surgeon makes a horizontal or vertical
incision 5–7 inches (13–18 centimeters) long in the abdomen, account for about 65
percent of all hysterectomies. This kind of procedure generally requires a hospital
stay of two to three days, and it leaves a visible scar on the abdomen. Full recovery
may require as long as six weeks.
In one type of MIP hysterectomy, the surgeon removes the uterus through a
small incision in the vagina, leaving no visible scar. In another type of MIP hys-
terectomy, one or more small incisions are made in the abdomen, through which a
laparoscope (a tube with a camera at the end) and surgical tools are inserted. Then,
while viewing the inside of the body on a video screen, the surgeon makes the
necessary cuts to remove the uterus through the small incisions. Some forms of
Hysterectomy 335
laparoscopic hysterectomy may involve the use of a robotic system of surgical
tools, which the surgeon can manipulate with remote controls outside the body.
All these MIP procedures allow the patient to spend less time in the hospital
and have shorter recovery times compared with traditional abdominal hysterecto-
mies. Those who have had an MIP hysterectomy may be able to resume their
normal daily activities in three to four weeks. Those who are obese or who have
certain other health problems are not good candidates for MIP hysterectomy.
Hysterectomy is considered a low-risk form of surgery. However, a small per-
centage of patients may experience complications after surgery such as chronic
pain, blood clots, infection, urinary incontinence, vaginal prolapse (in which part
of the vagina protrudes from the body), or formation of a fistula (an abnormal con-
nection between the vagina and bladder). Hysterectomy may cause earlier-than-
normal menopause. Some also experience feelings of sadness and depression after
a hysterectomy.
A. J. Smuskiewicz
See also: Cervical Cancer; Endometriosis; Gender Transition; Ovarian Cancer; Pelvic
Inflammatory Disease (PID); Uterine Cancer; Uterus.
Further Reading
Kelley, K. (2012). What 250,000 women know about hysterectomy. Seattle, WA: Amazon
Digital Services, Inc.
Mayo Clinic. (2019). Abdominal hysterectomy. Retrieved from https://www.mayoclinic
.org/tests-procedures/abdominal-hysterectomy/about/pac-20384559
Streicher, L. F. (2013). The essential guide to hysterectomy: Advice from a gynecologist
on your choices before, during, and after surgery. Lanham, MD: M. Evans &
Company.
I
Incest
The word “incest” comes from the Latin word “incestus,” meaning impure. Incest
refers to sexual contact of any kind between relatives, and approximately 34 per-
cent of child sexual abuse cases are committed by family members. Incest is ille-
gal in the United States, and each state has their own legal definition of what
constitutes incest. The reasoning behind incest being illegal is that children born
from incestuous relationships have a higher probability of being born with physi-
cal or intellectual disabilities. As such, many states used to require blood tests
prior to issuing marriage licenses. Incest can occur in many different forms, such
as sexual contact between siblings, a child and parent, child and grandparent or
aunt or uncle. Incest also refers to adult relationships where the individuals are
consenting but are too closely related to marry; this is also considered a crime but
not necessarily sexual abuse. Incest that is sexual abuse can have long-lasting
effects on the survivor as family members are seen as caretakers and are supposed
to keep the child safe. Oftentimes, the victims do not recognize that what has
occurred is abuse.
In many cases of incest between siblings, the event or events may have occurred
out of curiosity and as such are more along the lines of sex play, which is a healthy
part of childhood sexuality. The determinants of whether the incident is sexual
play include if the siblings are near in age; if coercion, threats, and aggression
were not involved; and if the participants gave consent. This type of play can be
seen as typical development and part of being a curious child. However, when the
above characteristics are not in play and there is a larger age gap, if coercion is
involved, or if there is a lack of consent between siblings, this type of victimiza-
tion can have a lasting effect on the individuals and does not fall within harmless
experiences. While this type of incest can occur between any formation of sib-
lings, the most common is that of older brothers and younger sisters.
Another form of incest is parent-child incest in which a parent takes advantage
of their child. Research indicates that stepfathers are more likely to sexually abuse
their stepdaughters than their biological children. Mothers can also sexually abuse
children, biological or step, but this is either much less common or much less
reported. Parent-child incest can be very hard to disclose because the parent figure
will covertly groom the child and explain to them, in many cases, that the behav-
ior is normal and how it is supposed to be. The nonoffending parent is often either
unaware or in denial. Also, it is common that the victim of the abuse will still care
for or love their abuser and be very confused about the feelings they are experi-
encing. Victims may also be concerned about the reactions of other relatives and
338 Infertility
be worried that people will not believe them. Sexual abuse by a parent breaks the
bond of trust that children have with most adults and can leave them feeling alone.
The effects of incest are similar to those of other forms of child sexual abuse;
however, research has shown that the effects tend to be more severe when the
abuser is a family member. Many survivors deal with guilt, shame, and blame
throughout their life. They may also struggle with low self-esteem and low self-
worth, and they may experience other unhealthy relationships as they grow into
adulthood. They may also deal with sexual dysfunctions or unhealthy sexual
behavior. All these symptoms may lessen over time with the help of therapy and
gaining understanding that what happened to them is not their fault. Children who
are raised in incestuous homes also may not realize that what happened to them
was abnormal, and they may continue the pattern of abuse in their own families.
Amanda Baker
See also: Child Sexual Abuse; Childhood Sexuality; Pedophilia; Rape; Rape, Abuse and
Incest National Network (RAINN); Sexual Abuse.
Further Readings
Davis, L. (1988). The courage to heal: A guide for women survivors of child sexual abuse.
New York: Perennial Library.
Herman, J. L. (1997). Trauma and recovery. New York: Basic Books.
O’Keefe, S. L., Beard, K. W., Swindell, S., Stroebel, S. S., Griffee, K., & Young, D. H.
(2014). Sister-brother incest: Data from anonymous computer assisted self inter-
views. Sexual Addiction & Compulsivity, 21(1), 1–38.
RAINN. (2019). Incest. Retrieved from https://www.rainn.org/get-information/types-of
-sexual-assault/incest
Stroebel, S. S., Kuo, S.-Y., O’Keefe, S. L., Beard, K. W., Swindell, S., & Kommor, M. J.
(2013). Risk factors for father-daughter incest: Data from an anonymous comput-
erized survey. Sexual Abuse: A Journal of Research and Treatment, 25(6),
583–605.
Infertility
Infertility is the inability to conceive or carry a pregnancy to term after twelve
consecutive months of unprotected intercourse for mixed-sex couples under the
age of thirty-five. The timespan is reduced to a period of six months for mixed-
sex couples who are age thirty-five and over. The Centers for Disease Control and
Prevention (CDC) reports that more than one in eight mixed-sex couples deal
with infertility. Some national and international health organizations, such as the
World Health Organization, the American Society for Reproductive Medicine,
and the American College of Obstetricians and Gynecologists, recognize infertil-
ity as a disease. Many factors, conditions, and diseases contribute to infertility for
both males and females, including cancers, lifestyle habits, sexually transmitted
infections (STIs), age, and reproductive disorders. Contrary to popular belief,
infertility is not solely a female problem. The National Survey of Family Growth,
a study conducted by the CDC in 2002, found that 7.5 percent of all sexually
Infertility 339
experienced men under the age of forty-five sought medical help for infertility-
related problems.
Age is a major factor in fertility for females since the production of ovum
ceases during menopause. Unlike males, females are born with all the primary
oocytes they will ever have. This means that female oocytes are as old as the per-
son to whom they belong. Primary oocytes are the immature eggs that eventually
go through meiotic cellular division to form mature ova. During the embryotic
stage, females have approximately three million oocytes in each ovary. By birth,
this number is reduced to about one million, and by puberty, the average female
has roughly 100,000 oocytes in each ovary. This loss of eggs is called atresia and
accounts for the loss of 95 percent of primary follicles by puberty. Atresia contin-
ues throughout adulthood until the average female is left with just 1,000 primary
follicles at around age forty and no follicles by around age fifty. Once females
reach the age of menopause, usually around age fifty, this marks the end of fertil-
ity, menstrual cycles, and ovulation. It should be noted that some people begin
menopause before age fifty, while others will enter menopause after the age of
fifty.
As the quantity of eggs diminishes, so does their quality, which also contrib-
utes to infertility with age. Up to 90 percent of ova have abnormal chromosomes
by age forty. At the age of thirty-five, a healthy female has about a 78 percent
chance of conceiving within one year if they are having monthly, unprotected
intercourse. Approximately 30 percent of females at this age will take longer than
a year to conceive. By the age of forty, fertility drastically declines. As much as 90
percent of the ova can be chromosomally abnormal, and the endometrial lining
becomes thinner as the blood supply to it is reduced. In any given month for a
healthy forty-year-old, the chance of conception is approximately 5 percent. This
percentage drops to 3 percent over age forty-five.
Lifestyle factors such as weight, smoking, consumption of alcohol, and stress
also greatly affect fertility. Being underweight or overweight can interrupt ovula-
tion due to hormonal imbalances that can result from excessive weight gain or
loss. The absence of ovulation will result in infertility, which can be corrected
once a more healthy weight is reached. Since the sex hormone estrogen is accumu-
lated in body fat, those who are underweight do not have enough body fat to store
the appropriate levels of estrogen in order to maintain menstruation and ovulation,
leading to infertility. In addition, those who are underweight tend to produce an
antiestrogen, which essentially causes a cessation of the menstrual cycle. Con-
versely, those who are overweight store too much body fat, which has an adverse
effect on the production of estrogen. Instead of estradiol, the principal female hor-
mone, those who are overweight metabolize estradiol into estrone and estriol, two
weaker forms of estrogen, which leads to the cessation of ovulation. In both cases,
infertility is the end result when weight gain or loss is too extreme.
Lifestyle habits such as excessive drinking, smoking, and stress can lead to
infertility as well. Alcohol interrupts the hypothalamic-pituitary regulation of the
sex hormones estrogen and progesterone, which interferes with menstruation
cycles and ovulation. Cessation of ovulation and menstrual cycles is more
340 Infertility
common in heavy drinkers and alcoholic women; however, studies have found
this same effect on female social drinkers who drank as few as three alcoholic
beverages a day. Smoking also has drastic effects on the reproductive system due
to the toxic chemicals present in cigarettes, such as nicotine, cyanide, and carbon
monoxide. These chemicals can lead to increased loss of ova, as they damage the
genetic material in the ovum, which implicates not only infertility but also prema-
ture menopause. Female smokers tend to experience menopause one to four years
earlier than nonsmokers. Also, infertility rates among smoking women are twice
that of nonsmokers.
Another lifestyle habit that greatly affects fertility and increases the chance for
infertility is stress. Stress may account for up to 40 percent of unexplained fertil-
ity. Scientists are unsure of exactly how stress affects fertility, but studies have
shown that ovulation occurs less frequently among those who are stressed com-
pared with those who are not under stress. Excessive levels of stress can lead to
functional hypothalamic amenorrhea, where there is a complete absence of the
menstrual cycle.
One of the most severe symptoms of infections, diseases, and conditions of the
female reproductive organs is infertility. In many cases, STIs such as chlamydia
and gonorrhea can lead to infertility if these infections develop into pelvic inflam-
matory disease (PID), which can result in damage, scarring, and blockage of the
fallopian tubes. The National Institute of Child Health and Human Development
reported in 2017 that 10–20 percent of chlamydia and gonorrhea cases result in
PID. This could mean that more than 24,000 women become infertile each year in
the United States from PID.
Several other conditions can also lead to infertility, often due to their interfer-
ence with the uterus, cervix, or fallopian tubes. Endometriosis, a disease that
causes the endometrial tissue to grow outside the uterus, can affect the fallopian
tubes and ovaries by obstructing them and preventing fertilization. Polycystic
ovary syndrome (PCOS) is one of the leading causes of infertility in women.
PCOS is when the presence of multiple cysts on the ovaries leads to a hormone
imbalance. The cysts cause an overproduction of androgens, or male sex hor-
mones, which can stop ovulation and menstruation. Other conditions involve
abnormalities of the uterus. Uterine fibroids, which are benign tumors that grow
on the uterus, can interfere with the implantation of a fertilized ovum. In less
common cases, the uterus or cervix can have abnormalities in the size, shape, or
structure, which can render females infertile due to the inability of sperm to reach
the ovum or obstruction in the implantation of a fertilized ovum.
While males do not encounter the same level of reproductive aging as females,
sperm is very susceptible to environmental and biological factors. There are sev-
eral factors that contribute to the quality and quantity of sperm needed for fertil-
ization. Sperm count is a major factor in fertility for males, as the average ejaculate
contains approximately three hundred million sperm. Those males who produce
20 percent below this amount are considered infertile. Frequency of ejaculation
also contributes to sperm count since sperm is produced at a constant rate of about
two hundred million per day. When males ejaculate too often, it can reduce the
number of sperm in the ejaculate. In addition, in the average healthy young male,
Infertility 341
approximately 20 percent of sperm are abnormal with different structural defor-
mities such as a missing tail, two tails, coiled tails, two heads, no head, or small
heads. This percentage increases as men age, which can also leave older men with
lower levels of fertility.
In the same way lifestyle factors affect females, these behaviors also impact
male fertility. Excessive alcohol consumption, smoking, drugs, poor diet, and
stress all reduce sperm count and fertility. Alcohol decreases testosterone levels in
males, which affects sperm production. Smoking directly affects sperm quality by
damaging a specific protein, protamine 2, contained in sperm. Sperm are not able
to fertilize an egg in the absence of this protein, rendering males infertile. Other
factors such as poor diet and excessive weight gain can reduce testosterone levels
and increase estrogen, affecting both quality and quantity of sperm.
Certain infections, conditions, and diseases adversely affect the male reproduc-
tive system often through tubal blockage, which prevents sperm from moving out
of the male body and into the female vagina. STIs, such as chlamydia and gonor-
rhea, if left untreated can lead to scarring and blockage of the epididymis, the
tubes where sperm mature. The development of varicoceles, a condition that leads
to infertility, occurs when the veins on the testicles are too large and cause the
testes to overheat from the increased blood supply. The testicles are maintained at
five degrees below normal body temperature for optimal sperm production. When
a varicocele is present, sperm production and quality can be reduced. Another
condition, cystic fibrosis, causes a blockage of the vas deferens, the tube that car-
ries sperm to the urethra. In some cases of cystic fibrosis, the vas deferens is com-
pletely missing from the reproductive system.
Transgender and gender-variant people may also deal with infertility. In addi-
tion to the considerations noted above, hormones and surgeries that may be pur-
sued during the gender transition process can result in infertility. Consequently,
trans people who wish to have biological children may need to consider sperm or
ova freezing and storage prior to transition, or may need to delay or stop some
biological aspects of transition until after they have children.
Lauren Wesley
See also: Artificial Insemination; Assisted Reproductive Technology; Endometriosis;
Fertility; Intracytoplasmic Sperm Injection; Menopause; Menstruation; Ova Donation;
Ovulation; Pelvic Inflammatory Disease (PID); Polycystic Ovary Syndrome (PCOS);
Pregnancy; Sperm; Surrogate Mothers.
Further Reading
Centers for Disease Control and Prevention. (2002). National survey of family growth.
Retrieved from http://www.cdc.gov/nchs/nsfg.htm
Centers for Disease Control and Prevention. (2019). Infertility. Retrieved from http://
www.cdc.gov/reproductivehealth/Infertility/Index.htm
National Fertility Association. (2019). Medical conditions. Retrieved from https://resolve
.org/infertility-101/medical-conditions/
National Institute of Child Health and Human Development. (2017). What is the link
between sexually transmitted diseases or sexually transmitted infections (STDs/
STIs) and infertility? Retrieved from https://www.nichd.nih.gov/health/topics/stds/
conditioninfo/infertility
342 Intercourse
National Institute on Alcohol Abuse and Alcoholism. (1994). Alcohol alert. Retrieved
from http://pubs.niaaa.nih.gov/publications/aa26.htm
Stillman, R. J. (2017). Smoking and infertility. Retrieved from https://www.asrm.org/
globalassets/asrm/asrm-content/learning--resources/patient-resources/protect
-your-fertility3/smoking_infertility.pdf
Intercourse
“Intercourse” is a word that describes specific sexual acts. Usually “intercourse”
describes one specific sexual act, the penis entering the vagina and thrusting until
the penis ejaculates. The word “intercourse” can also include the thrusting of the
penis into and out of the vagina, with the vagina meeting each thrust, so that it is
a two-person activity. Traditionally, intercourse is seen as the primary sex act,
largely for the purpose of procreation, since sexual intercourse is the way the
sperm and the egg can join together. In that case, intercourse continues until ejac-
ulation occurs, spurting forth semen and sperm as they travel along their path to
meet a single egg in the fallopian tube.
Aside from the reproductive model, there is also the recreational model, where
couples have sexual intercourse for pleasure. In a mixed-sex couple, this includes
penis insertion into a vagina, as well as thrusting usually until ejaculation and
orgasm, with the release of sperm and semen into the vagina. Of course, inter-
course is often accompanied by loving gestures, tenderness, kissing, holding, cud-
dling, touching, fondling, quiet talking, soft sounds, and pleasurable touching and
sharing. In a same-sex couple, insertive intercourse may also take the role of a
penis inserted into an anus or a sex toy or fingers inserted into an anus or vagina.
Also, more than two partners may be involved.
In addition, sexual intercourse can include oral intercourse, often called oral
sex, and anal sex, which is sex using the anus. Oral sex includes kissing, sucking,
or licking a partner’s genitals. Oral sex can also include fingers and toys for addi-
tional stimulation or pleasure. For protection from sexually transmitted infections
(STIs), some couples use either condoms or dams to cover the genitals.
During anal sex, a partner uses their fingers, penis, hands, mouth, lips, tongue,
or toys for penetration, pleasure, and stimulation of the anus. If there is penetra-
tion during anal intercourse, it is important to use a water-based lubricant. The
anus and rectum do not produce lubrication. If lubrication is not used, irritations
or tiny scratches and scrapes can result from the stimulation. In addition, it is
important, to use either insertive or receptive condoms. Receptive condoms
(sometimes also called female condoms) can be used for protection during anal
sex without the internal ring as it can be removed easily, but it’s important to use
water-based or silicone-based lubricant.
Some individuals see intercourse as the sole purpose of sex. However, in real-
ity, it is just one of the many ways people can feel and give pleasure. Some see the
tenderness, passion, and expressions of sensuality as “less than” or not “the real
thing.” Those with narrow views about intercourse as only the penis and the
vagina fail to see the entire body as a means for giving and receiving pleasure. For
example, if a man is worried about not having an erection, the partners can
International Classification of Diseases, Eleventh Revision (ICD-11) 343
pleasure each other without having penetrative intercourse, without judgment or
feeling as though they are lacking something. When there is illness or aging, it
should not matter if age affects traditional intercourse as other activities can be
explored that will also bring pleasure and connection. If the point of a sexual
experience is pleasure, people can use the bodies they have without narrowly
defining intercourse as the main event or without feeling like a failure if it is not a
part of their experience. So, while intercourse is one way to have sex, it is not and
does not need to be the goal or the “best part” of sex with another. It is just one of
the many ways to be intimate with someone else.
Judith Steinhart
See also: Anal Intercourse; Ejaculation; Oral Sex; Orgasm; Penis; Safer Sex; Vagina.
Further Reading
Byers, E. S., Henderson, J., & Hobson, K. M. (2009). University students’ definitions of
sexual abstinence and having sex. Archives of Sexual Behavior, 38(5), 665–674.
Gillibrand, R., & Turner, K. (2013). “Let’s talk about sex”: A post-structuralist discourse
analysis into the meanings and experiences of anal sex for gay men. Psychology of
Sexualities Review, 4, 54–67.
Herbenick, D., Reece, M., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, J. D.
(2010). Sexual behaviour in United States: Results from a national probability
sample of men and women ages 14–94. Journal of Sexual Medicine, 7, 255–265.
International Classification of Diseases,
Eleventh Revision (ICD-11)
The International Classification of Diseases for Mortality and Morbidity Statis-
tics, Eleventh Revision (ICD-11) is “the foundation for the identification of health
trends and statistics globally, and the international standard for reporting diseases
and health conditions” (World Health Organization [WHO], 2018). The ICD pro-
vides definitions and diagnostic criteria for diseases, disorders, injuries, and other
health conditions and can be used for research and clinical purposes. It is main-
tained and published by the World Health Organization.
The ICD was first published by the WHO in 1948. However, it evolved out of
the International List of Causes of Death, which had been used and maintained by
the International Statistical Institute since 1893. There were five versions of the
International List of Causes of Death, and so, when the ICD was published in
1948, it was known as ICD-6. Since then, additional versions have been published,
culminating in the most recent version, ICD-11, which was released on June 18,
2018. Member states of the United Nations will begin to use ICD-11 for their mor-
bidity reporting on January 1, 2022.
With respect to sexuality, ICD-11 has a dedicated chapter (chapter 17) titled
“Conditions Related to Sexual Health.” ICD-11 has additional categories for
changes in male or female genital anatomy, paraphilic disorders, adrenogenital
disorders, infections that can be transmitted sexually, and contact with health ser-
vices for contraceptive management.
The previous version, ICD-10, was approved in 1990. Because of significant
advances in research and clinical practice, as well as major shifts in social
344 International Foundation for Gender Education (IFGE)
attitudes, policies, laws, and human rights standards, many changes were included
in ICD-11 that were not recognized in previous versions.
Importantly, in the new ICD-11, all trans-related categories were deleted from
the chapter “Mental and Behavioral Disorders.” As such, the WHO has now offi-
cially recognized that being transgender and gender diverse are not mental health
conditions. Instead, new trans-related categories such as “Gender Incongruence of
Adolescence and Adulthood” and “Gender Incongruence of Childhood” have
been developed in the chapter “Conditions Related to Sexual Health.”
Sexual dysfunctions are also classified by the ICD-11 in the chapter “Condi-
tions Related to Sexual Health.” There are four main groupings of sexual dysfunc-
tions: (1) sexual desire and arousal dysfunctions, (2) orgasmic dysfunctions, (3)
ejaculatory dysfunctions, and (4) other specified sexual dysfunctions. There is
also a separate grouping of sexual pain disorders.
While ICD-11 has substantial overlap with the Diagnostic and Statistical Man-
ual of Mental Disorders, Fifth Edition (DSM-5), there are some notable differ-
ences. In ICD-11, a diagnosis of hypoactive sexual desire dysfunction can be
applied to both men and women, while in DSM-5, it is separated into female sex-
ual interest/arousal disorder and male hypoactive sexual desire disorder (Reed et
al., 2016). In addition, in ICD-11, there are separate categories for men and women
for genital arousal: female sexual arousal dysfunction and erectile dysfunction.
For women, this differs from how sexual interest/arousal disorder is classified in
DSM-5. In ICD-11, sexual arousal is considered separately from sexual desire. For
men, ICD-11 distinguishes between the subjective experience of orgasm (orgas-
mic dysfunction) and ejaculation (delayed ejaculation); this distinction is not rec-
ognized in DSM-5 (Reed et al., 2016). Finally, ICD-11 has a category for early
ejaculation as opposed to “premature (early) ejaculation” as classified in DSM-5.
Heather L. Armstrong
See also: Desire Disorders; Diagnostic and Statistical Manual of Mental Disorders
(DSM); Dyspareunia; Sexual Disorders, Female; Sexual Disorders, Male; Sexual Dys-
function, Treatment of.
Further Reading
Reed, G. M., Drescher, J., Krueger, R. B., Atalla, E., Cochran, S. D., First, M. B., … Sax-
ena, S. (2016). Disorders related to sexuality and gender identity in the ICD-11:
Revising the ICD-10 classification based on current scientific evidence, best clini-
cal practices, and human rights considerations. World Psychology, 15(3),
205–221.
World Health Organization. (2018). International classification of diseases for mortality
and morbidity statistics (11th Rev.). Geneva: Author. Retrieved from https://icd
.who.int/en
International Foundation for Gender Education (IFGE)
The International Foundation for Gender Education (IFGE), a nonprofit organiza-
tion, was founded in 1986 to promote acceptance of transgender people. Founder
Merissa Sherrill Lynn wrote in regard to its need:
International Foundation for Gender Education (IFGE) 345
The cross-dressing and transsexual phenomena have been an integral part of the
human experience as long as there has been a human experience. These phenomena
have manifested themselves in every society and in every walk of life throughout
history and continue to affect the lives of vast numbers of people. Yet, as common
as they are, ignorance of them, and the resulting intolerance and fear, continues to
cost good people their happiness, their jobs, their families, and their lives. It costs
society its neighbors, its friends, and its productive citizens. The International
Foundation for Gender Education is dedicated to overcoming this devastating igno-
rance. (International Foundation for Gender Education, 1996)
IFGE’s original headquarters was located at 123 Moody Street in Waltham, Mas-
sachusetts. IFGE operated a bookstore featuring books on transgender topics and
issues. The office included a reading room that was open to the public. During
office hours, IFGE would also provide information and referrals by phone.
IFGE held the first of its many annual conferences in 1987, entitled Coming
Together—Working Together, dedicated to “education, planning, and strategizing
about gender-related issues.” The convention was held in a different city each year
to provide support and exposure for local transgender communities. The final
conference was held in 2012 in conjunction with the annual Gold Rush convention
in Colorado.
Another major project was assuming publication of a full-color quarterly maga-
zine. The magazine began publishing in the late 1970s as The TV-TS Tapestry, by
the Tiffany Club in Boston, and covered a wide range of topics of interest to the
community. It became Transgender Tapestry in 1995. IFGE took over the maga-
zine and continued publication until the early 2000s. For many years, Tapestry
enjoyed the largest circulation for any magazine of its kind. IFGE also provided
training and education to professional service providers and organizations, such
as the American Psychiatric Association and the American Association of Sex
Education Counselors and Therapists, and produced video, audio, and printed
materials in support of education about issues of gender. In addition, IFGE main-
tained the mailing list for the Congress of Transgender Organizations, a loose
network of groups and organizations, mostly small grassroots clubs, across North
America dedicated to the transgender community.
Finally, IFGE oversaw the Winslow Street Fund, a permanent endowment for
grants and scholarships for transgender community members. The fund was man-
aged by an independent board of trustees and grew to an estimated $100,000. The
TSELF scholarship fund gave about $5,000 annually to community.
Denise LeClair became the executive director in 2000. Over time, the organi-
zation’s presence in Massachusetts closed, and the office moved to the Washing-
ton, D.C., area. IFGE appears to have ceased operations at the end of 2012. As of
2018, the status of the Winslow Street Fund is unknown along with any of the
organization’s remaining assets, if any.
C. Michael Woodward
See also: American Association of Sexuality Educators, Counselors and Therapists
(AASECT); Gender Expression; Gender Identity; GLSEN (Gay, Lesbian and Straight
Education Network); Nonbinary Gender Identities; Transgender; World Professional
Association for Transgender Health (WPATH).
346 Intersexuality
Further Reading
GenderWiki. (2014, September 13). IFGE. Retrieved from http://www.geekbabe.com/dlv/
mydlv/wiki/index.php/IFGE
International Foundation for Gender Education. (1996). What is IFGE? Retrieved from
https://www.digitaltransgenderarchive.net/files/vh53wv85s
LinkedIn. (2018). Denise LeClair. Retrieved from https://www.linkedin.com/in/dcleclair/
Intersexuality
According to the Intersex Society of North America, “intersex” is a general term
used for a variety of conditions in which a person is born with a reproductive or
sexual anatomy that does not seem to fit the typical definitions of female or male.
A baby may be born with genitals that appear to be in between the usual male and
female, or a baby may have external genitalia that resemble typical female geni-
tals but also have mostly male-typical anatomy on the inside. The individual may
not know of this internal anatomy until puberty, when the flood of hormones
causes multiple changes within their body. Clearly, human bodies do not come in
the neat packages that a gender binary assumes.
Intersex is a socially constructed category that reflects real biological variation.
Though it is difficult to say exactly how prevalent intersex conditions may be,
statistics show that 1 in every 1,500 to 1 in every 2,000 babies are born with atypi-
cal genitalia; however, that does not include all people with intersex conditions
because of the many hormonal and chromosomal variations that are not usually
noticeable at birth. Male people typically have XY sex chromosomes, and female
people typically have XX chromosomes. However, chromosomal mix-ups occur
in various ways. People can have additional X or Y chromosomes, such as XXY,
XXXY, XXX, or XYY. They may also be lacking a chromosome and so have only
an X chromosome. All these conditions are the result of abnormalities that occur
during cell division when producing eggs and sperm. Klinefelter syndrome is the
most common atypical sex chromosome pattern, and somewhere between 1 in
500 and 1 in 1,000 males born have one or more extra X chromosomes. People
with Klinefelter syndrome have some variation of extra chromosomes, such as
47,XXY or 48,XXYY. Most of these gender-identify as men and are never diag-
nosed; they may not find out until they undergo sterility testing later in life during
attempts to conceive children. Those with Klinefelter syndrome tend to be espe-
cially tall and have broader hips, less body hair, and less muscle control and
coordination.
Another chromosomal variation is Turner syndrome (45,X), which occurs when
an individual is born with only one X chromosome. This occurs when an X egg or
sperm merges with an egg or sperm without a sex chromosome. These individuals
usually gender-identify as women, and they tend to be short with distinctive fea-
tures such as a webbed neck, low-set ears, arched or “shield” chests, and a higher
likelihood of obesity; most are infertile and at higher risk for certain health prob-
lems. Research suggests that Turner syndrome appears in 0.8 percent of zygotes,
making it the most common human chromosomal anomaly, but only 3 percent of
Intersexuality 347
these fetuses survive to term. In the end, about 1 in 2,700 live newborns has
Turner syndrome. For people with Turner syndrome, the external genitalia,
vagina, and uterus develop normally, but the ovaries do not. In place of ovaries,
45,X people have only streaks of tissue called streak gonads/ovaries, and these do
not produce typical levels of hormones.
Intersex conditions can also be caused by hormonal variations. Congenital
adrenal hyperplasia (CSH) occurs when a fetus has a hyperactive adrenal gland
that produces masculinizing hormones. If the fetus is XX, then the baby will be
born with masculinized genitals, most notably an enlarged clitoris that resembles
a small to medium-sized penis. Most XX babies born with CSH identify as female
when they grow older. Androgen insensitivity syndrome (AIS) is caused by the
inability of cells to recognize androgens released by the testes both before and
after birth. AIS occurs in the bodies of people with XY chromosomes; these indi-
viduals develop testes that produce testosterone and other androgens; however,
their testes remain in their abdomens. Because their bodies do not recognize
androgens, as fetuses, their external genitalia development followed the female
body plan. Again, they may be unaware of their internal anatomy development
until puberty hits and unexpected changes begin to occur.
Babies born with external genitalia that varies from the typical male or female
genitalia have been “corrected” by doctors’ surgeries for years; however, more
recently there is greater acceptance and understanding of people with intersex
conditions. In 2018, the American Academy of Family Physicians issued a policy
opposing medically unnecessary surgeries on children with intersex conditions.
In the 1960s, surgeons popularized “normalizing” cosmetic operations, but no
data has ever demonstrated that these operations help children “fit in” or “function
in society.” Dr. Alice Dreger has studied sexual development disorders and the
people affected by these experiences. Dreger has noted that “the thing that people
with intersex suffer from most is shame, it’s not surgery. The surgeries are moti-
vated by shame” (Callahan, 2009). Dreger believes people with intersex condi-
tions need a positive message about love and acceptance as well as social
recognition. A recent European consensus statement on intersex surgery “advises
that the intervention be postponed until the individual is old enough to be actively
involved in the decision whenever possible.” Dreger also recommends that the
parents and child work with a multidisciplinary team of pediatricians, surgeons,
psychologists, geneticists, and social workers to make an informed decision on
surgery.
Numerous adults with intersex conditions have voiced their distrust of medical
professionals due to childhood surgeries. Some people who underwent surgeries
as children have begun to speak out against them as human rights violations. As
the result of surgeries, some individuals were assigned the wrong gender, while
others suffer from sexual dysfunction and infertility. Because of this, three U.S.
surgeons general, the United Nations, the World Health Organization, Physicians
for Human Rights, the American Academy of Family Physicians, Human Rights
Watch, and Amnesty International have condemned medically unnecessary sur-
gery on children with intersex conditions. In August 2018, California became the
first state to pass a resolution condemning the operations.
348 Intimacy, Sexual and Relational
While the gender binary continues to exist, the discourse of intersex rights
challenges the notions of solely two genders and sexes. Large-scale changes are
beginning to happen; intersex individuals in New York City obtained medically
accurate birth certificates, and Colorado issued its first intersex birth certificate in
2018. Germany became the first EU country to offer a third gender option on birth
certificates, and this was hailed as a “small revolution” by intersex activists. These
small victories for the human rights of people with intersex conditions are encour-
aging; however, governmental plans to define sex based on “genitalia at birth”
threatens this progress.
Martha Goldstein-Schultz
See also: Androgen Insensitivity Syndrome; Binary Gender System; Biological Sex;
Chromosomal Sex; Congenital Adrenal Hyperplasia; 5-Alpha-Reductase Deficiency;
Fluidity, Gender; Klinefelter Syndrome; Nonbinary Gender Identities; Sex Chromo-
somes; Sex Hormones; Sex Reassignment Surgery; Transgender; Turner Syndrome,
X Chromosome; Y Chromosome.
Further Reading
Callahan, G. N. (2009). Between XX and XY: Intersexuality and the myth of two sexes.
Chicago: Chicago Review Press.
Compton, J. (2018). “You can’t undo surgery”: More parents of intersex babies are reject-
ing operations. Retrieved from https://www.nbcnews.com/feature/nbc-out/you
-can-t-undo-surgery-more-parents-intersex-babies-are-n923271
Fausto-Sterling, A. (2018, October). Why sex is not binary. New York Times. Retrieved
from https://www.nytimes.com/2018/10/25/opinion/sex-biology-binary.html
Intersex Society of North America. (2019). What is intersex? Retrieved from http://www
.isna.org/faq/what_is_intersex
Knight, K. (2018). US Medical Association stands against unnecessary intersex surger-
ies. Retrieved from https://www.hrw.org/news/2018/09/17/us-medical-association
-stands-against-unnecessary-intersex-surgeries
O’Hara, M. E. (2018). Colorado is the first US state to issue an intersex birth certificate.
Retrieved from https://www.them.us/story/colorado-intersex-birth-certificate
Wade, L., & Ferree, M. M. (2015). Gender: Ideas, interactions, institutions. New York:
W. W. Norton & Company.
Intimacy, Sexual and Relational
Sexual and relational intimacy are aspects of a close interpersonal relationship.
Intimacy, in its most general sense, is the feeling of being close or connected to
someone and belonging together. Intimacy is not a thing but a process that changes
over time, that can wax and wane according to the individuals in the relationship.
Intimacy is thought to be an essential part of long-term love relationships.
There are many forms of intimacy, some existing specifically in a relationship
and others not. Within the context of a relationship, a person may experience emo-
tional, intellectual, physical, sexual, spiritual, or experiential intimacy. While
each of these forms of intimacy is valuable, every person will seek out the type of
intimacy that helps them to feel close and connected to another person or their
partner. Broadly speaking, relational intimacy occurs when two people have
Intimacy, Sexual and Relational 349
developed a relationship of safety, trust, and openness where they are able to con-
nect through physical touch (i.e., hand holding or bodily closeness), emotional
openness (sharing of one’s feelings), consensual sexual engagement (from kissing
to intercourse), or in-depth discussion of shared interests. In order for any form of
intimacy to occur, there must be reciprocal trust, emotional closeness, and self-
disclosure. The presence of relational intimacy is important because it validates
individuals’ self-worth by providing them a chance to feel understood and accepted
for who they are, and it is a buffer against mental health issues such as anxiety and
depression.
Sexual intimacy most often occurs in the context of a romantic relationship.
Sexual intimacy is a yearning for a sexual connection that may or may not include
intercourse. Often, sexual intimacy can be described as “making love,” because
there is a simultaneous emotional and physical connection. In more recent years,
however, sexual intimacy has been blurred due to the shifting experiences of sex-
ual engagement. For instance, sexual interactions exist in various relationship
forms, such as friends with benefits or in hookup culture. In these scenarios, two
people consent to a primarily sexual relationship that is mutually beneficial. Most
often, the sexual interactions in these more casual situations lack sexual intimacy
and are based on the mutual desire for sexual pleasure. In contrast, sexual inti-
macy involves the combining of sexual expression with the desire to feel close and
connected to another person.
In addition to sexual intimacy, one of the defining features of relational inti-
macy is the presence of, or desire for, emotional intimacy. Emotional intimacy
exists in a relationship where there is an emotional bond or connection to another
person. When two partners engage in an emotionally intimate relationship, they
crave openness, trust, closeness, and vulnerability. In essence, an individual is
able to feel seen, understood, and accepted. Emotional intimacy fosters closeness
and commitment and is only possible through communication.
Emotional intimacy plays a large role in maintaining sexual desire and relation-
ship satisfaction, which in turn predicts more sexual frequency and satisfaction.
In general, higher levels of intimacy, both sexual and emotional, are related to
greater satisfaction and well-being and more effective communication.
Abby Girard
See also: Companionate Love; Consummate Love; Dating; Friends with Benefits; Hookup
Culture; Love; Marriage; Romantic Attraction and Orientation; Sternberg’s Triangular
Theory of Love.
Further Reading
Timmerman, G. (1991). A concept analysis of intimacy. Issues in Mental Health Nursing,
12, 19–30.
van Lankveld, J., Jacobs, N., Thewissen, V., Dewitte, M., & Verboon, P. (2018). The asso-
ciations of intimacy and sexuality in daily life: Temporal dynamics and gender
effects within romantic relationships. Journal of Social and Personal Relation-
ships, 35(4), 557–576.
Yoo, H., Bartle-Haring, S., Day, R. D., & Gangamma, R. (2014). Couple communication,
emotional and sexual intimacy, and relationship satisfaction. Journal of Sex and
Marital Therapy, 40, 275–293.
350 Intracytoplasmic Sperm Injection
Intracytoplasmic Sperm Injection
Intracytoplasmic sperm injection (ICSI) is the process of injecting a single sperm
cell into an oocyte (egg) for the purpose of fertilization. Conventional in vitro
fertilization (IVF) requires many sperm to facilitate fertilization, while ICSI
allows it to occur when minimal sperm are available. ICSI is typically used in
situations where sperm count is very low, sperm motility (ability to move) or mor-
phology (shape of head, neck, and tail) is poor, sperm are unable to attach to the
oocyte, traditional IVF failed to produced fertilized oocytes, sperm is surgically
collected, sperm is frozen and of poor quality, and when embryos require genetic
testing.
Similar to IVF, fertility drugs will be administered to the female partner to
stimulate her ovaries to produce many mature oocytes. Sperm are collected via
masturbation, thawing, or surgically, if required. The ICSI procedure is done in a
sterile environment and is completed in several basic steps. First, a mature oocyte
is retained with a specialized pipette. Next, a surgical needle is used to pick up a
sperm cell. The needle is used to puncture the membrane of the oocyte, and the
sperm cell is released into the egg’s cytoplasm. Once oocytes and sperm are
merged, the remaining culturing (assisted growing) and embryo transfer processes
are the same as traditional IVF.
While ICSI is recommended for male factor infertility, many couples choose
the procedure to optimize chances for fertilization. In the United States, of the
more than one million IVF cycles that utilized fresh oocytes (nonfrozen) from
1996–2012, 65.1 percent used ICSI, and, of those, only 35.8 percent reported male
factor infertility. ICSI outcome is typically dependent on oocyte and sperm qual-
ity and the maternal age of the female partner. According to the American Society
of Reproductive Medicine, approximately 50– 80 percent of ICSI procedures pro-
duce an embryo (fertilized egg).
Problems associated with ICSI can include damaging the oocyte(s), the oocyte
not becoming fertilized, and suspended embryo growth. If any of these occur, the
merging of the two cells will not result in a pregnancy. Several analyses have
shown that compared to traditional IVF, ICSI has been linked to higher incidents
of autism, chromosomal abnormalities, birth defects, imprinting disorders, and
intellectual disabilities. It has been hypothesized that, unlike IVF and spontane-
ous in vivo conception, ICSI bypasses normal impediments to fertilization and
therefore increases the transmission rate of genetic defects. These genetic defects
are potentially related to the cause of infertility, other medical conditions the
patients may have, or the ICSI procedure itself.
Darci Shinn
See also: Artificial Insemination; Assisted Reproductive Technology; Fertility; Fertility
Drugs; Infertility; Pregnancy; Sperm.
Further Reading
American Society of Reproductive Medicine. (2014). What is intracytoplasmic sperm
injection (ICSI)? Retrieved from https://www.reproductivefacts.org/globalassets/
rf/news-and-publications/bookletsfact-sheets/english-fact-sheets-and-info
-booklets/what_is_intracytoplasmic_sperm_injection_icsi_factsheet.pdf
Intrauterine Device (IUD) 351
Boulet, S. L., Mehta, A., Kissin, D. M., Warner, L., Kawwass, J. F., & Jamieson, D. J.
(2015). Trends in use of and reproductive outcomes associated with intracytoplas-
mic sperm injection. Journal of the American Medical Association, 313(3),
255–263.
Jain, J., & Gupta, R. S. (2007). Trends in the use of intracytoplasmic sperm injection in
the United States. New England Journal of Medicine, 357(3), 251–257.
Intrauterine Device (IUD)
An intrauterine device, also known as an IUD, is a long-acting, reversible contra-
ceptive. It is a small T-shaped device that fits inside a person’s uterus. IUDs have
the highest user satisfaction among all types of reversible birth control in North
America and are the leading form of contraception worldwide. Their popularity is
unsurprising due to the effectiveness and hassle-free quality of IUDs. It is impor-
tant to note that an IUD does not prevent sexually transmitted infections or HIV
transmission. An IUD is inserted into the uterus by a doctor or trained practitio-
ner and may last between three and ten years with over 99 percent effectiveness at
preventing pregnancy. After insertion, there is no need to remember to take daily
pills, change patches or rings, or otherwise think about one’s primary form of
birth control. Though initially expensive, it is the most cost-effective birth control
option due to the one-time cost and longevity of the device.
In addition to being the most effective form of reversible birth control, an IUD
does not require a long period of abstinence following its removal. Return to fer-
tility is usually very quick, and pregnancy may occur as soon as a week after hav-
ing an IUD removed.
There are two types of IUDs: hormonal or copper. The T-shaped structure of
the IUD alters the lining of the uterus so that implantation cannot occur, therefore
preventing pregnancy. An IUD prevents fertilization from occurring and there-
fore is not an abortifacient or device that causes abortion.
Hormonal IUDs release levonorgestrel, a form of the hormone progestin. The
hormones in these IUDs thicken cervical mucus, making it more difficult for
sperm to get through the cervix and meet with an egg. The hormones also prevent
ovulation. In addition to effectively preventing pregnancy, a hormonal IUD may
help shrink fibroids and lessen the painful effects of endometriosis. It may also
help to prevent endometrial cancer. People who have very heavy menstrual peri-
ods or painful cramps may benefit from a hormonal IUD, which helps to reduce
cramping and lightens bleeding or halts the period altogether.
A copper IUD does not release any hormones. This IUD lasts a few years lon-
ger than a hormonal IUD. It is an option for women who do not want hormones or
who would like to have a regular period as the copper IUD does not interrupt
periods. Menstrual periods may even be heavier with this type of IUD. The cop-
per IUD releases copper ions, which prevent the sperm and egg from meeting and
destroy sperm once it enters the cervix.
A doctor or trained practitioner must insert an IUD through the cervical open-
ing. It cannot be inserted if the person is already pregnant or has a pelvic infec-
tion. Insertion may be uncomfortable, though many describe the discomfort as
352 Intrauterine Device (IUD)
mild. Ibuprofen may be taken prior to insertion to aid in pain management. It is
important to find a doctor who inserts IUDs regularly as experience aids in insert-
ing the device quickly and with minimal discomfort. Once the IUD is inserted,
two nylon strings will hang from the cervical os so it may be removed at a later
time. When it is time to remove an IUD, another may be inserted immediately if
desired. Some cramping and bleeding may be expected for a few days to few
weeks following insertion. After this subsides, the IUD should not be noticeable
in the uterus.
There is a small chance that an IUD may be expelled after it has been placed.
Between 2 and 10 percent of people with an IUD may experience this, and it is
more likely in those who have not had children. Expulsion is most likely to occur
within the first three months of the IUD being placed and is most common during
the first period.
In 2012, the American College of Obstetrics and Gynecology recommended
that the IUD should be considered as a first-line contraceptive method for female
adolescents. Recent research has confirmed young women find this form of birth
control effective and report a desire for continued use of IUDs for pregnancy
prevention.
Amanda Manuel
See also: Cervix; Contraception; Endometriosis; Menstruation; Pregnancy; Synthetic
Hormones; Uterus.
Further Reading
Friedman, J. O. (2015). Factors associated with contraceptive satisfaction in adolescent
women using the IUD. Journal of Pediatric and Adolescent Gynecology, 28(10),
38–42.
Joannides, P. (2012). Birth control: Sperm v. egg. In P. Joannides (Ed.), Guide to getting it
on (6th ed., 713–173). Waldport, OR: Goofy Foot Press.
Yarber, W., Sayad, B., & Strong, B. (2010). Contraception, birth control, and abortion. In
Human sexuality: Diversity in contemporary America (7th ed.). New York:
McGraw-Hill.
J
Jealousy
Jealousy can be described as a series of interrelated emotional, cognitive, and
behavioral processes. Jealousy is based on the fear that one could have something
they deem valuable taken away from them via an external source.
Jealousy as an emotion arises out of social comparison. Jealousy is a complex
emotion that combines the primary emotions of fear, sadness, and anger. The feel-
ing of jealousy is associated with unpleasant judgments of inadequacy, scarcity, or
diminished value. This connects jealousy to self-critical feelings like grief, humil-
iation, and shame. When present in relationships, jealousy also creates dissatisfac-
tion and suspicion. Routinely cited physiological reactions include a racing heart,
feelings of nausea, or a “sinking” feeling in one’s chest. This emotion can become
overwhelming and cause those experiencing it to develop more aggressive emo-
tional positions. Examples of these are rage, anxiety, and resentment.
Jealousy is widely understood as a different emotion than envy, although peo-
ple often use the terms interchangeably. Envy is commonly understood as desir-
ing a trait, possession, or the status of someone else. Envy also arises out of social
comparisons and feelings of inadequacy, like jealousy, which would explain why
the two terms are seen as synonymous. Jealousy is different because it is rooted in
the fear that someone will take something away from you. For example, Arnold is
jealous that his girlfriend hangs out with another guy because he fears that she is
cheating on him. Arnold is feeling jealous because he does not want to lose his
girlfriend’s attention. Arnold could start feeling resentful toward his girlfriend
and begin to feel insecure in this relationship.
Emotions influence cognitive processes. Jealousy as a cognitive construct is
rooted in one’s belief that they have a right to possess something they desire,
whether it be a physical possession like money or experiences of intrinsic value,
such as status or recognition. Jealousy is intensified by how much value is placed
on the item or experience and the depth of belief in its scarcity. Jealousy usually
involves a rival, so the thoughts associated with jealousy tend to lead to unfavor-
able hierarchy judgments and critical judgments of others, including deeming
them as being undeserving.
It is natural that, as a result of comparisons, jealousy will diminish one’s self-
esteem and cause the person feeling jealous to reevaluate their social status.
Jealousy causes us to focus on the negative and can create negative self-
judgments, such as thoughts that one is not good enough or deserves to lose what
is important to them. It would be expected that feelings of jealousy would first
arise from the thought that someone has something desirable, followed by a
354 Jealousy
perception of loss, and culminating in a sense of inadequacy. It is important to
note that these threats may be real or imagined. Thoughts based on jealousy can
be unconsciously motivated; people are not always explicitly aware that this
emotion is a driving force behind their thought processes. Negative self-
judgments can lower a person’s self-esteem and hold them back from pursuing
their goals. If jealousy is coupled with beliefs of unfairness, thoughts about
revenge or retribution may arise.
As with other emotions, feelings of jealousy often have behavioral outcomes.
The results of romantic jealousy are the most discussed in research. Given that
jealousy is the third leading motive in spousal homicide and the fourth leading
cause of domestic abuse, it is clearly an emotion worthy of investigation. Overtly
aggressive behaviors associated with jealousy are violence, belittling, stonewall-
ing, arguing, surveillance, and blaming. Jealousy can show up in covert ways in
social interactions, which also harm vital connections. Jealousy can be expressed
passive-aggressively through reactive attention-seeking, consistent bids for reas-
surance, sarcasm, and emotional distancing. Sibling rivalry is also a well-
researched context of jealous behavior. Older siblings tend to be jealous of their
younger siblings because of the changes in their guardians’ time and attention.
This could cause the siblings to fight or argue frequently or prompt the older sib-
ling to overcompensate in order to attain more of their parents’ attention. When
perceived as ineffective, children withdraw from the imagined competition alto-
gether and begin distancing themselves from family members.
Often, people cope with jealousy by practicing destructive solutions. Instead of
peacefully confronting the situation, people can bottle up this negative emotion
and begin emotionally or physically distancing themselves, creating disputes, or
making bids for reassurance. Moving through jealousy in a healthy, productive
manner can be difficult and requires one to become more self-aware. Talk therapy
is one of the most effective ways to resolve jealousy because the therapist helps the
client to analyze their cognitive processes and behaviors. Recognizing that jeal-
ousy is a negative emotion rooted in fear is the first step in resolving this issue.
Once one can acknowledge what they are afraid to lose, then they can focus on
how this has been affecting their behavior and take productive steps to getting
what they desire. Every situation is multifaceted and requires one to be honest
with themselves about their true motives.
Shadeen Francis and Nicole Williams
See also: Cheating and Infidelity; Intimacy, Sexual and Relational.
Further Reading
Castiglia, P. T. (1992). Jealousy. Journal of Pediatric Health Care, 6(4), 212–213.
Harris, C. R. (2002). Sexual and romantic jealousy in heterosexual and homosexual
adults. Psychological Science, 13(1), 7–12.
Salovey, P. (Ed.). (1991). The psychology of jealousy and envy. New York: Guilford Press.
Stearns, P. N. (2012). Jealousy. In V. Ramachandran (Ed.), Encyclopedia of human behav-
ior (2nd ed., 479–489). San Diego, CA: Elsevier.
White, G. L. (1981). A model of romantic jealousy. Motivation and Emotion, 5(4),
295–310.
Johnson, Virginia 355
Johnson, Virginia
Virginia E. Johnson was a pioneering American sexologist. She was the partner of
researcher William H. Masters, and the two helped bring the discussion of sex into
mainstream American society during the 1960s and 1970s. The pair was the first
to apply rigorous scientific techniques to study sex and enjoyed success helping
those who were suffering dysfunction. Johnson began as a research assistant but
worked her way into an equal relationship with Masters. She supplied many of the
ideas that helped make their work more acceptable to the general public and
brought a more personable touch to balance Masters’s sometimes dry scientific
approach.
Mary Virginia Eshelman (later Johnson) was born on February 11, 1925, in
Springfield, Missouri. She was the elder of two children. When Johnson was five,
her family moved to Palo Alto, California, where her father worked as a grounds-
keeper for a hospital. She proved to be a gifted student. When the family returned
to Missouri in 1933, Johnson skipped several grades. She also displayed a musical
talent and studied piano and voice. In 1941, Johnson enrolled at Drury College in
Springfield. After completing one year, she took a job at the state’s insurance
office. Johnson’s mother was a Republican state committeewoman and arranged
for Johnson to sing at many party functions. She sang country songs on a local
radio station under the name of Virginia Gibson. In 1947, Johnson took a job as a
business writer for the St. Louis Daily Record.
Johnson married a Missouri politician in the early 1940s, but the marriage
ended after two days. She also had a brief marriage to a much older lawyer. On
June 13, 1950, Johnson married George V. Johnson, the leader of a dance band.
She sang with the band until their two children, a boy and a girl, were born. In
1956, Johnson’s third marriage ended in divorce.
In 1956, Johnson decided to return to college at Washington University to earn
a sociology degree. Looking for a job, she was hired by Masters, professor of
clinical obstetrics and gynecology, as a research assistant. Masters was beginning
a study of human sexuality and believed he needed a mature woman who was
intelligent and outgoing to put his female subjects at ease. Johnson fit the bill, but
she soon proved to be much more capable than Masters realized.
Masters’s research was the first study of human sexuality that applied scientific
research standards. He had cutting-edge equipment that measured heart rates and
brain activity of volunteers as they masturbated or had sex. Color film captured
the action. A total of 382 men and 312 women eventually took part in the study.
Johnson helped Masters to understand the women’s point of view and offered
important advice about the study. The pair published their findings in 1966 in
Human Sexual Response. Although written in clinical language for a professional
audience, the book quickly captured the country’s attention. Johnson convinced
Masters to appear on popular talk shows and discuss their findings, making them
more accessible to everyone.
In 1964, Masters and Johnson opened the Reproductive Biology Research
Foundation in St. Louis and began treating couples with sexual problems. Johnson
became the assistant director in 1969 and codirector in 1973. The foundation
356 Jorgenson, Christine
became the Masters and Johnson Institute in 1973. Using a unique “couples ther-
apy” method, the institute claimed a success rate of 80 percent when treating dys-
functional couples. They also worked with same-sex couples. Masters and Johnson
controversially expanded their practice to include reparative therapy, or the prac-
tice of trying to change a person’s sexual orientation from gay to straight.
In 1971, the two were married after Masters divorced his first wife. Additional
books followed, including Human Sexual Inadequacy in 1970 and The Pleasure
Bond: A New Look at Sexuality and Commitment in 1975. Many awards followed,
and Masters and Johnson became a household name in sexuality.
Masters and Johnson divorced in 1992 but continued to collaborate profession-
ally. In the late 1990s, Johnson opened the Virginia Johnson Masters Learning
Center. She died of heart disease on July 24, 2013, in St. Louis.
Tim J. Watts
See also: Masters, William H.; Masters and Johnson Four-Stage Model of Sexual
Response; Sexology.
Further Reading
Fox, M. (2013, July). Virginia Johnson, widely published collaborator in sex research, dies
at 88. New York Times. Retrieved from http://www.nytimes.com/2013/07/26/us/
virginia-johnson-masterss-collaborator-in-sex-research-dies-at-88.html
?pagewanted=all&_r=0
Masters, W. H., & Johnson, V. E. (1966). Human sexual response. New York: Bantam
Books.
Jorgenson, Christine
Christine Jorgensen is considered the first American trans celebrity. She was born
George William Jorgensen Jr. on May 30, 1926, in Bronx, New York. Her father
was a carpenter and her mother a housewife; she was close with her older sister,
Dorothy. Jorgensen described herself as an ashamed and fearful child who knew
she was unlike other boys. This difference was observable as a physical, emo-
tional, and sexual immaturity. Specifically, Jorgensen spoke of her genitals as
underdeveloped and abnormal.
Standing five feet, six inches fully grown, Jorgensen was drafted into the army
and served as a clerk for over a year; afterward, she moved to Hollywood, where
she first discussed her feminine emotions with close confidants. Using her slight
frame and effeminate behavior as evidence for physiological causality, Jorgensen
pursued a medical explanation for her problem by enrolling in a training program
for medical technicians. In July 1950, Dr. Christian Hamburger, an endocrinolo-
gist in Copenhagen, agreed to provide Jorgensen with experimental hormone
treatment at no cost. After noticing subtle physical changes and significant psy-
chological changes from hormone therapy—her testicles atrophied, her libido
decreased, her capacity to become erect diminished, her nipple and genital regions
experienced the darkening of skin pigmentation, and her mood dramatically
improved, Jorgensen underwent surgery to remove her testicles in September
1951. Her scrotum was removed and shaped into labia in November 1952, shortly
Jorgenson, Christine 357
after the U.S. State Department approved the name change on her passport. In the
midst of these surgeries, Christine’s facial hair was removed via electrolysis, hor-
mones continued to enlarge her breasts, and she underwent plastic surgery on her
ears. Though she was treated with great respect in Denmark, Christine decided to
return home to the United States.
The New York Daily News broke her story on December 1, 1952; the front-page
headline read “Ex-GI Becomes Blonde Beauty,” and Christine Jorgensen became
an overnight celebrity. Speculation remains regarding the identity of the tipster.
Jorgensen reported an initial feeling of great shock that anyone paid attention to
her transition. She sold the rights to her story to American Weekly to be serialized
and distributed globally; the five-part narrative went beyond her feminine appear-
ance and behavior, introducing the world to a sympathetic human being tortured
by a glandular imbalance. At a time when postwar America wanted to reaffirm
rigid sex roles (in what was referred to as the “crisis of masculinity”), Jorgensen
highlighted ambiguity. She endorsed the European theories of human bisexuality,
stating that she was more woman than man; she and her doctors believed female
organs had always existed within her, comparing her postoperative body to a
woman who had undergone a hysterectomy (able to have sexual relations while
unable to have children). She clarified her stance on sex by stating that all human
beings are psychologically, hormonally, and genetically intersexed but that
pseudo-hermaphrodites have the genitals of both sexes. Becoming a voice for
many, Jorgensen noted her cultural impact as an American individualist during
the increasingly conformist Cold War era. Questions arose regarding the “normal-
ity” of Jorgensen’s sexuality: was her attraction to men prior to her operations
diagnostic for a homosexual mental disorder, or was she always a heterosexual
woman?
When further details of Jorgensen’s case became a matter of public record,
American society rejected her as a woman. Because her anatomy was considered
completely male before her operation, she was, in the eyes of the American scien-
tific community, a cross-dresser and not an intersexed person who required surgi-
cal and hormonal intervention. Though the controversy upset Jorgensen, it
maintained curiosity about her and allowed for nonintersexed individuals to
explore the possibility of transition.
After the initial surge of fame, during which she received over twenty thousand
letters, Jorgensen booked speaking and performance engagements throughout the
United States. She stated that her stage work generally drew heterosexual couples
of middle age. Jorgensen believed that she would never live to see the day that she
was not viewed first as a transsexual, noting the pressure to perform femininity
with precision and perfection. As a stigmatized celebrity under intense scrutiny,
Christine was the butt of many cruel jokes in popular culture. Counter to her proj-
ect on individualism, she wanted to be accepted as “normal,” and being the sub-
ject of ridicule felt torturous and isolating. In 1953, a feature-length cult film, Glen
or Glenda or I Changed My Sex, allegedly inspired by Christine’s story, was
released without Christine’s consent. Finding it insulting, Christine refused to act
in it, though the production company still used her name and photos to promote
the release.
358 Joy of Sex, The
By 1954, press in the United States began to differentiate between people who
were transsexual versus intersexed. Throughout the 1950s, the prevalence of sto-
ries that included people of trans experience grew dramatically due to the fame of
Christine Jorgensen. In 1959, Jorgensen’s request for a marriage license in the
state of New York was denied. The sex listed on her passport with a supporting
letter from her doctor did not suffice, because her birth certificate still read “male.”
She later decided not to marry. Christine presented herself as an independent
woman who wanted to marry but cared about having a life (especially friendships
and a career) of her own.
Jorgensen continued receiving medical treatment to support her transition until
her death. In 1954, she had a vagina constructed from skin grafts that were
removed from her thighs. There is speculation over whether or not she underwent
reconstructive surgery of the vagina in the late 1960s and in 1980. Jorgensen
released an autobiography, Christine Jorgensen: A Personal Biography, in 1967;
the text sold nearly half a million copies and was loosely adapted to film in 1970.
Life as an entertainer, lecturer, author, and public figure continued until her death.
She recognized the significance of her story for the worlds of science and Ameri-
can culture; she understood her individuality and candor as catalysts for the sexual
revolution of the 1960s.
In 1989, Jorgensen died from lung and bladder cancer at the age of sixty-two.
Her obituary in the New York Times featured photographs of her as George and
shortly after her 1952 return from Denmark to the United States (McQuiston,
1989).
Chrissandra Andrae
See also: Gender; Gender Identity; Gender Transition; Intersexuality; Sex Reassignment
Surgery; Transgender; Transsexual.
Further Reading
Jorgensen, C. (1957). Christine Jorgensen reveals. J Records.
McQuiston, J. (1989, May). Christine Jorgensen, 62, is dead; Was first to have a sex
change. New York Times, p. D22. Retrieved from https://www.nytimes.com/1989/
05/04/obituaries/christine-jorgensen-62-is-dead-was-first-to-have-a-sex-change
.html
Meyerowitz, J. J. (2002). How sex changed: A history of transsexuality in the United
States. Cambridge, MA: Harvard University Press.
Sopelsa, B. (2019). #Pride50: Christine Jorgensen—World’s first trans celebrity. Retrieved
from https://www.nbcnews.com/feature/nbc-out/pride50-christine-jorgensen
-world-s-first-trans-celebrity-n1006131
Joy of Sex, The
First published in 1972, Alex Comfort’s The Joy of Sex: A Gourmet Guide to
Lovemaking was the first illustrated sex manual released by a major publisher in
the United States. It sold 3.8 million copies in its first two years and became the
best-selling sex manual of the 1970s. Repeatedly updated and revised, the latest
edition is The New Joy of Sex (2008) by Alex Comfort and Susan Quilliam.
Joy of Sex, The 359
The author, Alexander Comfort (1920–2000), was a British biochemist and
physician. The author of fifty-one books and numerous scientific papers, he spe-
cialized in gerontology but also wrote novels, plays, poetry, and song lyrics (for
Pete Seeger), and became a noted peace activist and cofounder of the Campaign
for Nuclear Disarmament. For a time, he taught at the London Hospital Medical
College. It was his students’ shocking ignorance of many sexual matters that first
encouraged Comfort to write The Joy of Sex, which he originally conceived as a
medical textbook. He later taught at Stanford University and UCLA’s Institute for
Neuroscience and Human Behavior. While in the United States, Comfort visited
the Sandstone Retreat, a California resort that catered to swingers.
The Joy of Sex presented sex as fun and encouraged experimentation. Orga-
nized into sections labeled “Starters,” “Sauces,” “Main Courses,” and “Prob-
lems,” and sorted alphabetically within these sections, it presented definitions,
suggestions, and advice on sexual practices ranging from anal intercourse and
bondage to voyeurism and the “X position.” Uninhibited, lighthearted, and witty,
it lacked the moralizing tone of past marriage manuals and was accompanied by
pencil drawings of a loving couple enjoying the activities the book described.
Comfort’s advice often mixed the practical with humor, noting, for example, that
coin-operated vibrating hotel beds “are apt to run out at a critical moment, or
make you ill.”
The runaway success of Joy of Sex led to a sequel, More Joy of Sex (1973), as
well as The Joy of Gay Sex (1977) by Charles Silverstein and The Joy of Lesbian
Sex (1977) by Emily L. Sisley and Bertha Harris. Along with the original, all these
went through several print runs and updates, which included information on HIV
and other sexually transmitted infections as well additional sex advice. The later
editions of Joy of Sex eliminated, qualified, or revised Comfort’s sometimes ques-
tionable humor, preachy tone, and overstated preferences and opinions (including
his declaration that “vibrators are no substitute for a penis”), his fondness for body
hair, abhorrence of deodorants, and encouragement of orgies.
The success of The Joy of Sex opened the gates to what became a flood of sex
manuals in the 1970s, few of which matched Comfort’s gentle humor and genuine
interest in improving the sex lives of readers.
Stephen K. Stein
See also: Sex Education; Sexual Revolution.
Further Reading
Allyn, D. (2001). Make love, not war. The sexual revolution: An unfettered history. New
York: Routledge.
Comfort, A., & Quilliam, S. (2008). The new joy of sex. London: Mitchell Beazley.
Hebblethwaite, C. (2011, October). How the Joy of Sex was illustrated. BBC News Maga-
zine. Retrieved from http://www.bbc.com/news/magazine-15309357
Martin, D. (2000, March). Alex Comfort, 80, dies; a multifaceted man best known for
writing “The Joy of Sex.” New York Times. Retrieved from https://www.nytimes
.com/2000/03/29/us/alex-comfort-80-dies-a-multifaceted-man-best-known-for
-writing-the-joy-of-sex.html
Talese, G. (1980). Thy neighbor’s wife. New York: Doubleday.
K
Kama Sutra
The Kama Sutra, sometimes called Kama Sutra—A Guide to the Art of Pleasure, is
a compilation of advice about sensuality, sexual pleasure, and social expectations.
The book was written in India sometime around the first century BCE by a Hindu
man named Vatsyayana. There is some mystery surrounding the origins of the
Kama Sutra. The word “kama” means “the life of the senses.” A “sutra” is a manual
or scripture. Therefore, Kama Sutra is a manual of the life of the senses and focuses
heavily on sensual pleasures and the importance of celebrating sexual pleasure. The
Kama Sutra contains many sutras that are unable to be traced back to their origin.
The Kama Sutra has shaped culture in many ways as it has been a leader in the
world of sex manuals. It challenges some concepts of patriarchy, sexism, and het-
eronormativity as it explores and celebrates various aspects of female sexuality,
pleasure, and nontraditional sex practices. The Kama Sutra is also a reflection of
culture as it encourages “kama” and acknowledges sexual pleasure as an impor-
tant aspect of living a good life.
There are seven sections of the Kama Sutra. The first section is about society
and social norms. This text was intended for wealthy men. As such, it outlines
how to fill the role of a wealthy gentleman. The second section explores sexual
union. Sexual acts, body parts, and nonmarital sex, among other topics, are dis-
cussed. The third section details how a gentleman acquires a wife, while the fourth
section discusses the role of the wife. As this is a cultural and sexual manual, the
fifth section discusses the proper way to interact with the wives of other men. In a
similar fashion, the sixth section discusses “courtesans,” more commonly known
as prostitutes. The final section discusses the means of attracting others. Alto-
gether, this instructional guide influenced wealthy young men in the art of plea-
sure, their role in society, and the social norms of their culture and relationships.
The Kama Sh’astra Society of London and Benares first published the Kama
Sutra in 1883 in London. The publication was largely secret and was only put in
circulation for a private audience. The text was republished in the United States in
1961. It was met with some resistance due to its content. However, the United
States was also dealing with the release of Alfred Kinsey’s sex research, which
helped guide this “risqué” text into society’s awareness. The Kama Sutra itself is
a very difficult text to read as it was originally intended for the highly educated
men of India. As such, the Kama Sutra has been made into a commodity and may
now be seen in condensed versions that focus more on sexual positions and sexual
pleasures than on social and societal norms and expectations. The Kama Sutra has
been made into movies, pop-up books, shortened texts, and plays.
Amanda Manuel
362 Kaplan, Helen Singer
See also: Tantric Intercourse.
Further Reading
Grant, B. (2005). Translating The Kama Sutra. Third World Quarterly, 26(3), 509–516.
Kureishi, H. (2011). It’s a sin: The Kama Sutra and the search for pleasure. Critical Quar-
terly, 53(1), 1–5.
Peterson, V. (2002). Text as cultural antagonist: The Kama Sutra of Vatsyayana. Journal
of Communication Inquiry, 26(2), 133–154.
Kaplan, Helen Singer
Dr. Helen Singer Kaplan was a twentieth-century leader in the field of sex therapy.
She established the first-ever sexual disorders clinic at a U.S. medical school and
published numerous works on the treatment of sexual disorders. Because Kaplan
believed that sexual disorders might indicate deeper emotional issues, her approach
to treating sexual problems was deemed psychosexual therapy. Her frankness
about the subject of sex and her very vocal support of the sexual revolution of the
1960s earned her the nickname “Sex Queen.”
Kaplan was born Helen Singer in Vienna, Austria, on February 6, 1929, the
daughter of a wealthy Austrian couple who owned a jewelry business. As World
War II heated up in Europe, the family immigrated to the United States in 1940,
losing their fortune in the process; Kaplan gained citizenship seven years later.
A budding artist as a child, she studied painting at Syracuse University, receiving
her undergraduate degree with honors in 1951. From there, she went on to receive
a master’s degree in psychology from Columbia University in 1952 and, three
years later, completed her doctorate in psychology at the same school. Then, in
1959, she became a full-fledged medical doctor, earning her medical degree from
New York Medical College, a medical school that is part of the New York Medical
College–Metropolitan Hospital Center. As she began her career, she also contin-
ued her studies, completing an extended course in psychoanalysis in 1970.
After interning at several hospitals and clinics in New York, Kaplan worked as
a psychiatrist at the same time as she embarked on a professional teaching career.
She first developed and taught a behavioral sciences program for psychiatric resi-
dents at her alma mater, along with teaching basic psychiatric courses for fresh-
man medical students at the school. She later worked as a psychiatrist at three
hospitals, all the while continuing to hold multiple teaching and directorship posi-
tions in the behavioral sciences department at New York Medical College–
Metropolitan Hospital Center. In her role at the center, she also created trainings
in human sexuality for both the psychiatric and the obstetrics-gynecology staff.
In 1970, Kaplan became a professor of psychiatry at New York Medical
College–Metropolitan Hospital Center and began a six-year stint with the school’s
undergraduate psychiatry department. That same year, she also established the
human sexuality program at the Payne Whitney Clinic, which is part of the New
York Hospital–Cornell Medical Center organization. As part of the program,
Kaplan founded the first outpatient facility for the treatment of psychosexual dis-
orders. In her job as program director, she oversaw the training and coursework in
Kaplan’s Triphasic Model 363
the field of human sexuality for Cornell University medical students and the cen-
ter’s psychiatric residents.
The work done at the Payne Whitney Clinic generated extensive research into
the treatment of sexual dysfunctions. In part because of this clinical research,
Kaplan developed cutting-edge theories on sexual disorders and produced some
110 different publications on human sexuality and sexual dysfunctions. She also
gave lectures and presentations around the world and mentored some of the most
well-known sex therapists of the late twentieth century, including Dr. Ruth Wes-
theimer (more commonly known as Dr. Ruth). At the time of her death on August
17, 1995, in New York City, Kaplan remained at the helm of the prestigious human
sexuality program she founded. Her work is still considered highly relevant today,
and several of her books remain in print.
Tamar Burris
See also: Desire; Kaplan’s Triphasic Model; Psychosexual Therapy; Sexual Disorders,
Female; Sexual Disorders, Male; Sexual Revolution.
Further Reading
Greene, J. R. (2010). America in the sixties. Syracuse, NY: Syracuse University Press.
Kaplan, H. S. (1979). Disorders of sexual desire and other new concepts and techniques
in sex therapy (Vol. 2). New York: Simon & Schuster.
Kaplan, H. S. (2013). New sex therapy: Active treatment of sexual dysfunctions. New
York: Routledge.
Schroeder, E., & Kuriansky, J. (2009). Sexuality education: Past, present, and future.
Santa Barbara, CA: Praeger.
Kaplan’s Triphasic Model
The triphasic model is a model of sexual response developed by noted sex thera-
pist Helen Singer Kaplan in 1970. Kaplan’s aim in creating this theory was to revi-
sion the human sexual response cycle as created by her predecessors William
Masters and Virginia Johnson. The model views sexual responsiveness as both a
cognitive and physiological phenomenon resulting in three independent but inter-
related phases: desire, arousal, and orgasm.
The Kaplan triphasic model was developed following Masters and Johnson’s
1960s theory of the sexual response cycle. In their theory, Masters and Johnson
described four phases of human sexual response: an excitement phase, plateau
phase, orgasm phase, and a resolution phase. Kaplan believed sexual desire to be a
separate clinical entity from excitement (arousal) and subsequently reconceptual-
ized and condensed the model.
The characterizing feature of Kaplan’s sexual response model is the desire
phase. Sexual desire is an innate drive for sexual satisfaction, often referred to as
“lust.” Before Kaplan’s model, sexual desire had been overlooked as a necessary
stage in sexual response. However, Kaplan recognized that sexual experiences did
not necessarily contain an element of desire, such as in partnerships that lacked
passion or attraction but were consummated apathetically, reluctantly, or merely
out of obligation. Kaplan introduced desire as a catalyst for sexual experiences.
364 Kaplan’s Triphasic Model
She described desire as a carnal hunger preceding physical interaction, a psycho-
logical hunger that led to an interest in sexual activity and orgasm seeking. Desire
was a key mechanism in the sexual response process as it functioned to allow for
the arousal process to begin.
The excitement or arousal phase represents the second phase of Kaplan’s tri-
phasic model. While it is the starting place of Masters and Johnson’s theory,
Kaplan believed sexual response to start in the mind and then transition to the
body. In this stage, physical stimulation begins in response to psychological desire.
Sexual excitement is a series of physiological changes that prime an organism for
sexual activity. Characteristics of sexual excitement include increased heart rate,
increased breathing, and increased blood flow to the penis, testes, vulva, clitoris,
and nipples (also referred to as vasocongestion). Dilation of the pupils and
increased color in the cheeks and genitals may also occur. During this excitatory
process, erections may occur and vaginas may begin to lubricate in preparation
for sexual activity. The excitement phase may last for minutes or hours.
The resolution phase literally represents the climax of the triphasic model. Dur-
ing this phase, individuals are predicted to reach orgasm after acting on their
desire and excitement. An orgasm is seen as the highest point of sexual arousal,
during which a series of rhythmic, involuntary reflex muscle contractions of the
genitals and anus occur. Physically and emotionally, an orgasm produces highly
pleasurable feelings. Orgasms may result from a number of activities including
but not limited to oral sex, intercourse, manual stimulation, masturbation, inti-
mate massages, fantasies, and sex toys. The average orgasm only lasts a few sec-
onds and is typically accompanied by ejaculation for most men and often for some
women as well. As this is the final stage of sexual response proposed by Kaplan,
once orgasm is experienced the cycle returns to the prearoused state. Multiorgas-
mic individuals may not spend much time in prearousal before reentering the
cycle at the desire phase.
While the triphasic model was created to describe healthy sexual response, it has
also been used to address and assess sexual dysfunction. Kaplan believed that all
sexual dysfunction fell into one of the three categories and could be distinctly clas-
sified as a disorder belonging to a discrete stage. Because each of the categories was
separate and distinct, the thought was that an individual could properly function in
two of the phases but might find a problem in the third. In her book The Evaluation
of Sexual Disorders: Psychological and Medical Aspect, Kaplan describes psycho-
sexual dysfunctions as being among the most prevalent, worrying, and distressing
medical complaints of that time. She believed that if a disorder could be correctly
diagnosed into a stage, there was a good chance that it could be properly resolved.
Each stage-based disorder was associated with a different set of causes and was
therefore believed to respond to different and specific therapeutic interventions. For
example, Kaplan understood orgasmic problems to be dependent on an individual’s
level of distress; these problems were not seen as sexual but instead as problems of
pain or fear of pain. Effective treatments of orgasmic problems would then address
these underlying issues and allow for the pleasurable experience of orgasm.
Kaplan focused specifically on desire disorders within the clinical population
and found that 38 percent of 5,580 patients diagnosed with sexual disorders also
Kaplan’s Triphasic Model 365
met the criteria for sexual desire disorders. Finding the root of desire disorders,
such as hypoactive sexual desire disorder, proved to be incredibly complex as they
involved both immediate factors and historical factors that blocked desire. Kaplan
concluded that desire-phase disorders were not only distressing for couples but
were also the most difficult to treat as they were associated with deep-seated psy-
chological difficulties. Kaplan’s work on sexual dysfunction contributed a new
perspective to the field of sexual dysfunction, as it introduced the idea that intra-
psychic causes can be influenced by culture, development, and conflict. Kaplan’s
qualitative research resulted in the discovery that relationships with a lack of trust,
power struggles, contractual disappointments, sexual sabotage, and partner rejec-
tion were all more likely to also include some form of sexual dysfunction, espe-
cially disordered desire. She placed a strong emphasis on social learning theory as
a base for understanding the etiology and treatment of sexual dysfunction.
Kaplan’s treatments emphasized the use of erotic techniques and a concern with
the unconscious conflicts, fears, and desires that are involved in sexuality. It was
Kaplan’s belief that “it is possible to treat the symptom, even if it’s deep rooted”
(Kaplan, 1983).
While Kaplan’s model was generally well received for its attention to the psy-
chological aspects of sexual response, her framework also received some criti-
cism. The primary reason the triphasic model was called into question by the
psychological community was because it assumed that men and women have sim-
ilar sexual responses. Following research done by prominent sexologist and biolo-
gist Alfred Kinsey and the differences in sexual behavior between men and
women, a genderless response cycle made many concerned that the model pathol-
ogized normal behavior in women. For example, many women reported pleasur-
able sexual experiences that did not include desire at the onset but that grew
gradually throughout the experience. Others reported feeling desire and yet hav-
ing no interest in acting on it, or not feeling desire at all and being concerned that
they could not have satisfying sex without it. Of course, these situations proved
problematic in light of the proposed model.
Further, many women do not move progressively or sequentially through the
phases Kaplan described. Sex educator and researcher Beverly Whipple argues
that women may not even experience all the phases—they may reach orgasm and
satisfaction without experiencing sexual desire, or they can experience desire,
arousal, and satisfaction but not orgasm. This thinking was echoed by Rosemary
Basson, who later created a model of female sexual response that differentiated
between spontaneous desire and “responsive desire,” which was in reaction to a
partner’s sexual interest rather than a spontaneous stirring of her own libido. This
distinction initially helped explain the assumed difference between men’s typical,
seemingly instantaneous sexual interest and women’s more circular desire,
although more recent research suggests there are potentially more similarities
between the sexes than previously assumed.
Another critique came from feminist scholars after the pleasure revolution. As
a largely biologic model, Kaplan’s triphasic model has been criticized for failing to
take into account nonbiologic experiences of sex, particularly pleasure and satis-
faction. It also does not consider the role that sexuality and libido play in the
366 Kegel Exercises
progression of the cycle. As such, critics of the theory feel the model is overly
simplistic and limited in scope.
Shadeen Francis
See also: Arousal; Basson, Rosemary; Desire; Desire Disorders; Kaplan, Helen Singer;
Kinsey, Alfred; Masters and Johnson Four-Stage Model of Sexual Response; Orgasm;
Sexual Dysfunction, Treatment of; Sexual Satisfaction.
Further Reading
Kaplan, H. S. (1980). The new sex therapy. In J. Marmor & S. M. Woods (Eds.), The inter-
face between the psychodynamic and behavioral therapies (363–377). New York:
Springer.
Kaplan, H. S. (1983). The evaluation of sexual disorders: Psychological and medical
aspects. London: Psychology Press.
Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown,
& Co.
Sachs, B. D. (2007). A contextual definition of male sexual arousal. Hormones and Behav-
ior, 51(5), 569–578.
Whipple, B., & Brash-McGreer, K. (1997). Management of female sexual dysfunction. In
M. L. Sipski & C. J. Alexander (Eds.), Sexual function in people with disability
and chronic illness. A health professional’s guide (509–534). Gaithersburg, MD:
Aspen Publishers, Inc.
Wood, J. M., Koch, P. B., & Mansfield, P. K. (2006). Women’s sexual desire: A feminist
critique. Journal of Sex Research, 43(3), 236–244.
Kegel Exercises
Kegel exercises are a type of exercise for the pelvic floor muscles. The pelvic floor
muscles support the bladder, reproductive organs, and rectum in both men and
women. These muscles may become either too tight (hypertonic) or too loose
(hypotonic). In either case, this muscle dysfunction, known as pelvic floor dys-
function, can lead to urinary incontinence (resulting in the leaking of urine), fecal
incontinence (resulting in the leaking of stool or gas), or pelvic pain.
The pelvic floor muscles may be located by pretending to stop the flow of urine,
as the muscles that contract with this motion are some of the pelvic floor muscles.
A Kegel exercise involves the contraction and release of these muscles, with the
aim of strengthening the muscles. Kegels should not be done during urination as
this can lead to bladder dysfunction.
Popular advice suggests that all women should perform Kegel exercises to
maintain vaginal tightness, treat or prevent urinary incontinence, treat pain dur-
ing intercourse (dyspareunia), and improve orgasm. Men are told less often about
Kegels in popular sources, although some do recommend Kegel exercises for men
as a way of addressing urinary and fecal incontinence. Kegel exercises may also
be recommended for the treatment of erectile disorder, although the effect of Keg-
els depends on the cause of the erectile disorder.
Since incontinence and pain with intercourse may be caused by either hyperto-
nicity or hypotonicity of the pelvic floor, Kegel exercises may not help and can
actually worsen the problem. For women and men with pelvic floor muscles that
Kellogg, John Harvey 367
are too tight, Kegel exercises encourage them to hold the muscles even tighter,
which may cause symptoms to worsen, resulting in an increase in pain or inconti-
nence. It is important not to perform Kegel exercises without proper assessment
and instruction (many people perform Kegels incorrectly or when they are not
advised).
Kegel exercises are particularly recommended for women with vaginismus, a
condition in which the muscles of the outer third of the vagina contract involun-
tarily, causing penetration to be painful or impossible. However, as is the case
with pain and incontinence, Kegel exercises may worsen this condition. Women
with vaginismus may have underlying pelvic floor dysfunction with pelvic mus-
cles that are hypertonic. Kegel exercises can cause women to tighten their muscles
even more, thereby increasing muscle spasm and pain with penetration.
Instead of attempting Kegel exercises on their own, men and women with pel-
vic pain or incontinence symptoms can seek the services of a pelvic floor physical
therapist, a physical therapist that is specially trained to work with the pelvic floor.
The physical therapist can assess whether the pelvic floor is too tight or too loose,
perform manual muscle release, and instruct the patient in the proper Kegel exer-
cise technique if these exercises are indicated. Rather than traditional Kegel exer-
cises, the physical therapist may recommend reverse Kegels, or pelvic floor
relaxation.
Adrienne M. Bairstow
See also: Dyspareunia; Pelvic Floor Muscles; Vaginismus.
Further Reading
Pelvic Health Solutions. (2019). Reverse Kegels/pelvic floor drops. Retrieved from http://
pelvichealthsolutions.ca/for-the-patient/persistent-pelvic-pain/pelvic-floor-muscle
-tightness/reverse-kegelspelvic-floor-drops/
Pelvic Health Solutions. (2019). What is pelvic floor physiotherapy? Retrieved from http://
pelvichealthsolutions.ca/for-the-patient/what-is-pelvic-floor-physiotherapy/
Kellogg, John Harvey
John Harvey Kellogg (1852–1943) was a physician and skilled surgeon who was
avidly dedicated to health reform, including that related to sexuality. He empha-
sized the importance of a healthy diet, regular physical exercise, preventative
medicine, and natural remedies. He was also something of an inventor; among his
many creations were the breakfast cereals granola and corn flakes. Kellogg wrote
extensively and lectured widely on health topics. In 1879, Kellogg published Plain
Facts about Sexual Life, which was subsequently released in many revised edi-
tions, during which the name was changed to Plain Facts for Old and Young. It
was one of the earliest texts that directly addressed sexual matters, and it sold
over half a million copies. He also advocated enemas, hydrotherapy, and
vegetarianism.
In 1876, Kellogg took over as superintendent of the Western Health Reform
Institute, which had been started a decade earlier in Battle Creek, Michigan, by
Seventh-Day Adventists to promote natural remedies consistent with their
368 Kink
religious beliefs. He renamed it the Battle Creek Sanitarium, which became known
as The San, and greatly expanded its offerings. The San catered to a celebrity cli-
entele. Kellogg took no salary for running The San, but profits from his cereal and
book sales made him extremely wealthy.
Sexual activity, or rather abstinence from such activities, was a cornerstone of
Kellogg’s approach to hygiene. He felt that sexual activity was potentially hazard-
ous to one’s emotional, physical, and spiritual health and wellness. Kellogg sug-
gested that many diseases were caused by sexual intercourse and avidly advocated
for sexual abstinence. Interestingly, Kellogg and his wife, Ella Ervilla Eaton, are
thought to have never consummated their marriage; they had no biological chil-
dren but adopted and raised eight. Likewise, he was a staunch opponent of mastur-
bation and listed nearly forty problems he said masturbation caused, including
acne, bad posture, bashfulness, boldness, defective development, epilepsy, fickle-
ness, mood swings, and heart palpitations. A healthy diet, according to Kellogg,
was essential to controlling sexual desires. He believed that a simple, plain diet,
particularly one built around cereals and nuts, like the ones he developed and
forced on patients at The San, was helpful for controlling sexual urges. He recom-
mended avoiding stimulating food and drink, since he believed things like meat
and spiced foods were to blame for increasing one’s sex drive.
Victor B. Stolberg
See also: Abstinence; Masturbation.
Further Reading:
Hunnicutt, B. K. (1996). Kellogg’s six-hour day. Philadelphia: Temple University Press.
Kellogg, J. H. (1882). Plain facts for old and young. Burlington, IA: I. F. Segner.
Kellogg, J. H. (1902). Ladies’ guide in health and disease: Girlhood, maidenhood, wife-
hood, motherhood. Battle Creek, MI: Modern Medicine Publishing.
Kellogg, J. H. (1918). Rational hydrotherapy: A manual of the physiological and thera-
peutic effects of hydriatric procedures, and the technique of their application in
the treatment of diseases. Battle Creek, MI: Modern Medicine Publishing.
Wilson, B. C. (2014). Dr. John Harvey Kellogg and the religion of biologic living. India-
napolis: Indiana University Press.
Kink
In the late nineteenth century, “kinky” developed as a slang term that referred to
illicit or stolen goods. By the late 1950s, people in the United States and Britain
used “kink” or “kinky” to refer to a host of atypical sexual practices, including
cross-dressing, fetishism, group sex, role-playing, and a variety of sadomasochis-
tic activities, labeled BDSM in the 1990s. The term combines the abbreviations
for bondage and discipline (B&D), dominance and submission (D/S or D&S), and
sadism and masochism (S&M or S/M). “Kinky” can also refer to specific exotic or
fetishistic clothing, such as “kinky boots.”
Ideas as to what activities are kinky vary from person to person and have
changed over time, making exact definitions difficult. In Rick James’s hit song
Kink 369
“Super Freak” (1981), kinky and freaky are synonyms for promiscuity and group
sex. “Three’s not a crowd” for the “very kinky girl.” Sharon Crane Bakos opens
her book Kink (1995) with a chapter on anal sex and notes, “twenty years ago, oral
sex was considered kinky” (p. xvi). As sexual horizons expanded, the realm of
kinky activities narrowed. By the late 1990s, kink had become virtually synony-
mous with fetishism and BDSM activities, and Bakos devotes most of her book to
these topics.
Beginning with the Eulenspiegel Society in New York in 1971, clubs devoted to
fetish, BDSM, and other kinky activities formed in cities across the United States.
More than a hundred operated by 1986 when the National Leather Association
(NLA), an educational, social, and advocacy organization, formed. The NLA’s
leaders hoped to unite kinky people of all genders, orientations, and interests
across the United States and Canada. They organized Living in Leather, an annual
conference of people with fetish and BDSM interests that offered a mix of educa-
tional seminars, entertainments, and parties. The NLA grew to almost 1,000
members, but kinky people proved too diverse to unite behind any single
organization.
Instead, kinky organizations proliferated, as did events that catered to them,
which by the late 1990s ranged from Boston’s Fetish Fair Fleamarket devoted to
shopping, kinky pageants like the International Mr. and Ms. Leather contests in
Chicago and San Francisco, the Kink in the Caribbean couples’ party at a tropical
resort, and numerous local conferences that followed Living in Leather’s model of
presenting a mix of daytime educational seminars and evening sex parties. Cities
that one might not ordinarily associate with kinky sex, including Columbus, Ohio;
St. Louis, Missouri; Tulsa, Oklahoma, and many others have kinky organizations
that host annual conferences.
Numerous surveys, both popular and academic, indicate that many Americans
are interested in kinky activities, which helps explain the popularity of E. L.
James’s novel Fifty Shades of Grey (2011). People’s changing interests, though,
may well change what is considered kinky in the future.
Stephen K. Stein
See also: BDSM; Fetishism; Paraphilias; Sexual Expression.
Further Reading
Bakos, S. C. (1995). Kink: The shocking hidden sex lives of Americans. New York: St.
Martin’s Press.
Khan, U. (2014). Vicarious kinks: S/m in the socio-legal imaginary. Toronto: University of
Toronto Press.
Schmall, T. (2018, January). Your partner probably wants a kinkier sex life. New York
Post. Retrieved from https://nypost.com/2018/01/31/your-partner-probably-wants
-a-kinkier-sex-life/
Shahbaz, C., & Chirinos, P. (2017). Becoming a kink aware therapist. New York:
Routledge.
Stein, S. (2012). Twenty-five years of Living in Leather: The National Leather Associa-
tion, 1986–2011. Daytona Beach, FL: Adynaton.
Wismeijer, A. A. J., & Van Assen, M. A. (2013). Psychological characteristics of BDSM
practitioners. Journal of Sexual Medicine, 10(8), 1943–1952.
370 Kinsey, Alfred
Kinsey, Alfred
Alfred Kinsey (1894–1956) is best known for his research in sex, gender, and
reproduction. Among his writings were the hugely popular Sexual Behavior in the
Human Male (1948) and Sexual Behavior in the Human Female (1953), together
known as the Kinsey Report. He is also known for his measure of heterosexual
and homosexual behavior, known as the Kinsey Scale. Kinsey was born June 23,
1894, in Hoboken, New Jersey, to Alfred Seguine Kinsey and Sarah (née Charles)
Kinsey. He was the oldest of three children in a devout Methodist household. His
father was very strict and had many rules. Kinsey’s parents were poor during his
childhood, and this may have led to him receiving inadequate medical treatment
for a variety of diseases, including rickets. As a result, he developed a curvature of
his spine that prevented him from being drafted in 1917 for World War I.
Kinsey attended Columbia High School, where he was a quiet but hard-working
student, interested in biology, botany, and zoology. In 1912, Kinsey graduated as
valedictorian of his high school class. Despite the fact that Kinsey wanted to study
botany, his father insisted he study engineering at Stevens Institute of Technology.
However, after two years, Kinsey left Stevens and transferred to Bowdoin College
in Maine, where he studied biology. He graduated, magna cum laude, with a bach-
elor of science degree in biology and psychology in 1916.
Kinsey continued to study biology in graduate school at Harvard University’s
Bussey Institute, focusing his studies on gall wasps and amassing a collection of
more than five million. Kinsey was granted his doctor of science degree in 1919
and published several papers in 1920 on the gall wasp.
After graduation, Kinsey accepted a job as an assistant professor in zoology at
Indiana University in Bloomington, Indiana. A top expert on the gall wasp, in
1930 Kinsey published his findings in the paper The Gall Wasp Genus Cynips:
A Study in the Origin of the Species.
In 1938, Kinsey agreed to teach a marriage course at Indiana University. His
students wanted to learn a wide range of topics about marriage, and they wanted
the course to have both male and female students. To learn more about his stu-
dents, he required them to fill out a survey about their sexual histories. When his
students starting asking him questions about sex, Kinsey realized there was very
little scientific data on the matter. Members of the faculty at Indiana University
disliked what Kinsey was teaching and petitioned the president of the university
to remove him from the course. The president gave Kinsey a choice to keep his
class or do research but not both. Kinsey chose the research and decided to apply
the principles of scientific research toward the topic of sexual behavior, eventually
with funding from the National Research Council and the Rockefeller Founda-
tion’s Medical Division.
Kinsey, together with his research team, collected more than 17,000 sexual his-
tories between the years 1938 and 1956. Dr. Kinsey believed face-to-face inter-
views were the best way to get honest answers, and he required his team to
memorize over 300 questions and response codes for each. Kinsey promised com-
plete confidentiality to participants in order for them to share their deepest secrets
with him. The results of these interviews form the basis for the Kinsey Report
books.
Kinsey’s Continuum of Sexual Orientation 371
In 1920, Kinsey met his future wife, Clara McMillan, at a zoology department
picnic. Like Alfred, Clara had little experience dating and no experience with sex.
In January 1921, Alfred proposed, and the couple was married on June 3, 1921.
Because of their inexperience, Clara and Alfred struggled for almost a year before
consummating their marriage. They even went to see a local doctor who deter-
mined that Clara had an “adherent clitoris,” which required corrective surgery.
Alfred and Clara had four children together: Donald, born in 1922, who died of
diabetes at the age of four; Anne, born in 1924; Joan, born 1925; and Bruce, born
in 1928. They had an open marriage, and Alfred, who was bisexual, had both male
and female partners, including his student Clyde Martin. The couple was married
from 1921 until Alfred’s death in 1956.
In 1947, in order to guarantee absolute confidentiality to individuals inter-
viewed and to provide a secure, permanent location for the growing collection of
interview data and other materials Kinsey was collecting on human sexuality, he
established the Institute for Sex Research, known today as the Kinsey Institute as
a not-for-profit corporation affiliated with Indiana University. The Kinsey Insti-
tute is still in existence and advancing sexual health and knowledge worldwide.
In 1953, following the publication of Kinsey’s report on female sexuality, a
committee of the U.S. House of Representatives started investigating Kinsey and
the Rockefeller Foundation for possible ties to the Communist Party. As a result,
the foundation terminated Kinsey’s funding. Kinsey was devastated, and though
he spent the next two and a half years trying to secure funding from alternate
sources, he never succeeded. Kinsey died disappointed that he had not persuaded
the world that sex was good and that tolerance of the enormous variety of sexual
behavior that existed was right. But his dream did not die with him. Kinsey lived
just long enough to see the American Law Institute’s Model Penal Code, pub-
lished in 1955, which gives the right of consenting adults to engage in homosexual
and anal sex. In 2004, Liam Neeson starred in Kinsey, a movie dedicated to por-
traying Alfred Kinsey’s life and accomplishments.
Lauren Ewaniuk
See also: Kinsey’s Continuum of Sexual Orientation; Sexology; Sexual Behavior in the
Human Male and Sexual Behavior in the Human Female.
Further Reading
Christenson, C. V. (1971). Kinsey: A biography. Bloomington: Indiana University Press.
Kinsey Institute. (2012). The Kinsey Institute for research in sex, gender, and reproduc-
tion. Retrieved from http://www.kinseyinstitute.org
Public Broadcast Station. (2005, October 24). American experience: Kinsey. Retrieved
from http://www.pbs.org
Kinsey’s Continuum of Sexual Orientation
Dr. Alfred Kinsey (1894–1956) created the Kinsey Scale during his work as a
professor and sex researcher at Indiana University in Bloomington, Indiana. The
Kinsey Scale is a scale ranging from 0 to 6 that showcases a continuum of sexual
orientation and debunks the idea that there are only two sexual orientations,
372 Kinsey’s Continuum of Sexual Orientation
homosexuality and heterosexuality. The scale only considers sexual behavior in
its rating system and relies on self-report as the individual research participant or
client is the one reporting the frequency of their sexual behaviors with same- and
other-sex partners. Kinsey made some assumptions regarding gender and sex in
his scale, as only two genders and sexes are included. As such, it follows a gender
and sex binary, assuming people are male or female, man or woman (Yarber,
Sayad, & Strong, 2010).
Dr. Kinsey did not believe that being heterosexual or homosexual was fixed.
He also argued that, in accounting for one’s sexual orientation, it is important to
look at behavior and proportions of sexual behaviors. This led to the creation of
a 7-point scale ranging from 0-6 that accounts for different proportions of sexual
behaviors. On the scale, “0” indicates an individual has exclusively other-sex
behavior. Thus, the designation of a “0” also means “exclusively heterosexual.”
A “1” indicates mostly other-sex behavior with some same-sex behavior. This
may be thought of as “mostly heterosexual.” The number “2” equates to mostly
other-sex behavior with a good deal of same-sex behavior as well. This may be
classified as “somewhat bisexual.” A “3” on the rating scale indicates equal
amounts of same-sex and other-sex behaviors and may be considered “equally
bisexual.” A “4” is also “somewhat bisexual” as it indicates the individual has
some other-sex behavior but mostly same-sex behavior. A “5” is mostly same-sex
behavior with occasional other-sex behavior. Exclusively homosexual is indi-
cated by a number “6” on the scale and reveals sexual behavior is exclusive to
same-sex partners.
Dr. Kinsey and his staff of researchers and interviewers utilized the Kinsey
Scale during the interviews they conducted for data collection on sexual behavior.
While today the scale is largely used as a self-report measure, in many cases, Kin-
sey or his colleagues conducting the interview assigned a number to the partici-
pant after the interview based on what the participant described as their sexual
experiences. As such, the scale was not posed as a question to people unless they
described significant homosexual experiences. If this were the case, the inter-
viewer asked the participant to self-report on a scale from 0 to 6 where they fell on
the continuum after the scale was described to them. However, it was possible for
the interviewer to change the response if they did not believe it accurately reflected
what had been described to them by the participant. In addition, some leniency
was allowed in assigning a number to represent same- and other-sex sexual expe-
riences. While rare, it was possible for intermediate values to be used, such as 2–3
or 4–5 instead of relying on just one number.
There is a clear assumption in this scale that individuals are sexual. However,
Kinsey and his team of researchers occasionally came across individuals who
did not engage in sexual behaviors and were not interested in engaging in sexual
behaviors with persons of the same or other sex. Therefore, while not indicated
on the scale, in this case the interviewer assigned the participant an “X.” The
“X” category was meant to represent individuals who did not experience sexual
arousal or desire to either heterosexual or homosexual stimuli. This was always
a category that was assigned, not self-reported, as the only people who were
asked to self-report were people who described a certain level of homosexual
Kinsey’s Continuum of Sexual Orientation 373
experience, which, by default, excludes individuals who fell into the “X”
category.
Prior to Kinsey’s research about human sexuality and the development of the
Kinsey Scale, it was widely believed that only two sexual orientations existed:
heterosexuality and homosexuality. Bisexuality was not legitimized as a sexual
orientation, as many people assumed if someone ever engaged in any homosexual
behavior, they were homosexual. Kinsey argued against this narrow view of sex-
ual orientation as his research unfolded and found that many people who gave
their sexual histories had engaged in sexual behavior with both sexes regardless of
identifying as heterosexual or homosexual.
Kinsey’s research also revealed to him that sexual attraction might be fluid over
the course of someone’s life. As such, if someone has mostly other-sex interac-
tions today and is rated as a “1” on the Kinsey Scale, the following year it is pos-
sible for them to be a “3” or “4” on the scale as attraction and behavior may change.
To Kinsey, it was clear that bisexuality is a legitimate sexual orientation and that
one does not have to conform to a heterosexual or homosexual identity. Kinsey’s
work on sexual orientation and the creation of the Kinsey Scale ushered in criti-
cism of a dichotomous understanding of sexual orientation and has allowed there
to be space for bisexuality to be acknowledged. Also, the scale brought to light the
reality that, for many people, sexual orientation may be fluid, and sexual behav-
iors may change over time.
Kinsey and his work advocated for tolerance of sexual difference. His research
revealed that many people explored their sexuality through varying behaviors and
varying partners. As such, the distinction between what had been previously
assumed to be “normal” and “abnormal” sexual behavior was rendered meaning-
less as many people behaved in ways that contradicted societal expectations of
“normal” sexuality. The Kinsey Scale reflects this discovery by acknowledging
various sexual behaviors.
There have been many researchers, educators, and therapists who have criti-
cized the Kinsey Scale, arguing it is limiting in the understanding of sexual orien-
tation. Critics state that factors other than just sexual behavior contribute to sexual
identity. As this scale only considers sexual behavior, it provides limited insight
into an individual’s sexual attractions, feelings of love, fantasies, and desired
behaviors that have not been acted on. The criticism of the scale has spurred other
models to more fully account for a broader understanding of sexual orientation.
For example, the Klein Sexual Orientation Grid considers sexual attraction, sex-
ual behavior, sexual fantasy, emotional preference, social preference, heterosex-
ual/homosexual lifestyle, and self-identification in the past, present, and ideal
situation to expand on the understanding of sexual orientation spanning a
continuum.
Researchers, therapists, and educators have used and continue to use the Kin-
sey Scale in their work and practice. The scale is a good way to begin discussing
sexual orientation as a continuum and to steer away from a dichotomous view of
sexual orientation. For researchers, therapists, and educators with a behavioral
focus, the Kinsey Scale is a good tool for collecting data on sexual behavior.
Amanda Manuel
374 Kissing
See also: Bisexuality; Fluidity, Sexual; Heterosexuality; Homosexuality; Kinsey, Alfred;
Same-Sex Attraction and Behavior; Sexual Behavior in the Human Male and Sexual
Behavior in the Human Female; Sexual Orientation; Storms’s Model of Sexual
Orientation.
Further Reading
Weinrich, J. D. (2014). Notes on the Kinsey scale. Journal of Bisexuality, 14(3–4), 333–
340. doi: 10.1080/15299716.2014.951139
Yarber, W., Sayad, B., & Strong, B. (2010). Human sexuality diversity in contemporary
America (7th ed.). New York: McGraw-Hill.
Kissing
Kissing is a low-risk sexual activity that many people engage in on a frequent
basis. Kissing feels good because the lips and mouth are very sensitive to touch
due to high concentrations of nerves in these areas. Kissing is a sensual experi-
ence because so many of the senses are actively involved in kissing, such as taste,
touch, and smell.
Kissing serves an important function in mate selection. A French kiss, or kiss-
ing with tongue, allows genetic information to be exchanged during the kiss. This
information allows partners to determine if their kissing partner is a genetically
compatible partner. A 2008 study revealed that kissing allows many chemicals to
flood the brain. Neural messages induce sexual excitement, feelings of euphoria,
and partner bonding. A kiss is good for overall health as chemical reactions that
occur during kissing reduce stress and increase motivation and social bonding.
A study at the University of Albany revealed that kissing allows partners to
“know” their partner’s chemical makeup by the taste of their mouth and lips. The
study also showed that kissing promoted bonding by increasing levels of oxytocin
in the body (oxytocin is the bonding hormone) and decreasing cortisol in the body
(cortisol is the stress hormone). Finally, the study also concluded that kissing
increases sexual arousal.
Since kissing serves such an important role in helping a person determine if
their partner is a good fit chemically, it is not surprising that a “bad kiss” may be
deemed a deal breaker for a relationship. Technique and the chemical reaction that
occurs can determine a good kiss from a bad kiss. One study showed that 59 per-
cent of men and 66 percent of women could be initially attracted to someone and
then lose that feeling of attraction after a first kiss, if they deemed it to be a “bad
kiss.” Both men and women equally stated that a bad first kiss is a good reason to
stop dating or hooking up with someone.
Men and women may have different expectations about kissing. In a study at
the University of Albany, half of the male participants stated they would be com-
fortable having sex with someone without kissing them. The female participants,
on the other hand, responded quite differently, with only 15 percent reporting they
would be comfortable having sex with someone without kissing them. Studies
have also indicated that women tend to place more significance on a kiss than men
do in regard to foreplay. Women tend to experience kissing as very arousing and
Klinefelter Syndrome 375
tend to be more excited to kiss for a longer period of time than men. Men tend to
report that kissing is a step to more sexual activity and would prefer to spend less
time focused on this activity than women would.
Studies have also revealed that women tend to enjoy kissing more than men do
and may like to engage in this activity more frequently than men. Lesbian couples
tend to engage in the most kissing, with heterosexual couples coming in second
place; gay couples tend to spend the least amount of time kissing. However, men
are more likely to want to engage in kissing with tongue than women. They are
also more likely than women to believe that kissing will lead to sex. In one study,
50 percent of men reported that they believed kissing would lead to sex compared
with 33 percent of women who stated they believed kissing would lead to sex.
In many cultures, kissing is an expression of love and intimacy. It is often
highly acceptable as a sexual activity, and, in some cultures, it is appropriate to
engage in kissing publicly. Persons of all genders, sexual orientations, and ages
may enjoy various forms of kissing.
In American culture, many people think of kissing as a peck on the lips, a lip
lock, a French kiss, or a long make-out session. However, these forms of kissing
are not universal to all cultures. In some cultures, breath is considered to be highly
intimate. Therefore, instead of necessarily touching lips or tongues together, peo-
ple may exchange breath with one another. In other cultures, people may rub their
noses together. Kissing styles vary across cultures in all types of relationships.
Amanda Manuel
See also: Afterplay; Arousal; Foreplay; Intimacy, Sexual and Relational; Oxytocin;
Touching, Sexual Arousal and.
Further Reading
Herbenick, D., & Stoddard, G. (2012). Great in bed: Thrill the body, blow the mind. New
York: DK Publishing.
Walter, C. (2008). Affairs of the lips. Scientific American Mind, 19(1), 24–29.
Yarber, W., Sayad, B., & Strong, B. (2010). Human sexuality: Diversity in contemporary
America (7th ed.). New York: McGraw-Hill.
Klinefelter Syndrome
Klinefelter syndrome is a chromosomal disorder affecting males. Males with the
syndrome are born with at least one extra X chromosome (one of two sex chromo-
somes), which can slow sexual development because of lowered testosterone and
cause increased breast growth. Depending on its severity, the condition is treat-
able with testoterone replacement therapy, breast reduction, or counseling.
Occurring in approximately 1 in every 500–1,000 males, Klinefelter syn-
drome (named for Harry Klinefelter, an American physician who in 1942
described a set of symptoms that characterized the condition) is one of the most
common chromosomal disorders affecting males. Typically, males have both an
X and a Y chromosome. In the most common cases of Klinefelter syndrome,
males are born with one extra X chromosome (XXY instead of XY). In rarer
variants of the syndrome (occurring in approximately 1 in every 50,000
376 Krafft-Ebing, Richard von
newborns), males are born with several extra X chromosomes or one extra X
chromosome in some cells but not in others (known as mosaic Klinefelter syn-
drome). In any instance of the disorder, it is not an inherited condition but rather
arises from a disruption occurring during production of the egg or sperm cells,
which then meet to form the embryo.
The risk of health conditions increases with the number of extra X chromo-
somes. Men with generalized Klinefelter syndrome often have small testicles,
weak bones, taller than average stature, enlarged breast tissue, decreased sex
drive, and fertility issues. Often the condition remains undiagnosed until adult-
hood. In boys, the disorder may be suspected in the event of delayed, absent, or
incomplete puberty. Variants of Klinefelter syndrome tend to cause more severe
signs and symptoms than classic Klinefelter syndrome. In addition to affecting
male sexual development, variants of Klinefelter syndrome are associated with
intellectual disability, distinctive facial features, skeletal abnormalities, poor
coordination, and severe problems with speech. Individuals with mosaic Klinefel-
ter syndrome, on the other hand, may have milder signs and symptoms depending
on how many cells have an additional X chromosome.
Researchers suspect that Klinefelter syndrome is underdiagnosed because the
condition may be mild in many instances or the features of the condition may
overlap with those of other conditions. The two main tests used to diagnose the
disorder are hormone testing and chromosome (karyotype) analysis. In each case,
blood samples can reveal abnormalities in hormone levels or the shape or number
of chromosomes that characterize the presence of the disorder. Other tests involve
an examination of the genital area as well as tests to check reflexes and mental
function. Although the chromosomes cannot be repaired, one or more treatments
may minimize problems once a diagnosis is made, such as testosterone replace-
ment therapy (to improve bone density), breast tissue reduction, fertility treat-
ments, or counseling.
Linda Tancs
See also: Chromosomal Sex; Gynecomastia; Intersexuality; Puberty, Delayed; Sex Chro-
mosomes; Testosterone; Turner Syndrome; X Chromosome; Y Chromosome.
Further Reading
Wattendorf, D. J., & Muenke, M. (2005). Klinefelter syndrome. American Family Physi-
cian, 72(11), 2259–2262.
Weingarten, C. N., & Jefferson, S. E. (2009). Sex chromosomes: Genetics, abnormalities,
and disorders. Hauppauge, NY: Nova Science Publishers.
Krafft-Ebing, Richard von
Richard von Krafft-Ebing was a German psychiatrist during the nineteenth cen-
tury who became the first major researcher in sexual paraphilias and diversity. In
his major work, Psychopathia Sexualis, he popularized or coined such terms as
“heterosexual,” “homosexual,” “sadism,” “masochism,” and “pedophile.”
Although Krafft-Ebing saw people with differing sexual practices as deviants or
morally corrupted individuals, he favored an approach stressing treatment and
Krafft-Ebing, Richard von 377
cure instead of criminal confinement. Krafft-Ebing’s pragmatic liberalism was
evident in his support for the decriminalization of homosexuality in Germany and
the study of women’s sexual desires.
Richard von Krafft-Ebing was born on August 14, 1840, in Mannheim, Ger-
many, into a family of the minor nobility. He followed his maternal grandfather
into medicine but was attracted to psychiatry as a specialty. Beginning in 1872, he
taught psychiatry at the University of Strasbourg but soon took a position at the
University of Graz. Besides his teaching duties, Krafft-Ebing also worked as
superintendent of the Feldhof mental asylum. He was troubled by the fact that
patients there were treated more like criminals than individuals needing treat-
ment. In 1879, Krafft-Ebing published his first book, Text-Book of Insanity. It
called for doctors to search for the cause of a patient’s mental illness and offer
therapy.
In 1886, Krafft-Ebing published his most important work, Psychopathia Sexu-
alis. He attempted to classify various types of sexual deviance and to suggest their
causes and methods of treatment. He illustrated each type of behavior with case
studies of patients he had examined. Krafft-Ebing believed his book should be a
reference source for doctors, psychiatrists, and judges. He realized the subject of
his study would attract great attention. To reduce the access of the lay public to the
lurid details, Krafft-Ebing wrote much of Psychopathia Sexualis in Latin. The
work went through twelve editions during Krafft-Ebing’s lifetime. In each edition,
he added to the number of case studies. After the first edition of Psychopathia
Sexualis, many individuals with sexual disorders contacted Krafft-Ebing. They
spoke to him on condition of anonymity, often to discuss taboo behavior they had
been unable to share with family or friends.
Krafft-Ebing’s pioneering work greatly influenced later sexologists and psy-
chologists, including Sigmund Freud and Carl Jung. The latter pair eclipsed him
in the field, but his writings laid the groundwork on which they built. Krafft-Ebing
helped to move sexual dysfunction from being ignored, dismissed as insanity, or a
matter for religious authorities. For all his liberal attitudes about causes and treat-
ment of sexual deviant behavior, however, Krafft-Ebing remained true to his Vic-
torian culture. He believed that any sex act that was not committed in the context
of marriage and for the purpose of procreation was morally wrong. Homosexual-
ity was therefore wrong, even if it was not a crime. In 1871, the German Empire
implemented a legal code, including Paragraph 175, that criminalized homosexu-
ality. Krafft-Ebing raised eyebrows when he publicly opposed the statute. He also
believed that normal, healthy women were sexually passive and had little or no
interest in sex. Any exceptions were signs of mental illness.
Krafft-Ebing died in Graz, Austria-Hungary, on December 22, 1902.
Tim J. Watts
See also: BDSM; Freud, Sigmund; Paraphilias; Victorian Era.
Further Reading
Hunnicutt, A. (2015). Krafft-Ebing, Richard von (1840–1902). In GLBTQ: An encyclope-
dia of gay, lesbian, bisexual, transgender & queer culture. Retrieved from http://
www.glbtqarchive.com/ssh/krafft_ebing_r_S.pdf
378 Krafft-Ebing, Richard von
Krafft-Ebing, R. (1903). Psychopathia sexualis (12th ed., F. J. Rebman, Trans.). New
York: Rebman Company. (Original work published 1886).
McFatridge, K. (n.d.). Richard von Krafft-Ebing (1840–1902). Retrieved from http://
psychistofwomen.umwblogs.org/sexuality/pre-kinsey/krafft-ebing/
L
Labia
The labia are two pairs of folds of skin that are the visible portion of the vulva. The
labia majora is the outer pair, which usually covers the inner labia minora. They help
protect the urethra and vagina and can play an important role in sexual arousal and
orgasm. Normal, healthy labia can vary widely in size and appearance. However,
some women are concerned that their labia seem larger than they should be and so
seek plastic surgery, known as labiaplasty, to reshape one or both sets of labia.
The word “labia” is derived from the Latin word for “lip.” To a certain extent,
both pairs of labia play the same role as the lips do for the mouth. The labia majora
is the generally larger, outer pair. They begin just below the mons pubis and above
the clitoris. The labia majora rejoin above the perineum. They are composed of
skin and fatty tissue and are normally larger toward the front. During and after
puberty, the skin may become darker than the rest of the body. At puberty, pubic
hair also begins to emerge on the labia majora. The inner and outer surfaces have
sebaceous (oil) glands as well as two types of sweat glands.
The labia minora is the inner and generally smaller pair. They are folds of soft,
fat-free skin without any hair. The upper portions join at the clitoris hood and
rejoin just below the vaginal opening. The inner surface is moist and contains
many sebaceous glands.
The labia are one of the erogenous zones. Stimulation causes an increased flow
of blood to the area, and the labia will increase in size. Orgasms and the accompa-
nying contractions will help remove the blood, and the labia will return to their
normal appearance.
Some women have larger labia, which may cause discomfort, especially when
wearing tight clothing or when participating in some activities. Other women may
be concerned that their labia’s appearance is not “normal” because they are com-
paring themselves to unrealistic ideals, such as is seen in pornography. A contro-
versial surgical procedure known as labiaplasty can be performed to change the
labia’s size or appearance. As with any surgery, there are dangers such as infection,
scarring, or bleeding. Sexual intercourse may also be painful after a labiaplasty.
Tim J. Watts
See also: Erogenous Zones; Labiaplasty; Pubic Hair; Vulva.
Further Reading
Center for Young Women’s Health. (2019). Labia. Retrieved from https://youngwomens
health.org/2013/07/16/labia/
Women’s Health Victoria. (2019). The labia library. Retrieved from http://www.labialibrary
.org.au
380 Labiaplasty
Labiaplasty
Labiaplasty is a surgery that reduces or reshapes the labia majora or labia minora.
The surgery may be medically necessary in cases where the size of the labia
causes a person significant emotional distress or physical discomfort. Surgery can
be warranted in cases of symptomatic structural abnormalities related to labial
size or shape; in these cases, the labia create physical discomfort. Female genital
cosmetic surgery strictly for aesthetics warrants careful consideration about the
difference between medical need and trends in physical enhancements.
The labia minora are part of the female exterior genitalia commonly referred to
as the inner lips. They are paired folds of non-hair-bearing smooth tissue within
the labia majora. The labia majora are fatty, hair-bearing outer lips. The labia
minora cover the urethral opening and the opening of the vagina except during
sexual arousal, when the labia deepen in color, engorge, and flair slightly. This
engorgement is part of the female sexual response cycle and is the result of
increased pelvic blood flow. Because the labia minora are attached to the base of
the clitoral glans, movement of the labia minora indirectly stimulates the clitoris.
Typically, the labia are of roughly equal dimension and are most visible when
the legs are separated. Labia minora diagnosed as enlarged, or hypertrophic, may
be greatly unequal in dimension or protrude beyond the cusp of the labia majora.
Labia majora may be diagnosed if they are significantly asymmetrical or
elongated.
The medical community has not reached consensus on what normal, functional
labia look like. Defining normal labia minora as being hidden between labia
majora is subjective, as normal female genitalia vary in their length, shape, and
coloration.
Labial size is usually congenital; however, size can also be affected by expo-
sure to exogenous androgens in infancy, hormonal changes, childbirth, manual
stretching, and aging. Labial enlargement also may occur secondary to some med-
ical conditions. The size of the labia minora is no indication of masturbation or
partnered sexual activity, contrary to some common misconceptions.
Labia minora that protrude beyond the labia majora may be irritated by tight
clothing, create hygiene problems during menstruation or toileting, interfere with
sexual activities, and/or feel uncomfortable while a person is sitting or participat-
ing in exercise.
The goal of labiaplasty on the labia minora is to remove labial tissue a patient
deems excessive and to create symmetrical, smaller labia. Several types of proce-
dures are in use, but the data are limited on long-term outcomes. Patients should
be aware of the options and discuss the risks and benefits of each with their
surgeon.
One technique for labiaplasty involves a straight amputation of the tissue
deemed excessive. This results in a scarred suture line along the new edge of the
labia. The new edge is smoother and lighter pink than the natural edge was, which
can give the labia a more youthful look; however, the scar line can lead to irrita-
tion and discomfort later on.
Another technique involves the amputation of V-shaped wedges of tissue. One
cut is made from the midline of the labia to the outer edge; another cut is from the
Labiaplasty 381
midline cut toward the end of the labia close to the vaginal opening. The tissue is
sutured to close the gap created by the removal of the wedge to maintain the natu-
ral edge.
Sometimes, a second surgery is required to correct wound dehiscence, which
occurs when a wound ruptures along surgical suture. Patients at greater risk for
dehiscence tend to be either older or obese, or they may have diabetes. Poor knot-
ting or grabbing of stitches, as well as trauma to the wound after surgery, may also
lead to wound dehiscence.
Labia majora deemed excessively large can be reduced in size through liposuc-
tion or laser surgery. If age, weight loss, or pregnancy have caused the labia majora
to lose fullness, or to appear to sag, the labia can be reduced through surgery. The
labia majora can also be injected with fat transferred from elsewhere on the
patient’s body. Synthetic fillers can be used but generally have less desirable
outcomes.
Labiaplasty carries the same risk of any surgery in terms of infection, bleeding,
and wound healing issues. People who take blood thinners, smoke, or have
immune suppressive disorders are at greater risk for surgical complications.
Problems specifically related to labiaplasty on the labia minora, which is more
common than labia majora surgery, may include permanent changes in sensation,
ongoing pain, asymmetry of the labia, scarring, and dyspareunia. These issues
can interfere with sexual pleasure, which can, in turn, have an impact on sexual
relationships. If the clitoral hood is also reduced in size, complications may occur
in terms of damage to the clitoral glans and nerves responsible for sexual
pleasure.
While cost is not a medical risk, it can be a personal financial risk. Labiaplasty
for strictly cosmetic reasons is not covered by insurance. Another risk is that while
someone may expect the surgery to resolve body image issues, there is no guaran-
tee that the labia will look as expected or that any result would satisfy that psycho-
logical need.
It is not uncommon for adolescents to be concerned about their body looking
attractive. As sexually explicit images have become increasingly accessible, phy-
sicians are seeing more young female patients who seek labiaplasty. Some sur-
geons have advocated that the minimum age for this procedure be set at eighteen
years.
The risk of being unhappy with the surgical outcome will decrease if patients
should seek out surgeons willing to share before and after photos of their surger-
ies. This will increase the odds that both surgeon and patient agree on the desired
aesthetic outcome.
According to the American Society for Aesthetic Plastic Surgery, labiaplasty
procedures increased 44 percent between 2012 and 2013. The tailoring of body
parts to suit societal perceptions of beauty is not new, but most other cosmetic
procedures do not require the resection (removal) of healthy, normal tissue related
to sexual function.
The practice of female genital cosmetic surgery, specifically labiaplasty, has
increased in popularity as images of female genitals in sexually explicit media
have idealized small, symmetrical labia minora. The trend of pubic hair removal
382 Lee’s Theory of Love Styles
makes labia more visible and subject to critical assessment as well. While some
people pressure themselves to match the idealized form, many patients seeking
labiaplasty recall having heard specific negative comments about their labia from
sexual partners and others. Another reason people seek out cosmetic labiaplasty is
to satisfy their desire to have more youthful-looking genitalia.
Women who consider their labia minora to be unattractive or irritating may feel
deformed or abnormal, and these feelings can result in embarrassment, negative
body image, and low sexual self-esteem. Some of these concerns may be allevi-
ated if health care providers and surgeons explain that variations in labial dimen-
sion are normal.
Many surgical websites promote postsurgical improvements in self-esteem,
body image, and sexual relationships; however, no long-term studies evaluating
the effects of such surgery have been done. What is known is that most women do
not have female cosmetic genital surgery, and women with all shapes and sizes of
labia can feel confident and sexually satisfied.
Melanie Davis
See also: Dyspareunia; Hymenoplasty; Labia; Pornography; Vulva.
Further Reading
Creighton, S. M., & Liao, L.-M. (2019). Female genital cosmetic surgery: Solution to
what problem? Cambridge: Cambridge University Press.
Goodman, M. P. (2013). You want to do what? Where? Everything you ever wanted to
know about women’s genital plastic & cosmetic surgery. Davis, CA: author.
Lee’s Theory of Love Styles
Lee’s theory of love styles was developed by Canadian sociologist John Lee (1973).
He proposed that there were six ways of loving or understating love, which he
called love styles. The three primary love styles are eros, storge, and ludus. The
three additional styles are pragma, mania, and agape. In general, people tend to
have a fairly consistent love style throughout their life, but they can also express
different styles within a romantic relationship, and they may experience different
love styles in relationships with different partners.
Eros, named for the Greek god of love, encompasses erotic, powerful, physical,
and passionate love. Experiencing erotic love is important for relationship and
sexual satisfaction with a partner. The eros love style is associated with a sense
that the individual and the partner were meant for one another and that they have
the right physical chemistry between them.
The storge love style is love that is based on a strong sense of friendship and
compatibility. It develops when people enjoy similar activities and starts as liking
and friendship and then can build into affection and commitment. This style of
love can be seen as love and affection between siblings and friends, but storgic
love can also be seen in romantic relationships. In these relationships the friend-
ship and long-term commitment are valued above short-term excitement, sexual
gratification, or physical appearance.
Ludus, named for the Latin word for game or play, is a love style in which love
is seen as a game to be played. Typically, people with a ludic love style tend to
LeVay, Simon 383
enjoy short-term sexual relationships with a variety of people, without commit-
ment. A ludic love style tends to be associated with lower relationship satisfaction.
Males may be more likely to report a ludic love style than females, and it may be
more common among younger people and those who have never been married.
The pragma love style may be considered as having elements of both storge and
ludus love styles. In this love style, compatibility is the ultimate goal. Someone
with a pragmatic love style may have a list of qualities that they are looking for in
a partner, and potential partners are then screened against this list to see how well
they match up. Pragmatic love involves making rational decisions and prioritizing
compatibility and other desired characteristics above emotion.
The mania love style has been described as the ludus style but “without the
confidence.” This style of love is possessive, jealous, and insecure. It is dependent
and obsessive, and someone with a manic love style may have trouble concentrat-
ing on anything other than their partner. People with a manic love style may desire
love, but they also tend to be mistrustful, jealous, and insecure.
The final love style is agape love. Agape love is selfless, giving, and altruistic
love. This love may be characteristic of a parent’s love of their child. Within a
romantic relationship, a person with an agape love style tends to be compassionate
and to place their partner’s happiness above their own. This style of love is rare.
Heather L. Armstrong
See also: Attachment Theory of Love; Companionate Love; Consummate Love; Love;
Sternberg’s Triangular Theory of Love.
Further Reading
Hendrick, S. S. (2004). Close relationship research: A resource for couple and family
therapists. Journal of Marital and Family Therapy, 30(1), 13–27.
Hendrick, S. S., & Hendrick, C. (1997). Love and satisfaction. In R. J. Sternberg & M.
Hojjat (Eds.), Satisfaction in close relationships (56–78). New York: Guilford
Press.
Lee, J. A. (1973). Colours of love: An exploration of the ways of loving. Toronto, ON: New
Press.
Lee, J. A. (1988). Love-styles. In R. J. Sternberg & M. L. Barnes (Eds.), The psychology
of love (38–67). New Haven, CT: Yale University Press.
Smith, K. B. (2017). Attraction, intimacy, and love. In C. F. Pukall (Ed.), Human sexual-
ity: A contemporary introduction (2nd ed.). Don Mills, ON: Oxford University
Press.
LeVay, Simon
Simon LeVay is a British neuroscientist who has practiced and lived in the United
States since 1972. His early work involved investigations into the visual cortex of
animals, but he is best known for his investigation into biological and anatomical
causes of homosexuality. LeVay was motivated to start his research because of his
own sexual orientation and a personal crisis. When he proposed in 1993 that gay
and straight men had differences in their brains, scientists and the general public
quickly responded. Although LeVay never claimed his work proved a biological
cause of homosexuality, many observers treated it as if it had. LeVay has spent the
rest of his life trying to educate the public about homosexuality and its roots.
384 LeVay, Simon
LeVay was born on August 28, 1943, in Oxford, England. His father was an
orthopedic surgeon, and his mother was a pathologist who stayed home to care for
their five sons. The couple divorced when LeVay was eleven. He attended private
schools as a child before enrolling at the University of Cambridge. His parents
encouraged him to become a doctor, so he began focusing on the sciences. LeVay
received a bachelor’s degree in natural sciences in 1966 but later dropped out of
medical school. He then entered the University of Gottingen in Germany and
studied neuroanatomy. LeVay earned a PhD in 1971 and accepted a position as a
postdoctoral research fellow at Harvard Medical School in 1972. He remained at
Harvard until 1984, when he moved to the Salk Institute for Biological Studies in
San Diego. Most of LeVay’s early research centered on the visual cortex of
animals.
LeVay had realized he was gay when he was thirteen and became comfortable
with that fact. While studying in Germany, he began a long-term relationship with
Richard Hersey, an American student. Hersey was one of the reasons LeVay
moved to the United States. After twenty-one years together, Hersey died in 1990
of AIDS. Deeply affected, LeVay decided to direct his research toward something
related to his gay identity. He was aware that researchers had discovered sex-
related differences in the brains of men and women. The nerve bundles connect-
ing the two halves of the brain were usually larger in women than in men, for
example.
To determine if gay men’s brains differed from those of straight men, LeVay
autopsied the brains of forty-one people. Nineteen were homosexual men, sixteen
were heterosexual men, and six were women. Special attention was paid to the
third interstitial nucleus of the anterior hypothalamus (INAH3). The hypothala-
mus is a small part of the brain known to direct male sexual behavior, including
attraction to women. The examination of the INAH3 could not be performed on
living people. In 1991, LeVay published his findings in an article entitled “A Dif-
ference in Hypothalamic Structure between Heterosexual and Homosexual Men”
in Science. He found that gay men had INAH3 clusters that were half the size of
straight men’s. The female brains had INAH3 clusters that were about the same
size as those of gay men. LeVay concluded that his findings suggested sexual ori-
entation has a biological basis.
The response to LeVay’s article was swift. Some gay rights advocates believed
that he had shown being gay was not a choice but biologically driven, like eye
color. Others criticized his work, pointing out the small sample size and the failure
to include lesbians. In addition, the very small size of the INAH3 clusters made
relative differences very small. LeVay responded to the criticism by stating that he
believed other factors helped determine a gay identity. He believed prenatal influ-
ences were very important, for example. LeVay’s research helped encourage other
researchers to explore if other physical differences based on sexual orientation
could be found.
LeVay resigned his position at the Salk Institute in 1993 to devote himself to
educating others about homosexuality. He helped found the Institute of Gay and
Lesbian Education, an open institute for those who wanted to know more about
LGBTQ+ 385
gay and lesbian individuals in society. In 2003, LeVay became the director of
human sexuality studies at Stanford University.
Tim J. Watts
See also: Biological Theories of Sexual Orientation; Homosexuality; Sex Differentiation
of the Brain and Sexual Orientation; Sexual Orientation.
Further Reading
LeVay, S. (1991). A difference in hypothalamic structure between heterosexual and homo-
sexual men. Science, 253(5023), 1034–1037.
LeVay, S. (2016). Gay, straight, and the reason why: The science of sexual orientation.
New York: Oxford University Press.
LGBTQ+
“LGBTQ+” is an acronym used to refer to the community of individuals who
identify as sexual and gender minorities. “L” stands for lesbian, “G” for gay, “B”
for bisexual, “T” for transgender, “Q” for either questioning or queer, and “+” for
those who identify within the community but are not represented by the first five
letters. LGBTQ+ has generally replaced other acronyms such as GLBT or LGB
that were previously used. Aside from the initials used in LGBTQ+, several oth-
ers are used in various contexts. Other commonly used initials include a second
“Q” to represent questioning or queer, “I” for intersex, “A” for asexual or ally, “P”
for pansexual, “D” for demisexual, “2-S” or “2S” for two-spirit, “NB” or “N-B”
for nonbinary, “S” for skoliosexual, “GNC” for gender nonconforming, “SGL” for
same-gender loving, “C” for curious, and an additional “A” for either asexual
or ally.
The term “gay” first became slang for men who were sexually attracted to men
in the mid-1900s. As the gay rights movement gained momentum during the
1960s, some began using the term “gay” to refer to all sexual minorities. Within
the early 1970s, the phrase “gay and lesbian” became more prominent as lesbians
established a more public profile. During the 1980s, the acronym “GLB” was
often used to refer to those who were gay, lesbian, or bisexual. During the 1990s,
the acronym “GLBT” became more common as individuals who identified as
transgender became a more prominent part of the sexual and gender minority
community. Within the early 2000s, the G and L began switching places, with
“LGBT” becoming the most commonly used acronym.
As individuals who identified as sexual or gender minorities but did not iden-
tify as lesbian, gay, bisexual, or transgender became more vocal within the later-
2000s and early to mid-2010s, the acronym underwent several variations.
Additional letters were added within different media in an attempt to incorporate
the variety of identities included under the umbrella of sexual and gender minori-
ties. The length and infinite variations of these acronyms became known as alpha-
bet soup and led to some confusion. For example, there has been a great deal of
disagreement about what the Q stands for. The 2016 GLAAD Media Reference
Guide states that the preferred acronym is “LGBTQ,” with the Q representing
386 Love
queer, but others suggest the Q should represent those who are questioning their
sexual or gender identities. Also, some question using an A to stand for allies, as
they feel allies, while important, are not part of the sexual and gender minority
community. In order to limit the length of the acronym while remaining inclusive
of individuals who identify as any sexual or gender minority, “LGBTQ+” has
become the most commonly used acronym.
Aside from “LGBTQ+,” several other acronyms are used in different contexts.
Within the social and health sciences, “SGM” is often used to represent sexual
and gender minorities. Alternatively, medical literature commonly uses the acro-
nyms “MSM” (men who have sex with men) or “WSW” (women who have sex
with women) as their research is more focused on sexual behaviors rather than the
personal or social identities of those engaging in the behaviors. Within educa-
tional environments, the acronym “GSA” was originally used to stand for gay-
straight alliance but has often also been described as gender and sexuality
alliance.
Richard A. Brandon-Friedman
See also: Asexuality; Bisexuality; Gender Identity; Homosexuality; Queer; Sexual Iden-
tity; Sexual Orientation; Transgender.
Further Reading
Chauncey, G. (1994). Gay New York. Chicago: University of Chicago Press.
Faderman, L. (2015). The gay revolution: The story of struggle. New York: Simon &
Schuster.
GLAAD. (2016). GLAAD media reference guide (10th ed.). New York: Author.
Love
Love tends to be considered as a powerful emotion that may be present within
multiple types of relationships where one feels compassion and companionship.
However, love as is usually conceptualized in Western cultures is a relatively new
phenomenon and can take on many different roles within society. There are many
different types of love, such as sexual love, familial love, friendly love, and pas-
sionate love. Each type of love has its role within our lives.
According to anthropologists, romantic love plays a primary role in Western
cultures where the main focus tends to be on the individual. Consequently, roman-
tic love is allowed and able to play a major role in an individual’s life and can also
become a part of their identity. In Eastern cultures, the focus tends to be more on
collectivism, and, as such, romantic love is not seen as needed for individual iden-
tity. In Western cultures, romantic love is often seen as the primary reason to be in
a relationship with someone and to marry. In Eastern cultures, because cultural
values focus more on responsibilities toward family and society, romantic love is
not seen as necessary for marriage, and the practice of arranged marriages is more
common.
There are many types of love. Most often when discussing love, individuals
think of romantic love, which is defined as the idealization of another. This is the
Love 387
strong emotional bond individuals feel toward a romantic partner. Individuals can
also feel love toward family and friends. This is a different type of love, involving
deep care and concern with the other’s well-being. Some experiences of love may
be considered as unconditional love, where the person is able to look past any
negative traits or behaviors of the other and still love them, such as the love
between parent and child.
In 1986, Dr. Robert Sternberg created the triangular theory of love. He theo-
rized that there were three main components of love, just like there are three
angles in a triangle. The three components are intimacy, passion, and commit-
ment. Sternberg proposed that different types of love could be described based on
the relative amount of each component present. He also proposed that the relative
amount of each component, the therefore the style of love experienced, can also
change over the course of a relationship. This theory consists of eight different
types of love:
1. Consummate love, where passion, intimacy, and commitment are all present
2. Liking, where only intimacy is present
3. Infatuation, where only passion is present
4. Empty love, where only commitment is present
5. Romantic love, where intimacy and passion are present but commitment is
absent
6. Companionate love, where intimacy and commitment are present but passion
is absent.
7. Fatuous love, where passion and commitment are present but intimacy is
absent
8. Nonlove, where commitment, intimacy, and passion are all absent
Attachment theory can also be used to describe love. In the 1960s, John Bowlby
discussed how people develop expectations and understanding of relationships
based on the attachment they form in childhood with their primary caregivers,
typically their mother. According to attachment theory, these early experiences
can have a significant impact on how people love and experience relationships as
adults. As adults, there are four main types of attachment: secure, anxious-
ambivalent (or preoccupied), fearful-avoidant, and dismissive-avoidant. Individu-
als with a secure attachment experienced positive, responsive relationships with
their primary caregiver and as a result develop the expectation of positive, sup-
portive relationships as adults. They have a positive view of self and of others.
Individuals who experienced unsupportive or challenging relationships with their
caregivers as children develop insecure attachment patterns as adults. Individuals
with an anxious-ambivalent attachment have a negative self-view but a positive
view of others. As adults, they may be overly dependent on others for self-worth
and may be preoccupied and insecure with their relationships. Individuals with a
fearful-avoidant attachment style have negative feelings of others and a negative
self-view. Consequently, they often fear letting others get close to them and report
high levels of fear of rejection. Finally, adults with a dismissive-avoidant
388 Lubricants
attachment experience a positive self-view but a negative view of others. Conse-
quently, they are self-reliant and report a low need for intimacy. In a relationship,
they are often distant and may downplay the importance of intimacy.
Amanda Baker
See also: Attachment Theory of Love; Companionate Love; Consummate Love; Intimacy,
Sexual and Relational; Lee’s Theory of Love Styles; Sternberg’s Triangular Theory of
Love.
Further Reading
Perel, E. (2006). Mating in captivity. New York: HarperCollins.
Psychologist World. (2019). Attachment theory. Retrieved from https://www
.psychologistworld.com/developmental/attachment-theory
Robert, J. S. (n.d.). Triangular theory of love. Retrieved from http://www.robertjsternberg
.com/love
Lubricants
Lubricants are substances, either organic or manufactured, that assist in the reduc-
tion of friction between surfaces that come in contact with one another. Lubri-
cants are useful in many sexual situations. Men produce a natural lubricant that is
clear and colorless and is emitted from the urethra of the penis during sexual
arousal. This is often called preejaculate or precum. Preejaculate helps neutralize
the urethra area, as urine is acidic, creating a more favorable environment for the
passage of sperm. Women naturally produce their own lubrication in the vagina
during sexual arousal to reduce friction and irritation from penetration and to
enhance sexual arousal. External lubricants can also be used to enhance the sex-
ual experience.
The production of lubrication varies from woman to woman. Some women may
produce large amounts of lubrication, while others may be unable to create enough
lubrication to reduce friction. Lubrication production will also vary over time and
in different contexts. Lubrication production is influenced by hormone levels. As
an example, a woman may have less lubrication during menopause as the result of
lower estrogen levels. In addition to changes in hormones, other reasons that cause
low levels of vaginal lubrication may be breastfeeding, chemotherapy, other treat-
ments for breast cancer, dehydration, and depression medication (Obos Sexuality
& Relationship Contributors, 2014). When this is the case, external lubricants can
be useful during sexual activity.
External lubricants are a liquid or gel-type substance that can be applied during
sex to make the vulva, vagina, or anal areas wetter. Lubrication can also be applied
to a penis to reduce friction from penetration. To choose lubricants, one must be
aware of their own comfort and safety, and sometimes people may have to try dif-
ferent types of lubricants to find the one that works best for them.
There are three different types of lubrication: water based, silicone based, and
oil based. The most common type is water-based lubrication. Most water-based
lubricants contain synthetic glycerin, a lipid, oil, or fat that is used to moisturize
and soften skin, to create the effect of natural lubrication. Water-based lubricants
Luteinizing Hormone 389
are safe to use with latex condoms, easy to find, and low cost. Lubricants that con-
tain synthetic glycerin may dry out quickly and can trigger yeast infections in
women who are prone to them. Water-based lubricants that do not contain glyc-
erin tend to last longer than lubricants that do. These lubricants are also safe to use
with latex condoms but are usually thicker than ones with glycerin. These lubri-
cants are not as easily found in a drugstore and so are usually found online or at
sex stores.
Silicone lubricants last three times longer than water-based lubricants but can
cause irritation if not immediately rinsed off after sex. These lubricants also con-
tain glycerin, and they can be expensive and cannot be used with other silicone
sex toys. They are safe to use with latex condoms. Silicone lubricants are not as
easily accessible as water-based lubricants and may be purchased online or in sex
stores.
Oil-based lubricants may be natural or synthetic oil based. These types of lubri-
cants are fairly easy to find as they can already be in your kitchen or bathroom.
Natural oil-based lubricants work well for sexual arousal and foreplay, are usually
very safe to use, and are low cost and easily accessible. Coconut oil is one exam-
ple. Synthetic oil-based lubricants may irritate the vulva, vagina, and anus and so
should be used only for external play like massages or masturbation. One major
drawback of oil-based lubricants is that they destroy latex condoms, making them
much more prone to breaking during intercourse. Because of this, if condoms are
being used during the sexual experience, a water- or silicone-based lubrication
should be used.
Casey T. Tobin
See also: Condoms, Female (Receptive); Condoms, Male (Insertive); Vaginal
Lubrication.
Further Reading
Herbenik, D., Reece, M., Schick, V., Sanders, S., & Fortenberry, D. (2014). Women’s use
and perceptions of commercial lubricants: Prevalence and characteristics in a
nationally representative sample of American adults. The Journal of Sexual Medi-
cine, 11(3), 642–652.
Jozkowski, K. N., Herbenik, D., Schick, V., Reece, M., Sanders S., & Fortenberry D.
(2013). Women’s perceptions about lubricant use and vaginal wetness during sex-
ual activities. The Journal of Sexual Medicine, 10(2), 484–492.
Obos Sexuality & Relationship Contributors. (2014). How to choose a lubricant for plea-
sure and safety. Retrieved from https://www.ourbodiesourselves.org/book
-excerpts/health-article/how-to-choose-lubricant/
Luteinizing Hormone
Luteinizing hormone (LH) is one of several hormones secreted by the anterior
lobe of the pituitary gland, located beneath the brain near the skull’s center. LH,
along with follicle-stimulating hormone (FSH, another pituitary secretion), regu-
lates the activity of the gonads (ovaries and testes). These hormones are crucial to
the reproductive process for all people.
390 Luteinizing Hormone
In women of childbearing age, LH and FSH trigger a monthly increase in pro-
duction of estrogen by the ovaries, leading, in turn, to ovulation. These hormones
also prompt the monthly development of the corpus luteum, a structure in the
ovaries that secretes a hormone called progesterone, which leads to the growth
and maintenance of the endometrium, an extra lining of cells and blood vessels in
the walls of the uterus. The endometrium is necessary for pregnancy—that is, the
implantation of the embryo in the uterine wall and its subsequent growth into a
fetus.
The monthly increase in a woman’s LH secretion, known as the “LH surge,”
lasts from about twenty-four to forty-eight hours, during which time the hormone
produces its main effects. If pregnancy does not occur, LH levels decline as men-
struation happens. Levels of LH also decline if pregnancy does occur. As an
embryo develops in the uterus, its placenta secretes an LH-like hormone called
human chorionic gonadotropin, which takes over LH’s role in maintaining the
function of the corpus luteum.
The LH surge can be used to predict ovulation and, thus, the time when sexual
intercourse is most likely to result in pregnancy. Levels of LH can be easily mea-
sured in urine samples at home with urinary ovulation predictor kits, also called
LH kits. Used daily at the expected approximate time of ovulation, a change from
a negative to positive reading on a test strip indicates that ovulation will occur
within twenty-four to forty-eight hours.
In men, LH and FSH stimulate Leydig cells in the testes to produce testoster-
one. This hormone prompts the development of male sexual characteristics,
including the maturing of the testes so that they produce healthy, viable sperm.
Levels of LH (which can be measured in either blood or urine samples) nor-
mally change throughout an individual’s life. They typically rise in women after
menopause because of the loss of a biochemical feedback mechanism that helps to
regulate LH levels during childbearing years. This rise is normal in older women
and poses no special health risks. Normal LH levels for women before menopause
range from five to twenty-five international units (IU) per liter (L). These levels
peak during the middle of menstrual cycles. Normal levels after menopause range
from fourteen to fifty-two IU/L. Normal LH levels in men older than age eighteen
range from about two to nine IU/L.
High or low LH levels can be signs of certain disease conditions. In younger
women, persistently elevated LH levels (lasting longer than the LH surge) might
suggest premature menopause, polycystic ovary syndrome (ovary abnormalities
that include cysts, menstrual cycle problems, and a hormone imbalance), Swyer
syndrome (the absence of functional gonads), Turner syndrome (a chromosomal
abnormality that causes physical and mental disabilities), or other conditions.
In men, higher-than-normal levels of LH are usually associated with testicular
problems. Such problems may be related to any of several conditions, including
injury, cancer, or Klinefelter syndrome (a chromosomal abnormality).
Lower-than-normal levels of LH may be signs of hypogonadism (failure of the
ovaries or testes), hypopituitarism (failure of the pituitary gland), hyperprolac-
tinemia (excess amounts of prolactin hormone, leading to sexual problems),
Lymphogranuloma Venereum 391
Kallman syndrome (failure of puberty to begin or to be completed), anorexia ner-
vosa (an eating disorder), stress, or other conditions.
A. J. Smuskiewicz
See also: Follicle-Stimulating Hormone; Hypogonadism; Menstruation; Ovulation; Preg-
nancy; Sex Hormones; Testosterone.
Further Reading
Endocrine Society. (2018). What is luteinizing hormone? Retrieved from https://www
.hormone.org/your-health-and-hormones/glands-and-hormones-a-to-z/hormones/
luteinizing-hormone
Society for Endocrinology. (2018). Luteinizing hormone. Retrieved from https://www
.yourhormones.info/hormones/luteinising-hormone/
Lymphogranuloma Venereum
Lymphogranuloma venereum (LGV) is a sexually transmitted infection (STI)
caused by specific strains of Chlamydia trachomatis that can cause genital ulcer
disease (GUD) and other complications depending on where in the body the infec-
tion is located. Like many other STIs, LGV can be present in a person without
causing signs or symptoms of disease. Similar to the other bacterial causes of
GUD, there are tests available for diagnosis, and it can be treated with antibiotics.
LGV can be effectively prevented by the use of condoms for sexual intercourse.
While syphilis and herpes are commonly transmitted with oral sex as well as
anal and vaginal intercourse, it is less common for LGV to be transmitted orally,
although it is possible, and there are occasional reports of oral transmission in
men who have sex with men. More commonly, penile-anal or penile-vaginal con-
domless sex is the means of transmission.
Unlike other more common forms of Chlamydia trachomatis, LGV can cause a
lesion at the site of infection during the first stage of the disease process. The
lesion is usually small and painless, although in the past few years there have been
medical reports of some LGV lesions being somewhat tender; this may be because
of coinfection with HIV or other STIs. Sites of infection can be the penis, vulva,
vagina, cervix, anus, rectum, mouth, or throat. Infection can happen when a per-
son has sex with a person who has LGV and condoms are not used. The person
with LGV usually does not know they have it because the lesion may be hidden,
small, and not painful. LGV may be diagnosed at the same time as another STI,
including HIV.
LGV is seen more often in men, and, since the early 2000s, LGV has been more
common in men who have sex with men. Prior to this time, LGV was more com-
monly seen with heterosexual activity in tropical countries such as in parts of
Asia, the Caribbean, and Africa, and in men who have multiple sexual partners,
such as soldiers, sailors, and tourists returning to their home country after being
in tropical countries where LGV is more common. LGV may be harder to detect if
the lesion is located internally in the vagina or rectum.
392 Lymphogranuloma Venereum
LGV can progress through three stages of disease if left untreated. Between
three and twenty-one days after exposure, a small, painless sore appears at the site
of infection. If the lesion is missed and not treated, it usually heals up within a
week by itself; however, if the infection was acquired anally, it can cause anorectal
pain, bleeding, and pus. After the lesion heals, the bacteria remains in the lymph
tissues, leading to the second stage of LGV, two to four weeks later. Symptoms of
the second stage depend on where the bacteria entered the body. If the lesion was
deep in the vagina or cervix, the lymph nodes in the pelvis become painful and
inflamed, so the woman might experience fevers and back and pelvic pain. If the
lesion was in the anus or rectum, then inflammation and infection of the rectum
can occur with pain, blood, and discharge. If the bacteria entered the body via the
vulva or penis, then the second stage appears as painful swollen lymph nodes in
the groin, which may rupture if not treated. If the lesion was on the lips or the
throat, then the symptoms will appear in that area. If LGV is left untreated after
the second stage, symptoms can become more severe in stage three. There can be
extreme swelling of the lymph glands and genitals, which can cause long-term
damage, including scarring, chronic swelling, pain, and sexual dysfunction.
LGV can be prevented by using condoms. People who are sexually active
should be tested regularly for STIs, and if they have any STI symptoms, they
should visit their doctor or an STI clinic for diagnoses and treatment as
prescribed.
Antibiotic resistance is becoming an increasing concern globally. Several STIs
have become resistant to the antibiotics used for treatment, thus creating the need
for newer and more expensive antibiotics to effectively treat the disease. Resis-
tance to some antibiotics used to treat LGV has been found in some infections, but
the majority of cases remain treatable with azithromycin or doxycycline. If these
treatments fail, sexual health physicians may prescribe moxifloxacin.
Kelwyn Browne
See also: Safer Sex; Sexually Transmitted Infections (STIs).
Further Reading
Centers for Disease Control. (2015). 2015 sexually transmitted diseases treatment guide-
lines: Lymphogranuloma venereum (LGV). Retrieved from https://www.cdc.gov/
std/tg2015/lgv.htm
Ceovic, R., & Gulin, S. J. (2015). Lymphogranuloma venereum: Diagnostic and treatment
challenges. Infection and Drug Resistance, 8, 39–47.
World Health Organization. (2016). Global health sector strategy on sexually transmitted
infections, 2016–2021. Geneva: World Health Organization.
Wylie, K. R. (Ed.). (2015). ABC of sexual health (3rd ed.). Chichester, UK: Wiley
-Blackwell.
M
Madonna-Whore Dichotomy
Historically, female sexuality has been seen as passive, which is in direct opposi-
tion of male sexuality, which is perceived as aggressive. Social conditioning
begins early for all people. Young girls are often taught and rewarded for being
passive “good girls.” A “good girl” is one who adheres to the double standards
imposed on her by society. A “good girl” does not have sex often, she does not
have sex early on in a relationship, and she does not sleep with a lot of men. These
standards are quite different for men, who are viewed as hypermasculine when
they have frequent sex with many women. Women who “behave like men” by
having and enjoying lots of sex, when they want and with whomever they want,
are a threat to the traditional standards set forth by men. This type of woman is
labeled as a “whore,” while a “good girl” is labeled as a “Madonna.” Researchers
have argued that these Western ideas about female sexuality are shaped by Chris-
tian teachings and that women are categorized and judged based on the degree to
which they have carnal knowledge and their degree of submission to authority. A
Madonna is virginal, sweet, and nurturing, while a whore is a woman who has sex
outside of marriage and exudes sexuality. These labels act as a way to limit and
control women’s behavior and keep men in a position of power. The two boxes
women fall into encapsulate the Madonna-whore dichotomy. The Madonna-whore
complex arises when men seek loving and committed relationships with women.
Sigmund Freud (1856–1939), considered by some to be the father of psychol-
ogy, first began using the term “Madonna-whore dichotomy” or “Madonna-whore
complex” in order to explain issues that arise for men in relationships with women
they love. Freud suggested that men place women into one of two categories: that
of “Madonna” or that of “whore.” He postulated that men do this in order to under-
stand the discomfort they experience due to the polarization of both desiring and
fearing women.
Men seek nurturing, virginal, maternal women as wives and mothers of their
children. However, they also want women who they can have sex with. It is diffi-
cult for men to see a woman as both sexual and sweet, nurturing, and maternal. As
such, the Madonna-whore dichotomy and Madonna-whore complex can be quite
problematic for men and their relationships with women.
The Madonna-whore dichotomy sees a woman’s goodness and her sexuality as
mutually exclusive. Love is good and wholesome; sex is dirty and shameful. When
a man loves a woman, he can admire and respect her. However, if she has sex with
him, she must be dirty and not worthy of respect. This may cause sexual issues
within a relationship as a man tries to reconcile how to see his partner as both a
good woman and a sexual person. In an effort to maintain the Madonna view of
394 Male Sexuality
this partner, he may seek an outside affair to satisfy his need for sex without
debasing his Madonna partner. His outside affair would be with a woman labeled
a “whore.”
Researchers argue that while many of Freud’s theories are antiquated, the
Madonna-whore complex is still visible in society. The media constantly high-
lights female sexuality and encourages women to purchase products to appear
attractive and desirable to men—thus engaging the “whore” label. However,
women are also endlessly shamed for being sexual as exemplified by insults such
as “slut” used to curtail overtly sexual behavior or suggestion. Therefore, women
are expected to be both Madonnas and whores and yet are vilified for not fitting
neatly into one of those two boxes. Likewise, men continue to want both a woman
they can bring home to their family and a woman to be sexual with. As such,
Freud’s description of the Madonna-whore dichotomy as a way to describe this
dialectical conundrum is still relevant today.
Amanda Manuel
See also: Double Standards, Sexual; Female Sexuality; Feminist Theory; Freud, Sig-
mund; Gender Roles, Socialization and; Male Sexuality; Religion, Diversity of Human
Sexuality and; Slut Shaming; Social Learning Theory, Gender and.
Further Reading
Conrad, B. K. (2006). Neo-institutionalism, social movements, and the cultural reproduc-
tion of a mentalité: Promise Keepers reconstruct the Madonna/whore complex.
The Sociological Quarterly, 47, 305–331.
Hartman, U. (2009). Sigmund Freud and his impact on our understanding of male sexual
dysfunction. Journal of Sexual Medicine, 6(8), 2332–2339.
Landau, M. J., Goldenberg, J. L., Greenberg, J., Gillath, O., Solomon, S., Cox, C., Mar-
tens, A., & Pyszczynski, T. (2006). The siren’s call: Terror management and the
threat of men’s sexual attraction to women. Journal of Personality and Social
Psychology, 90(1), 129–146.
Male Sexuality
The descriptive term “male” in the phrase “male sexuality” implies that this type
of sexuality is different than the sexualities of those with female or intersex geni-
talia and the socialization that accompanies a person’s gender identity. Male sexu-
ality is often understood to mean cisgender (i.e., when a person’s assigned sex is
aligned with their gender identity; commonly abbreviated as “cis”) male sexuality.
When the prefix “cis” is left off of a term related to assigned sex or gender, the
default assumption by most people is that the person being referred to is cisgender.
This is due to the influence of heteronormative and heterosexist beliefs associated
with assigned sex, gender, and sexuality. However, as with many default assump-
tions, this is not always the case. For example, “male sexuality” can also refer to
trans men or trans males (i.e., men who were assigned female at birth but identify
as men, as opposed to men who were assigned male at birth and identify as cis
males or men). In these cases, the term “male sexuality” expands to include sexual
experiences of people who have a penis and testicles but also of those who have a
Male Sexuality 395
clitoris, vulva, and vagina. It is important to remember that while words like
“male” and “sexuality” seem easily definable, they can have widely varying mean-
ings to different people.
As mentioned above, male sexuality is typically understood to refer to the
experience of cisgender males due to the influence of heteronormativity and het-
erosexism on the way people think about masculinity and sexuality. While the
constructs of heteronormativity and masculinity are slowly expanding to be more
inclusive and less heterosexist, the fear of stigma associated with not being mas-
culine or heteronormative enough continues to be widespread. While it seems
clear that male sexuality is expanding to accommodate what were previously con-
sidered nonconforming sexual and gender expressions, it is also clear that beliefs
around heteronormative masculinity and sexuality continue to get in the way of
self-awareness and repress sexuality by reinforcing privilege and shaming sexual
exploration.
This phenomenon tends to be particularly true for males and masculine people,
who are generally expected to express their sexuality in a more heteronormative
way as compared to the expectations on females or feminine people. Males and
masculine people can get caught in a cycle of never feeling they are masculine
enough, leading to fear of exposure that they are not masculine enough, leading to
feeling shame about this fear, which loops back into fearing not being masculine
enough, and so on. Shame around the fear of never being masculine enough leads
to self-censorship, and shameful silence is the glue that holds up the mask of het-
eronormative masculinity.
Research on male sexuality indicates that sexual shame is created and main-
tained by the social constructs of heteronormativity, heterosexism, and phallocen-
tric and hegemonic masculinity. Heteronormativity leads to stigma in those with
nonconforming sexual preferences, which can result in sexual shame and mental
health issues associated with internalized stigma, including depression and
detachment from one’s identity. While today there is a variety of attitudes toward
sexual pleasure, Victorian-era sex, negativity dating back nearly two centuries,
has instilled and driven a need to control nonconforming sexuality.
Sexual shame does not originate within the individual but is created within an
individual through the internalization of social and cultural messages (via media,
academia, language, etc.) that devalue people because of who they are or who they
are not. Some people (i.e., the less privileged) are more susceptible to internaliz-
ing stigma and experiencing the resulting shame than others (i.e., the more privi-
leged). People with less privileged identities (e.g., individuals who are assigned
female at birth but identify as men or those who are gender nonconforming, non-
straight, and nonwhite) tend to be on the receiving end of social stigma more fre-
quently and consistently than are people with more privileged identities (e.g., those
who are cisgender males, heterosexual, and white). It follows that those with less
privileged identities tend to experience stigma more frequently beginning at an
earlier age than those who are more privileged, and therefore they tend to suffer
more from the mental health issues associated with shame than those who are
more privileged. Those with more privileged identities who have not been affected
by stigma, or who have experienced stigma less frequently, have been protected
396 Male Sexuality
by their privileged identities and insulated from experiencing the sexual shame
that might otherwise result from internalizing the stigma related to an atypical
sexual practice.
Research on privileged status and sexual expression shows that white males
with higher socioeconomic status (SES) can “risk” sexual expression that is con-
sidered less masculine according to heteronormative standards, because privi-
leges associated with having a higher SES can offset stigma associated with being
perceived as less masculine. Conversely, black men face stereotypes of being
hypersexual and hypermasculine, so the social cost to black men with atypical
sexualities can be higher given that they face racism and potential stigma on mul-
tiple levels. This is an example of hegemonic masculinity, which has been
described as a set of normative practices exemplified by hypermasculine authority
figures (e.g., sports and entertainment industry icons) that allow for and promote
male dominance over females and white male dominance over black males.
Though only a minority of men might want to or be able to enact these practices,
hegemonic masculinity puts men who do not comply at odds with those who do,
reinforcing a power structure among men with different social locations and
between men and other genders.
Contrary to the idea of hegemonic masculinity, male sexuality is actually more
fluid and functions as a shifting set of practices that are relative depending on
context (like social, cultural, and political location and identification). The authors
support the idea that male sexuality can and does change, given that challenges to
hegemonic masculinity (e.g., feminist resistance to patriarchy and men with atypi-
cal sexual expressions and preferences) and adjustments to those challenges are
common. The authors state that because of these challenges, hegemonic masculin-
ity takes substantial effort to maintain and requires the policing of male sexuality.
Along these lines, some argue that the deterioration of hegemonic masculinity
gives males the freedom to act in ways that have traditionally been considered
nonnormative for male sexuality. It is promising that masculinity is being exam-
ined in this way and seems to be exhibiting signs of change. However, the fear of
stigma associated with not being “masculine enough” continues to be widespread
and slow to dissipate. Some believe there is a cultural balancing of power taking
place in the subsiding of male social dominance, though it is difficult to say what
effect this will have on male sexuality.
Even though heteronormativity and heterosexism still have influence, male
sexuality has been expanding to include social interactions with different sex-
ual orientations, behaviors previously considered more feminine (e.g., sexual
passivity, emotional intimacy, and physical affection), and a decreased toler-
ance of violence. Research examining online sexual culture has found that peo-
ple are gaining a more expansive, nuanced, and multifaceted understanding of
their identities, taking factors into account like skin color, atypical sexual pref-
erences and expressions, and different types of interactions, like friendships,
romantic relationships, and hookups. The authors state that heteronormative
male sexuality no longer provides the roadmap it once did for sexual relation-
ships or lifestyle, and a broader understanding of identity is needed to embrace
a more accurate, expanded concept of male sexuality. While this growing
Male Sexuality 397
inclusivity is promising, both obvious and hidden forms of heteronormativity
and heterosexism persist in the sociopolitical privileging of heterosexuality and
masculinity.
Dulcinea Pitagora
See also: Binary Gender System; Black Sexuality; Female Sexuality; Femininity; Gender
Identity; Gender Roles, Socialization and; Heterosexism; Masculinity; Sexual Disorders,
Male; Sexual Expression.
Further Reading
Anderson, E. (2012). Shifting masculinities in Anglo-American countries. Masculinities
and Social Change, 1(1), 40–60.
Anderson, E., & McCormack, M. (2016). Inclusive masculinity theory: Overview, reflec-
tion and refinement. Journal of Gender Studies. Published online October 23,
2016.
Beasley, C. (2015). Introduction to special issue of men and masculinities: Heterodox
hetero-masculinities. Men and Masculinities, 18(2), 135–139.
Blashill, A. J., & Powlishta, K. K. (2012). Effects of gender-related domain violations and
sexual orientation on perceptions of male and female targets: An analogue study.
Archives of Sexual Behavior, 41(5), 1293–1302.
Branfman, B. A. (2015). “(Un)Covering” in the classroom: Managing stigma beyond the
closet. Feminist Teacher, 26(1), 72–82.
Connell, R. W., & Messerschmidt, J. W. (2005). Hegemonic masculinity: Rethinking the
concept. Gender & Society, 19, 829–859.
Dean, J. J. (2014). Heterosexual masculinities, anti-homophobias, and shifts in hegemonic
masculinity: The identity practices of black and white heterosexual men. The
Sociological Quarterly, 54(4), 534–560.
Dowsett, G. W., Williams, H., Ventuneac, A., & Carballo-Diéguez, A. (2008). “Taking it
like a man”: Masculinity and barebacking online. Sexualities, 11(1–2), 121–141.
Foucault, M. (1990). The history of sexuality, volume 1: An introduction. New York: Vin-
tage Books.
Hunter, A. (1993). Different door, same closet: A heterosexual sissy’s coming out party. In
S. Wilkinson & C. Kitzinger (Eds.), Heterosexuality: A feminism and psychology
reader (367–385). London: SAGE Publications.
Kimmel, M. S. (1997). Masculinity as homophobia. In M. M. Gergen & S. N. Oavis
(Eds.), Toward a new psychology of gender. London: Routledge.
Kippax, K., & Smith, G. (2001). Anal intercourse and power in sex between men. Sexuali-
ties, 4(4), 413–434.
Lehmiller, J. (2018). Tell me what you want: The science of sexual desire and how it can
help you improve your sex life. Boston: De Capo Lifelong Books.
Li, G., Pollitt, A. M., & Russell, S. T. (2015). Depression and sexual orientation during
young adulthood: Diversity among sexual minority subgroups and the role of gen-
der nonconformity. Archives of Sexual Behavior, 4(2), 1–15.
McCormack, M., & Anderson, E. (2014). Homohysteria: Definitions, context and inter-
sectionality. Sex Roles, 71(3–4), 152–158.
Pachankis, J. E. (2007). The psychological implications of concealing a stigma: A
cognitive–affective–behavioral model. Psychological Bulletin, 133(2), 328–345.
Quinn, D. M., & Chaudoir, S. R. (2009). Living with a concealable stigmatized identity:
The impact of anticipated stigma, centrality, salience, and cultural stigma on
398 Maltz Hierarchy
psychological distress and health. Journal of Personal and Social Psychology,
97(4), 634–651.
Schlicter, A. (2004). Queer at last? Straight intellectuals and the desire for transgression.
GLQ: A Journal of Lesbian and Gay Studies, 10(4), 543–564.
Maltz Hierarchy
Wendy Maltz introduced the hierarchy of sexual interaction in 1995 as a frame-
work for evaluating sexual behavior in an interpersonal context to be used in sex
education, sex addiction recovery work, and sex therapy. The model contains two
parts. The first part describes the two directions in which sexual energy can be
channeled: positive or negative. The positive direction leads toward feelings of
integration and connectedness, whereas the negative direction leads to disintegra-
tion and disconnection. The second part describes different levels of positive and
negative sexual interactions and the effects they generate on both individuals.
The Maltz Hierarchy defines sexual energy as a benign, natural force that is
influenced by innate drives and hormones. Maltz asserts that this sexual energy is
inherently neutral and describes it as a sort of hotel lobby, in that it is at ground
zero. It can be channeled in a positive direction (the “above ground” levels), lead-
ing to increased intimacy and connection, or a negative direction (the “below
ground” levels), leading to disconnection and disintegration. In both the negative
and positive direction, there are three levels that describe either increasingly
harmful or beneficial sexual interaction.
In the negative levels, sex is an upsetting or traumatic ordeal imposed on one
person by another rather than a journey that partners take together. The under-
ground levels become increasingly constricted in terms of interpersonal options,
and the negative consequences of the behavior become more intense. Disconnec-
tion and disintegration of both the perpetrator and victim increase as the levels
move more “below ground,” and victims may suffer from serious damage to their
self-image or sense of sexuality.
Level -1 is known as “impersonal interaction.” This level describes sexual
energy that is channeled in a way that leaves partners feeling misused and misun-
derstood. This level involves legal but coercive sexual interaction and failures of
communication that lead to regret, sexual shame, or physical harm. Partners may
be depersonalized or treated as sexual objects. This is often due to belief in soci-
etal myths (e.g., that sex is uncontrollable, that women should be sexually subser-
vient). Both partners may engage in dishonest or unsafe behavior, such as failing
to communicate about using protection or failing to ensure consent and enjoyment
of both partners, leading to at least one partner feeling used.
Level -2 is known as “abusive interaction.” This level describes sexual energy
and communication that is intentionally abusive and exploitative. One person acts
to control the other using psychological pressure, manipulation, or other means of
control. Examples are often illegal, such as nonviolent acquaintance rape, spousal
rape, and incest. Victims are seen as subservient and not as agents who can change
or control the sexual experience. The perpetrator of this damaging behavior uses
Maltz Hierarchy 399
humiliation, degradation, or threats as weapons to control the sexual encounter.
Perpetrators often feel entitled to sexual contact and use distorted thinking and
beliefs to rationalize the harm they are causing to victims.
Level -3 is known as “violent interaction.” At this level, which is the most dis-
integrated and disconnected in the hierarchy, the perpetrator uses all the tools of
manipulation and coercion seen in the previous level but also asserts absolute con-
trol over the victim’s body. Sexual energy is channeled into expressing rage and
hate. Perpetrators at this level see sex organs as weapons and targets and often
victimize others in a mechanical and ritualistic way. In the most extreme cases,
this involves sexual torture and serial killings.
On the upper levels, sexual energy is channeled in a way that results in mutual
choice, caring, respect, and a sense of safety. As in the negative levels, these posi-
tive traits and the feelings of intimacy increase with each level.
Level +1 is known as “role fulfillment.” This level describes sexual energy that
adheres to social norms regarding role fulfillment. This is typically based on well-
defined gender roles, where partners are following rules as to how sex is initiated
and performed and who is subservient and who is dominant. Those in the subser-
vient role may agree to sex to please the other out of a sense of duty. This is dis-
tinct from the negative levels because the subservient partner does not feel
coerced, and the dominant partner does not intentionally coerce them. Both gain a
positive sense of self as a result of fulfilling a duty or role. Staying at this level is
ultimately limiting as sex lacks creativity or passion. There is little room for
enhancing sexual pleasure or deepening emotional intimacy.
Level +2 is known as “making love.” This level describes sexual energy that is
focused on mutual pleasure and communication. There is permission and allow-
ance for both partners to experiment with what feels good and right, and both
partners share a view that sex is special and should be improved and enhanced for
both. Sex becomes a celebration of the body. At this level, both partners feel able
to reveal their true selves and feel more intimately connected. They create a bond
through sexual relating that leads to increased feelings of specialness and caring.
However, while both partners have broken free from prescribed roles, this level
can still be limiting due to the subtle pressure felt to be a “good lover.” Sexual
pleasure and orgasm may be seen as an ultimate goal.
Level +3 is known as “authentic sexual intimacy.” This level results in a shared
sense of deep connection and respect for both the other person and their body.
Both partners have an authentic and conscious intention of expressing love for the
other person through sex (rather than simply focusing on enhancing sexual plea-
sure). This level of relating can open up new dimensions in the relationship, lead-
ing to a true spiritual connection and a sense of deep safety and security. Both
know that they can stop to negotiate the sexual experience at any time without
shame or guilt. Emotional honesty and true intimacy are seen as more important
than whether both partners climax or how long the sexual encounter lasts.
The Maltz Hierarchy is a valuable tool for examining sexual interactions. It is
useful for sex education as it teaches that sexual behavior and the consequences it
creates are based on choices of individuals and couples. In sex therapy work, it
can help victims of sexual violence understand the damage caused by these events.
400 Marriage
It does not judge specific sexual acts. Spanking, for example, can be seen as
either a positive or negative behavior depending on the context in which it is per-
formed and the intent. Further, the levels are fluid in that partners can move
between them, even within the same sexual encounter.
While Maltz explicitly states that the model is intended to apply to individuals
from all sexual orientations, there is explicit use of binary gender language, leav-
ing it unclear if the model can accurately represent the sexual experiences of non-
binary or trans individuals.
On an important note, there is currently no empirical research to support the
Maltz Hierarchy, and yet there are several potentially fruitful paths here. Research-
ers might investigate the model’s claims regarding motivations, cognitions, and
psychosocial effects that exist at each level. This model will only be sustained if
research is conducted to support its claims and to expand its use.
Ed de St. Aubin, Lucas Mirabito, and Juan Pablo Zapata
See also: Intimacy, Sexual and Relational; Psychosexual Therapy; Sex Education; Sexual
Abuse.
Further Reading
Maltz, W. (1995). The Maltz Hierarchy of sexual interaction. Sexual Addiction and Com-
pulsivity, 2, 5–18.
Marriage
Marriage is present in most cultures in one form or another. It may be religious or
political and may take on many different structures, but some form of joining
people together has been present for much of history. Marriage can be defined in
legal or religious structures and may mean different things. For example, mar-
riage in a Christian context denotes a partnership between two people, tradition-
ally a man and a woman, based on a conclusion reached from interpretations of
natural law. These definitions will stem from the context in which marriage is
believed to exist (i.e., spiritual, social, or legal).
In most societies, many evolutionary biologists conclude that marriages devel-
oped as a structure in which to have children. Marriages are often viewed as per-
manent in most cultures and can take on many different structures in relation to
society.
The structure of marriage can largely be grouped into two categories: monog-
amy and polygamy. Monogamy (“mono” meaning “one,” “gamos” meaning “mar-
riage”) traditionally refers to a marriage with one partner. As society’s use of
these words developed, monogamy became used to describe a sexual relationship
in which two partners only have sexual experiences with each other. However, in
terms of a contractual marriage, it means that there is only one contract between
two people. Polygamy (“poly” meaning “many,” “gamos” meaning “marriage”)
refers to a marriage structure containing many marital contracts. This group can
further be broken down into polyandry (“andros” meaning “men”) in which a
woman is married to multiple men, or polygyny (“gyne” meaning “woman”), in
which a man is married to multiple wives. These terms were developed in a
Marriage 401
traditional gender binary and leave little room for definitions of marriages includ-
ing trans, intersex, and genderqueer individuals. Less common marital structures
include group marriages (many people living together, considering themselves
married) or common-law marriages (a legal default of long-term couples cohabi-
tating). While common-law marriage is a common experience, not all states in the
United States recognize it, and thus it is less often considered in the marriage
discussion.
Some psychologists and sociologists will further clarify marriages into marital
typologies. The nature of the typology may depend on the particular focus of the
scholar making the distinction. For example, whether a wife is considered prop-
erty of the husband (despotic marriage type) or if husband and wife are viewed as
equals (democratic marriage type) can be a marital type based on the role of the
wife and power. The distinction of a marriage based on a wife and political power
is a more economic distinction, while relationship dynamics between the couple
guide most of the marital typology today. More recent marriage and relationship
scholars like John Gottman identify types of stable marriages and what makes a
couple work. Through his studies, Gottman found five marriage types: validating,
volatile, conflict-minimizing, hostile, and hostile-detached. The validating, vola-
tile, and conflict-minimizing couples were most stable and least likely to divorce,
while the hostile and hostile-detached couples were more likely to divorce.
Many cultures and religions observe marital ceremonies differently. Some reli-
gious ceremonies involve expressing love before a divine being or deity, accompa-
nied with some rituals meaningful to that particular community. Whether the
ritual involves a hand wrapping, gifting of a symbolic token to the marital parties,
the giving of a dowry, a sacrifice, or a donation, the meaning of such a ritual exists
in nearly every type of culture and society. The underlying theme from all these
ceremonies is the expressed new status of members being wed. Many ceremonies
involve a change in appearance, such as clothing, which can also have a symbolic
meaning. There is often a change in social status and living situation of the indi-
viduals being married (often called a bride and groom).
Marriage ceremonies also have a familial component. Whether the burden is
financial or symbolic, it is a common cultural tradition that the families of the
bride and groom are involved in a certain way. Even religious ceremonies of the
same denomination can change based on geographic location of the families or
simply family traditions.
In the United States, the legal structure of marriage is based on the Christian
tradition, often requiring an official (of the state or religious clergy member recog-
nized by the state) and at least two witnesses to be present. All states require that
a couple obtain a marriage license, and the requirements for this may vary. Some
states require sexually transmitted infection tests for couples about to wed or have
regulations on who can marry whom (i.e., the closeness of relatives may affect
their ability to marry depending on the state).
In many cultures, sex and sexuality are tied to marital contracts. The production
of children can be seen as part of this marital contract. The conception of children
outside of this contract may be seen as “infidelity” or a breach of this contract.
Consequently, many monogamous marriages see sexual activity with other people
402 Marriage
who are not part of the marriage as sexually immoral. This experience is often
termed “extramarital sex.” In the United States, marriage may be seen as the only
socially acceptable platform for sexual activity by some groups and people.
In most cultures, there are sexual components built into the expectation of mar-
riage. Components of virginity, fertility, children, frequency of sexual activity,
sexual satisfaction, or sexual taboos are often present in subtle or overt discus-
sions of marriage. For example, in some Mediterranean cultures, it is appropriate
to display a bloody sheet after the marital sexual encounter (often called the con-
summation of a marriage) to show the breaking of a hymen and prove the virgin-
ity of a wife. Other Christian cultures have expectations of children and may even
mandate that a couple procreate. Other cultures, such as Hinduism and Judaism,
may have specific guidelines on how sexual pleasure can be given or how often it
should be sought.
Not only are these components present in the expectation of marriage, but they
are also an integral part of the language we use to discuss marriage. For example,
“gamos,” the Greek word for marriage, is also the root of the word “gamete,”
another name for the reproductive cells (sperm and egg). This gives us an idea of
the intersection of the naming of cells and the role of sex and marriage in society.
As mentioned above, virginity is often closely tied to marriage during discus-
sion of sexuality. Virginity can be defined in many different ways. Research has
looked for a consensus, but a specific and consistent definition among various
groups has not been identified. While varying definitions exist, the theme revolves
around vaginal-penile intercourse. This reality, however, may create a social
stigma based on the inferiority of women. In one qualitative study, researchers
asked midwives about virginity control and hymen reconstruction (a process by
which a female-bodied person may seek surgical measures to rebuild a hymen to
portray virginity) and identified three themes. These themes included the recogni-
tion of misogynistic practices that reinforce the gendered order, the desire to raise
awareness of these practices that demean women based on this order, and the idea
of promoting autonomy in women and providing culturally sensitive care. The
study concluded that the concept of virginity is closely tied to the concept of the
patriarchy. The article suggests various types of activism, such as international
debates and interdisciplinary cooperation, may assist in increased gender equality.
An important note is that the hymen can break from various other activities, such
as intense exercise or riding a bicycle, and it is not indicative of one’s virginity
status. Though it has been long believed to be related to sexual purity, current
research claims otherwise.
Mark A. Levand
See also: Adultery; Extramarital Sex; Fertility; Intercourse; Marriage, Cross-Cultural
Comparison of; Monogamy; Open Marriage; Polygamy; Polygyny; Premarital Sex; Reli-
gion, Diversity of Human Sexuality and; Unconsummated Marriage; Virginity.
Further Reading
Adams, J. A., Botash, A. S., & Kellogg, N. (2004). Differences in hymenal morphology
between adolescent girls with and without a history of consensual sexual inter-
course. Archives of Pediatrics & Adolescent Medicine, 158(3), 280–285.
Marriage, Cross-Cultural Comparison of 403
Bersamin, M. M., Fisher, D. A., Walker, S., Hill, D. L., & Grube, J. W. (2007). Defining
virginity and abstinence: Adolescents’ interpretations of sexual behaviors. Jour-
nal of Adolescent Health, 41(2), 182–188. doi: 10.1016/j.jadohealth.2007.03.011
Christianson, M., & Eriksson, C. (2015). Promoting women’s human rights: A qualitative
analysis of midwives’ perceptions about virginity control and hymen “reconstruc-
tion.” European Journal of Contraception & Reproductive Health Care, 20(3),
181–192. doi: 10.3109/13625187.2014.977435
Gottman, J. M. (1993). The roles of conflict engagement, escalation, and avoidance in
marital interaction: A longitudinal view of five types of couples. Journal of Con-
sulting and Clinical Psychology, 61(1), 6.
Gottman, J. M. (1999). The marriage clinic: A scientifically-based marital therapy. New
York: W. W. Norton & Company.
Hans, J. D., & Kimberly, C. (2011). Abstinence, sex, and virginity: Do they mean what we
think they mean? American Journal of Sexuality Education, 6(4), 329–342. doi:
10.1080/15546128.2011.624475
Hegazy, A. A., & Al-Rukban, M. O. (2012). Hymen: Facts and conceptions. The Health,
3(4), 109–115.
Marriage, Cross-Cultural Comparison of
Marriage is the union of two people in a socially or formally recognized manner,
establishing legal rights and obligations between them. In many cultures, mar-
riage requires a legal contract; in others, a marriage can be recognized socially
without the involvement of a legal document or ceremony. Throughout the twenti-
eth century, marriage laws have changed around the world to allow people of dif-
ferent races or religions to marry and to limit or forbid child marriages, forced
marriages, and polygamy. Most recently, the definition of marriage in some cul-
tures has shifted to include same-sex couples—notably in the United States, where
the U.S. Supreme Court ruled on June 26, 2015, that same-sex couples have a
constitutional right to marry.
The purpose of marriage has changed significantly over the course of recent
centuries. In ancient and medieval times, throughout much of the world, marriage
was used to form alliances between families, accumulating property and skills to
strengthen a family’s position and to perpetuate their well-being. As wealth and
prosperity became elements of power within civilizations, marriages were
arranged to form unions between wealthy families, accumulating resources and
effectively keeping out those who were “beneath their station.” Marriage became
a strategy rather than an act of love, even to the point of creating political capital
by matching a man and a woman from powerful families.
In predominantly rural, preindustrial societies in Europe and Asia, most young
people married before they were out of their teens, becoming part of extended fam-
ilies that shared responsibility for tending the land and livestock. From the Middle
Ages until the 1700s, families in many European countries required a potential
wife to buy her husband with a dowry—a collection of money, property, and other
goods that added to the man’s wealth and influence. People in the lower classes also
considered these issues, even if there was no official dowry—marrying to merge
404 Marriage, Cross-Cultural Comparison of
adjoining tracts of land, bring goodwill to their homes from other families, or gain
skills from which the combined families could benefit. Marriage was viewed as a
business transaction or a negotiated contract.
The modern cultural view of marriage for love did not emerge until the late
eighteenth century, when it took hold in the United States and western Europe.
The concept rose from a desire to find personal satisfaction and fulfillment from
the choice of a mate rather than basing the decision to marry solely on financial
and social gain.
In the 1950s and 1960s, marriage in the United States became idealized as a
union between a male breadwinner and a female homemaker, a structure that
emerged in earnest after World War II. With the advent of the women’s liberation
movement of the 1970s and 1980s, two-income families became the new norm,
and women even emerged as family breadwinners in the 1990s. By 2002, accord-
ing to the U.S. Bureau of Labor Statistics, one in three married women in America
earned more money than her husband.
Marriage practices around the world have been defined first by traditional reli-
gious values and more recently by the realities of everyday life, especially as rural
communities have been replaced by cities and industry. Many countries have
passed laws in the twentieth and twenty-first centuries that limit or forbid tradi-
tions that violate basic human rights.
In the Middle East and North Africa, for example, the common practice of mar-
rying early—especially for women in their teens—has given way in recent years
as the population in these countries moves to the cities. The Population Reference
Bureau reports that women are marrying later, in their twenties and thirties, and
only 1–4 percent of women ages fifteen to nineteen are married in Tunisia, Alge-
ria, and Lebanon, countries that promoted teenaged marriage in the twentieth cen-
tury. Families in Egypt and other Middle Eastern countries require a dowry from
the groom in many cases, half of which is held in reserve to use in a settlement if
the couple should seek divorce.
In China, passage of the 1980 New Marriage Law gave people the freedom to
choose their own marriage partner rather than relying on parents and others to
choose a spouse for them. The law forbids coercion into marriage by third parties,
establishes gender equality between a husband and wife, and prohibits abuse and
desertion by either spouse. Until 2015, China also exercised a policy of one child
per marriage (with many exceptions) and two children if the first one is a girl. As
a result of this devaluation of female children, some couples aborted their female
babies once they discovered the gender of the fetus. This practice, exercised since
the law’s passage in 1979, created a significant shortage of women to marry the
eligible men—with unmarried men outnumbering unmarried women by million
in 2013. Since 2016, China has changed the policy to a two children per marriage
policy.
In Latin American countries, many young couples have opted to live in consen-
sual unions with their partners rather than formalizing their relationship with
marriage. In Colombia, El Salvador, Honduras, and Ecuador, as much as 20 per-
cent of the population age fifteen and over lives in consensual unions as opposed
to less than 5 percent in the United States, according to the United Nations
Masculinity 405
Statistics Division’s Demographic Yearbook. This predominantly Roman Catholic
region of the world does not view divorce as an option for ending a marriage, so
divorce was illegal in countries including Brazil and Argentina until as recently as
1987. Fewer than one in one thousand people are divorced in most Latin American
countries.
The complexities of marriage in India date back to before the evolution of Hin-
duism, but the modern era has brought the subjugation of women and the practice
of teenage marriage largely to an end in South Asia. Arranged marriages are still
prevalent, but both people must consent to the marriage, and they have the right to
refuse the match. Many couples meet on their own and decide that they will marry
and then go through the rituals of arranged marriage to create lasting bonds
between their extended families. The actual rituals and traditions vary by region
throughout the country, but they often involve a “sponsor,” a relative who may
bring in a professional matchmaker to help identify the best candidates for mar-
riage. While this system may seem archaic, it does result in one of the lowest
national divorce rates in the world: only 1.1 percent of marriages in India end in
divorce. (Compare this with 45.8 percent in the United States.)
Marriage traditions in Africa differ distinctively from one group of people or
region to the next, but some themes can be found throughout the continent. Afri-
can brides are considered the link between the ancestors and the children yet to be
born, so they are trained from a young age to prepare for the responsibilities of
marriage. The marriages themselves are often negotiated between families, and in
some cultures the bride and groom have never met before the wedding day arrives.
In Sudan, the woman must bear two children before the marriage is considered
completed, while the Wodabee of Niger choose their own cousins for marriage. In
Ethiopia, the Amhara people permit a temporary marriage, in which the bride
moves in with the groom and receives a housekeeper’s wages while she performs
the duties of a wife—including bearing children. This form of marriage can move
to permanent status by agreement between the spouses.
Randi Minetor
See also: Civil Union; Dating, Cross-Cultural Comparison of; Marriage; Monogamy;
Open Marriage; Polyamory; Same-Sex Marriage.
Further Reading
Coontz, S. (2006). Marriage, a history: How love conquered marriage. New York:
Penguin.
Stockard, J. E. (2002). Marriage in culture: Practice and meaning across diverse societ-
ies. Belmont, CA: Wadsworth Publishing Company.
Masculinity
Masculinity is the set of traits, attributes, behaviors, and roles traditionally associ-
ated with men or manhood of a given culture; however, these qualities are distinct
from biological sex and therefore can be exhibited by persons of any sex or gen-
der. Traditional Western forms of masculinity surround notions of stoicism, inde-
pendence, and virility. Some visions of model manhood also include culturally
406 Masculinity
specific milestones (e.g., the onset of facial hair, loss of virginity, tribal warrior
rituals, bar mitzvahs) as well as more universal notions, such as producing and
providing for offspring.
During the late 1980s and early 1990s, social theory exploring the context of
masculinity gained substantial attention. Particularly, feminist and gender theo-
rists examined the conventional expectations and roles associated with gender
identities. Theorists such as Michel Foucault, Kate Bornstein, John Money, Anne
Fausto-Sterling, and Leslie Feinberg explored various parts of gender identity
development including biological, psychological, sociological, and philosophical
considerations. Although their respective opinions may vary on the significance
of biological predisposition, it is generally accepted that rigid masculine social
scripts are upheld by both implicit and explicit guidelines imposed to replicate a
socially constructed cultural ideal of manhood. In other words, masculinity is not
inherent or established by a single milestone but contingent on ongoing displays of
masculinity, whatever they may be according to any given culture.
While many cultures have historically acknowledged varying forms of gender
expression, traditional Western views generally promote the notion of a binary
gender system (i.e., “man” or “woman”). This is where the idea of femininity as
the complete opposite of masculinity stems from. Systems divided into two cate-
gories such as this imply a polarized “opposition,” which means that to be one is
to not be the other. Incidentally, rigid social scripts (of any kind) that are more
focused on exclusionary criteria ultimately limit the potential for adequate script
fulfillment by way of creating more room for criticism and failure than success.
Modern examples regarding masculinity often include “real men do not cry,” “real
men are aggressive,” “real men are the head of their household,” and many other
similar narratives. An overemphasis of exclusion as fundamental criteria pro-
motes an inflexible and uniform expression of masculinity known as “hegemonic
masculinity.” When these strict “masculine” traits are overidealized and assumed
to be a complete opposite to “feminine” traits, a hierarchy of social measure is
established that devalues feminine expression and female persons, such as exhib-
ited in patriarchal societies. In Latin America, the term “machismo” is used to
describe the phenomena of a patriarchal masculine pride that denigrates feminin-
ity, particularly in Latino communities. Like many other forms of hegemonic
masculinity, machismo explicitly deems feminine traits as undesirable and a
direct deviation from masculine performance. It can easily be seen how these
social constructs would be problematic to the social position of women in any
given culture where they may be present. That is not to say men do not face alien-
ation or injustice under patriarchal authority or that healthier and more flexible
expressions of masculinity do not (and cannot) exist; in fact, academic exploration
of masculinity studies support that they do indeed.
Preoccupation with a singular version of manhood ignores the great variance of
masculine expression both cross-culturally and cross-historically. Normative
Westernized models of masculine ideals tend to overlook or actively invalidate
experiences of those who do not meet all the expectations of hegemonic masculin-
ity, such as male persons who are not heterosexual, able-bodied, cisgender, or of
Masculinity 407
heritage other than the predominant race. This can be seen in typical models of
masculinity that do not include homosexual men (due to heterosexist and homo-
phobic assertions of gay men as feminine), disabled men (according to expecta-
tions of physical prowess and exceptional fertility), transgender men (due to their
assigned sex at birth), as well as people of color often navigating additional and/or
conflicting masculine scripts. Specifically, people of color are often subject to ill-
fitting or contradictory masculine scripts and prejudices that their white counter-
parts are not. Such can be seen among American stereotypes that emasculate
Asian and East Asian men, who may adhere to masculine expressions more tradi-
tional to their own cultural heritage, and the stereotypes that hypersexualize black
and Latino men, painting them as dangerously masculine. Therefore, modern
Westernized interpretations of masculinity are often innately exclusionary and/or
unattainable for many. Historically speaking, these modern constraints remain
suspect even when limited to the experience of white males. Although the nine-
teenth century white European “dandy,” a docile and educated man of the upper
class, would be deemed effeminate by modern standards, it was the ideal of mas-
culine sophistication in its day. While several historical models of masculinity
may have remained somewhat preserved, such as “the warrior” and “the family
man,” there are apparent limitations regarding who can “be a man” and how they
may do it.
Ultimately, the definition of “masculinity” is subject to the culture in which it
exists as well as direct circumstance. Although typically associated with men,
social constructionism recognizes the essence of masculinity to be rooted in per-
formance and not biology. Once again, this indicates that it is not inherently related
to the male sex or gender but contingent on the active expression of culturally
designated attributes. Just as one must commit acts of kindness to be deemed
kind, one must act under the scripts of masculinity to be deemed masculine.
Ilyssa Boseski
See also: Binary Gender System; Black Sexuality; Bornstein, Kate; Cisgender; Fausto-
Sterling, Anne; Feinberg, Leslie; Femininity; Feminist Theory; Foucault, Michel; Gen-
der; Gender Identity; Gender Roles, Socialization and; Heterosexism; Heterosexuality;
Homophobia; Homophobia, Internalized; Homosexuality; Male Sexuality; Money, John;
Sexism; Stereotypes, Sexual; Transgender.
Further Reading
Butler, J. (2004). Undoing gender. New York: Routledge.
Cortes, J. (2014). Macho ethics: Masculinity and self-representation in Latino-Caribbean
narrative (Bucknell studies in Latin American literature and theory). Lewisburg,
PA: Bucknell University Press.
Fausto-Sterling, A. (2012). Sex/gender: Biology in a social world. New York: Routledge
Taylor & Francis Group.
Foucault, M. (1978). The history of sexuality: An introduction. New York: Pantheon
Books.
Kimmel, M. S., & Messner, M. A. (2012). Men’s lives (9th ed.). New York: Pearson.
Plante, R. F., & Maurer, L. M. (2010). Doing gender diversity: Readings in theory and
real-world experience. Boulder, CO: Westview Press.
408 Mastectomy
Mastectomy
Mastectomy is the surgical removal of a breast. The main reason that this proce-
dure is performed is to treat people who have breast cancer by removing breast
tissue and, thereby, preventing the cancer from spreading to other tissues and
organs in the body. Some people get a mastectomy to prevent the development of
breast cancer. Those individuals usually know that they have certain gene muta-
tions that raise the risk of breast cancer development, or they know that other
women in their family have had breast cancer. Such procedures are known as
prophylactic mastectomies.
There are different types of mastectomies that can be performed after a cancer-
ous tumor is discovered in the breast. Such discoveries are usually made with an
x-ray procedure called a mammogram. The type of mastectomy performed in any
case depends on the size and location of the tumor, the extent to which the cancer
might have spread, and the age and general health of the patient. A simple, or total,
mastectomy involves removal of the entire affected breast, often including the
overlying skin. A double mastectomy involves removal of both breasts. In a sub-
cutaneous mastectomy, the underlying breast tissue is removed, but the skin and
nipple are preserved. In a conventional radical mastectomy, the breast is removed
along with the lymph nodes under the arm and the muscles in the chest wall. In a
modified radical mastectomy, the breast and the underarm lymph nodes are
removed, but the muscles of the chest wall are left intact.
Modified radical mastectomies have been the most common type of breast can-
cer surgery since the 1970s. Before that, conventional radical mastectomies were
more common. However, the conventional type of surgery leaves the body severely
disfigured as a result of the removal of chest muscle. Furthermore, the individual
may be unable to use their arm after the surgery. Modified radical mastectomies
have been shown to be just as effective at removing cancer as the conventional
procedure, and the person keeps the use of the arm and can have the breast more
easily reconstructed. A typical modified radical mastectomy lasts two to three
hours, during which time the patient is under general anesthesia. The patient is
typically in the hospital for no more than three days.
Breast reconstruction is a surgical procedure in which the removed breast tis-
sue is replaced with natural tissue taken from other parts of the body or with an
artificial implant. The implant consists of a soft silicone shell filled with either
silicone gel or saline (salt water). It is positioned beneath the chest muscle. Some
people choose to have breast reconstruction during the same operation in which
the breast is removed. However, doctors may recommend waiting several months
to undergo reconstruction. Healing from immediate reconstruction could lead to
delays in radiation treatment or chemotherapy for those who would benefit from
such therapies after surgery. Those who do not wish to undergo breast recon-
struction can wear a breast prosthesis, which is an artificial breast placed inside
a bra.
In some cases, breast cancer may not need to be treated with a full mastectomy
for successful treatment. If the mammogram reveals only a limited area of cancer
inside the breast, the tumor, along with a small amount of surrounding tissue and
the underarm lymph nodes, can be removed in a procedure called a lumpectomy,
Masters, William H. 409
or partial mastectomy. The rest of the breast is preserved and treated with radia-
tion to kill any cancer cells that might remain inside. Lumpectomy is usually con-
sidered only if the tumor is smaller than two inches (five centimeters). Cancer may
return after some lumpectomies—and even after some mastectomies. Some peo-
ple who are good candidates for lumpectomy because of their small tumor size
may still choose to undergo a full mastectomy because it provides a greater chance
that all the cancer will be removed.
There are several additional reasons that a mastectomy may be performed.
Trans men may choose to have a double mastectomy as part of their gender transi-
tion process. Boys or men may also choose to undergo mastectomy if they have a
condition called gynecomastia, in which male breast tissue swells to resemble
female breasts. This condition is caused by a hormone imbalance or the use of
certain drugs.
Many well-known women have had mastectomies. Actress Angelina Jolie
chose to have a double mastectomy, followed by reconstructive surgery, in 2013.
Jolie did not have breast cancer at the time; however, she feared that such cancer
would eventually develop, because she had a close family history of breast cancer,
and genetic tests showed that she had the BRCA1 gene mutation, which is known
to increase risk. Mutations in the BRCA2 gene are also associated with breast
cancer.
A. J. Smuskiewicz
See also: Breast, Female; Breast Cancer; Gender Transition.
Further Reading
Breastcancer.org. (2019). Mastectomy. Retrieved from http://www.breastcancer.org/
treatment/surgery/mastectomy
Lesh, M. (2013). Let me get this off my chest: A breast cancer survivor over-shares. West
Covina, CA: StoryRhyme.com Publishing.
Lucas, G. (2005). Why I wore lipstick to my mastectomy. New York: St. Martin’s Griffin.
Masters, William H.
William Howell Masters (1915–2001) was a world-renowned gynecologist who
devoted his career to the sexual function of humans. Dr. Masters was born on
December 7, 1915, in Cleveland, Ohio. Along with his research partner, Virginia
Johnson, he helped revision sex therapy and sex education in the United States. He
pioneered research into the nature of the human sexual response and the diagnosis
and treatment of sexual disorders and dysfunctions.
Dr. Masters attended Lawrenceville School in New Jersey and afterward went
to Hamilton College in Clinton, New York, where he graduated in 1938 with his
bachelor’s degree. He then enrolled at the University of Rochester Medical School.
During medical school, he worked under his mentor, Dr. George Washington Cor-
ner, who introduced Masters to reproductive research. Once he graduated with his
medical degree, he opted to focus on studying the physiology of sex in humans
due to this being an under researched area at the time and one he felt would be
challenging.
410 Masters, William H.
After graduation, Dr. Masters moved to St. Louis to start a career in obstetrics
and gynecology at St. Louis Maternity Hospital and Barnes Hospital. In 1944, he
also began studying pathology at Washington University School of Medicine. Then,
in 1947, he joined the faculty of the Washington University School of Medicine,
where he became a specialist on hormone replacement therapy for aging women.
In 1954, Dr. Masters started his research into human sexuality. In 1956, he
added his coresearcher, Virginia Johnson. Their research was extremely contro-
versial for the time. Masters and Johnson would watch clients who presented with
sexual dysfunctions have sex. They also used cameras and electronic devices to
gain even more data from their research. For example, they were able to place
cameras inside a plastic phallus to see the physiological responses of the vagina
during stimulation. As a result of directly observing anatomical and physiological
sexual responses, they were able to develop a different method for the treatment of
sexual dysfunctions. In 1959, the duo started to counsel individuals with sexual
difficulties, and they formed a specific approach to sex therapy, which they later
taught to other clinicians at the Masters and Johnson Institute. They developed the
therapy technique of sensate focus and showed that 80 percent of clients they
treated with their approach experienced a long-term resolution of sexual dysfunc-
tion. Masters’ research focused on the mechanics of sex and the moral reasoning
behind it, which often led him down controversial paths. However, with this, Mas-
ters and Johnson were able to help make sex therapy popular in the United States.
Masters and Johnson published their first research on the human sexual response
cycle in a book aptly named Human Sexual Response in 1966. In this book, they
described a four-stage model of the sexual response cycle: (1) excitement, (2) pla-
teau, (3) orgasm, and (4) resolution. In 1970, they published Human Sexual Inade-
quacy, which discussed treatment for premature ejaculation, erectile dysfunction
(impotence), and the inability to experience orgasm. Both books were aimed at a
medical audience but became best sellers among the general public as well.
Dr. Masters retired in 1994 and closed down the Masters and Johnson Institute.
Dr. Masters was married three times, including once to his research partner, Vir-
ginia Johnson. In his first marriage, he had two children. Dr. Masters passed away
on February 16, 2001, in Tucson, Arizona, from Parkinson disease at the age of
eighty-five.
Amanda Baker
See also: Hormone Replacement Therapy; Johnson, Virginia; Masters and Johnson Four-
Stage Model of Sexual Response; Sensate Focus; Sexology; Sexual Dysfunction, Treat-
ment of; Start-Stop Technique.
Further Reading
Bullough, V. L. (1994). Science in the bedroom: A history of sex research. New York:
Basic Books.
Kinsey Institute, Indiana University. (2019). Masters and Johnson collection. Retrieved
from https://kinseyinstitute.org/collections/archival/masters-and-johnson.php
Masters, W. H., & Johnson, V. E. (1966). Human sexual response. New York: Bantam
Books.
Masters, W. H., & Johnson, V. E. (1970). Human sexual inadequacy. New York: Bantam
Books.
Masters and Johnson Four-Stage Model of Sexual Response 411
Masters, W. H., & Johnson, V. E. (1974). The pleasure bond. New York: Bantam Books.
Masters, W. H., & Johnson, V. E. (1979). Homosexuality in perspective. New York: Ban-
tam Books.
Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1977). Ethical issues in sex therapy and
research. Boston: Little, Brown and Company.
Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1986). Masters and Johnson on sex and
human loving. Boston: Little, Brown and Company.
Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1994). Heterosexuality. New York:
Gramercy Book.
Severo, R. (2001, February). William H. Masters, a pioneer in studying and demystifying
sex, dies 85. New York Times, p. B7. Retrieved from https://www.nytimes.com/
2001/02/19/us/william-h-masters-a-pioneer-in-studying-and-demystifying-sex
-dies-at-85.html
Masters and Johnson Four-Stage Model of Sexual Response
In 1957, William H. Masters and Virginia E. Johnson as a team began researching
human sexual response, dysfunction, and disorders at the Department of Obstet-
rics and Gynecology at Washington University in St. Louis. They were influenced
by growing public and educational support that medicine should consider sexual-
ity. In their words, “if the problems in the complex field of human sexual behavior
are to be attacked successfully, psychologic theory and sociologic concept must at
times find support in physiologic fact” (Masters & Johnson, 1966). To do this,
they used direct observation of anatomical and physiological sexual responses of
humans. Their earliest research culminated in 1966 with the publication of their
book Human Sexual Response.
Masters and Johnson owed some of their interest in sexology to Alfred Kinsey.
Between 1930 and 1952, Kinsey compiled statistics reflecting patterns of sexual
behavior in the United States. This work was of great sociological value, but it
could not be used to interpret physiological or psychological response to sexual
stimulation. Realizing this, two basic questions formed the basis for Masters and
Johnson’s research program: (1) What physical reactions develop as people
respond to effective sexual stimulation? (2) Why do people behave as they do
when responding to effective sexual stimulation? In other words, the intent of the
questions was to create a foundation of basic scientific information. They were not
trying to answer why men and women respond as they do. Furthermore, they real-
ized that their lab and clinical research populations were insufficient representa-
tions of the general population for drawing definitive conclusions.
Their 1966 work was based on the observations of 10,000 sexual response
cycles. The observations were not limited to intercourse with a partner. Three-
quarters of the cycles observed were of heterosexual women, while 2,500 were of
heterosexual men. In their 1979 work, Homosexuality in Perspective, Masters and
Johnson reported observations of 1,200 response cycles of eighty-two homosexual
women and ninety-four homosexual men. Through their research, they deter-
mined that a more concise picture of physiological reactions to sexual stimuli
could be accomplished by dividing the human male and female cycles of sexual
412 Masters and Johnson Four-Stage Model of Sexual Response
response into four separate phases. These phrases are (1) excitement, (2) plateau,
(3) orgasm, and (4) resolution. The phases were intended to be a framework for a
detailed description of physiological variations in sexual reactions. They were not
built as a finalized theory but as a basis for categorization and developing scien-
tific theory.
With this framework in place, they identified many variations in male sexual
response. Those variations primarily differed in terms of duration rather than
intensity. As a result, they found only one general sexual response pattern for
males. For females, intensity and duration mattered. Specifically, three sexual
response patterns were identified for females. These responses were not affected
by sexual orientation or the nature of the sexual activity (e.g., masturbation, part-
nered activity). The source of sexual stimulation (e.g., tactile or psychological)
also did not matter (Masters & Johnson, 1966).
The sexual response cycle has the same four phases for all people. In the first
phase, the excitement phase, sexual response develops from any source of tactile or
psychological stimulation. The pelvic region fills with an increased supply of blood
and other fluids; breathing, heart rate, and blood pressure increase; and the skin may
flush. Myotonia (increased muscle tension) and vasocongestion (engorgement of
blood vessels) also occurs. In females, the vagina produces a lubricant, the clitoris
swells, breasts enlarge, and the cervix and uterus move upward. In males, the testes
swell, the penis grows erect, and the scrotum tightens. If there is enough stimulation
for an individual, the intensity of response increases rapidly. This allows the excite-
ment phase to be lengthened or shortened. If the stimulation is physically or psycho-
logically objectionable, or interrupted, the phase may lengthen or even end.
If effective simulation continues, the person enters the plateau phase. Sexual
tensions are intensified and eventually reach an extreme level just before an
orgasm. Muscle spasms may begin in the feet, face, and hands. The tip of the
penis may increase in size and darken in color, and the Cowper’s gland may
secrete lubricating fluid. The outer labia darken as well and the outer passageway
of the vagina narrows. In addition, testes withdraw into the scrotum in males, and
the clitoris retracts under its hood in females. The length of this phase depends
largely on the effectiveness of the stimuli combined with individual drive for sex-
ual tension to increase. If either the stimuli or the drive is inadequate, the indi-
vidual will fall into a prolonged resolution phase.
If sufficient stimulation is present, the subsequent phase is the orgasmic phase.
This phase is limited to the few seconds when the vasocongestion and myotonia
from sexual stimuli are released. These contractions occur at the base of the penis
for men, while in females, the vaginal muscles and uterus contract. This rate slows
down after five to twelve contractions in females and after three to four in males.
Such an involuntary climax represents the maximum sexual tension of a particu-
lar encounter. Contractions occur at a rate of one every 0.8 seconds. Sensual
awareness of an orgasm is focused on the pelvis. For females, the focus is concen-
trated on the clitoris, vagina, and uterus. For males, the focus is concentrated on
the penis, prostate, and seminal vesicles. The female orgasmic experience varies
greatly in terms of intensity and duration, while the male experience tends to fol-
low the pattern of ejaculation with less individual variation. Total body involve-
ment is experienced depending on the individual’s reaction pattern.
Masters and Johnson Four-Stage Model of Sexual Response 413
After the orgasm is the resolution phase. In simple terms, the resolution phase
is an involuntary reverse reaction pattern that returns an individual through the
plateau and excitement levels of stimulation into an unstimulated state. Muscles
begin to relax. Females have the potential to reach the orgasmic phase from any
point in the resolution phase as long as there is effective stimulation again. Males
have a refractory period, which might extend the resolution phase in terms of
lower excitement levels. Only after the refractory period can a male reach higher
levels of sexual tension. A male’s physiological ability to respond to stimulation
again is much slower than a female’s, with only a few exceptions. Sexual tension
only completely dissipates when all sexual stimuli have stopped.
Masters and Johnson made sure to emphasize that individual variation in the
duration and intensity of every physiological response is wide. They went as far as
to say that their four-phase model is not able to evaluate psychological aspects of
elevated sexual tension. However, they also said that the model provides a struc-
ture for investigation and ensures the correct placement of physiological responses
within a sequential continuum. Some researchers have said that such a linear
model primarily reflects a male response cycle, while a nonlinear model may bet-
ter reflect a female response cycle.
To be sure, there are clear differences of anatomy between the sexes as well as
the already stated differences in duration and intensity patterns. Yet, in Masters
and Johnson’s book, they recognize a number of direct parallels in sexual response
between the sexes and emphasize the similarities between the sexes more than the
differences. That is, the mechanisms of arousal for males and females are similar:
vasocongestion and myotonia, engorgement of blood vessels, and increased blood
flow into tissue.
Masters and Johnson’s work helped dispel widely held beliefs of the time: that
women experience different sorts of orgasms and that only men seek sexual satis-
faction. They also dispelled the belief that homosexual and heterosexual satisfac-
tion are fundamentally different, because orgasmic frequency was comparable for
both.
The four-phase model of sexual response had a major impact on sexology
research, yet it was only the beginning. For Masters and Johnson, definitive data
on sex would only “become available as the mores of our society come to accept
objective research in human sexuality” (Masters & Johnson, 1966). Complete and
definitive data is perhaps growing today, while pharmaceutical companies and
psychiatric and mental clinicians use their model to define sexual health and sex-
ual problems.
Louis Varilias
See also: Afterplay; Arousal; Foreplay; Johnson, Virginia; Kaplan’s Triphasic Model; Kin-
sey, Alfred; Masters, William H.; Orgasm; Sexual Desire Model; Sexual Satisfaction.
Further Reading
Kinsey Institute. (2018). Masters and Johnson collection. Retrieved from https://
kinseyinstitute.org/collections/archival/masters-and-johnson.php
Masters, W. H., & Johnson, V. E. (1966). Human sexual response. Boston: Little, Brown.
Masters, W. H., & Johnson, V. E. (1970). Homosexuality in perspective. Philadelphia: Lip-
pincott, Williams & Wilkins.
414 Masturbation
Our Bodies Our Selves. (2011). Models of sexual response. Retrieved from https://www
.ourbodiesourselves.org/book-excerpts/health-article/models-sexual-response/
USBC SexInfo. (2019). The sexual response cycle. Retrieved from http://www.soc.ucsb
.edu/sexinfo/article/sexual-response-cycle
Masturbation
Masturbation is the touching and stimulation of one’s own genitals and other body
parts for the purpose of sexual pleasure. Fingers as well as sex toys, such as vibra-
tors and dildos, may be used in masturbation. Masturbation may or may not
include orgasm or ejaculation. According to most physicians and psychiatrists,
masturbation is a common, natural, generally harmless, and potentially beneficial
activity. However, many people feel guilt and shame over the practice as a result
of religious beliefs or other ideas regarding morals and ethics. In some cultures
and societies, masturbation is strongly condemned as sinful and immoral.
Masturbation is somewhat more common among men than women. In one
major U.S. study, 95 percent of men said that they have masturbated at least once
compared with 89 percent of women. The percentages of adults who masturbate
on a regular basis are estimated to be about 70 percent for men and 50 percent for
women.
Children and adolescents also masturbate. Although masturbation is usually
associated with sexual self-satisfaction, children may begin masturbating long
before they reach puberty. If this occurs, motivation is likely to be curiosity, self-
exploration, and self-soothing rather than sexual in nature. Masturbation typically
increases greatly in frequency after puberty before leveling out—in many, but not
all, people—during the twenties or thirties.
People may masturbate for different reasons. It is a way to experience sexual
pleasure when a partner is not available—though some statistics suggest that peo-
ple who do have regular sex partners masturbate more often than those who do not
have partners. Masturbation is also a way to relieve stress and tension and to relax.
To help them masturbate, people usually think of or look at erotic, sexual imag-
ery, such as pornographic photographs or videos or memories of a previous sexual
encounter. People with penises often stimulate the penis, scrotum, perineum (the
area between the genitals and anus), or anus. People with vulvas often stimulate
the clitoris, labia, vaginal opening, perineum, or anus. Other sensitive body parts,
such as the breasts, nipples, and thighs, may also be touched.
Masturbation has many benefits. Stress relief is one of the most common psy-
chological benefits. Other potential psychological benefits could include a sense of
peace and well-being; improved sleep; and enhanced understanding of, confidence
in, and comfort with one’s own sexuality.
Potential physical benefits include help with sexual dysfunctions, such as erec-
tile dysfunction and difficulty with orgasm. This enhanced sexual function could
result from improved knowledge about sexual stimulation obtained through mas-
turbation. Better sexual function might also be related to strengthened muscle
tone in the pelvic, genital, and anal areas obtained from masturbation. For some
Mattachine Society 415
people, masturbation might help to relieve menstrual cramps and might help to
decrease the risk of urine leakage and uterine prolapse.
Some partners engage in mutual masturbation, in which they masturbate in the
presence of each other. They may also help each other masturbate with their fin-
gers or sex toys. Benefits of mutual masturbation could include greater under-
standing of what “turns each other on,” both physically and emotionally, resulting
in a stronger, healthier relationship. In addition, mutual masturbation is safer than
sexual intercourse because there is less risk of sexually transmitted infections and
no risk of pregnancy.
There are some risks associated with masturbation. The main physical risk of
frequent masturbation is skin irritation, unless adequate lubrication is used. If an
erect penis is forcefully bent during masturbation, there is a risk of rupturing the
blood-filled chambers inside the penis—a condition that requires surgery to repair.
Psychological risks of masturbation are potentially more serious. For some peo-
ple, masturbation may become compulsive to the point that it interferes with their
social relationships, sexual relationships, work activities, or other daily function-
ing. Some individuals who frequently masturbate may eventually experience dif-
ficulties having an orgasm through conventional intercourse because they are so
used to the experience during masturbation.
Contrary to certain popular myths, masturbation does not lead to blindness,
unusual hair growth, shrinking sex organs, or stunted growth, and it cannot
deplete sperm cells in men.
A. J. Smuskiewicz
See also: Adolescent Sexuality; Childhood Sexuality; Mutual Masturbation; Orgasm;
Religion, Diversity of Human Sexuality and; Sex Toys; Touching, Sexual Arousal and.
Further Reading
National Health Service. (2018). Masturbation Q&A. Retrieved from https://www.nhs.uk/
live-well/sexual-health/masturbation-faqs/
Planned Parenthood. (2019). Masturbation. Retrieved from https://www.plannedparenthood
.org/learn/sex-and-relationships/masturbation
Mattachine Society
The Mattachine Society was one of the earliest homophile organizations in the
United States. Harry Hay was one of the key founders of Mattachine. Hay was a
communist organizer in Los Angeles and a sought-after teacher of communist
theory. In 1950, he assembled a group of his friends, including Rudi Gerenreich,
Bob Hull, Chuck Rowland, and Dale Jennings, to organize the International Bach-
elors Fraternal Order for Peace and Social Dignity (sometimes referred to as
Bachelors Anonymous). Steeped in communist strategy, the organization was
structured as a secret society with underground guilds that were separated so that
no one person could reveal the identities of other members. Within a year, the
group reorganized along a more conventional form and filed as a California non-
profit corporation, renamed the Mattachine Society, in 1951. At the same time,
they set up the Mattachine Foundation for legal purposes. The name was inspired
416 Mattachine Society
by the Société Mattachine, a secret fraternal organization in thirteenth- and
fourteenth-century France and Spain of unmarried townsmen who performed
music, dance, and rituals while wearing masks to hide their identities. Mattachine
Society wanted to educate people about gay issues.
In 1952, Dale Jennings, one of the Mattachine board members, was arrested
and charged with lewd conduct. Most people charged in the 1950s with lewd con-
duct would plead guilty and pay a fine so as to avoid publicity that could destroy
their marriages or employment. Jennings felt that the police had set him up and
that it was a case of entrapment. He sought and received help from the Mattachine
to fight the charges. Jennings stood up in court and admitted to being gay and
educated the jury about police entrapment and how police routinely targeted gay
people for abuse. The jury was hung (eleven wanted acquittal), and the judge dis-
missed the case. Although this was the first successful defense against police
entrapment of gay individuals, none of the mainstream press carried the story.
In 1953, some of the members of the Mattachine wanted to publish a monthly
newsletter. To that end, the Mattachine formed a new organization, ONE, Incor-
porated. It began publishing in January 1953 and became the voice of the gay
rights movement. Immediately, the U.S. postmaster general seized copies of
ONE, claiming the publication was obscene, lewd, lascivious, and filthy, and
refused to deliver it. ONE sued and eventually won a Supreme Court Case,
ONE, Inc. v. Olesen. The court ruled that material on homosexuality was not
automatically obscene and could be distributed through the postal system. This
was probably the most important court decision in the gay rights movement, as
it allowed gay men and lesbian women to educate society to reduce hatred and
discrimination.
Also, in 1953, Fred M. Snyder, legal adviser to the Mattachine Foundation, was
called by Joseph McCarthy to testify before the House Un-American Activities
Committee. Snyder was unabashedly open about being gay. This confused McCar-
thy since the committee and other government organizations were used to people
trying to hide their homosexuality. At the same time, a convention was held in Los
Angeles with more than 500 representatives from other chapters of Mattachine
and homophile organizations attending. At that time, it was the largest such gath-
ering of gay people in U.S. history. A power struggle occurred between those who
wanted Mattachine to become more politically active and those who wanted a
more moderate, education-based organization. The moderates won, and the old
Mattachine Foundation board resigned, including the founders and the old com-
munist influences.
Over the next forty years, the Mattachine Society and ONE evolved, changed
names a number of times, floundered, regrouped, merged, but survived. Now, the
ONE Institute is primarily a library and archive collection located on the campus
of the University of Southern California. It contains the largest collection of books,
magazines, articles, paintings, and memorabilia on homosexuality in the world,
with more than 1 million items catalogued.
Chuck Stewart
See also: Gay Rights Movement; Sexual Orientation; Sexual Rights.
Media and Sexuality 417
Further Reading
Kaczorowski, C. (2015). Mattachine Society. Retrieved from http://www.glbtqarchive
.com/ssh/mattachine_society_S.pdf
Martin, K. (2018). The Mattachine Society & LGBTQ history. Retrieved from https://
www.magellantv.com/articles/the-mattachine-society-lgbtq-history
Media and Sexuality
The media are communication tools used for sharing information in a variety of
ways. We most often think of “the media” as mass media, meaning those channels
of communication that reach a large audience: radio, television, motion pictures,
books, newspapers, magazines, the internet, and so on. Sexuality has been present
in media since the beginning of time. Many of the earliest drawings, paintings,
and sculptures are representations of naked bodies or sexual behaviors.
While sexual content has always been present in the media, its existence has
also been cause for concern. Various people have criticized the media’s depictions
of sexuality for promoting immoral behavior, perpetuating sexism, corrupting
youth, and demeaning human beings. Within a hundred years of the invention of
the printing press, the first illustrated pornographic book, I Modi by Pietro Arret-
ino and Marcantonio Raimondi, was printed in Rome (and destroyed by the
Vatican).
In the mid-nineteenth century, photography became generally available to the
public, and by 1873, the U.S. Congress passed the nation’s first obscenity law, ban-
ning some photos. Soldiers in the Civil War had acquired through the mail large
numbers of photographs of naked women, and the new law made them illegal.
A couple decades later, when Thomas Edison popularized the moving picture, one
of the first films seen by the masses was “The Kiss.” It caused a sensation in 1896,
and newspapers and the Catholic Church called for censorship. A major concern
was that motion pictures were morally problematic for youth. Critics said that
children would so desire to see the movies that they would steal the price of admis-
sion, and once inside the theater, they would watch scenes of immoral behavior
and then imitate what they saw in the films.
In the early to mid-twentieth century, radio and television started out relatively
tame. However, more recently, with the proliferation of cable television and inter-
net radio channels, more and more sexual content is broadcast. Cable television
programs may include full frontal nudity, a broad range of sexual behaviors, and
depictions of sexual violence. Some radio stations regularly play sexually sugges-
tive music and feature on-air personalities who discuss sexuality in ways that
would have been impossible twenty years ago. Research into the content of prime-
time television programs shows that more than 75 percent of them contain sexual
content. However, only 14 percent of sexual references address the risks or respon-
sibilities of sexual behavior. Television shows targeting teenagers actually have
more sexual content than programs targeting adults.
Researchers who have investigated popular music have found that 37 percent
of the most popular songs in a given year have sexual content. Of these songs,
418 Media and Sexuality
65 percent had references to degrading sex, which is characterized by one per-
son having an insatiable sexual appetite, the other person being objectified, and
sexual value being based only on physical attributes. Most of these sexually
degrading songs were rap music. Other research suggests that young people who
listen to a lot of this music are more likely to engage in sexual activity than
those who do not listen to it as much.
Americans access the internet more and more, with continuous opportunities to
view sexual content, whether it is intentional or inadvertent. The internet offers
many websites with information on sexual health and education and access to a
wide array of sexually explicit material. Data from 2014 show that the average
American is online for nearly five hours daily, between their use of computers and
cell phones (not voice calls). Virtually all (92 percent) young people use the inter-
net daily. People go online to connect with friends and to meet people in chat-
rooms, newsgroups, bulletin boards, social networking sites, online dating or
“hookup” sites, in multiplayer games, and so on (Bonebrake, 2002). Sexual con-
tent is available in all these online spaces and certainly on sites that offer explicit
scenes of every kind of sexual behavior.
With so much sexual content in the media, some individuals are particularly
concerned with its impact on young people. Adolescents are developing their ideas
about sexual identity, gender role and expression, body image, and sexual behav-
ior. Many adults worry that the messages that youth receive are irresponsible or
inaccurate. In the absence of effective, comprehensive sexuality education in
schools, the media have become the United States’ most persistent sexuality edu-
cators. Unfortunately, much of the sexual content in the media does not contribute
to young people’s healthy sexual development.
Teenagers spend seven and a half hours a day with media, more time than is
spent doing anything else but sleep, so the influence of the media on teens’ devel-
opment cannot be overestimated. Adolescents often use more than one media
source at a time, for example, reading while listening to music or texting while
watching television. Their exposure to media is therefore often more intense than
if they were using just one form of media at a time.
In one study, 51 percent of teenagers said they had actively looked for sexual
content in the media. Males were more likely to look for this kind of content (63%)
than females (40%), and movies were the most often used source, followed by
television, music, online pornography, and magazines.
Some analysts have pointed out media portrayals that normalize gender ste-
reotypes may encourage youth to emulate narrow and sexist behaviors. The
images of ideal bodies in advertising, television, and movies can lead to shame,
poor self-esteem, or disordered eating among young people who do not resemble
the ideal. The volume of sexual behaviors that are shown or implied is enormous
when compared to the amount of time devoted to discussions of safer sex, contra-
ception, or the challenges of an unplanned pregnancy. The ultimate message con-
veyed in mass media is that sex is fun, that everyone is doing it, and that there are
few negative outcomes. Researchers debate the impact this has on youth, but the
facts are that teenagers in the United States have significantly higher rates of
Media and Sexuality 419
unintended pregnancy and sexually transmitted infections than teens in other
developed nations.
Some researchers suggest that a heavy diet of sexual content in the media leads
to earlier sexual intercourse. Others contend that adolescents who are more inter-
ested in sex are both more likely to view sexual media and to initiate sexual
behaviors but that there is no cause-and-effect relationship between the two. In an
analysis of twenty-one longitudinal studies, Wright found a doubled risk for early
sexual intercourse among teens who are exposed to more sexual content. He sug-
gested that the effect of media on sexual behavior is driven by the acquisition and
activation of sexual scripts. Script theory has been applied to sexual behaviors
since the 1960s and posits that scripts give behavioral options in daily life, includ-
ing those that can lead to sexual behavior. One of the ways that individuals are
exposed to sexual scripts is through the media.
Some cultural analysts have suggested that mass media portrayals of gender
are problematic. They cite examples of male characters in action and adventure
movies and television shows where the only emotion they typically display is
anger. Often when a female character displays anger, other characters’ response
to her is that she is crazy or out of control. When characters are sad, the male may
have a single tear but otherwise remain stoic, while the female is portrayed as
vulnerable and actually cries emotionally. Gender stereotypes like these and
many others are pervasive in the media and suggest to people who are exposed to
them that this is normal, desirable behavior rather than emotionally limiting and
dehumanizing.
The appeal of sexual content in the media helps to make media producers prof-
itable. People are naturally interested in sexual imagery and messages, and vari-
ous media outlets use that interest to entertain and sometimes exploit. Some media
producers are interested in promoting products, and others are interested in pro-
viding helpful information and services to support sexual health. Whatever their
goals, media producers have a profound influence on how we learn about sexual-
ity, help to shape our values about sexuality, and contribute to public discussions
and policies about sex, gender, and relationships.
While some people might seek to censor sexual content in the media, there is
no way to escape exposure to it. Various groups advocate for media literacy to
help young people think critically about the media environment in which we live.
Key points to consider are that all media messages are constructed, and they each
have their own creative ways of making their story effective. Each user of media
will interpret the message through the lens of their own experience. Media have
embedded values and points of view. The National Enquirer will tell a story dif-
ferently than the New York Times because they have different points of view.
Finally, most media messages are developed to gain profit or to influence the con-
sumer. Media literacy helps people to recognize fantasy and constructively inte-
grate it with reality.
Michael J. McGee
See also: Advertising, Sex in; Gender; Pornography; Sex Education; Sexual Health; Sex-
ual Identity; Sexual Script; Sexualization.
420 Medical Treatment of Sex Offenders
Further Reading
Bleakley, A., Hennessy, M., & Fishbein, M. (2011). A model of adolescents’ seeking of
sexual content in their media choices. Journal of Sex Research, 48(4), 309–315.
Bonebrake, K. (2002). College students’ Internet use, relationship formation, and person-
ality correlates. CyberPsychology & Behavior, 5, 551–557.
Brown, J. D., L’Engle, K. L., Pardun, C. J., Guo, G., Kenneavy, K., & Jackson, C. (2006).
Sexy media matter: Exposure to sexual content in music, movies, television, and
magazines predicts black and white adolescents’ sexual behavior. Pediatrics,
117(4), 1018–1027.
Butters, G. R. (2007). Banned in Kansas: Motion picture censorship 1915–1966. Colum-
bia: University of Missouri Press.
Collins, R. L., Martino, S. C., Elliott, M. N., & Miu, A. (2011). Relationships between
adolescent sexual outcomes and exposure to sex in media: Robustness to
propensity-based analysis. Developmental Psychology, 47(2), 585.
Gray, F. (2003). The Kiss in the Tunnel (1899): G. A. Smith and the emergence of the
edited film in England. In L. Grieveson & P. Kramer (Eds.), The silent cinema
reader. London: Routledge.
Kunkel, D., Eyal, K., Finnerty, K., Biely, E., & Donnerstein, E. (2005). Sex on TV 4: A
biennial report to the Kaiser Family Foundation. Menlo Park, CA: Kaiser Family
Foundation.
Lenhart, A. (2015, April 9). Pew Research Center. Teens, social media & technology over-
view 2015. Retrieved from http://www.pewinternet.org/2015/04/09/teens-social
-media-technology-2015/
McGarry, M. (2000). Spectral sexualities: Nineteenth-century spiritualism, moral panics,
and the making of US obscenity law. Journal of Women’s History, 12(2), 8–29.
Primack, B. A., Gold, M. A., Schwarz, E. B., & Dalton, M. A. (2008). Degrading and non-
degrading sex in popular music: A content analysis. Public Health Reports, 123(5),
593.
Rideout, V. J., Foehr, U. G., & Roberts, D. F. (2010). Generation M 2: Media in the lives of
8- to 18-year-olds. Menlo Park, CA: Henry J. Kaiser Family Foundation.
Steinberg, L., & Monahan, K. C. (2011). Adolescents’ exposure to sexy media does not
hasten the initiation of sexual intercourse. Developmental Psychology, 47(2),
562.
Strasburger, V. C. (2012). Adolescents, sex, and the media. Adolescent Medicine-State of
the Art Reviews, 23(1), 15.
Talvacchia, B. (2001). Taking positions: On the erotic in Renaissance culture. Princeton,
NJ: Princeton University Press.
Thoman, E., & Jolls, T. (2008). Literacy for the 21st Century: An overview and orientation
guide to media literacy education. Malibu, CA: Center for Media Literacy.
Wright, P. J. (2011). Mass media effects on youth sexual behavior assessing the claim for
causality. Communication Yearbook, 35, 343–385.
Medical Treatment of Sex Offenders
The use of pharmaceutical interventions in the management of adult sex offenders
is typically used in conjunction with psychological interventions. Unfortunately,
to date there has been relatively little empirical research conducted on the use of
Medical Treatment of Sex Offenders 421
pharmacological agents to help control deviant sexual arousal among convicted
sex offenders. The research that has been conducted on antilibidinal drugs relates
primarily to three medications: medroxyprogesterone acetate (MPA), cyproterone
acetate (CPA), and leuprolide acetate. Interest in sex drive–reducing medications
has increased over the last two decades primarily based on the theoretical assump-
tion that a reduction in sex drive or elimination of the ability to achieve erections
will subsequently lead to a reduction in deviant sexual behavior.
Research on the effectiveness of MPA in sex offender treatment has shown that
MPA decreases testosterone to castration levels and decreases both the frequency
and intensity of deviant sexual urges. Bradford and Pawlak (1993) conducted a
double-blind crossover study examining the effects of CPA in nineteen sex offend-
ers who met diagnostic criteria for a paraphilia (i.e., sexual deviation). Results
indicated that CPA was associated with reductions in sexual fantasies and some
decrease in sexual arousal as measured by self-report.
Several researchers have commented on the negative side effects that may
accompany the use of such medications. Side effects can include weight gain,
depression, liver damage, difficulty breathing, gynaecomastia, nausea, and diabe-
tes. Given the range of side effects associated with these medications, compliance
has become an issue both within clinical settings and for the purpose of complet-
ing research studies.
Leuprolide acetate, although prescribed for a variety of conditions that are not
forensic in nature (e.g., fertility problems in women and in the treatment of pros-
tate cancer) began to be used with sex offenders in the early 1990s. This medica-
tion was associated with reductions in sex drive as well as having relative
tolerability with reference to side effects. Unfortunately, only one controlled study
using long-term rates of recidivism as a dependent measure has been conducted
with sex offenders. Previous research on leuprolide acetate administration with
sex offenders has been limited to case studies. Although limited in nature, the
case study approach has resulted in findings supportive of the use of leuprolide
acetate with sex offenders. For example, Kreuger and Kaplan (2001) presented
twelve case reports of men suffering from various paraphilic disorders who
received leuprolide acetate. Self-report data from these clients indicated that leup-
rolide acetate administration was associated with suppression of deviant sexual
interests and behavior.
One study compared a group of sex offenders receiving both leuprolide acetate
and cognitive behavioral treatment (CBT) directed at sex offending, with two
comparison groups: a group of sex offenders who received only CBT and a group
of violent non-sex offenders who received no treatment. As the vast majority of
sex offenders also presented with a history of nonsexual offenses, the second com-
parison group was considered appropriate. Results indicated that the group of sex
offenders receiving both leuprolide acetate and CBT were significantly less likely
to reoffend than the violent non-sex offenders, using any violent recidivism as the
criterion outcome measure and using Cox regression analyses to control for differ-
ences between groups on actuarial risk assessment data.
Jan Looman, Jeffrey Abracen, and Alessandra Gallo
422 Megan’s Law
See also: Androgens; Castration; Compulsivity, Sexual; Out-of-Control Sexual Behavior.
Further Reading
Bradford, J. M., & Pawlak, A. (1993). Double blind placebo crossover study of cyproter-
one acetate in the treatment of the paraphilias. Archives of Sexual Behavior, 22(5),
383–402.
Dickey, R. (1992). The management of a case of treatment resistant paraphilia with a long
acting LHRH agonist. Canadian Journal of Psychiatry, 37(8), 567–569.
Gallo, A., Abracen, J., Looman, J., Jeglic, E. L., & Dickey, R. (2019). The use of leupro-
lide acetate in the management of high-risk sexual offenders. Sexual Abuse, 31(8),
930–951.
Harrison, K. (Ed.). (2010). Managing high-risk sex offenders in the community. Portland,
OR: Willan Publishing.
Krueger, R. B., & Kaplan, M. S. (2001). Depot-leuprolide acetate for treatment of para-
philias: A report of twelve cases. Archives of Sexual Behavior, 30(4), 409–422.
Raymond, N., Robinson, B., Kraft, C., Rittberg, B., & Coleman, E. (2001). Treatment of
pedophilia with leuprolide acetate: A case study. Journal of Psychology & Human
Sexuality, 13(3–4), 79–88.
Rosler, A., & Witzum, E. (2000). Pharmacotherapy of paraphilias in the new millennium.
Behavioral Sciences and the Law, 18, 43–56.
Saleh, F., & Berlin, F. (2003). Sex hormones, neurotransmitters, and psychopharmaco-
logical treatments in men with paraphilic disorders. Journal of Child Sexual
Abuse, 12(3–4), 233–253.
Megan’s Law
Megan’s Law was created in response to the rape and murder of seven-year-old
Megan Kanka on July 29, 1994, in Mercer County, New Jersey, by her neighbor
Jesse Timmendequas. Timmendequas had two previous convictions for sexually
assaulting young girls. The murder attracted national attention and led to the
introduction of Megan’s Law, which requires law enforcement authorities to
make information available to the public regarding registered sex offenders. Indi-
vidual states decide what information will be made available and how it should be
disseminated. Information can include the offender’s name, picture, address,
incarceration date, and nature of their crime. The information is often displayed
on free public websites but can be published in newspapers or distributed in pam-
phlets or through various other means. The federal law requires all fifty states to
release information to the public about known convicted sex offenders. If a state
fails to comply with minimal release of information standards established by the
federal government, then that state risks losing federal law enforcement
funding.
Before Megan’s Law, the Jacob Wetterling Crimes Against Children and Sexu-
ally Violent Offender Registration Act of 1993 required states to have a sex
offender and crimes against children registry. It is named for Jacob Wetterling,
who was abducted near his home and murdered in 1989. Investigators later learned
that, unbeknownst to local law enforcement, sex offenders were being sent to live
in halfway houses nearby. This was amended with Megan’s Law in 1996.
Menarche 423
After Megan’s Law, the Adam Walsh Child Protection and Safety Act (2006)
supplements the law with new registration requirements and a three-tier system
for classifying sex offenders according to their risk to the community. This act
significantly strengthens registration and notification laws across the nation by
increasing the duration of registration for sex offenders, increasing in-person veri-
fications, requiring active sex offender notification programs, requiring certain
juveniles to register, requiring registration for adults convicted of an instant
offense that may not be a sex crime if they have a prior sex crime conviction that
predates Megan’s Law, requiring registration for sex offenders entering the coun-
try, creating a federal felony for sex offenders failing to register (maximum pen-
alty of up to ten years), and providing funding to the U.S. marshals to track down
those offenders.
Lauren Ewaniuk
See also: Child Sexual Abuse; Rape; Sexual Assault.
Further Reading
Crime Victims Center. (n.d.). Megan’s Law & The Adam Walsh Child Protection Act.
Retrieved from https://www.parentsformeganslaw.org/public/meganFederal.html
Zgoba, K., Dalessandro, M., Veysey, B., & Witt, P. (2008). Megan’s Law: Assessing the
practical and monetary efficacy. Washington, DC: United States Department of
Justice.
Menarche
Menarche is a person’s first menstrual period, which occurs in the later stages of
puberty, usually between the ages of nine and fifteen, with most people who have
a uterus having their first menstrual period around the age of twelve or thirteen.
The largest determining factors of the age at which most adolescents will experi-
ence menarche are heredity, weight, racial background, and other factors.
Many young people have concerns over the timing of menarche. Some worry
that they will be the last of their peers to experience this milestone, while others
are concerned about being the first of their friends. There is clearly a lot of worry,
fear, and uncertainty that comes with menarche—when and where it will happen
(in school, at a friend’s house, while swimming at a pool party), what it will be
like, and whether anyone will notice or somehow be able to tell.
One factor that appears to have a great impact on how a young person will view
their menarche experience is whether, and to what degree, they felt prepared for
the experience. This includes knowing what to expect, being informed that men-
arche is a normal experience that all folks with uteruses go through, and having
information about menstrual hygiene, such as using pads, tampons, and menstrual
cups. Research has shown that the more prepared a young person is, the more
positively they will view their experience with menarche. Many folks in the
United States experience their first period without knowing what is happening to
them, which can understandably be a very frightening experience. This helps to
highlight the importance of reproductive health education both from school and at
home.
424 Menopause
Along with all this concern, many young people are also very excited and eager
about getting their first menstrual period. Some see it as an important milestone, a
step toward womanhood and maturity. Others may just be curious to know what
all the fuss is about or desire to be like their peers who have already experienced
menarche. Some choose to celebrate this milestone with their close family and
friends by having a menarche party (also called a first moon party or period party),
though this is still fairly uncommon as much of American society, like many other
societies, still often view menstruation with great stigma and secrecy and largely
consider it to be a very private matter that should be kept hidden from others.
The event of menarche is responded to in a variety of ways in other cultures. In
many Indigenous/Native American societies, women are considered powerful
life-givers; therefore, a young person’s first menstruation is held in high reverence
and celebrated with several days of honored rituals. Conversely, in other cultures,
such as in some areas of Nepal, menstruation is viewed with extreme stigma and
superstition. In cultures such as these, it is believed that menstruating women are
unclean and thought to be so toxic that their touch alone could cause crops to die,
spoil their cow’s milk, or cause men to become seriously ill. These girls and
women are often sent to live outdoors in a hut away from the family (a practice
that was recently criminalized, but still occurs illegally), and they must adhere to
very strict rules and prohibitions until they are no longer menstruating.
Lyndsay Mercier
See also: Menstruation; Puberty; Sex Education.
Further Reading
Boston Women’s Health Book Collective. (2005). Our bodies, ourselves. New York:
Scribner.
Harris, R. H. (2018). It’s perfectly normal: Changing bodies, growing up, sex, and sexual
health. Somerville, MA: Candlewick Press.
Nalebuff, R. K. (2009). My little red book. New York: Twelve.
Menopause
Menopause is the time in a woman’s or other female-bodied person’s life when
they stop having periods and are no longer able to become pregnant without medi-
cal intervention. In North America, this is roughly around the age of fifty-one
years but can vary between about age forty-five and fifty-five. During this time,
hormone levels change, and the ovaries decline in function and stop releasing
eggs. Menopause is considered to have occurred when a person has not had a
menstrual period for one year.
Perimenopause is the period of development prior to menopause; for most, this
begins in their mid-thirties or forties. During this time, hormones levels begin to
drop, and fertility decreases; many also experience irregular menstrual cycles. At
perimenopause, an individual’s brain begins to change due to hormonal shifts in
the body, and these differences in the levels of estrogen and progesterone can cause
individuals to experience mood swings, irritability, anxiety, and depression. Other
symptoms associated with menopause include lower sexual desire, difficulty
Menopause 425
sleeping, hot flashes, and loss of bone density. During menopause, many people
also experience a reduction in their natural vaginal lubrication, which causes the
tissue of the vagina to become thinner and drier. This may make sex uncomfort-
able or painful, although for some, this is helped by the use of commercial lubri-
cants. It is important to note that not all individuals experience symptoms, and a
person’s expectations of menopause, as well as their overall general health, can
greatly influence their experience.
Hormonal treatments, often called hormone replacement therapy (HRT), are
available to those experiencing menopausal changes to help alleviate some of the
symptoms. HRT contains female hormones, typically estrogen and progesterone,
and can come in pill, cream, or patch form. If these medications are taken, it is
recommended to use the lowest dose possible for a short period of time as research
from the Women’s Health Initiative (2016) found that using HRT can lead to an
increased risk for breast cancer, heart disease, stroke, blood clots, and urinary
incontinence. Menopausal and postmenopausal individuals may introduce or con-
tinue self-care regimens in their lives, such as yoga, meditation, physical exercise,
social support, and other practices to support the whole self.
The experiences associated with menopause differ widely from one person to
the next, and a psychosocial lens is necessary to analyze the biological changes
and the cultural attitudes toward menopause. In cultures that reward women for
reaching the end of the fertile period, menopause is associated with fewer physi-
ological symptoms. According to one researcher, women in India described meno-
pause as being associated with increased social status, and more recent studies
also support the view that women from different cultural groups have diverse atti-
tudes about menopause that reflect a more or less positive context for this life
stage. A woman’s personal attitudes about aging and her multiple roles in life may
influence the ease or difficulty with which she experiences menopause.
The North American Menopause Society (NAMS) provides a variety of
resources on health-related issues, such as sexual changes, osteoporosis, and sleep
disturbances associated with the hormonal changes of menopause. NAMS advises
women to see this transition as a stimulus for new beginnings, to take a closer
look at one’s own health, relationships, and satisfying activities. Menopause is a
significant event in an individual’s life, with biological, social, and psychological
changes reflecting their personal and cultural values of motherhood, fertility, and
aging.
Martha Goldstein-Schultz
See also: Andropause; Estrogen; Female Sexuality; Fertility; Hormone Replacement
Therapy; Infertility; Menstruation; Perimenopause; Progesterone; Sex Hormones; Sexu-
ality among Older Adults.
Further Reading
Costanian, C., McCague, H., & Tamin, H. (2018). Age at natural menopause and its asso-
ciated factors in Canada: Cross-sectional analysis from the Canadian Longitudi-
nal Study on Aging. Menopause, 25(3), 265–272.
Devi, N. J. (2007). The secret power of yoga: A woman’s guide to the heart and spirit of
the Yoga Sutras. New York: Three Rivers Press.
Erikson, E. H. (1963). Childhood and society (2nd ed.). New York: Norton.
426 Menstruation
Gillespie, C. (1989). Hormones, hot flashes, and mood swings: Living through the ups and
downs of menopause. New York: Harper Perennial.
Lerner-Geva, L., Boyko, V., Blumstein, T., & Benyamini, Y. (2010). The impact of educa-
tion, cultural background, and lifestyle on symptoms of the menopausal transi-
tion: The Woman’s Health at Midlife study. The Journal of Women’s Health, 19,
975–985.
National Institutes of Health. (2016). Menopausal hormone therapy information.
Retrieved from www.nih.gov/health-information/menopausal-hormone-therapy
-information
Newman, B. M., & Newman, P. R. (2015). Development through life: A psychosocial
approach. Stamford, CT: Cengage Learning.
North American Menopause Society. (2019). Retrieved from www.menopause.org
Northrup, C. (2012). The wisdom of menopause: Creating physical and emotional health
during the change. New York: Bantam Books.
U.S. Department of Health and Human Services Women’s Health Office. (2018). Meno-
pause and sexuality. Retrieved from www.womenshealth.gov/menopause /
menopause-and-sexuality
Menstruation
Menstruation is the monthly fluctuation of hormones that controls the female
body’s production and release of an egg from the ovaries into the uterus for fertil-
ization. It culminates with the discharge of the uterine lining if a fertilized egg
fails to implant in the uterus. The hormones typically fluctuate on a twenty-eight-
day cycle; however, each body has its own rhythm, so some people experience
cycles that are longer or shorter. The menstrual cycle is a cooperative act between
the ovaries, uterus, and the hormones that control them.
There are several hormones involved in the menstrual cycle, and they are all
important to the overall process. Hormones act as regulators of communication
between various parts of the body. In this case, these hormones communicate
between the hypothalamus in the brain and the reproductive organs. Follicle-
stimulating hormone (FSH) acts on different areas depending on the sex of a per-
son. In females, follicle-stimulating hormone is responsible for promoting the
growth of the egg cell. The next hormone, luteinizing hormone (LH), is responsi-
ble for triggering ovulation as well as maintaining the corpus luteum, which
develops from the follicle after ovulation. In short, FSH matures the egg cell, and
LH controls the ovulation process. Estrogen is the main female hormone and has
many important uses throughout the body, both in men and women. In the men-
strual cycle, estrogen is responsible for both the growth of the uterine lining and
the regulation of FSH. Progesterone is also important during menstruation. It is
secreted by the corpus luteum in the ovary in order to support blood flow to the
endometrium. Progesterone’s role also varies in later stages of the menstrual cycle
depending on if there is an embryo to maintain.
The ovarian process begins at the beginning of the menstrual cycle. There are
two phases in this process: the follicular phase and the luteal phase. The follicular
phase occurs first. This is when FSH stimulates the ovary to develop and mature
Menstruation 427
an egg cell. This begins after the cessation of the previous menstrual flow (men-
ses). Many cells begin to develop during this time; however, typically only one
reaches full maturation as once a cell becomes dominant, the others regress. After
an egg cell reaches its full maturation, there is a spike in LH, which causes the
next step, ovulation. Ovulation is when the mature egg cell breaks from its casing,
pushes out through the ovarian wall, and travels down the fallopian tube into the
uterus. A person is most fertile during the few days before and after ovulation.
This is because as the egg travels down the fallopian tube, it is possible for fertil-
ization to occur if sperm cells are present.
Just after menses, while the ovaries are in the follicular stage, the uterus is in
the proliferative phase. This is when estrogen is at its highest production. While
glands in the uterine wall grow, the tissue that lines the inner wall of the uterus
(endometrium) thickens. The endometrium is at its thickest when ovulation occurs.
This timing is important because the thickened wall is where the fertilized egg
will be implanted. Implantation is when the fertilized egg burrows into the endo-
metrium and begins to grow. It is also possible to have an egg that is fertilized but
does not implant.
The second half of the ovarian process is called the luteal phase. After the
release of the egg out of the casing to the fallopian tubes, the casing remains in
the ovaries and is known as the corpus luteum. LH promotes the extended life of
the corpus luteum while it secretes progesterone. These levels peak in the week
after ovulation. There are two possibilities after this point. If fertilization and
implantation take place, the implanted embryo will produce its own hormones,
causing the corpus luteum to grow and secrete even more progesterone to main-
tain the pregnancy. If fertilization and implantation do not occur, then the corpus
luteum will disintegrate over the remaining time of the cycle.
If there is implantation and an embryo starts to form, the increased progester-
one will help maintain the endometrium and increase blood flow, and the endome-
trium will continue to thicken in order to better maintain the embryo. If there is no
pregnancy, the degeneration of the corpus luteum will cause progesterone levels to
drop. When the hormone levels drop, the endometrium loses its blood supply and
sheds itself during menses. Both the endometrium tissue and blood from the tis-
sues detach and flow down the cervix and out of the vagina.
Rebecca Polly
See also: Endometrium; Estrogen; Fallopian Tubes; Fertility; Follicle-Stimulating Hor-
mone; Luteinizing Hormone; Menarche; Menopause; Ovaries; Ovulation; Pregnancy;
Progesterone; Sex Hormones; Uterus.
Further Reading
Bobel, C. (2010). Third-wave feminism and the politics of menstruation. New Brunswick,
NJ: Rutgers University Press.
Boston Women’s Health Book Collective. (2005). Our bodies, ourselves. New York:
Scribner.
Harris, R. H. (2018). It’s perfectly normal: Changing bodies, growing up, sex, and sexual
health. Somerville, MA: Candlewick Press.
Hope, S., & Ravnikar, V. (2005). The abnormal menstrual cycle. Abingdon, UK: Taylor
& Francis.
428 Miller v. California
Nalebuff, R. K. (2009). My little red book. New York: Twelve.
Shail, A., & Howie, G. (2005). Menstruation: A cultural history. New York: Palgrave
Macmillan.
Miller v. California
Miller v. California is a landmark Supreme Court decision made in 1973. It is cur-
rently the settled law used by U.S. courts to determine if something is obscene. In
the Supreme Court’s decision, it was determined that there were three criteria that
must be met in order to determine if something is obscene:
1. Whether “the average person, applying contemporary community standards”
would find that the work, taken as a whole, appeals to the prurient interest
2. Whether the work depicts or describes, in a patently offensive way, sexual
conduct specifically defined by the applicable state law
3. Whether the work, taken as a whole, lacks serious literary, artistic, political,
or scientific value (Miller v. California, 1973).
It is important to note that in order for something to be considered obscene, it must
meet all three of these criteria. However, it is common for people to focus on the
third criterion, which is sometimes referred to as the LAPS test, for lacking liter-
ary, artistic, political, or scientific value. The ruling is also notable in that the
court stated that things that were found to be obscene were not protected by the
First Amendment right to free speech.
The case originated in 1968, when Marvin Miller used the United States Postal
Service to mail brochures advertising the sale of books and a movie with a sexual
theme. Miller was convicted on charges of distributing obscenity, a decision that
he then appealed. The appeal was eventually heard by the U.S. Supreme Court.
Part of Miller’s defense was based on an earlier decision made by the Supreme
Court in the 1966 Memoirs v. Massachusetts case, in which the court deemed that
if something had any literary value, it was protected under the freedom of speech.
The Miller v. California decision reversed this, and the conviction of Mr. Miller
was upheld. While there have been other cases that have attempted to redefine
obscenity in the United States, the three-pronged test established by the Miller v.
California decision remains the standard used to decide if something is obscene.
There are many critiques and criticisms of this decision, one of which is that the
criteria are too vague. In the Miller v. California decision, the court addresses the
fact that it is not possible to set one definition of obscenity for the entire country.
The use of the term “contemporary community standards” in the first criterion
was an attempt made by the court to allow the individual states to make their own
decisions as to what was to be considered obscene. Since there is no clear defini-
tion of what community standards are, it is possible for a person to commit a
crime and not realize that they have done so until a jury of their peers tells them
they have.
In addition, the concept of focusing on local standards may have been easier to
apply in the 1970s than it is today. Since the advent of the internet, the majority of
Molluscum Contagiosum 429
pornography is distributed digitally. In a situation where an attempt is made to
determine if something distributed online is obscene, it is difficult to identify what
“community” means and therefore what that community’s standards are.
Susan Milstein
See also: Commission on Obscenity and Pornography; Media and Sexuality;
Pornography.
Further Reading
Adams, R. (2012). An objective approach to obscenity in the digital age. St. John’s Law
Review, 86(1), 211–247.
Gelber, K., & Stone, A. (2017). Constitutions, gender and freedom of expression: The
legal regulation of pornography. In H. Irving (Ed.), Constitutions and gender
(463–481). Cheltenham, UK: Edward Elgar Publishing.
Miller v. California. (1973). Retrieved from https://www.oyez.org/cases/1971/70-73
Walters, L. G., & DeWitt, C. (2005). Obscenity in the digital age: The re-evaluation of
community standards. NEXUS, 10, 59.
Molluscum Contagiosum
Molluscum contagiosum is a common harmless viral skin infection that appears
as small smooth spherical lumps the same color as the skin. The growths often
have a dimple in the middle and occasionally can become itchy. As the name sug-
gests, it is infectious and easily transmitted through skin-to-skin contact, includ-
ing sexual activity, as well as by sharing contaminated objects like towels, toys, or
clothes. A person with molluscum contagiosum can also spread the virus to other
parts of their body via their hands and touch.
Molluscum contagiosum is caused by a poxvirus, molluscum contagiosum
virus. The only symptom of molluscum contagiosum is the small bumps on the
skin, which can range in size from a pinhead to as large as a pencil eraser. Most
people will get about ten to twenty bumps, although people with a weakened
immune system can have one hundred or more.
Molluscum contagiosum can be problematic for people with weakened immune
systems, such as those living with HIV. Before the availability and use of antiret-
roviral therapy (ART) for the treatment of HIV, infection with molluscum conta-
giosum could be widespread on the body and face and not limited to the ano-genital
areas. Management of the infection was also more challenging since the immune
system was not strong enough to fight the virus. However, among people living
with HIV who are on ART, treatment of molluscum contagiosum is the same for
those who are not living with HIV.
Treatment for molluscum contagiosum is generally not recommended because
the infection usually clears up on its own and does not normally cause any symp-
toms other than the spots. However, if the spots are affecting quality of life, or if
people have a weakened immune system, treatment may be offered. Treatment
may include topical medication or destruction of the papule in a clinic setting.
This is recommended for lesions on the face and on the genitals and can easily be
achieved by freezing each lesion with a small amount of liquid nitrogen, or through
430 Money, John
laser therapy, in a doctor’s office. A more time-consuming and low-tech solution
is to “de-roof” each spot using a needle to pop the papule, removing the contents
with a swab, and then applying medication to the base of the papule. Over-the-
counter topical creams are also available, such as medications to treat skin warts—
for example, podophyllotoxin (0.5 percent). For small children who are fearful of
creams or needles, oral cimetidine medication can be used.
Kelwyn Browne
See also: Human Immunodeficiency Virus (HIV); Sexually Transmitted Infections
(STIs).
Further Reading
American Academy of Dermatology. (2018). Molluscum contagiosum. Retrieved from
https://www.aad.org/public/diseases/contagious-skin-diseases/molluscum
-contagiosum
Centers for Disease Control. (2015). Molluscum contagiosum. Retrieved from https://
www.cdc.gov/poxvirus/molluscum-contagiosum/index.html
National Health Service. (2019). Molluscum contagiosum. Retrieved from https://www
.nhs.uk/conditions/molluscum-contagiosum/#
Money, John
John Money (1921–2006) was born on July 8, 1921, in Morrinsville, New Zealand.
Money was a well-known psychologist and sex researcher whose specialty was
rooted in sexual and gender development. Money coined the terms “gender iden-
tity” and “gender role” and was the first to start the debate on the distinction
between gender and biological sex. He was also the creator of “lovemaps,” an
individual’s internal preference and understanding of sexual and erotic desires
based on their past.
Money completed high school at age sixteen and went on to get a double mas-
ter’s degree from Victoria University in Wellington. He then became a junior lec-
turer at the University of Otago in Dunedin in 1944. He immigrated to the United
States in 1947 to pursue more education. He started working as a clinical psy-
chologist in Pittsburg, Pennsylvania, at a psychiatric clinic. From there, he went
on to complete his PhD in psychology from Harvard University. He graduated in
1952 and went on to pursue a career at Johns Hopkins University.
During Money’s career, he published more than forty books and authored hun-
dreds of academic papers. Most notable was his 1972 book Man & Woman, Boy &
Girl: Gender Identity from Conception to Maturity, which he coauthored with Dr.
Anke Ehrhardt. Money stayed with Johns Hopkins University throughout his
entire career. In 1966, he helped establish the Johns Hopkins Gender Identity
Clinic. At Johns Hopkins, Money focused his research on gender identity and gen-
der roles, paraphilias, and lovemaps.
Money’s most notable contribution to the world of sex research was his intro-
duction of terminology for gender identity and gender role. Money helped estab-
lish the difference between these terms, biological sex assignment, and sexual
functioning of an individual, and he considered that biological sex and gender
were two different concepts.
Monogamy 431
Money also contributed to the understanding of paraphilias and was successful
in changing the wording of DSM-III from “perversions” to “paraphilias.” Money
proposed that “paraphilia” was a less judgmental word for individuals who were
dealing with sexual problems outside the norm. He also advocated for changing
“sexual preference” to “sexual orientation” due to his belief that sexual attraction
is not completely voluntary or chosen.
Money also created the term “lovemaps,” which he identified as an individual’s
sexual and erotic desires that are played out within interpersonal relationships.
Money also described “vandalized lovemaps,” which can result from trauma in one’s
lovemap and can lead to sexualization or repression and sometimes to paraphilias.
Money was well known for his role in the David Reimer case, also known as
the John/Joan case. After Mr. Reimer had a botched circumcision at eight months
old, his parents consulted with Money, who recommended for David to be raised
female and to undergo surgery to remove his testes. Money believed that gender
roles were entirely socialized so believed that David would successfully be raised
as a girl. However, this turned out not to be true, and David (who was renamed
Brenda) experienced lifelong psychological and physical distress. This case made
national news and brought much scrutiny to Money. Money stood by his recom-
mendation, although he opted to not talk about this case later in his career.
Money continued his research and writing throughout his life. He passed on
July 7, 2006, the day before his eighty-fifth birthday. He had one short marriage
and no children. Money was a lover of art and donated his collection to the East
Southerland Gallery in Gore, New Zealand. Money’s own lifelong works are
housed at the Kinsey Institute at the University of Indiana.
Amanda Baker
See also: Biological Sex; Gender; Gender Identity; Gender Identity Development; Gender
Roles, Socialization and; Paraphilias; Reimer, David.
Further Reading
Ehrhardt, A. A. (2007). John Money, Ph.D. Journal of Sex Research, 44(3), 223–224.
Green, R. (2006). John Money, Ph.D. (July 8, 1921–July 7, 2006): A personal obituary.
Archives of Sexual Behavior, 35(6), 629–632.
Kinsey Institute, Indiana University. (2016). John Money, Ph.D. Retrieved from https://
www.kinseyinstitute.org/about/profiles/john-money.php
Money, J. (1994). Sex errors of the body and related syndromes: A guide to counseling
children, adolescents, and their families (2nd ed.). Baltimore: P. H. Brooks Pub-
lishing Company.
Money, J. (1999). The lovemap guidebook: A definitive statement. New York:
Continuum.
Money, J., & Ehrhardt, A. (1972). Man & woman, boy & girl: Gender identity from con-
ception to maturity. Northvale, NJ: Jason Aronson.
Monogamy
Monogamy is a type of relationship in which both partners are exclusive with each
other. Originally, monogamy meant having only one partner for life, but its under-
standing has evolved into being with only one person at a time (serial monogamy).
432 Mutual Masturbation
Monogamy is the most widely known relationship type and the one that is most
socially acceptable by the majority of religions. Monogamy has also been heavily
debated as to whether or not it is the natural state for humans.
From a scientific standpoint, monogamy can be viewed from two different per-
spectives: genetic monogamy and social monogamy. Genetic monogamy occurs
where there is a mutually exclusive reproduction or mating arrangement between
two partners. Humans are one of the few primates that participate in genetic
monogamy. In the animal kingdom, genetic monogamy is rare, although some
birds are also genetically monogamous. Social monogamy refers to pair bonding,
where two partners are socially exclusive of other potential partners; however,
reproduction is not necessarily the goal of the dyad.
More recently, serial monogamy has become more socially acceptable and
refers to a relationship style in which an individual dates or partners with only one
individual at a time. Serial monogamy is very common; individuals are in one
monogamous relationship until the relationship ends, and then they form a new
monogamous relationship with their next partner.
Historically, Greek and Roman men were only allowed to be married to one
female at a time and were not allowed concubines during marriage. These rules
were even applied to rulers, and this was the accepted norm of this society.
Monogamy has also been shown to be the dominant form of relationships within
the Egyptian and Babylonians societies. Monogamy continues to be the most
commonly reported type of relationship in the United States, and individuals who
engage in polyamorous relationships (with more than one partner) often experi-
ence judgment, stigma, and discrimination.
Amanda Baker
See also: Polyamory; Polyandry; Polygamy; Polygyny; Serial Monogamy.
Further Reading
Low, B. S. (2003). Ecological and social complexities in human monogamy. In U. H.
Reichard & C. Boesch (Eds.), Monogamy: Mating strategies and partnerships in
birds, humans, and other mammals (161–176). Cambridge: Cambridge University
Press.
Perel, E. (2006). Mating in captivity. New York: HarperCollins.
Perel, E. (2017). The state of affairs. New York: HarperCollins.
Phillips, A. (1996). Monogamy. New York: Random House
Reichard, U. H. (2003). Monogamy: Past and present. In U. H. Reichard & C. Boesch
(Eds.), Monogamy: Mating strategies and partnerships in birds, humans, and
other mammals (3–25). Cambridge: Cambridge University Press.
Ryan, C., & Jethá, C. (2010). Sex at dawn: The prehistoric origins of modern sexuality.
New York: Harper.
Mutual Masturbation
Mutual masturbation is a sexual activity that involves stimulating one’s own
genitals—masturbating—for sexual pleasure in the presence of another person
who is also masturbating. It is a way of being sexually intimate with another per-
son without the risk of sexually transmitted infection or pregnancy.
Mutual Masturbation 433
Mutual masturbation can be a good way for partners to teach each other the
kind of touch they enjoy, both in terms of where and how they like to be touched.
Mutual masturbation can be a highly arousing activity because it allows partners
to see each other become aroused and, if they continue long enough, to experience
orgasm.
Some people are embarrassed to suggest mutual masturbation to a partner due
to cultural taboos about masturbation. Some religions teach that masturbation is
sinful, and some cultural beliefs lead people to think that masturbation should not
be necessary when people are involved in partnered sexual relationships. Individ-
uals should use their judgment about whether to practice self-pleasure and mutual
masturbation. There are no medical reasons not to masturbate; indeed, there are
many benefits to learning how to pleasure one’s own body, such as relaxation,
stress reduction, and increased awareness of control over one’s sexual responses.
Mutual masturbation is simply the act of sharing a healthy form of sexual expres-
sion with another person.
Mutual masturbation is a form of nonpenetrative sex because it does not include
penetration of the mouth, vagina, or anus by a partner, unless sex toys are used.
This qualifies mutual masturbation as a form of outercourse. People enjoy outer-
course for many reasons, including a desire to avoid sexually transmitted infec-
tions and pregnancy, a desire to avoid penetrative sexual activity, and as a form of
arousing sex play.
People who practice abstinence typically avoid penetrative sexual activity. The
reasons for practicing abstinence vary from person to person. Some people prac-
ticing abstinence accept mutual masturbation as a healthy option; others feel that
the behavior does not fall within their understanding of abstinence.
Like other sexual activities, mutual masturbation should only be practiced
when both partners participate willingly and enthusiastically. If either partner
feels pressured into the behavior, it will be neither a positive nor healthy
experience.
Another definition of mutual masturbation is when partners touch each other’s
genitals for the purposes of sexual pleasure. This activity is also often called
heavy petting. Mutual masturbation may involve touching another person’s geni-
tals over or under their clothing. In this instance, a risk for sexually transmitted
infection exists if one person’s hand or sex toy touches both their own and another
person’s genitals.
If individuals participating in mutual masturbation only touch themselves, no
safer sex techniques are required. However, people who engage in mutual mastur-
bation involving contact with each other’s bodies should practice safer sex.
Depending on the bodies of the partners involved, safer sex techniques may
require the use of condoms, dams, or only touching each other over their
clothing.
Melanie Davis
See also: Abstinence; Arousal; Masturbation; Sex Toys; Touching, Sexual Arousal and.
Further Reading
Dodson, B. (2011). Hands and toys for orgasms at any age. In J. Price (Ed.), Naked at our
age (143–144). Berkeley, CA: Seal Press.
434 Mutual Masturbation
Joannides, P. (2017). Hand jobs and genital massage for females. In P. Joannides (Ed.),
Guide to getting it on (7th ed.). Waldport, OR: Goofy Foot Press.
Klein, M., & Robbins, R. (1998). Let me count the ways. New York: Tarcher Putnam.
Moon, A. (2014). Girl sex 101. San Francisco, CA: Lunatic Ink.
Planned Parenthood. (2019). Outercourse. Retrieved from http://www.plannedparenthood
.org/learn/birth-control/outercourse
Encyclopedia of Sex and Sexuality
Encyclopedia of Sex and Sexuality
Understanding Biology, Psychology, and
Culture
VOLUME 1I: N–Z
Heather L. Armstrong, Editor
Copyright © 2021 by ABC-CLIO, LLC
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or
otherwise, except for the inclusion of brief quotations in a review, without prior permission in
writing from the publisher.
Library of Congress Cataloging-in-Publication Data
Names: Armstrong, Heather L., editor.
Title: Encyclopedia of sex and sexuality : understanding biology,
psychology, and culture / Heather L. Armstrong, editor.
Description: Santa Barbara, California : Greenwood, [2021] | Includes
bibliographical references and index. |
Identifiers: LCCN 2020024424 (print) | LCCN 2020024425 (ebook) | ISBN
9781440847684 (v. 1 ; hardcover ; alk. paper) | ISBN 9781440847691 (v. 2 ;
hardcover ; alk. paper) | ISBN 9781610698740 (set ; hardcover ; alk.
paper) | ISBN 9781610698757 (ebook)
Subjects: LCSH: Sex—Encyclopedias. | Sex (Biology)—Encyclopedias. | Sex
(Psychology)—Encyclopedias.
Classification: LCC HQ21 .E647 2021 (print) | LCC HQ21 (ebook) | DDC
306.703—dc23
LC record available at https://lccn.loc.gov/2020024424
LC ebook record available at https://lccn.loc.gov/2020024425
ISBN: 978-1-61069-874-0 (set)
978-1-4408-4768-4 (vol. 1)
978-1-4408-4769-1 (vol. 2)
978-1-61069-875-7 (ebook)
25 24 23 22 21 1 2 3 4 5
This book is also available as an eBook.
Greenwood
An Imprint of ABC-CLIO, LLC
ABC-CLIO, LLC
147 Castilian Drive
Santa Barbara, California 93117
www.abc-clio.com
This book is printed on acid-free paper
Manufactured in the United States of America
For the curious.
Contents
Introduction xxiii
Entries
Abortion, Elective 1
Abortion, Late-Term 3
Abortion, Medical 5
Abortion, Risks of 7
Abortion, Surgical 8
Abortion, Therapeutic (Medically Necessary) 10
Abortion, Unsafe 12
Abortion Legislation 14
Abstinence 16
Acquired Immunodeficiency Syndrome (AIDS) 17
Adolescent Sexuality 20
Adrenarche 22
Adultery 23
Advertising, Sex in 25
Advocate, The 26
Afterplay 27
Age of Consent 29
Agender 30
viii Contents
American Association of Sexuality Educators, Counselors
and Therapists (AASECT) 32
Anal Intercourse 33
Androgen Insensitivity Syndrome 34
Androgens 36
Androgyny 39
Andropause 41
Anorgasmia 43
Antigay Prejudice 44
Aphrodisiac 46
Arousal 48
Artificial Insemination 50
Asexuality 52
Assisted Reproductive Technology 53
Association of Black Sexologists and Clinicians 55
Attachment Theory of Love 57
Bacterial Vaginosis 59
Barrier Contraceptive Methods 60
Basson, Rosemary 62
BDSM 63
Benign Prostatic Hyperplasia 66
Benjamin, Harry 68
Bigender 69
Binary Gender System 71
Biological Sex 72
Biological Theories of Sexual Orientation 73
Biphobia 75
Birth Control Pills, Estrogen-Progestin 76
Birth Control Pills, Progestin-Only 78
Bisexuality 79
Black Sexuality 81
Born This Way Foundation 84
Contents ix
Bornstein, Kate 85
Breast, Female 87
Breast Cancer 89
Breastfeeding 91
Bulbourethral Glands 93
Castration 95
Casual Sex 96
Celibacy 98
Cervical Cancer 99
Cervical Cap 101
Cervical Mucus Method 102
Cervix 103
Chancroid 104
Cheating and Infidelity 106
Child Sexual Abuse 108
Childhood Gender Nonconformity 110
Childhood Sexuality 112
Chlamydia 114
Chromosomal Sex 115
Circumcision 116
Cisgender 118
Civil Union 119
Clitoris 120
Colposcopy 122
Coming Out 123
Commission on Obscenity and Pornography 125
Communication, Sexual 126
Companionate Love 128
Compulsivity, Sexual 129
Conception 131
Condoms, Female (Receptive) 133
Condoms, Male (Insertive) 134
x Contents
Congenital Adrenal Hyperplasia 136
Consummate Love 138
Contraception 139
Contraceptive Implant 141
Contraceptive Injectables 143
Contraceptive Patch 144
Date Rape 147
Dating 149
Dating, Cross-Cultural Comparison of 152
Demisexuality 156
Dental Dam 157
Desire 158
Desire, Models of 160
Desire Discrepancy 161
Desire Disorders 162
DHEA 163
Diagnostic and Statistical Manual of Mental Disorders (DSM) 165
Diamond, Milton 166
Diaphragm 168
Disabilities, Sexual Function and 169
Dodson, Betty 172
Don’t Ask, Don’t Tell 173
Double Standards, Sexual 175
Douching 176
Down Low 178
Drag 180
Dysmenorrhea 182
Dyspareunia 184
Ejaculation 187
Ellis, Albert 188
Ellis, Henry Havelock 190
Contents xi
Emergency Contraception 192
Endometriosis 193
Endometrium 195
Epididymis 196
Erectile Dysfunction 198
Erectile Dysfunction Drugs 199
Erection 200
Erogenous Zones 203
Erotophilia and Erotophobia 204
Essure Coil 207
Estrogen 208
Evolutionary Perspectives on Gender and Sexual Behavior 209
Exhibitionism 211
Extramarital Sex 212
Fallopian Tubes 215
Family Planning Clinics 216
Fantasy, Sexual and Erotic 218
Fausto-Sterling, Anne 220
Feinberg, Leslie 221
Female Ejaculation 222
Female Genital Cutting 224
Female Sexuality 226
Femininity 227
Feminist Theory 229
Fertility 230
Fertility Awareness Methods of Contraception 234
Fertility Drugs 235
Fetishism 237
5-Alpha-Reductase Deficiency 239
Fluidity, Gender 241
Fluidity, Sexual 243
xii Contents
Follicle-Stimulating Hormone 245
Foreplay 246
Foreskin 248
Foucault, Michel 249
Freud, Sigmund 251
Friends with Benefits 253
Frotteurism 254
FTMInternational 255
Galactorrhea 257
Gay Affirmative Therapy 258
Gay Rights Movement 259
Gay-Straight Alliance (GSA) 262
Gender 264
Gender Diversity 266
Gender Dysphoria 269
Gender Expression 271
Gender Identity 272
Gender Identity Development 274
Gender Roles, Socialization and 276
Gender Transition 277
GenderPAC 279
Genderqueer 280
Genital Dysphoria 282
Genital Warts 284
GLAAD 286
GLMA: Health Professionals Advancing LGBTQ Equality 288
GLSEN (Gay, Lesbian, and Straight Education Network) 289
Gonorrhea 290
Grafenberg Spot (G-Spot) 292
Green, Jamison 293
Gynecomastia 295
Contents xiii
Hepatitis 297
Herpes 298
Heterosexism 300
Heterosexuality 302
Hirschfeld, Magnus 304
Homophobia 305
Homophobia, Internalized 307
Homosexuality 309
Hooker, Evelyn 312
Hookup Culture 314
Hormone Replacement Therapy 315
Hot Flashes 317
Human Immunodeficiency Virus (HIV) 319
Human Papillomavirus (HPV) 320
Hyde Amendment 324
Hymen 326
Hymenoplasty 327
Hypersexuality 329
Hypogonadism 332
Hysterectomy 334
Incest 337
Infertility 338
Intercourse 342
International Classification of Diseases, Eleventh Revision (ICD-11) 343
International Foundation for Gender Education (IFGE) 344
Intersexuality 346
Intimacy, Sexual and Relational 348
Intracytoplasmic Sperm Injection 350
Intrauterine Device (IUD) 351
Jealousy 353
Johnson, Virginia 355
xiv Contents
Jorgenson, Christine 356
Joy of Sex, The 358
Kama Sutra 361
Kaplan, Helen Singer 362
Kaplan’s Triphasic Model 363
Kegel Exercises 366
Kellogg, John Harvey 367
Kink 368
Kinsey, Alfred 370
Kinsey’s Continuum of Sexual Orientation 371
Kissing 374
Klinefelter Syndrome 375
Krafft-Ebing, Richard von 376
Labia 379
Labiaplasty 380
Lee’s Theory of Love Styles 382
LeVay, Simon 383
LGBTQ+ 385
Love 386
Lubricants 388
Luteinizing Hormone 389
Lymphogranuloma Venereum 391
Madonna-Whore Dichotomy 393
Male Sexuality 394
Maltz Hierarchy 398
Marriage 400
Marriage, Cross-Cultural Comparison of 403
Masculinity 405
Mastectomy 408
Masters, William H. 409
Masters and Johnson Four-Stage Model of Sexual Response 411
Contents xv
Masturbation 414
Mattachine Society 415
Media and Sexuality 417
Medical Treatment of Sex Offenders 420
Megan’s Law 422
Menarche 423
Menopause 424
Menstruation 426
Miller v. California 428
Molluscum Contagiosum 429
Money, John 430
Monogamy 431
Mutual Masturbation 432
National Center for Transgender Equality 435
National Health and Social Life Survey 436
National LGBTQ Task Force 438
National Organization for Women (NOW) 439
National Transgender Advocacy Coalition (NTAC) 441
Nocturnal Emissions 442
Nonbinary Gender Identities 443
Obstetrics and Gynecology 447
Oedipus Complex 450
Online Dating 452
Online Sexual Activity 454
Oophorectomy 456
Open Marriage 458
Oral Sex 460
Orchiectomy 462
Orgasm 464
Outing 467
Out-of-Control Sexual Behavior 469
xvi Contents
Ova 471
Ova Donation 472
Ovarian Cancer 474
Ovaries 476
Ovulation 478
Oxytocin 479
Pansexuality 481
Pap Smear 483
Paraphilias 485
Passing 486
Pedophilia 488
Pelvic Floor Muscles 489
Pelvic Inflammatory Disease (PID) 490
Penile Cancer 492
Penis 493
Performance Anxiety 495
Perimenopause 496
Perineum 498
Pfizer Global Study of Sexual Attitudes and Behaviors 499
PFLAG 501
Pheromones 503
Phimosis 504
Physical Attractiveness 505
Planned Parenthood 507
Planned Parenthood v. Casey 509
PLISSIT Model of Sex Therapy 510
Polyamory 512
Polyandry 515
Polycystic Ovary Syndrome (PCOS) 516
Polygamy 518
Polygyny 519
Contents xvii
Pornography 521
Pornography Addiction 525
Preejaculate Fluid 527
Pregnancy 528
Premarital Sex 531
Premature Ejaculation 533
Premenstrual Dysphoric Disorder (PMDD) 535
Premenstrual Syndrome (PMS) 536
Priapism 537
Progesterone 539
Pronoun Usage 540
Prostate 542
Prostate Cancer 543
Prostatectomy 545
Prostatitis 546
Prostitution 547
Psychosexual Therapy 550
Puberty 552
Puberty, Delayed 554
Pubic Hair 555
Pubic Lice 557
Public Displays of Affection 559
Purity Pledges 560
Queer 563
Questioning 564
Rape 569
Rape, Abuse and Incest National Network (RAINN) 571
Rape Shield Laws 572
Rape Trauma Syndrome 573
Reimer, David 575
Religion, Diversity of Human Sexuality and 576
xviii Contents
Reparative Therapy 579
Reproductive Coercion 581
Retrograde Ejaculation 582
Roe v. Wade 584
Roman Catholic Church Sexual Abuse Scandal 586
Romantic Attraction and Orientation 587
Safer Sex 589
Same-Sex Attraction and Behavior 590
Same-Sex Marriage 593
Sanger, Margaret 594
Satcher, David 596
Savage, Dan 598
Scabies 599
Scrotum 601
Semen 602
Seminal Vesicles 603
Seminiferous Tubules 604
Sensate Focus 605
Serial Monogamy 607
Sex Chromosomes 608
Sex Differentiation of the Brain and Sexual Orientation 609
Sex Education 610
Sex Guilt 612
Sex Hormones 613
Sex Reassignment Surgery 616
Sex Tourism 617
Sex Toys 618
Sex Work 621
Sex Workers, Male 623
Sexaholics Anonymous 624
Sexism 625
Contents xix
Sexology 627
Sexting 630
Sexual Abuse 631
Sexual Assault 634
Sexual Avoidance 635
Sexual Behavior in the Human Maleand Sexual Behavior
in the Human Female 636
Sexual Consent 637
Sexual Dimorphism 640
Sexual Disorders, Female 643
Sexual Disorders, Male 644
Sexual Dysfunction, Treatment of 646
Sexual Expression 647
Sexual Harassment 649
Sexual Harassment in College 651
Sexual Harassment in Education 652
Sexual Harassment in the Workplace 654
Sexual Health 655
Sexual Identity 657
Sexual Learning 659
Sexual Orientation 660
Sexual Revolution 663
Sexual Rights 665
Sexual Satisfaction 668
Sexual Script 670
Sexual Slavery 671
Sexuality across the Life Span 674
Sexuality among Older Adults 676
Sexuality among Younger Adults 678
Sexualization 680
Sexually Transmitted Infections (STIs) 681
xx Contents
Shepard, Matthew 684
Slut Shaming 685
Smegma 687
Social Learning Theory, Gender and 688
Society for the Scientific Study of Sexuality (SSSS) 690
Sodomy Laws 691
Somnus Orgasm 693
Sperm 694
Spermicides 695
Sponge, Contraceptive 697
Start-Stop Technique 698
Statutory Rape 699
Stereotypes, Gender 700
Stereotypes, Sexual 702
Sterilization 705
Sternberg’s Triangular Theory of Love 707
Stonewall Riots 708
Storms’s Model of Sexual Orientation 710
Sugar Daddies and Sugar Babies 711
Surrogate, Sexual 712
Surrogate Mothers 713
Swinging 715
Synthetic Hormones 716
Syphilis 719
Tantric Intercourse 723
Teen Pregnancy 724
Teena, Brandon 726
Testicles 728
Testicular Cancer 729
Testing, STI 731
Testosterone 732
Contents xxi
Testosterone Replacement Therapy 734
Touching, Sexual Arousal and 736
Transexual Menace 738
Transgender 739
Transphobia 741
Transsexual 742
Transvestite 744
Trichomoniasis 745
Tubal Ligation 749
Turner Syndrome 751
Tuskegee Syphilis Study 752
Two-Spirit 754
Ulrichs, Karl 757
Unconsummated Marriage 758
Urethra 759
Uterine Cancer 760
Uterus 762
Vagina 765
Vaginal Lubrication 766
Vaginal Ring 767
Vaginal Secretions 768
Vaginismus 769
Vaginitis 771
Vas Deferens 774
Vasectomy 775
Victorian Era 777
Virginity 778
Voyeurism 781
Vulva 783
Vulvodynia 784
Withdrawal Method 787
xxii Contents
World Professional Association for Transgender Health (WPATH) 788
X Chromosome 791
Y Chromosome 793
Yeast Infection (Candidiasis) 795
About the Editor and Contributors 799
Index 827
N
National Center for Transgender Equality
The National Center for Transgender Equality (NCTE) is a national organization
dedicated to advocating for legal and social justice for transgender people. The
NCTE mission is “By empowering transgender people and our allies to educate
and influence policymakers and others, NCTE facilitates a strong and clear voice
for transgender equality in our nation’s capital and around the country” (National
Center for Transgender Equality, 2019a).
The NCTE is a 501(c)(3) nonprofit organization founded in 2003 in Washington,
D.C., by Mara Keisling, a native of Scranton, Pennsylvania. Keisling earned a bach-
elor of arts degree from Penn State University and studied American government at
Harvard University as a graduate student. Prior to moving full time into transgen-
der advocacy, she worked in public health marketing research and was an adjunct
instructor in government at George Mason University and Marymount University.
In alignment with their mission, NCTE programs and projects address a very
long list of issues that affect the transgender community, ranging from health,
homelessness, military and veterans, immigration, voting rights, education, aging,
and much more. In addition, NCTE works at all levels of government to improve
related laws and legislation. The organization also educates the public about trans-
gender issues, increases transgender people’s awareness of their legal rights and
the resources available to them, and encourages community engagement and civic
participation. NCTE’s first major achievement was leading the years-long effort to
pass the Matthew Shepard and James Byrd Jr. Hate Crimes Prevention Act. Signed
by President Barack Obama in 2009, it was the first federal law ever to explicitly
protect transgender people. Also, the NCTE Privacy and Documentation program
has significantly modernized national, state, and local policies related to identity
documentation for transgender people, providing more people access to correctly
updated drivers’ licenses, birth certificates, and passports.
Of NCTE’s many successes, however, the most impactful thus far may be the
data collected from the national surveys NCTE has conducted. The 2011 National
Transgender Discrimination Survey and the even larger 2015 U.S. Transgender
Survey are the largest surveys ever specifically focused on the lives and experi-
ences of transgender and nonbinary people (6,400 and 28,000, respectively). The
results of these studies have helped policy makers and others to quantify and thus
comprehend the epidemic of violence and discrimination transgender and nonbi-
nary people experience.
In 2017, following the election of Donald Trump, the NCTE leadership launched
a separate 501(c)(4) organization, the National Center for Transgender Equality
436 National Health and Social Life Survey
Action Fund. The action fund works more directly in the political process by
mobilizing voters and engaging in electoral work supporting progressive, trans-
inclusive candidates as well as transgender candidates running for office. The first
three candidates endorsed by the NCTE Action Fund all won their races: Phillip
Cunningham and Andrea Jenkins (Minneapolis City Council) and Danica Roem
(Virginia House of Delegates).
As of 2018, NCTE had an annual budget of just over $2 million and more than
twenty staff, fellows, and interns, with Keisling continuing to serve as founding
executive director. Attorney Lisa Mottet, a close friend of the organization since
its beginning, joined the staff as deputy executive director in 2013.
C. Michael Woodward
See also: Gender Expression; Gender Identity; National Transgender Advocacy Coalition
(NTAC); Nonbinary Gender Identities; Shepard, Matthew; Transgender; Transsexual.
Further Reading
DiGuglielmo, J. (2011, November 17). Queery: Mara Keisling. Retrieved from http://www
.washingtonblade.com/2011/11/17/queery-mara-keisling/
National Center for Transgender Equality. (2013, May 13). NCTE welcomes Lisa Mottet
as deputy executive director. Retrieved from https://transequality.org/press
/releases/ncte-welcomes-lisa-mottet-deputy-executive-director
National Center for Transgender Equality. (2018, April). Annual report 2017: Forward
together. Retrieved from https://transequality.org/sites/default/files/docs/resources
/annual report 2017 final.pdf
National Center for Transgender Equality. (2019a). National Center for Transgender
Equality. Retrieved from https://transequality.org/
National Center for Transgender Equality. (2019b). National Transgender Discrimination
Survey. Retrieved from https://transequality.org/issues/national-transgender
-discrimination-survey
National Health and Social Life Survey
The National Health and Social Life Survey (NHSLS) was conducted in 1992 by
the National Opinion Research Center at the University of Chicago. The study
surveyed 3,432 women and men between the ages of eighteen and fifty-nine years
who were living in the United States. It was designed to obtain information on a
broad range of sexual activities and the social factors that might influence these
behaviors. It separates itself from previous research in the field of sexuality in that
it was one of the first large-scale studies conducted that used sound methodologi-
cal research practices. It was hailed as “the most comprehensive representative
survey to date of sexual behavior in the United States general population.” The
data were gathered utilizing both face-to-face interviews that lasted approxi-
mately ninety minutes as well as self-administered questionnaires.
The process of conducting the survey began in 1987, in part to try and gather
more information about people’s behaviors in response to the HIV epidemic. At
that time, there was a lack of current information about people’s sexual behaviors
and their engagement in sexual practices that could spread HIV and other sexually
National Health and Social Life Survey 437
transmitted infections (STIs). The funding for the original research project was
supposed to be provided by the National Institutes of Health (NIH). However, due
to some politicians’ concerns that the government should not be supporting sex
research, a bill was passed that included an amendment that prevented the NIH
from funding the original study. Due to the lack of funding from government
agencies, the survey had to be scaled down from its original intended size of over
10,000 participants to less than half that.
Findings from the NHSLS showed that those who were younger reported hav-
ing more sexual partners than those of the older generations. While the age of
engaging in first intercourse was lower in the younger respondents, they were also
waiting longer to get married. The increase in sexual partners may therefore have
been due to a longer time period between initiating sexual activity and getting
married. The survey also found that the rate of cheating on a spouse was low, with
less than 20 percent of women and 15–35 percent of men reporting being unfaith-
ful while married.
The study also found that there were some behavior changes as a result of the
HIV epidemic. Those who were considered most at risk of contracting HIV, the
ones with multiple partners, were more likely to report that they had been tested
for HIV and had changed their behaviors. These changes included using condoms
more frequently, limiting their number of sexual partners, and being more aware
of who their sexual partners were.
Since the NHSLS was conducted, it has not become substantially easier for
researchers to receive government funding to investigate sexuality-related issues,
despite the fact there is a public health concern regarding sexual behaviors and
STIs. In 1989, one in twenty people between the ages of eighteen and twenty-four
reported having had an STI in the last twelve months. Currently, the estimate is
that half of all new STIs in the United States are in adolescents and young adults
between the ages of fifteen and twenty-four.
Much has changed in the twenty-six years since the study was conducted. The
NHSLS found that the majority of people had met their spouses and sexual part-
ners through their social networks. The study was conducted before the internet,
and researchers today are still trying to understand the impact that online dating
and dating apps may have on people’s sexual behaviors.
Susan Milstein
See also: Sexology; Sexuality across the Life Span; Sexually Transmitted Infections
(STIs).
Further Reading
Laumann, E. O., Gagnon, J. H., Michael, R. T., & Michaels, S. (1992). National Health
and Social Life Survey. Ann Arbor, MI: Inter-university Consortium for Political
and Social Research [distributor].
Michael, R. T., Gagnon, J. H., Laumann, E. O., & Kolata, G. (1994). Sex in America:
A definitive survey. Boston: Little, Brown and Company.
Michael, R. T., Isaacs, S., & Knickman, J. (1997). The National Health and Social Life
Survey: Public health findings and their implications. In S. L. Isaacs & J. R.
Knickman (Eds.), To improve health and health care (232–250). San Francisco:
Jossey-Bass.
438 National LGBTQ Task Force
Miller, P. (1995). A review: They said it couldn’t be done: The National Health and Social
Life Survey. The Public Opinion Quarterly, 59(3), 404–419.
Satterwhite, C. L., Torrone, E., Meites, E., Dunne, E. F., Mahajan, R., Ocfemia, M. C. B.,
& Weinstock, H. (2013). Sexually transmitted infections among US women and
men: Prevalence and incidence estimates, 2008. Sexually Transmitted Diseases,
40(3), 187–193.
Sociometrics. (2017). National Health and Life Survey, 1992. Retrieved from https://www
.socio.com/products/aids-1213
National LGBTQ Task Force
The National Lesbian, Gay, Bisexual, Transgender, and Queer Task Force
(National LGBTQ Task Force or the Task Force) was formed in 1973 and is the
oldest still-active LGBTQ advocacy organization in the United States. When it
started in 1973, it was known as the National Gay Task Force, which later changed
to the National Gay and Lesbian Task Force, and most recently, in 2014, was
renamed the National LGBTQ Task Force. These name changes were enacted in
order to be more inclusive of a diversifying community that includes many differ-
ent sexual orientations and gender identities.
The Task Force’s official mission is to advance full freedom, justice, and equal-
ity for LGBTQ people. The vision and goal of the Task Force is to come together
in building and strengthening grassroots movements, harnessing the power of the
LGBTQ community. This is accomplished in a variety of ways, including provid-
ing training for activists and both state and local organizations working against
anti-LGBTQ and for pro-LGBTQ legislations and referenda, helping to build
capacity for creating social movements in the LGBTQ community. The Task
Force also operates The Policy Institute, a progressive think tank offering policy
analysis and doing research to further a pro-LGBTQ movement and to counter
legislative and media attacks against LGBTQ individuals and communities.
Historically, the Task Force has been involved in many political issues tied to
the LGBTQ community. From its inception in the 1970s, the Task Force has
engaged regularly with women’s and feminist movements, ensuring representa-
tion of lesbian women at the National Organization for Women’s national confer-
ence and successfully getting an endorsement of gay and lesbian rights from the
International Women’s Year’s conference in 1977. In the 1980s, the Task Force
received some of the first federal funding dollars in order to offer community-
based AIDS education and was very vocal on policies regarding national blood
testing and the Federal Drug Administration’s approval of a test for antibodies.
The Task Force’s work on monitoring how gay men and lesbian women were por-
trayed in the media and other venues of entertainment eventually led to the cre-
ation of the Gay Media Task Force, an organization that worked with television
stations to improve the portrayal of gay men and lesbian women in their program-
ming. A further political commitment of the Task Force is engaging with civil
rights, including working against antisodomy laws, religious freedom laws that
would legalize discrimination based on sexual orientation and gender identity, and
National Organization for Women (NOW) 439
now using a more intersectional lens to support issues of immigration and racism
within and against the LGBTQ community.
Another large component of the Task Force is the creation and ongoing imple-
mentation of the national Creating Change Conference on a yearly basis. This
conference is the largest gathering in the United States of LGBTQ organizers,
leaders, and activists and is held in a different city each year in order to offer loca-
tions around the country. Creating Change 2019 was held in Detroit, Michigan,
and provided attendees the opportunity to attend workshops about a variety of
issues affecting the LGBTQ community, including immigration, sexuality, reli-
gion, disability, racial and ethnic identities, parenting, education, counseling/ther-
apy, grassroots movements, activism, and more.
Shanna K. Kattari
See also: Acquired Immunodeficiency Syndrome (AIDS); GenderPAC; GLAAD;
LGBTQ+; National Organization for Women (NOW); Sodomy Laws.
Further Reading
Creating Change Conference. (2019). Home page. Retrieved from http://www.creating
change.org/
National Gay and Lesbian Task Force Records, 1973–2017. (n.d.). Retrieved from http://
rmc.library.cornell.edu/EAD/htmldocs/RMM07301.html
National LGBTQ Task Force. (2019). About: Mission and history. Retrieved from http://
www.thetaskforce.org/about/mission-history.html
National Organization for Women (NOW)
The National Organization for Women (NOW) is the largest organization of femi-
nist activists in the United States. Since its founding in 1966, NOW’s goal has
been to ensure gender equality for women of all classes and backgrounds. In its
conception, NOW focused especially on securing women’s economic equality
through an amendment to the U.S. Constitution. Other principal causes include
women’s reproductive rights, opposing racism and heterosexism, and ending vio-
lence against women.
NOW is regarded as the nonpartisan, grassroots wing of the women’s rights
movement. The organization communicates through collective action; they orga-
nize marches, rallies, nonviolent civil protests, public forums, and petitions.
NOW’s actions have established the organization as a major feminist force in the
political arena. Their movements have promoted women into political positions;
increased the academic and professional opportunities for women; and influenced
tougher laws against domestic violence, sexual harassment, and racial
discrimination.
The Civil Rights Act of 1964 was presented to Congress as a means to end dis-
crimination on the basis of sex, race, nationality, and religion. Activists lobbied
extensively for the inclusion of an amendment to outlaw sex discrimination in
employment decisions. After much disagreement, this demand was realized
through Title VII, a prohibition of discrimination in the workplace. To enforce and
oversee national adherence to Title VII, the Equal Employment Opportunity
440 National Organization for Women (NOW)
Commission (EEOC) was created. Despite their responsibilities to protect minori-
ties in the workforce, the EEOC did not take a stance against gender-segregated
job advertising. A few weeks after the legislation was passed, Yale law professor
Dr. Pauli Murray publicly denounced the EEOC for its refusal to oppose sexist
hiring practices. This caught the attention of author Betty Friedan, who immedi-
ately contacted Dr. Murray to discuss alternative strategies with other frustrated
women’s rights activists. More than twenty women assembled in Friedan’s hotel
room in solidarity. Friedan wrote the acronym NOW on a napkin, and out of the
group’s determination to create lasting institutional change, a new organization
emerged.
In August 1967, NOW activists picketed wearing vintage clothing to make a
statement against the New York Times’ old-fashioned policies of gender-segregated
advertising. Their demonstrations helped shift national advertising practices.
Later that year, NOW drafted the “Bill of Rights for Women.” This document
pushed for the passage of the Equal Rights Amendment, the repeal of laws pre-
venting abortion, and for the availability of publicly funded child care. NOW was
the first national organization to support the decriminalization of abortion.
NOW made strides in the academic arena as well. In 1969, NOW chapters
across the country laid the foundation for the first recognized women’s studies
courses in Michigan, California, and at Princeton. In 1973, NOW activists created
the national march and vigil called Take Back the Night. This event was a protest
of violence against women, with a highlight on sexual assault. Take Back the
Night continues as an annual event across many countries, communities, and
campuses.
On August 26, 1973, NOW’s proposal for the memorialization of the passage of
the suffrage amendment was accepted by Congress and the president, and the
anniversary of the end of the suffrage movement became recognized as Women’s
Equality Day.
NOW has been criticized by various groups for their feminist and political
views. NOW is often in opposition with fathers’ rights groups and those who are
against feminism as a movement, who experience the demand that women be
treated equitably to be at their expense. NOW has also received the criticism that
the organization focuses more on pursuing liberal politics rather than truly advo-
cating for women’s rights. Many political activists feel that NOW’s scope is too
narrow in focusing on American women and not using their power and privilege
to support women internationally. Antiabortion activists take issue with NOW’s
discrediting of women who are not in support of abortion and consider the organi-
zation exclusionary. Also to the point of exclusion, in NOW’s conception, several
openly lesbian members of standing were expelled from the organization to make
a point to the public that they were more than a gay rights group. There was sig-
nificant pushback from over 400 feminists challenging NOW for heterosexism.
After a public opposition at the 1970 Congress to Unite Women, NOW changed its
stance on lesbian visibility, and in 1973 the NOW Task Force on Sexuality and
Lesbianism was established. However, many feminists are still put off by the
organization for the initial offense.
Shadeen Francis
National Transgender Advocacy Coalition (NTAC) 441
See also: Abortion Legislation; Feminist Theory; Gender; Heterosexism; Sexual Assault;
Sexual Rights.
Further Reading
National Archives and Records Administration. (1964). The civil rights act of 1964 and
the Equal Employment Opportunity Commission. National Archives Identifier:
299891. Retrieved from https://www.archives.gov/education/lessons/civil-rights
-act/
National Organization for Women. (1966). The National Organization for Women’s 1966
statement of purpose. Retrieved from http://now.org/about/history/statement-of
-purpose/
United States Equal Employment Opportunity Commission. (1964). Title VII of the civil
rights act of 1964. Retrieved from https://www.eeoc.gov/laws/statutes/titlevii.cfm
National Transgender Advocacy Coalition (NTAC)
The National Transgender Advocacy Coalition (NTAC) was a 501(c)(4) civil rights
organization “working to establish and maintain the right of all transgender, inter-
sex, and gender-variant people to live and work without fear of violence or
discrimination.”
NTAC was the result of a dinner conversation on February 24, 1999, at La
Panetteria restaurant in Bethesda, Maryland, during the GenderPAC Lobby Days
event in Washington, D.C. The diners were all experienced community organiz-
ers and allies, mostly volunteers, from around the country who were engaged in
GenderPAC’s educational training and congressional lobbying event to build a
national community voice, educate members of Congress about transgender peo-
ple, and increase both national and municipal legislation protecting gender iden-
tity and expression. In the late 1990s, GenderPAC made a dramatic shift in its
mission and strategy, moving away from advocacy specifically on behalf of trans-
gender and gender-diverse people and toward a broader effort to decrease gender-
based bias in society. Many leaders in the trans community disagreed with the
political strategy and felt abandoned by the only visible national advocacy orga-
nization dedicated to their issues. Those at the dinner felt that a national voice for
the community was still very much needed and agreed to work together toward
this effort.
NTAC’s primary function became educating transgender people about the
political process and protocol and about how to have strategic conversations with
representatives and their aides about the issues as a private citizen or constituent.
The Lobby Days event provided community members and allies a day of training,
preparation, and practice, then a full day on Capitol Hill meeting with said offi-
cials in both houses of Congress. The goal was not only to get transgender issues
on the table nationally but also to empower those participating to continue lobby-
ing and educating at the local level.
The seven founders from the dinner included Dawn Wilson (Lexington, Ken-
tucky), Anne Casebeer (Louisville, Kentucky), Vanessa Edwards Foster (Houston,
Texas), Jessica Redman (Houston, Texas), Sarah Fox (Columbus, Ohio), Cathy
Platine (Delaware, Ohio), and award-winning journalist Monica Roberts (Houston,
442 Nocturnal Emissions
Texas). Additional members joining the board shortly after its founding included
Yosenio Lewis (first board president), Christine Stinson (first board treasurer),
Transgender American Veterans Association (TAVA) cofounders Angela Bright-
feather Sheedy and Monica Helms (who also designed the now-iconic transgender
flag), and eighteen other activists from around the country.
NTAC was active from 1999 to 2009. In that time, it produced National Lobby
Days five times in Washington, each time documenting in detail the conversations
had by each citizen lobbyist. This provided a record of how legislators’ knowledge
and support of transgender issues changed over the years. The 2004 Lobby Days
was captured by director Timothy Watts in the documentary film Citizen
Lobbyist.
In addition to Lobby Days, NTAC helped expand the observation of the Trans-
gender Day of Remembrance, a vigil honoring the lives of transgender people lost
to violence each year, to cities worldwide. NTAC was also among the organiza-
tions that protested in Washington in 2007 after gender identity protections were
again excluded from the Employment Nondiscrimination Act that was proposed
(but never passed) by Congress.
C. Michael Woodward
See also: Gender Expression; Gender Identity; GenderPAC; National Center for Trans-
gender Equality; Transgender; Transsexual.
Further Reading
GLAAD. (2019). Transgender resources. Retrieved from www.glaad.org/transgender
/resources
Transgender Day of Remembrance. (2019). Retrieved from tdor.tgeu.org
Nocturnal Emissions
A nocturnal emission (also known as a wet dream) is the experience of ejaculation
or orgasm during sleep for people assigned male at birth. This most often occurs
during puberty when the testicles begin producing sperm, usually between the
ages of twelve and fourteen years. Occasionally, there may be an overproduction
of sperm, and if this happens, the body may naturally expel the sperm during
sleep in the form of ejaculation. A sexual dream may or may not occur during the
nocturnal emission. Since adolescents often initiate masturbation (resulting in
ejaculation) around the time of puberty, a buildup of semen may not occur at all.
Consequently, not all people who are assigned male at birth will experience a noc-
turnal emission, and it is estimated that only about half do. Once masturbation (or
ejaculation due to other causes, such as sexual activity) is initiated, nocturnal
emissions typically stop. Many girls and women (assigned female at birth) also
experience orgasm during sleep, which is a similar yet distinct experience known
as somnus orgasm.
It is possible, but rather rare, for adult males to experience ejaculation during
sleep. This is likely because most adult males typically release semen through
other means, such as masturbation or sexual activity. Some adults who have
penises may experience a nocturnal emission after very long periods of abstaining
Nonbinary Gender Identities 443
from ejaculation or orgasm, though this may take months or even several years of
abstinence. Other folks may still experience an occasional nocturnal emission for
no apparent reason, though this is uncommon.
Experiencing ejaculation and orgasm during sleep is a normal and healthy
event. It cannot be controlled, and it is not caused by any underlying medical,
social, or psychological condition or behavior. Even though nocturnal emissions
are perfectly normal, many people are unaware that they exist, and some cultures
view the experience as very negative and harmful. One study found that boys who
were not well informed about the experience of nocturnal emissions reported feel-
ing frightened upon first ejaculating during sleep, comparable to many people’s
experiences of menarche. This highlights the importance of sexual health educa-
tion both in schools and within the home so that young people are informed that
nocturnal emissions are common and normal.
In some cultures, semen is often thought to be a very powerful and vital bodily
fluid that contains supernatural qualities and ensures a man’s health and longevity.
Dhat syndrome is the belief held by some men in certain Indian cultures that noc-
turnal emissions are a serious threat to a man’s health. This can result in a severe
preoccupation due to fear of losing what is considered to be an extremely impor-
tant bodily fluid necessary for mental, spiritual, and physical well-being. Receiv-
ing accurate sexual health education is reportedly the most effective treatment for
Dhat syndrome, as it dispels some of the misconceptions surrounding nocturnal
emissions and semen loss.
Lyndsay Mercier
See also: Ejaculation; Orgasm; Puberty; Semen; Sex Education; Somnus Orgasm.
Further Reading
Gaddis, A., & Brooks-Gunn, J. (1985). The male experience of pubertal change. Journal
of Youth and Adolescence, 14, 61–69.
Harris, R. H. (2018). It’s perfectly normal: Changing bodies, growing up, sex, and sexual
health. Somerville, MA: Candlewick Press.
Malhotra, H. K., & Wig, N. N. (1975). Dhat syndrome: A culture-bound sex neurosis of
the Orient. Archives of Sexual Behavior, 4(5), 519–528.
Nonbinary Gender Identities
Within Western societies, gender is often viewed as a binary with male on one
side and female on the other (gender binary), but gender is more complex. As a
social construct, gender has been understood to include other variations within
other cultures and during other time periods. Many cultures traditionally referred
to those who identified outside the gender binary as a third gender, but these indi-
viduals are commonly referred to as nonbinary within Western society. Nonbi-
nary is an umbrella term to represent individuals who do not identify as exclusively
female or male, including varying degrees of female and male, neither female nor
male, another gender, or a combination of genders. The nonbinary umbrella
includes genderqueer, genderfluid, bigender, trigender, among others as well as
nonbinary as a gender, sometimes abbreviated as NB or enby.
444 Nonbinary Gender Identities
Three cultural examples of nonbinary identities include the hijra of India, two-
spirit people of First Nation tribal societies, and the māhū of Hawaii. Perhaps the
most known is the hijra, who are individuals assigned male at birth but are recog-
nized as neither male nor female and perform important cultural ceremonies.
Despite legal recognition as a third gender and unique role in Indian society, the
hijra continue to be seen as outcasts. Two-spirit people are individuals who
embody both masculine and feminine spirits and have been revered since the sev-
enteenth century. In First Nation societies, gender is not synonymous with bio-
logical sex but rather associated with roles within the society (e.g., caregiving,
hunting). Finally, the māhū are free to equally express masculinity and femininity,
similar to the Hawaiian god or goddess Laka, and they are respected for maintain-
ing customs. Māhūs almost disappeared with Western colonization until a Hawai-
ian cultural renaissance in the 1970s. Similar to hijra, māhūs have been recognized
as a third gender but face discrimination, with the name māhū sometimes used as
a derogatory term. While facing discrimination, these culturally diverse identities
have also been revered and admired—the hijra as sacred, two-spirit as healers,
and the māhū as historical teachers.
Nonbinary individuals are inherently gender nonconforming as their gender by
definition does not align with dominant gender norms. Gender nonconformity can
increase the risk of experiencing microaggressions, particularly being misgen-
dered (identifying someone by the wrong gender through incorrect pronouns).
Stigmatizing experiences for nonbinary individuals can include being called by a
former (often gendered) name rather than a chosen name; not seeing their gender
represented on educational, medical, and legal forms; being tokenized (e.g.,
expected to be a representative their gender), and being asked to explain their
gender.
Nonbinary gender expression varies and can include temporary, semiperma-
nent, and permanent forms. Based on social norms, the expression of masculinity
and femininity can be presented through hairstyles, body hair (removal or growth),
and accessories. In addition, numerous prosthetics have been created, including
breast forms, packers, and stand-to-pee devices. Youth may pursue puberty block-
ers to postpone puberty while postpubertal young adults and adults may use hor-
mone replacement therapy. Permanent changes include top surgery (breast
augmentation or removal of chest tissue) and gender affirmation surgery (genital
surgery). Nonphysical expressions of gender include a chosen name and pronouns.
They or them pronouns are the most often used gender-neutral pronouns by non-
binary individuals, although over one hundred gender pronouns have been pro-
posed since the mid-nineteenth century. Correct use of pronouns has been found
to be as important as the use of the correct name. Some nonbinary individuals
describe political activism to be an expression of their gender identity and can
include roles as a representative, a role model, and an educator.
A nonbinary gender identity development model was created to increase under-
standing of the unique experiences of nonbinary individuals. The eight stages of
this model are (1) early freedom, (2) gender identity confusion, (3) language acqui-
sition, (4) reconciling repression, (5) gender experimentation, (6) envisioning an
ideal self, (7) disclosing gender identity, and (8) gender identity integration. In
early freedom, gender is explored at a young age with few restrictions (e.g., tomboys).
Nonbinary Gender Identities 445
Gender identity confusion follows due to a lack of language to describe nonbinary
genders as well as enforcement of gender norms. Language acquisition is a pivotal
point in nonbinary gender identity development, which is noteworthy as such lan-
guage has only emerged in the last decade within Western culture. Along with
affirmation from language comes the potential for building gender-based commu-
nities. For those who attempt to conform to gender norms, the model includes a
stage for overcoming repression of a nonbinary gender identity and working toward
acceptance that includes rejecting the gender binary (understanding of gender as
exclusively male or female). During gender experimentation, gender is tried on in
safe spaces to discover and self-identify one’s gender and gender expression. The
ability to envision an ideal self is associated with a greater comfort with gender
identity and is challenged by the diversity of genders within the nonbinary umbrella
and a lack of modeling of nonbinary identities in mainstream media. The decision
to disclose nonbinary gender identities is dependent on the relationship to others
and the environment with relevance, trust, and safety of concern. Finally, identity
integration among nonbinary individuals is an acceptance of a nonbinary gender
identity internally as well as an understanding of the strengths and limitations of
the external environment.
As awareness and representation of nonbinary identities increases, a growing
number of people are openly identifying as nonbinary, particularly among youth.
Over a quarter of youth surveyed in California described their gender expression
as nonconforming. Increasing numbers in gender diversity have been attributed to
expanding language, labels, and information to describe gender diversity, and
online support communities, as well as greater representation in media and grow-
ing acceptance. The multitude of gender identity options in social media reflects
the expansion and growing acceptance of gender identity labels. In 2017, the first
nonbinary character on television aired with Dillon on Billions, played by Asia
Kate Dillon, who also identifies as nonbinary. In the same year, nonbinary identi-
ties received national news coverage with cover stories in National Geographic
and Time magazine. Representation has increased with nonbinary role models and
activists such as Alok Vaid-Menon, iO Tillet Wright, and Ruby Rose, who advo-
cate for awareness of nonbinary experiences. Collectively, nonbinary activism has
been described as a movement focused on the development of supportive commu-
nities, representation through documentation and research, and education to
increase cultural awareness in media, social services, health care, and policies that
affect nonbinary individuals.
M. Killian Kinney
See also: Agender; Bigender; Binary Gender System; Childhood Gender Nonconformity;
Fluidity, Gender; Gender; Gender Expression; Gender Identity; Gender Identity Develop-
ment; Genderqueer; Questioning; Two-Spirit.
Further Reading
Aulette, J. R., & Wittner, J. (2015). Gendered worlds (3rd ed.). New York: Oxford Univer-
sity Press.
Barker, M.-J. (2014, February 15). 57 genders (and none for me)? Reflections on the new
Facebook gender categories. Rewriting the rules. Retrieved from https://www
.rewriting-the-rules.com/gender/57-genders-and-none-for-me-reflections-on-the
-new-facebook-gender-categories/
446 Nonbinary Gender Identities
Baron, D. (2015, September 14). Some notes on singular they [web blog post]. Retrieved
from https://blogs.illinois.edu/view/25/247504
Bergman, S. B., & Barker, M.-J. (2017). Non-binary activism. In C. Richards, W. P. Bou-
man, & M. J. Barker (Eds.), Genderqueer and non-binary genders (31–51). Lon-
don: Palgrave Macmillan.
Brown, M. E., & Burill, D. (2018). Challenging genders: Non-binary experiences of those
assigned female at birth. Miami, FL: Boundless Endeavors.
Flores, A. R., Herman, J. L., Gates, G. J., & Brown, T. N. (2016, June). How many adults
identify as transgender in the United States. Los Angeles: The Williams
Institute.
Fosco, M. (2015, October 24). Inequality within India’s third gender community. Seeker
Global Issue. Retrieved from http://www.seeker.com/inequality-within-indias
-third-gender-community-1501537275.html?utm_source=facebook&utm
_medium=seekersocial&utm_campaign=owned
Frohard-Dourlent, H., Dobson, S., Clark, B. A., Doull, M., & Saewyc, E. M. (2017). “I
would have preferred more options”: Accounting for non-binary youth in health
research. Nursing Inquiry, 24(1), 1–9.
Kinney, M. K. (2018a). Carving your own path: A nonbinary gender identity development
model. Manuscript in preparation.
Kinney, M. K. (2018b). Carving your own path: Exploring non-binary identities. Manu-
script in preparation.
Lauria, E. (2017). Gender fluidity in Hawaiian culture. The Gay & Lesbian Review World-
wide, 24(1), 31–32.
McLemore, K. A. (2015). Experiences with misgendering: Identity misclassification of
transgender spectrum individuals. Self and Identity, 14(1), 51–74.
McNabb, C. (2018). Nonbinary gender identities: History, culture, resources. Lanham,
MD: Rowman & Littlefield.
Poteat, V. P., Sinclair, K. O., DiGiovanni, C. D., Koenig, B. W., & Russell, S. T. (2013).
Gay-straight alliances are associated with student health: A multischool compari-
son of LGBTQ and heterosexual youth. Journal of Research on Adolescence,
23(2), 319–330.
Rankin, S., & Beemyn, G. (2012). Beyond a binary: The lives of gender-nonconforming
youth. About Campus, 17(4), 2–10.
Richards, C., Bouman, W. P., & Barker, M. J. (Eds.). (2017). Genderqueer and non-binary
genders. London: Palgrave Macmillan.
Wilson, B. D. M., Choi, S. K., Herman, J. L., Becker, R., & Conron, K. J. (2017). Charac-
teristics and mental health of gender nonconforming adolescents in California:
Findings from the 2015–2016 California health interview survey. Los Angeles:
The Williams Institute and UCLA Center for Health Policy Research.
O
Obstetrics and Gynecology
Obstetrics and gynecology is the field of medicine concerned with pregnancy,
childbirth, and the female reproductive organs. The term “obstetrics” refers to
pregnancy, childbirth, and neonatal care (care of the baby during the first four to
six weeks of life). “Gynecology” refers to the reproductive organs, including the
ovaries, fallopian tubes, uterus, cervix, and vagina. Physicians who specialize in
obstetrics are called obstetricians; those who specialize in gynecology are called
gynecologists. However, many physicians specialize in both fields and are com-
monly referred to as OB/GYNs.
With respect to obstetrics, an OB/GYN cares for the health of both the pregnant
person and the fetus throughout pregnancy. Responsibilities before delivery
include providing advice to the mother on how to recognize signs of labor and
perhaps deciding whether and when to induce labor. Then the OB/GYN may play
a major medical role in the safe and healthy delivery of the baby. During delivery,
the OB/GYN may help decide on the type of pain relief to provide while preserv-
ing the ability to use muscle movement for giving birth. The OB/GYN may also
need to decide whether a vaginal birth or cesarean section (incisions made in
abdomen and uterus for deliveries that would otherwise be problematic) is prefer-
able or necessary. Furthermore, any complications that occur during delivery
must be handled by the OB/GYN. In uncomplicated and unproblematic pregnan-
cies, the pregnant person may choose not to use the services of an OB/GYN and
may instead use a midwife.
In the weeks following delivery, the OB/GYN may provide postpartum care,
including physical examinations to ensure that recovery is progressing appropri-
ately from the physically demanding processes of pregnancy and childbirth. Care
may involve the management of both physical problems (such as infections and
blood clots) and psychological problems (such as postpartum depression). During
this period, the OB/GYN also monitors the health of the newborn, addressing any
problems that may develop.
Outside of their pregnancy and childbirth duties, OB/GYNs are involved in the
treatment of female reproductive organ problems. Some of these gynecological
problems are congenital, meaning that the individual was born with the condi-
tions. Examples of congenital gynecological conditions include malformations of
the vaginal tissues, cervix, and uterus. Other gynecological problems are caused
by infections, such as vulvitis (inflammation of the folds of skin outside the
vagina), vaginitis (inflammation of the vagina), cervicitis (inflammation of the
cervix, often caused by sexually transmitted infections), pelvic inflammatory dis-
ease (infection of female reproductive organs, also often caused by sexually trans-
mitted infections), and urinary tract infections.
448 Obstetrics and Gynecology
Still other gynecological problems are the result of imbalances in hormone lev-
els, resulting in such problems as menstrual irregularities, abnormal vaginal
bleeding, infertility, and loss of sex drive.
Tumors of the female reproductive organs make up a substantial portion of con-
ditions treated by OB/GYNs. In some cases, the tumors are benign (noncancer-
ous); in other cases, the tumors are malignant (cancerous).
Some people also report to OB/GYNs with injuries to their reproductive organs
as a result of trauma, such as that sustained in rape.
Yet another problem treated by OB/GYNs is endometriosis, a painful condition
in which uterine tissue grows outside the uterus, such as on the ovaries or else-
where in the pelvic region. This condition can have any of several causes, such as
abnormal menstruation, immune system disorders, and surgical scars.
Besides handling health conditions involving the female reproductive organs,
many OB/GYNs also treat disorders of the breasts, such as cancerous and benign
tumors.
OB/GYNs can use many different techniques to diagnose their patients’ med-
ical problems. In addition to physical examinations and blood tests, diagnostic
techniques include the following:
• Amniocentesis: examination of the amniotic fluid surrounding the fetus for
signs of chromosomal abnormalities and birth defects
• Ultrasonography: an imaging technology for making prenatal diagnosis of
birth defects, for general monitoring of the fetus’s health, and for gynecologi-
cal conditions
• Routine examinations of the vagina and cervix and their secretions to detect
signs of cancer
• Pap smear: examination of cervical cells for signs of cancer
• Other biopsies of the reproductive organs to check for cancer
• Mammograms (X-rays of the breast) to check for cancer or other abnormalities
• Genetic tests to evaluate the risks of breast and ovarian cancer and other
hereditary conditions
There is a vast variety of treatment methods provided by OB/GYNs, depending on
the patient’s particular needs.
Medications prescribed by OB/GYNs include contraceptive pills and other
hormone-based drugs, antibiotics to fight infections, and drugs to kill cancer cells.
Radiation therapy is also provided to fight cancer.
Some common obstetrical surgical procedures are cesarean section, episiotomy
(incisions to enlarge the vaginal opening to make delivery easier), and abortion.
Common gynecological surgical procedures include hysterectomy (removal of the
uterus), repair of damage sustained as a result of childbirth or traumatic injuries,
removal of benign or malignant tumors, and various other procedures involving
the urinary and genital tracts.
OB/GYNs can provide all methods of birth control in addition to oral contra-
ceptives, ranging from implanted devices (such as intrauterine devices) to
Obstetrics and Gynecology 449
permanent sterilization (tubal ligation). They can also provide any infertility treat-
ment, such as in vitro fertilization and embryo implantation.
OB/GYNs sometimes have to address minor psychiatric problems that are
associated with childbirth and other female reproductive issues. For patients strug-
gling with severe psychiatric problems, referrals to psychiatrists or clinical psy-
chologists are made.
To become an OB/GYN, a student must first earn an undergraduate degree,
preferably one focusing on science and mathematics. They then apply to a medical
school and upon passing the admission test attend the school for four years of
basic medical education, laboratory work, and clinical rotations in hospitals and
clinics under the supervision of a physician. Following graduation from medical
school, the student undergoes an additional four years of residency training in
reproductive and primary health care for women.
After this education and training, the individual must pass an examination to
become licensed and legally able to practice. In the United States, the examina-
tion, which evaluates both knowledge and judgment, is called the United States
Medical Licensing Examination (for MDs, or allopathic physicians) or the Com-
prehensive Osteopathic Medical Licensing Examination (for DOs, or osteopathic
physicians).
Many OB/GYNs pursue subspecialties for which special certification is
required. These subspecialties include maternal-fetal medicine (focusing on high-
risk pregnancies), reproductive endocrinology (focusing on hormone and infertil-
ity issues), gynecologic oncology (dealing with cancer), urogynecology and
reconstructive pelvic surgery (dealing with such abnormalities as pelvic organ
prolapse and urinary tract disorders), and pediatric and adolescent gynecology
(focusing on gynecological care for female children and teenagers).
To obtain these subspecialty certifications, OB/GYNs undergo about three
years of fellowship training, and they must pass examinations administered by
specialty boards, either the American Board of Obstetrics and Gynecology (for
MDs) or the American Osteopathic Board of Obstetrics and Gynecology (for
DOs). OB/GYNs must periodically renew their licenses and certifications to
ensure that they remain up-to-date with medical advances.
OB/GYNs in the United States earned an average salary of approximately
$212,500 in 2013. This profession is expected to see substantial job growth at least
into the 2020s.
Before the dawn of the modern, scientific era of medicine in the early 1800s,
women known as midwives were the main “professionals” who assisted during
childbirth. Several medical advances shifted the responsibility of childbirth assist-
ance from midwives to physicians and obstetricians. These advances included the
development of delivery forceps, antiseptic delivery methods, anesthesia, and
cesarean sections. However, midwives continue to practice today, and some
women prefer their services to those of physicians.
The public acceptance of gynecological medical procedures was long held back
by moral and religious objections to the examination of female genitalia. These
public attitudes gradually changed as a result of some of the same scientific
450 Oedipus Complex
advances that furthered the practice of obstetrics—particularly the benefits of
anesthesia and antiseptic methods of care.
During the mid- to late 1900s, there were many additional advances in obstet-
rics and gynecology. These included the widespread availability of effective birth
control methods, increased knowledge regarding ways to prevent birth defects,
technologies for monitoring the health of the baby in the womb (such as amnio-
centesis and ultrasonography), medicines for enhancing the health of newborns
and mothers, and technologies for helping infertile couples achieve pregnancy
(such as in vitro fertilization and embryo implantation).
A. J. Smuskiewicz
See also: Female Sexuality; Infertility; Pap Smear; Pregnancy; Sexual Disorders, Female.
Further Reading
American College of Obstetricians and Gynecologists. (2019). Home page. Retrieved
from https://www.acog.org
American Journal of Obstetrics & Gynecology. (2019). Home page. Retrieved from http://
www.ajog.org
Bowdler, N. C., & Elson, M. (2008). The gynecologic history and examination. The global
library of women’s medicine. Retrieved from http://www.glowm.com/section
_view/heading/TheGynecologicHistoryandExamination/item/3
Oedipus Complex
The Oedipus complex is a concept in psychoanalytic theory, originally introduced
by Sigmund Freud. It refers to a male child’s unconscious sexual desire for his
mother and fear and aggression toward his father. This psychodynamic conflict is
usually resolved by the child identifying with his father and in adulthood seeking
a sexual and romantic partner similar to his mother. Freud saw this as crucial for
development of adult sexuality and personality (psychosexual development).
Although originally formulated using material from men, Freud and later theorists
have sought to apply this process to development in women as well.
Freud first described this concept in Interpretation of Dreams, and the name
“Oedipus complex” was first used in A Special Type of Choice of Object Made by
Men. In the former text, he describes how the idea arose from his own reactions
and introspection from watching a performance of the play Oedipus Rex by
Sophocles. The play is about the ancient Grecian myth of Oedipus, a man who
fulfills an oracle’s prophecy of killing his father and marrying his mother. Freud
attributed the emotional impact of the play, which was very popular in his time, to
a universal, repressed desire among men to slay their fathers and sexually possess
their mothers. He noted the trope in other literary works, including Shakespeare’s
Hamlet. This is described as an example of a latent content in dreams and is of
importance to dream interpretation during psychoanalysis. He further developed
this dynamic and how it manifests in the development of male sexuality (as well as
the ego) in the latter publication.
The Oedipus complex, like many of Freud’s ideas, emphasized the role of libido.
For Freud, libido meant an overarching energetic drive toward life, which includes
Oedipus Complex 451
sex but also other physical urges such as hunger. In his model, for an infant son,
the most important focus of the libido at the start of life is the breast, and by exten-
sion, the mother (due to dependence on sustenance from breastfeeding). As a
result of this libidinal drive, the son desires to become closer to the mother, the
source of his life and survival. However, as he grows older, he becomes aware that
he cannot be the sole possessor of his mother, as his father also has claim to her.
During the “phallic phase” of development (ages three to six years old), the son
becomes more aware of his and others’ bodies and begins to explore these bodies,
and his libido shifts its focus to the penis. During this phase, he becomes aware
that he cannot possess his mother through the use of his penis, as his mother
sleeps with and has sex with his father. This leads to competition and jealousy dir-
ected at the father, and the child wishes to destroy the father. However, the develop-
ing ego, which operates based on the contingencies of reality, understands that he
cannot directly aggress against the father, as the father is by far the more physic-
ally powerful of the two. This ambivalence results in significant distress and ten-
sion in the child, which is manifested as a fear of castration by his father (castration
anxiety).
To resolve this tension, the child represses his desires for his mother and his
aggression toward his father. Furthermore, the child identifies with (incorporates
into his forming ego and superego) the traits and values of his father. This dimin-
ishes castration anxiety, as the child’s similarity to his father protects him from
the father’s wrath. In this process, the child is able to individuate from the mater-
nal care and identify with his same-sex parent. Eventually, this means growing up
to be a man like his father, with the capacity to find a woman like his mother in
order to gratify his adult libidinal urges.
This identification also means the child internalizes his father’s adult sense of
social morality. The child hence learns to obey societal laws and conventions as
opposed to acting only through fear of punishment or anticipation of reward. If the
child is unable to resolve this complex through identification with the father, it can
lead to neurotic difficulties later in life. For example, maintaining a competitive
stance with the father can lead to an adult man who is vain and aggressive. Freud
also attributed some presentations of sexual promiscuity, paraphilic behaviors,
and homosexuality to developmental difficulties in resolving the Oedipus
complex.
Freud and later psychoanalytic authors have attempted to generalize the prin-
ciples of the Oedipus complex to female psychosexual development as well. This
includes the feminine Oedipus complex from Freud and the Electra complex from
Carl Jung. However, these early models were not well developed, and understand-
ing female sexuality appeared to have been a persistent area of difficulty for early
psychoanalysts.
One recent model that seeks to elaborate on the feminine aspect of the Oedipus
complex is the Persephone complex. This model takes its name from the ancient
Grecian myth of Persephone, who oscillates between the shadowed underworld of
her husband, Hades, and the sunny overworld of her mother, Demeter. The trian-
gular conflict between child, mother, and father are seen as asymmetrical between
boys and girls due to the biological role of the maternal care (e.g., breastfeeding)
452 Online Dating
regardless of the sex of the child. Unlike for boys, competition between girls and
their same-sex parent (mother) not only risks aggression from a more powerful
adult but also the loss of life-giving maternal nurturance. Furthermore, girls must
shift the focus of their libido to the father, someone who is relatively unfamiliar
when compared to the mother. This results in ambivalence and conflicting loyal-
ties to the mother and the father. To resolve this dynamic conflict, many girls often
relinquish their sense of agency over their capacity both for sexuality and com-
petitive aggression in order to protect their maternal relationship.
The Oedipus complex has remained controversial ever since its original publi-
cation. It has been criticized for being inapplicable to the experiences of women,
pathologizing nonheterosexual (and noncisgender) sexuality, and for being exclu-
sively focused on sexual motivations. Freud’s approach emphasized repressed and
transformed motivations and feelings as well as methods like introspection and
free association. As such, the Oedipus complex, like many of Freud’s models, has
been difficult to operationalize and evaluate empirically outside of individual case
studies. In contemporary research on the psychology of sexuality, other theories
relating to child-parent relationships, such as attachment theory, have gained
greater prominence. However, the Oedipus complex remains an important idea for
psychoanalysis practitioners and theorists and in the study of literature and the
humanities.
Silvain S. Dang
See also: Female Sexuality; Freud, Sigmund; Male Sexuality; Psychosexual Therapy.
Further Reading
Freud, S. (1953). The method of interpreting dreams: An analysis of a specimen dream.
In J. Strachey (Ed. & Trans.), The standard edition of the complete psychological
works of Sigmund Freud (Vol. 4, 96–121). London: Hogarth Press. (Original work
published 1900).
Freud, S. (1953). A special type of choice of object made by men. (Contributions to the
psychology of love I). In J. Strachey (Ed. & Trans.), The standard edition of the
complete psychological works of Sigmund Freud (Vol. 9, 163–176). London: Hog-
arth Press. (Original work published 1910).
Holtzman, D., & Kulish, N. (2000). The feminization of the female oedipal complex, part
I: A reconsideration of the significance of separation issues. Journal of the Amer-
ican Psychoanalytic Association, 48(4), 1413–1437.
Holtzman, D., & Kulish, N. (2002). The feminization of the female oedipal complex, part
II: Aggression reconsidered. Journal of the American Psychoanalytic Association,
51(4), 1127–1151.
Scott, J. (2005). Electra after Freud: Myth and culture. Ithaca, NY: Cornell University
Press.
Online Dating
Online dating is a method of arranging meetings between people—usually of a
romantic or sexual nature—over the internet. This system of dating has exploded
in popularity among a wide range of demographic groups during the twenty-first
century, with tens of millions of people in the United States alone using online
Online Dating 453
dating as a way to find partners. There are hundreds of dating websites catering to
virtually every imaginable type of dating or sexual interest, including conven-
tional two-person mixed-sex and same-sex relationships as well as less common
relationships, interests, and lifestyles, such as swinging, polyamory, gender min-
ority, dominatrixes/sadomasochism, and various fetishes. Some online dating
sites specialize in particular age, ethnic, occupational, or religious groups, such as
teenagers or middle-aged people, African Americans or Arabs, business people or
farmers, and Christians or Jews.
Some online dating services are free to join; others charge fees to become a
member. To participate, a user typically sets up a profile page by answering a ser-
ies of questions about their appearance and interests and uploading personal
photographs. The user also sets up search criteria for the type of partner they seek.
When the user sees someone of interest, they can contact that individual through
the online system and exchange messages, arranging an in-person meeting if so
desired.
Dating apps for mobile phones facilitate the online dating process by making it
easier and more convenient to browse through, find, and chat with potential part-
ners who have similar interests and who live in the same area.
According to data compiled in 2015 by the highly respected Pew Research
Center, approximately 15 percent of all adults (older than age eighteen) in the
United States have arranged dates using online dating services, including dating
websites (such as eHarmony, OkCupid, or Match.com), social networking web-
sites (such as Facebook or Twitter), or mobile dating apps (such as Tinder). The
most common adult age group that participates in online dating consists of indi-
viduals aged eighteen to twenty-four with about 27 percent reporting use;
between 21–22 percent of adults age twenty-five to forty-four have arranged dates
online. However, when the population size is narrowed to those adults who are
“single and actively looking” for partners, this percentage increases to 38 percent
(2013 data). Men use online dating slightly more often than women. Given that
the popularity of online dating has continued to grow in recent years, it is
expected that the actual percentage of users has now increased. In addition, 59
percent of adults surveyed in 2015 reported that online dating is a good way to
meet people, indicating that attitudes are continuing to be more favorable toward
online dating.
In 2013, Pew data revealed that about 23 percent of online daters either married
or developed serious, long-term relationships with people they met online. Other
data, however, suggest that romantic relationships originating online do not last as
long as relationships between people who meet in traditional, offline ways.
Online dating carries some risk that the people being communicated with are
not really what they seem to be or who they claim to be. This risk stems from the
obvious fact that it is easier to lie about one’s identity online than in person.
Many people are aware of the negative aspects of online dating—but that does
not necessarily stop them from engaging in the practice. In 2013, 54 percent of
online daters agreed that “someone else seriously misrepresented themselves in
their profile.” Furthermore, 28 percent of online daters said they were “contacted
by someone through an online dating site or app in a way that made them feel
454 Online Sexual Activity
harassed or uncomfortable.” Among female online daters, 42 percent agreed with
that statement, compared with 17 percent of males.
There have been numerous media reports of bad—even deadly—personal
experiences when online daters meet in person. In one of the more extreme
examples, a man who came to be known as the “Craigslist killer” was charged
with robbing and killing a woman whom he met via an ad for “massage services”
posted on the Craigslist website in 2009. He was also a suspect in at least two
other robberies of women.
Critics of online dating argue that such dangers are inherently greater with
online dating than traditional meetings, because online daters typically have never
met before their initial romantic get-together. By contrast, traditional dates are
more likely to be preceded by at least some informal, friendly get-togethers in
which the individuals have a chance to get to know each other a bit before a formal
date.
Some critics also blame online dating for making it too easy to participate in
the “hookup culture,” in which individuals meet purely for casual sex with no
interest in pursuing a more meaningful relationship.
As such, if using online dating, it is important to be clear about one’s expecta-
tions and desired outcomes and to ensure that steps are taken to ensure that any
encounters occur safely.
A. J. Smuskiewicz
See also: Casual Sex; Dating; Dating, Cross-Cultural Comparison of; Hookup Culture;
Online Sexual Activity; Sugar Daddies and Sugar Babies.
Further Reading
Smith, A., & Anderson, M. (2016, February). 5 facts about online dating. Retrieved from
https://www.pewresearch.org/fact-tank/2016/02/29/5-facts-about-online-dating/
Smith, A., & Duggan, M. (2013, October). Online dating & relationships. Retrieved from
http://www.pewinternet.org/2013/10/21/online-dating-relationships/
Wortham, J. (2013, February). Tinder, a dating app with a difference. New York Times.
Retrieved from http://bits.blogs.nytimes.com/2013/02/26/tinder-a-dating-app-with
-a-difference/?_r=0
Online Sexual Activity
Online sexual activity, also sometimes referred to as cybersex, refers to sexually
arousing or satisfying internet-based computer activities. Online sexual activ-
ities include viewing or reading erotica; chatting with others about sex by using
text or voice communication; sending or receiving sexually explicit emails;
sharing sexual fantasies; participating in real-time cybersex in chatrooms, game
spaces, or by using video streaming; contacting partners for real-time sexual
encounters outside of cyberspace; chatting with others who share similar sexual
interests; contacting others to pay for or to be paid for sex work; and seeking
individuals to commit sex-related crimes. The scope and variety of online sex-
ual activities continues to expand along with the scope of internet-facilitated
activities.
Online Sexual Activity 455
Sexual subjects are the most searched-for topics on the internet. Early studies
of cybersex in the 1990s suggested that up to one-third of internet users accessed
some type of sexual content online, though many of these studies did not distin-
guish between sexual content designed to produce sexual arousal or gratification
and those searches that were more educational. Technological advances and
increased access to the internet, both at home and through smartphones, have
made online sexual activities accessible to more individuals; researchers currently
estimate that the percentage of the population who engages in online sexual activ-
ities is much higher than in earlier decades.
Research studies consistently indicate that the greatest levels of online sexual
activity are reported by males, young people (adolescents and young adults), sin-
gle individuals, and those living in urban areas. These data suggest that male col-
lege students may be among the highest users of online sexual activity and also
the most at risk for problematic use. As a group, men are up to six times more
likely to use internet pornography compared to women. Men report more interest
in solitary online sexual activities such as viewing pornography and are more
likely to pay for sexual images than women. Men are also more likely to report
that their interest in online sexual activity decreases with age and is not problem-
atic, and they are less likely to view online sexual activity as infidelity compared
to women. In contrast, women report more personal problems with online sexual
activity and are more likely to view it as cheating. Women also more often choose
online sexual activities that involve a relational or romantic component, and some
studies indicate that women are more likely than men to pursue real-life meetings
with those they contact online. Interest in online sexual activity among women
often remains stable across adulthood, with women ages thirty-five to forty-nine
reporting more online sexual activity than similarly aged men.
Sexual orientation may also affect online sexual activity. Several studies sug-
gest that gay men are more likely to engage in online sexual activity than hetero-
sexual men, and cybersex and other online sexual activities may be part of the
coming-out process for many individuals.
Studies suggest that online sexual activity may be related to loneliness, lack of
a happy relationship, and a history of sexual problems. Cybersex has not been
consistently or strongly related to sexual aggression, sensation seeking, domi-
nance, hypermasculinity, or negative attitudes toward women. The relationship
between online sexual activity and religion is a variable one; some highly reli-
gious people report lower levels of cybersex participation. However, several stud-
ies suggest that religious adults may engage in online sexual activities at rates
similar to nonreligious peers.
Online sexual activities, including cybersex, present both benefits and draw-
backs for users. These activities may provide sexual education and reproductive
information, model safer sex behaviors, support relationship intimacy at a dis-
tance, and make sexual products more available to consumers. Distress related to
cybersex and online sexual activities is often found in the forms of relationship
isolation, impairment in sexual activities with a partner, perceptions of infidelity,
superficial pseudo-intimacy with distant partners, exposure of youth to sexually
explicit materials or sexual predators, impaired job performance and job loss,
456 Oophorectomy
criminal convictions if illegal activities are pursued, financial strain from internet
purchases, spiritual conflict, depression, anxiety, guilt, and an increased risk of
sexually transmitted infections from partners met online.
Research suggests that the majority of cybersex users do not report problems
related to cybersex activities. Some studies suggest that about 5 percent of cyber-
sex users would be classified as having sexual compulsions, and another 10–20
percent may be at risk for other negative consequences from cybersex. However,
no single cybersex behavior accurately predicts problematic use. Many problem-
atic users of cybersex also report problems with other sexual compulsions, depres-
sion and bipolar disorder, anxiety, chemical dependency, and eating disorders.
Several brief assessments of online sexual activity problems are available, such
as the Internet Sex Screening Test. A consultation with a mental health profes-
sional who specializes in sexual concerns is recommended before determining if
an individual has an online sexual activity problem. Treatment for problematic
online sexual activity often focuses on anxiety management, depression treat-
ment, conflict resolution, and identifying face-to-face means of meeting sexual
needs and interests. Treatment may be offered in inpatient hospital settings, out-
patient counseling, twelve-step groups, and online programs.
Elizabeth A. Maynard
See also: Adultery; Fantasy, Sexual and Erotic; Online Dating; Pornography; Pornog-
raphy Addiction; Sex Work.
Further Reading
Cooper, A. (Ed.). (2013). Cybersex: The dark side of the force (special issue). Journal of
Sexual Addiction and Compulsivity, 19(1–2), 1–160.
Young, K. S., & Nabuco de Abreu, C. (2011). Internet addiction: A handbook and guide to
evaluation and treatment. Hoboken, NJ: John Wiley & Sons.
Oophorectomy
An oophorectomy is the removal of the ovaries. The ovaries are almond-shaped
organs that are responsible for the production of ova as well as the female sex hor-
mones, and they are connected to the uterus via the fallopian tubes. An oophorec-
tomy is a surgical procedure and can differ between individuals on the extent of
the surgery required. For example, certain people may only require one ovary to
be removed, while others may need the removal of both ovaries. This procedure is
notable for its potential life-saving results for those who have or are at high risk
for ovarian and breast cancer. As well as cancer risk reduction and removal,
oophorectomies are performed for the reduction of ectopic pregnancies, endome-
triosis, noncancerous ovarian cysts, chronic pelvic pain, and pelvic inflammatory
disease.
As previously mentioned, there are different types of oophorectomies. The
individual’s needs and the doctor’s recommendation will determine which type of
surgery is performed. The unilateral oophorectomy involves the removal of one
ovary. Typically, a unilateral oophorectomy might be used to address and remove
cancer that is housed in a single ovary. Usually if cancer is present, the adjacent
Oophorectomy 457
fallopian tube will also be removed due to the shared blood supply between
the cancerous ovary and the connecting fallopian tube. When both an ovary and a
fallopian tube are removed, the procedure is referred to as a unilateral salpingo-
oophorectomy.
Another type of oophorectomy involves the removal of both ovaries and is
called a bilateral oophorectomy. This procedure is performed when an individual
would like to reduce their risk for both ovarian and breast cancer. Removing both
ovaries also removes the production of female sex hormones such as estrogen and
progesterone, which then reduces the risk of cancer. In addition to cancer reduc-
tion, a bilateral oophorectomy may also be done to prevent the spread of already
existing cancer cells in the ovaries. In some cases, both fallopian tubes may also
be removed, rendering the procedure a bilateral salpingo-oophorectomy.
In addition, an oophorectomy can be either performed alone or with other pro-
cedures. As already mentioned, an oophorectomy paired with a salpingectomy is
the removal of both the ovary and the connecting fallopian tube. An oophorec-
tomy paired with a hysterectomy is called a complete hysterectomy and usually
results in the removal of the ovaries, fallopian tubes, cervix, and uterus. When
deciding whether a unilateral or bilateral oophorectomy needs to be performed,
one issue that needs to be considered is if the individual still wants to become
pregnant or carry a child. With both ovaries removed, ova are no longer released
into the fallopian tubes, and, as such, internal fertilization of the egg is no longer
possible. However, if both ovaries have been removed, pregnancy and birth may
still be possible through alternative medical procedures like in vitro fertilization.
However, if a hysterectomy is performed, pregnancy is no longer possible due to
the complete removal of the uterus.
The actual oophorectomy surgical procedure can last anywhere from one to
four hours, depending on the type of oophorectomy performed as well as the sur-
gical route taken. There are two types of surgeries that can result in an oophorec-
tomy. The first type of surgery is a laparoscopic surgery. This kind of surgery is
ideal as it is the least invasive, and most patients can be out of the hospital soon
after it is performed. During this surgery, four small incisions are made on the
abdomen. Using these incisions, the doctor will use a small camera to see inside
the body accompanied by small tools to remove the ovaries. In a typical proced-
ure, the doctor will separate the ovary from its main blood supply and then pull
the organ out from one of the small incisions.
The second option for surgery is referred to as a laparotomy. This surgery is
typically not as preferred by doctors because of its invasive nature; however, in
some cases, a laparotomy is the only option. During this operation, the doctor
makes one large incision to remove the ovaries. Like the laparoscopic surgery, the
doctor will then separate the ovary from its blood supply and subsequently remove
the organ. Regardless of the procedural route taken, the patient will be put under
general anesthesia during the operation.
Like any medical procedure involving surgery, potential complications may
arise. For example, a surgery may start out with the laparoscopic approach, but
after complications may result in the doctor performing a laparotomy instead.
Other potential complications during the surgery may include bleeding, blood
458 Open Marriage
clots, and damage to other surrounding organs. In addition, proper aftercare is
important to reduce the risk of potential infection of the surgical area and to make
recovery as smooth as possible. Depending on the patient and the surgery, the
recovery process may differ. Some individuals may stay in the hospital for hours
or days after their oophorectomy. Those who received a laparoscopic surgery can
usually make a full recovery within a few weeks. Contrastingly, those who
received their oophorectomy via a laparotomy usually take six weeks to make a
full recovery, and that recovery process can be extremely painful due to the inva-
sive nature of the surgery. Similar to a laparotomy, a complete hysterectomy also
takes a full six weeks to heal.
During the healing process, menopause may also be an experience that some
will have to manage. Those who received a unilateral oophorectomy or a unilat-
eral salpingo-oophorectomy should not experience any differences with their hor-
mone levels or their menstrual cycle, if they are still menstruating. However, if an
individual has not yet entered menopause and has a bilateral oophorectomy, a doc-
tor might prescribe low doses of hormones to reduce menopause-related symp-
toms as the removal of both ovaries will affect sex hormone production, resulting
in premature menopause for some women. Unfortunately, hormones prescribed
might also have side effects such as headache, mood swings, and nausea.
Oophorectomies can differ in relation to how many ovaries are removed and
whether or not the fallopian tubes are removed as well. In general, an oophorec-
tomy may be used as a last-resort procedure because of its potentially invasive
nature and the potential for the individual to enter early menopause. However,
despite these drawbacks, an oophorectomy can still be beneficial and can be a life-
saving procedure for those who have been diagnosed with ovarian cancer and for
those hoping to reduce their risk of ovarian and breast cancers.
Casey T. Tobin
See also: Breast Cancer; Endometriosis; Estrogen; Fallopian Tubes; Hormone Replace-
ment Therapy; Hysterectomy; Menopause; Ovarian Cancer; Ovaries; Progesterone; Sex
Hormones.
Further Reading
American Cancer Society. (2018). What is ovarian cancer? Retrieved from https://www
.cancer.org/cancer/ovarian-cancer/about/what-is-ovarian-cancer.html
Boston Women’s Health Book Collective. (2011). Our bodies, ourselves. New York:
Simon & Schuster.
Rocca, W. A. (2017). Bilateral oophorectomy, accelerated aging: Late breaking news on a
controversial issue. Maturitas, 103, 89.
Open Marriage
“Open marriage” is an umbrella term that includes different types of consensual
nonmonogamous arrangements within a couple. Historically, the term was used to
distinguish marriages where people had freely chosen each other. This was in
opposition to closed marriages, where partnerships had been arranged by families
or other systems, such as political alliances. In 1972, the publication of the book
Open Marriage 459
Open Marriage by Nena and George O’Neill marked the transition of this term
“open marriage” to indicate openness to consensual extramarital relationships
within traditionally monogamous marriages. Other terms commonly used include
“open relationships,” “ethical nonmonogamy,” and “responsible nonmonogamy.”
There are several types of open marriages, including practices like swinging,
polyamory, and ad hoc arrangements. For example, some couples might agree that
it is acceptable for the other partner to have sex with someone else when traveling
or if one of the partners becomes sick and sexually unavailable for a long period of
time. Open marriage arrangements are only one type of nonmonogamy on a global
scale, given that plural marriages of different kinds are not unusual in a range of
places across the globe and in different religious traditions.
Open marriages have different norms and rules, which are very much depend-
ent on the model adopted by the couple. Swingers, for example, usually view sex
as a recreational activity to be pursued as a couple, usually with other swingers,
and there is an understanding that romantic attachment is reserved for the couple
and is not to be entered into with other people. On the other hand, polyamorous
arrangements can include romantic as well as sexual attachments outside the mar-
riage. Rules and norms in open marriages might also change as couples grow,
come into contact with different ideas and communities, and broaden their own
experiences and understanding of what they want their open marriage to be like.
Sometimes marriages are open from the beginning and for the duration of the
relationship; at other times couples might open their marriage for a period of time,
then close it again. In addition, some marriages might be open only for specific
partners and no other people in general. Within polyamorous practices, these are
sometimes known as polyfidelitous arrangements, which can also be referred to as
a closed group marriage.
Regardless of the type of open marriage, one of the common traits of an open
marriage is the existence of ground rules and contracts within the couple. Those
ground rules and contracts determine the rules of engagement for each partner. In
some relationships, the rules might be different for each partner based on needs,
comfort, and power dynamics. Even though ground rules and contracts in open
marriages are usually freely entered into, couples are not immune from power
dynamics that might influence the rules and contracts agreed. Power dynamics
and communication are definitely issues to be carefully considered when negotiat-
ing ground rules or contracts in open marriages or when working with people who
are considering opening up their marriage.
Communication is a key issue in open marriages, given that it is needed not
only to negotiate ground rules and contracts but also to discuss new sexual
encounters and relationships, negotiate safer sex, and manage emotions such as
jealousy. The latter can be present to varying degrees in open marriages and needs
to be carefully negotiated both when discussing opening a marriage and to main-
tain the relationship. Some couples might keep the status of their open marriage
secret for fear of family or societal disapproval as well as because of potential
legal repercussions. If couples have children, for example, they might fear that
being visible as part of an open marriage might expose them to scrutiny from
child protective services.
460 Oral Sex
In recent years, some notable figures have been more public about their open
marriages, and there has been more widespread media attention to ethical nonmo-
nogamous practices in general, also reflected in a broader range of published
resources and online networks. The prevalence of open marriages is not known,
even though some scholars have tried to estimate it. However, given the range of
relationships that might fall under this category, an accurate estimate has not been
widely agreed on.
Alex Iantaffi
See also: Communication, Sexual; Extramarital Sex; Marriage; Marriage, Cross-Cultural
Comparison of; Monogamy; Polyamory; Polyandry; Polygamy; Polygyny; Swinging.
Further Reading
Barker, M. (2018). Rewriting the rules: An anti self-help guide to love, sex and relation-
ships (2nd ed.). New York: Routledge.
Barker, M., & Langdridge, D. (2010). Whatever happened to non-monogamies? Critical
reflections on recent research and theory. Sexualities, 13(6), 748–772.
Bergstrand, C., & Williams, J. B. (2000). Today’s alternative marriage styles: The case of
swingers. Electronic Journal of Human Sexuality, 3(10), 1–10.
Block, J. (2009). Open: Love, sex, and life in an open marriage. Berkeley, CA: Seal Press.
Grunt-Mejer, K., & Campbell, C. (2016). Around consensual nonmonogamies: Assessing
attitudes toward nonexclusive relationships. The Journal of Sex Research, 53(1),
45–53.
Munson, M., & Stelboum, J. (2013). The lesbian polyamory reader: Open relationships,
non-monogamy, and casual sex. London: Routledge.
O’Neill, N., & O’Neill, G. (1972). Open marriage: A new life style for couples. New York:
M. Evans and Company.
Rubin, R. H. (2001). Alternative lifestyles revisited, or whatever happened to swingers,
group marriages, and communes? Journal of Family Issues, 22(6), 711–726.
Taormino, T. (2013). Opening up: A guide to creating and sustaining open relationships.
San Francisco: Cleis Press.
Oral Sex
“Oral sex” is an umbrella term that encompasses both cunnilingus and fellatio.
Cunnilingus is the stimulation of the vulva, vagina, and clitoris using one’s mouth
and tongue. Fellatio is the stimulation of the penis and testicles using one’s mouth
and tongue. Analingus, or the stimulation of the anus using one’s mouth and
tongue, also falls under the category of oral sex.
There are many terms used to describe oral sex. A common phrase to describe
both fellatio and cunnilingus is “going down” on someone. Some popular terms
used for fellatio are “giving head” and “blowjob.” Cunnilingus may sometimes be
referred to as “eating out.” Many other euphemisms exist to describe oral sex in
general, or fellatio or cunnilingus specifically. Oral sex is most often performed or
received from a partner. However, when it comes to fellatio, some people are flex-
ible enough to perform oral sex on their own penis, which is called autofellatio.
Oral Sex 461
Oral sex, when performed simultaneously, is called “69.” It is called “69” as the
shape of that number is a visual representation of simultaneous oral sex.
Oral sex has become more popular and acceptable as a sexual practice over the
past few decades. In a study of college students, 70–90 percent report engaging in
oral sex at some point during their lives. A large majority of these study partici-
pants stated they had both performed and received oral sex. In this study, women
reported giving oral sex more frequently than men gave oral sex.
Oral sex is a common sexual practice for persons of all genders and sexual ori-
entations. It is most common among white middle-class Americans. It is most
frequently performed and received during beginning stages of a sexual relation-
ship and is most popular among high school and college-aged people.
In another national survey study conducted in 2002 of twenty-five- to forty-
four-year-olds, 90 percent of men and 88 percent of women reported having
engaged in oral sex with a partner. In participants aged fifteen to seventeen years,
13 percent of males and 11 percent of females had had oral sex but not penetrative
sex. Among those aged eighteen and nineteen years, 11 percent of males and
9 percent of females had engaged in oral sex but not penetrative sex. In a college
sample, just over 45 percent of both men and women reported engaging in oral
sex with a partner within the last thirty days. Only one-fifth of study participants
indicated they had never engaged in oral sex.
While oral sex has less risk of acquiring a sexually transmitted infection than
penetrative sex, it still carries a chance of infection. Chlamydia, gonorrhea, her-
pes, HPV, and syphilis are all transmissible through oral sex. Although rare, HIV
may also be transmitted through oral sex. As such, it is important to take precau-
tions when engaging in oral sex, such as using condoms or dental dams. Open
communication between partners about testing and sexual health is very import-
ant. Oral sex should be avoided when the person performing oral sex has a cold
sore. In fact, anyone experiencing open sores in their mouth should take a break
from oral sex until the mouth has healed, as these lacerations increase the risk of
infection. However, even when cold sores are not present, herpes can still be trans-
mitted from a partner who has ever had a cold sore, although the risk is less than
when a sore is present.
More evidence is being collected about the transmission of HPV through oral
sex, which may lead to cancers of the mouth, head, throat, or neck. This was
brought into the spotlight in the media when actor Michael Douglas attributed his
throat cancer to HPV he acquired through oral sex.
Fortunately, barrier methods of contraceptives are great for use during oral sex.
Unfortunately, the use of protection during oral sex is quite uncommon. Condoms
may be used for protection during fellatio. Many flavored condoms exist for the
purpose of oral sex, and regular, unflavored condoms work just as well. Likewise,
a dental dam, which is a thin piece of latex, may be used for protection during
cunnilingus or analingus. If a dental dam is not available for use during cunnilin-
gus or analingus, a condom may be used by cutting up the length of the condom
and removing the ring. This will create a sheet of latex, which can then be
spread over the vulva or anus. If using dental dams or unflavored condoms is
462 Orchiectomy
unappealing due to the latex taste, flavored lubricants are available that can make
it more palatable.
Oral sex is able to provide very direct stimulation to highly sensitive areas of
the body. On a female body, the clitoris cannot always be directly stimulated dur-
ing penetrative sex. However, during oral sex the clitoris is able to receive that
stimulation, which is why orgasm may be more likely to occur during oral sex
rather than penetrative sex.
Individuals who have a positive attitude toward their own body and genitals
tend to be the most comfortable with oral sex. When looking at gender differ-
ences, men report feeling more pleasure in both giving and receiving oral sex than
their female counterparts. Among both men and women, watching a partner
receive pleasure is the biggest motivating factor in performing oral sex on
someone.
Amanda Manuel
See also: Clitoris; Dental Dam; Penis; Safer Sex; Sexually Transmitted Infections (STIs);
Testicles; Vagina; Vulva.
Further Reading
Herbenick, D. (2012). Sex made easy: Your awkward questions answered for better,
smarter, amazing sex. Philadelphia: Running Press.
Seidman, S., Fischer, N., & Meeks, C. (2011). Introducing the new sexuality studies (2nd
ed.). London: Routledge.
Yarber, W., Sayad, B., & Strong, B. (2010). Human sexuality: Diversity in contemporary
America (7th ed.). New York: McGraw-Hill.
Orchiectomy
An orchiectomy (also known as an orchidectomy) is the surgical removal of one or
both testicles. Reasons for an orchiectomy may include testicular cancer, infection
in the testes, or gender or sex reassignment surgery. There are three main types of
orchiectomy: simple, subcapsular, and inguinal; each of these is generally done
under local anesthesia. While common today for health purposes, historically, the
orchiectomy was used as a form of punishment.
A simple orchiectomy is commonly performed as part of sex reassignment sur-
gery for transgender women. It may also be used as treatment for advanced cases
of prostate cancer or in the event of a testicular injury. For this procedure, the
patient lies flat on an operating table with the penis taped against the abdomen.
The nurse then shaves a small area for the incision. After anesthetic has been
administered, the surgeon makes an incision in the midpoint of the scrotum and
cuts through the underlying tissue. The surgeon then removes the testicle(s) and
parts of the spermatic cord through the incision. The incision is closed with two
layers of sutures and covered with a surgical dressing. If the patient desires, a
prosthetic testicle (or two) can be inserted before the incision is closed to mimic
the look of the presurgery scrotum, which may help increase body image and
self-esteem.
For transgender women, an orchiectomy may be used as a treatment for gender
dysphoria as it will decrease the amount of male hormones in the body and change
Orchiectomy 463
the external genital area to better match the individual’s gender. It is commonly
used alongside a penectomy, which is the surgical removal of the penis, and a
vaginoplasty, which is the surgical creation of a vagina.
A subcapsular orchiectomy is also commonly performed for the treatment of
prostate cancer. The operation is very similar to that of a simple orchiectomy, with
the exception that just the glandular tissue that surrounds each testicle is removed
rather than the entire gland itself. A subcapsular orchiectomy is done to remove
the part of the testicle that produces testosterone. It assists in cases of prostate
cancer and is an option available for men who do not want to undergo hormonal
treatment while achieving the same outcome. The operation leaves the testicles in
place, with a slightly smaller appearance than before. This type of orchiectomy is
done primarily to keep the appearance of an ordinary scrotum, mainly to decrease
the patient’s chances of experiencing negative body image or feelings of demascu-
linization after surgery.
Inguinal orchiectomy, also called radical orchiectomy, is performed when the
onset of testicular cancer is suspected and is completed to prevent a possible
spread of cancer from the spermatic cord into the lymph nodes near the kidneys.
An inguinal orchiectomy can be either unilateral or bilateral, meaning removing
just one or both testicles. During this procedure, the surgeon makes an incision in
the patient’s groin area that is bigger and more invasive than the scrotal incision in
the previously described methods. In addition to one or both testicles, the entire
spermatic cord is also removed. A long, nonabsorbable suture may be left in the
stump of the spermatic cord in the case that more surgery is deemed necessary in
the future. After the cord and testicle(s) have been removed, the surgeon washes
the area with saline solution and closes the various layers of tissues and skin with
various types of sutures. The wound is then covered with sterile gauze and ban-
daged. This version of an orchiectomy is much more serious and invasive, and it
carries a longer rate of postoperative healing, but is necessary to treat more
advanced stages of testicular cancer.
Negative effects that a patient may experience after an orchiectomy include
several different physical and psychological concerns, such as infertility and
hypoandrogenism. Hypoandrogenism occurs when there is a lack of male hor-
mones, called androgens, in the body. Because the testes produce much of the
body’s androgens, if they are removed, this production stops. Symptoms associ-
ated with hypoandrogenism include hot flashes, osteoporosis (a medical condition
in which the bones become brittle and fragile from loss of tissue), feelings of
demasculinization, sexual dysfunction, and depression, as well as gynecomastia
(swelling of the breast tissue in males, caused by an imbalance of the hormones
estrogen and testosterone). If a patient is able to retain one testicle, there are fewer
side effects, and erectile function and sperm production may not be affected. With
both testicles removed, however, the body is unable to make as much testosterone
as it needs, which may result in a lower sex drive and make it challenging to have
erections. A doctor can prescribe a testosterone gel, patch, or shot that may help
ease these symptoms. Some patients may also require psychological counseling
following an orchiectomy as part of their long-term aftercare. Many men have
very strong feelings about issues involving their genitals and may feel depressed
or anxious about their bodies or their relationships after genital surgery. In
464 Orgasm
addition to individual psychotherapy, support groups are often helpful. There are
active networks of prostate cancer support groups in Canada and the United States
as well as support groups for men’s issues in general.
While orchiectomies are now used as a surgical procedure for those seeking
sex reassignment or as a treatment for cancer, they were historically used as pun-
ishment, similar to historical uses of castration. While the overall understanding
of castration also includes the removal of the penis, removing the testicles alone
was considered the true removal of “manhood” because the ability to reproduce
was removed. Castration and removal of the testes would occur for things such as
broken laws, rape, or for stepping out of social norms. It was also believed that
castration had the ability to act as an anger management technique (Glass & Wat-
kin, 1997).
However, historically, orchiectomy (or, at the time, castration) was not only
used for punishment but also as a mark of leadership. Eunuchs existed in several
early civilizations and would commonly work directly under the emperor or leader
in power. These individuals were trusted and sought out for two main reasons.
The first was the loyalty associated with choosing to be castrated as the act was
believed to show a love and commitment toward a ruler as well as to show that the
man was willing to devote his life to that work and not to marriage and a family.
The second reason these men were sought out was because they were deemed
trustworthy to have around the royal women, as it was assumed that they would
not be tempted (Glass & Watkin, 1997). Historically, the use of orchiectomies has
had many purposes. From punishment and leadership symbols to medical treat-
ment and now sex reassignment, there are a plethora of reasons this procedure is
relevant to sexuality today and in the future.
Casey T. Tobin
See also: Castration; Prostate Cancer; Sex Reassignment Surgery; Testicles; Testicular
Cancer.
Further Reading
Delta Medix Urology. (2017). Radical & simple orchiectomy. Retrieved from https://
www.deltamedix.com/urology/orchiectomy.php
Glass, J., & Watkin, N. (1997). From mutilation to medication: The history of orchidec-
tomy. BJU International, 80(3), 373–378.
LeVay, S., Baldwin, J., & Baldwin, J. (2018). Discovering human sexuality (4th ed.). Sun-
derland, MA: Sinauer Associates.
Rosen, A., Jayram, G., Drazer, M., & Eggener, S. E. (2011). Global trends in testicular
cancer incidence and mortality. European Urology, 60(2), 374–379.
Orgasm
An orgasm is a brief period of intense, pleasurable physical release after a buildup
in sexual tension. The sexual tension builds as part of a sexual response cycle.
There are several models of sexual response, one of which can be visualized as a
circle, starting with seduction, when feelings of desire are triggered, before or
while physiological arousal begins. Next the body experiences sensations, when
Orgasm 465
arousal and excitement increase through sexual activity until a plateau is reached.
Orgasm occurs if a person gives in to sexual release. During a period of reflection,
the body rests or readies for more stimulation, and the mind interprets the
experience.
It is normal for individuals to respond differently to sexual stimulation. For
instance, some people experience orgasm very quickly, so the stages of sexual
arousal seem to merge. Some people, usually women, are able to experience mul-
tiple orgasms. Most people require direct genital stimulation to build enough
excitement to experience orgasm; however, some people can experience it through
other means, such as nipple stimulation.
During an orgasm, most people experience similar sensations. Females com-
monly experience muscle contractions in the vagina, uterus, and pelvic region.
Males commonly experience these same contractions in the penis, prostate, and
pelvic regions. Other common characteristics include tension in the feet; increased
blood pressure, heart rate, and breathing; decreased sensitivity to pain; and a sud-
den, forceful release of sexual tension. Flushing (blushing) may occur over the
entire body before orgasm and disappear shortly afterward. Upon orgasm, males
usually ejaculate, releasing seminal fluid through the urethra; some females ejacu-
late as well.
People can experience orgasm many ways, including for women through stimu-
lation of the clitoris, labia, urethral opening, vaginal opening, and vagina. Other
sensitive areas reach through the vagina, including the cervix; the G-spot, a sensi-
tive area in the anterior wall (toward the lower abdomen); the clitoral crura; and
the anterior fornix, located at the end of the anterior wall of the vagina. For men,
orgasm may occur when stimulation is provided to the glans of the penis and
frenulum (located where the glans and shaft meet), prostate, anus, and rectum.
Some people are able to experience orgasm when other areas of the body, such as
the nipples, are stimulated, as well as through imagination alone. Orgasms may
involve the entire body or feel localized. The “right” orgasm is any kind a person
enjoys.
Orgasms can provide a sense of comfort and well-being. They can help people
feel either relaxed or energized. The contractions that accompany orgasm help
tone the pubococcygeus muscle, which helps support the sexual organs and
increase sexual pleasure. Orgasms may also bring partners physically and emo-
tionally closer together.
The myth persists that orgasm comes naturally and easily to everyone who is
sexually active; however, orgasm may be difficult to experience if people
• are unfamiliar with their sexual anatomy
• do not understand what an orgasm is
• do not feel free to express themselves sexually
• feel embarrassed by their sexual interest and responses
• have underlying emotional issues or cultural messages that impede sexual
pleasure
• fear getting pregnant or getting a sexually transmitted infection
466 Orgasm
• focus only on a partner’s needs
• spend too little time on arousal and stimulation
• are in an unhealthy or unsafe sexual relationship
• have a history of sexual abuse or intimate partner violence
• take medication that reduces desire, such as some blood pressure medications,
antihistamines, and antidepressants
• have a medical condition that affects the sexual response cycle, such as diabe-
tes or a neurological disease
• have had medical treatment affecting the sexual organs or nerves involved in
orgasm
• have poor circulation throughout the body, particularly to the genitals
• experience hormonal changes that decrease sexual desire, increase time
necessary for arousal, and may decrease the intensity of sexual response
• overindulge in alcohol and some nonprescription drugs
Humans have the physiological ability to experience orgasm from birth, but not
everyone pursues it. Some very small children enjoy rubbing their genitals by
hand or against pillows and other items. Others begin touching themselves—
masturbating—during puberty, while others wait until they have sexual partners.
Some people never experience orgasm due to psychological or cultural reasons or
due to medical conditions or treatments that affect sexual arousal and orgasm.
The aging process can create changes in how people experience orgasm: more
direct genital stimulation is usually needed as well as more time to build arousal.
Older males and females often experience less strong physical sensations during
orgasm; however, these changes need not indicate a decrease in sexual satisfaction
overall.
For some people, orgasm is a spiritual, transcendent experience. For others,
its benefits are more related to physical pleasure and comfort. Orgasm may be
enjoyed by oneself or with a partner. While some people feel pressured to expe-
rience orgasm, intimacy and sexual activity can be enriching and satisfying
regardless of whether orgasm is experienced. Indeed, many people find the sen-
suality of building arousal to be more emotionally rewarding than a few seconds
of orgasm.
Melanie Davis
See also: Anorgasmia; Arousal; Ejaculation; Female Ejaculation; Masters and Johnson
Four-Stage Model of Sexual Response; Sexual Disorders, Female; Sexual Disorders,
Male; Somnus Orgasm.
Further Reading
Cass, V. (2004). The elusive orgasm. Bentley, Australia: Brightfire Press.
Joannides, P. (2017). Guide to getting it on (9th ed.). Waldport, OR: Goofy Foot Press.
Nagoski, E. (2015). Come as you are. New York: Simon & Schuster Paperbacks.
Whipple, B., & Brash-McGreer, K. (1997). Management of female sexual dysfunction. In
M. L. Sipski & C. J. Alexander (Eds.), Sexual function in people with disability
and chronic illness: A health professional’s guide (509–534). Gaithersburg, MD:
Aspen Publishers.
Outing 467
Outing
“Outing” refers to revealing an individual’s sexual orientation or gender identity
to other people. While individuals can “out” themselves, which is generally
referred to as “coming out,” “outing” occurs when someone other than the indi-
vidual reveals the individual’s sexual orientation or gender identity. Outing can
occur with the individual’s permission, but the phrase generally refers to inform-
ing others about the individual’s sexual orientation or gender identity without the
individual’s permission. Outing has been used by some sexual minority rights
activists as a political weapon by exposing public figures who are perceived to be
anti-LGBTQ+ but are themselves LGBTQ+.
Outing can occur at any social level, from telling a peer, colleague, or family
member about someone’s sexual orientation or gender identity to making a public
pronouncement about a public figure’s sexual orientation or gender identity. While
individuals coming out and being open about their sexual orientations or gender
identities is generally associated with positive psychosocial outcomes, there are
risks involved in doing so. Risks include social or familial rejection, social ostra-
cization, harassment, and physical violence. These risks will also vary depending
on an individual’s country and culture. In some countries and cultures, sexual and
gender minority individuals face severe legal and social consequences, including
in some cases death. In Western cultures, these risks for youth may include being
kicked out of their home; losing parental monetary and emotional support; and
being subjected to considerable harassment, assault, and bullying within their
social and educational environments.
When youth are able to choose the time, location, and to whom they will come
out, they are able to judge the safety of the situation and to plan for various reac-
tions. Youth generally evaluate the benefits and possible costs involved with com-
ing out, making individualized decisions. When outed, however, youth are unable
to control who learns about their sexual orientations and/or gender identities and
may be unprepared for the negative responses that may occur. Many youth fear
being outed so much that they do not report harassment or assault as doing so
might out them to parents, peers, or others. Arguments in favor of outing youth
include others feeling the youths’ parents, school personnel, service providers,
and so on deserve to know the youth’s sexual orientations or gender identities; that
youth need to be able to discuss their sexual orientations or gender identities with
adults who can help guide them, and they cannot do this without those people
knowing their sexual orientations or gender identities; and that letting others know
the youth’s sexual orientation or gender identities will aid in protecting the youth.
Yet, the youth often also feel their privacy has been violated and may experience
considerable distress, leading most mental health professionals to strongly recom-
mend youth come out on their own terms and at their chosen time.
For adults, while problematic for many of the same reasons as noted for youth,
outing may have less impact due to adults having more social and financial inde-
pendence; being able to change their educational, occupational, or living environ-
ment with more ease; and having a more developed ability to control emotional
responses. Even with that, adults who are outed may experience significant nega-
tive psychosocial outcomes, such as mental health and substance use concerns,
468 Outing
loss of employment, social isolation, and many of the other noted difficulties for
youth. As with youth, it is generally believed that adults should also be able to
control to whom they come out and when and where that occurs.
Politically, outing can have significant repercussions. Starting in the later 1980s
and becoming much more prevalent in the early 1990s, gay rights activists began
publicly exposing public figures who they felt were being hypocritical by support-
ing legislation or policies that were harmful to LGBTQ+ individuals while either
being LGBTQ+ themselves or engaging in same-sex sexual relationships. This
practice was very controversial, with some viewing outing as a violation of indi-
viduals’ privacy, while other prominent gay rights figures such as Michelangelo
Signorile and Peter Tatchell defended the practice.
The politics of outing were heavily debated during the mid- and late 1990s and
early 2000s by authors such as Larry Gross, Richard Mohr, Warren Johansson,
and William Percy. Arguments made in favor of outing included exposing per-
ceived hypocrisy, forcing individuals to publicly acknowledge their sexual orien-
tations or gender identities and confront the possible repercussions of their political
or public positions or statements to themselves and others like them, combating
homophobia that may be linked to internalized homonegativity, helping others
recognize that they know individuals who are sexual or gender minorities so that
the others are forced to reconcile their assumptions about sexual or gender minori-
ties and the reality of the people they know, and using it as a means of self-defense
against those who threaten the LGBTQ+ community while secretly being a part of
it. Opposing arguments generally focused on the invasion of privacy that occurs
when individuals are outed, questions of mixing individuals’ public and private
identities, and the hypocrisy of LGBTQ+ rights activists promoting the rights of
LGBTQ+ individuals to have private lives not subject to social or legal judgment
from others while violating those rights for public figures. Other concerns were
raised about possible mistaken outings and the effects that these could have on the
careers of those erroneously exposed as LGBTQ+.
Outing has ended the careers of several politicians and led to the resignations of
prominent religious leaders. In response to ethical concerns about these conse-
quences, Johansson and Percy (1994) provided a matrix for making decisions
about whether outing an individual was ethical, focusing on areas such as the
motive for doing so, the source of the individual’s public reputation, and the likely
consequences of doing so on the individual’s career, family life, and sexual life.
Public discussion of the practices of political outing largely dissipated by the mid-
2000s without any consensus about the propriety of the actions.
Richard A. Brandon-Friedman
See also: Coming Out; Gender Identity; LGBTQ+; Passing; Sexual Identity.
Further Reading
Gross, L. (1993). Contested closets: The politics and ethics of outing. Minneapolis: Uni-
versity of Minnesota Press.
Heatherington, L., & Lavner, J. A. (2008). Coming to terms with coming out: Review and
recommendations for family systems-focused research. Journal of Family Psy-
chology, 22(3), 329.
Out-of-Control Sexual Behavior 469
Johansson, M. A., & Percy, W. A. (1994). Outing: Shattering the conspiracy of silence.
New York: Harrington Park Press.
Kosciw, J. G., Greytak, E. A., Giga, N. M., Villenas, C., & Danischewski, D. J. (2016).
The 2015 National School Climate Survey: The experiences of lesbian, gay, bisex-
ual, transgender, and queer youth in our nation’s schools. New York: GLSEN.
Mohr, R. D. (1992). Gay ideas: Outing and other controversies. Boston: Beacon Press.
Orne, J. (2012). “You will always have to ‘out’ yourself”: Reconsidering coming out
through strategic outness. Sexualities, 14(6), 681–703. doi: 10.1177/1363460711420462
Schafer, A. (2015). Quiet sabotage of the queer child: Why the law must be reframed to
appreciate the dangers of outing gay youth. Howard Law Journal, 58(2), 597–636.
Vaughan, M. D., & Waehler, C. A. (2010). Coming out growth: Conceptualizing and mea-
suring stress-related growth associated with coming out to others as a sexual
minority. Journal of Adult Development, 17(2), 94–109. doi: 10.1007/s10804
-009-9084-9
Ziering, A. (Producer), & Dick, K. (Director). (2009). Outrage [Motion picture]. Magnolia
Pictures.
Out-of-Control Sexual Behavior
The need to control our sexual urges, thoughts, and behaviors is human. Failing to
successfully regulate one’s sexual life can be distressing. Feeling sexually out of
control involves excessive preoccupying sexual thoughts or repeating sexual
behaviors that have shaming, hurtful, or damaging consequences. When a person
concludes that their sexual urges, thoughts, and behaviors are beyond their con-
trol, they may call themselves a sex addict, pervert, scumbag, or cheater. Others
may look on them with derision, contempt, fear, disgust, and punitive judgments.
After centuries of condemning out-of-control sexual behavior as rooted in devil
possession, the last century medicalized this human behavior with diagnoses of
nymphomania, Don Juanism, and hypersexuality. Each was eventually discarded,
leaving the twenty-first century in a state of division and conflict among physi-
cians, psychotherapists, sex therapists, sex researchers, and addiction counselors
about whether sexual behavior on the extreme end of the normal range actually
crosses a threshold from a behavior problem to a separate and distinct disease.
The World Health Organization’s International Classification of Diseases
(ICD-11) places compulsive sexual behavior disorder (CSBD) within the spectrum
of impulse control disorders characterized by persistent failure over time to con-
trol intense, repetitive sexual impulses or urges, resulting in repetitive sexual
behavior that leads to marked distress or impairment in personal, family, social,
educational, occupational, or other important areas of functioning. Field testing
will be conducted to determine if the ICD-11 construct is cross-culturally gener-
alizable. In the meantime, it remains unsettled how clinicians can distinguish nor-
mal variations in sexual behavior frequency, type, and consequences from CSBD.
Sexual imagery created for entertainment, sexual excitement, erotic arousal, and
facilitating orgasm (almost universally called pornography) is portable and avail-
able 24/7 online and through mobile phone apps. Despite some people feeling
deeply conflicted about their use and interest in sexual imagery, there remains no
470 Out-of-Control Sexual Behavior
recognized diagnostic category of a disease of pornography addition in the
medical, psychological, or other scientific literature. In some religious, moral, or
cultural contexts, viewing sexual imagery for pleasure and porn-assisted orgasms
pose existential moral threats (i.e., banishment, divorce, loss of everlasting life and
salvation). Sex researchers have rigorously examined the notion of porn addiction.
Their studies find that the perception of “porn addiction” is especially prevalent
among highly religious individuals who have a relatively low frequency of actually
viewing sexual imagery but who hold high levels of moral disapproval.
Out-of-control sexual behavior (OCSB) is defined as a sexual health problem in
which a person’s consensual sexual urges, thoughts, or behaviors feel out of their
control. The term “OCSB” is not a diagnosis or conclusory label. It describes an
individual’s feelings and experiences about problematic consensual sexual behavior.
OCSB does not include nonconsensual sexual behavior. Violating another person’s
body by using force, coercion, or exploitation in order to engage in a sexual act is not
considered an out-of-control sexual behavior problem, and experts with specialized
training in nonconsensual sex should be consulted if this occurs. An OCSB assess-
ment for consensual sexual behavior first considers how drugs and alcohol, mental
health, and medical conditions or medication-related side effects affect sexual
behavior. OCSB assessment also screens for intimate partner violence.
OCSB treatment interventions emphasize changing both sexual and nonsexual
self-regulation. Clients aim to improve their sexual health and regain control of
their sexual lives through balancing safety and pleasure within their sex lives.
Others may need to face their shame and secrecy about a specific sexual turn-on.
Distinguishing sexual prejudice from a sexual behavior problem is a necessary
treatment focus when conflicted or when rejecting one’s own sexual orientation or
erotic nature.
Saying that one has a sex addiction has become the common means to convey a
real contradiction between one’s sexual activity and their personal, relational, or
spiritual values. It is also a way to ask for help. Self-diagnosing sexual behavior
concerns can unfortunately lead to premature evaluation. If someone is experi-
encing OCSB, they should seek out a licensed therapist for professional help. It is
also important to ask the clinician or therapist about their sexological training as
well as the degree to which their religious beliefs influence their clinical assess-
ment and treatment methods. Studies find that therapists who are more religiously
influenced are more likely to label feeling sexually out of control as a sexual
addiction disorder. A therapist certified by a national sex therapy association (e.g.,
American Association of Certified Sex Educators, Counselors, and Therapists) or
a relationship therapist with advanced training in human sexuality will be pre-
pared to explore a wide range of factors that can contribute to feeling sexually out
of control. Out-of-control sexual behavior, while not a psychiatric disorder, is a
real problem of sexual behavior regulation experienced by many people.
Douglas Braun-Harvey
See also: American Association of Sexuality Educators, Counselors, and Therapists
(AASECT); Cheating and Infidelity; Compulsivity, Sexual; Hypersexuality; International
Classification of Diseases, Eleventh Revision (ICD-11); Pornography Addiction; Sex
Guilt.
Ova 471
Further Reading
Braun-Harvey, D., & Vigorito, M. (2016). Treating out of control sexual behavior:
Rethinking sex addiction. New York: Springer Publishing.
Dickenson, J. A., Gleason, N., Coleman, E., & Miner, M. H. (2018). Prevalence of distress
associated with difficulty controlling sexual urges, feelings, and behaviors in the
United States. JAMA Network Open, 1(7), e184468.
Grubbs, J. B., Perry, S. L., Wilt, J. A., & Reid, R. C. (2018). Pornography problems due to
moral incongruence: An integrative model with a systematic review and meta-
analysis. Archives of Sexual Behavior, 48(20), 397–415.
Montgomery-Graham, S. (2017). Conceptualization and assessment of hypersexual disor-
der: A systematic review of the literature. Sexual Medicine Reviews, 5(2),
146–162.
Reed, G. M., First, M. B., Kogan, C. S., Hyman, S. E., Gureje, O., Gaebel, W., ... Claudino,
A. (2019). Innovations and changes in the ICD-11 classification of mental, behav-
ioural and neurodevelopmental disorders. World Psychiatry, 18(1), 3–19.
Ova
Ova, or eggs (singular ovum), are the round female sex cells that are stored in the
ovaries. Human ova are very large cells and may be visible to the naked eye. Each
ovum contains twenty-three chromosomes that are made up of half of the female’s
DNA or genes. During conception, the twenty-three chromosomes in the ovum
pair with the twenty-three male chromosomes carried by a sperm, the male sex
cell, in order to form the genetic material necessary to produce a baby.
Currently it is believed that an individual with ovaries has all the eggs they will
ever have at birth. In other words, it does not appear that the body is able make eggs
after birth. Typically, a female individual is born with approximately 800,000 eggs.
However, by the time an individual reaches puberty, only about 300,000 eggs
remain. Over time, the number of eggs an individual has continues to decrease, and
so by menopause there are usually fewer than 10,000 eggs remaining. This is a
very different process compared to sperm, which are continuously produced by
male individuals, starting at puberty and lasting for the rest of their life. Because of
this process, male individuals can potentially contribute to a pregnancy throughout
their entire lives. Female individuals, however, can only become pregnant between
puberty and menopause (roughly between the ages of eleven to fifty-one years).
At puberty, changes in hormones lead to the first ovulation. During this time,
hormones begin to cause an egg to mature. During ovulation, hormones trigger
the egg, causing it to emerge from its follicle in the ovary. It is then moved from
the ovary into the fallopian tube and down toward the uterus. Between puberty
and menopause, ovulation typically occurs every month, usually around day four-
teen of the menstrual cycle. Usually, one egg emerges each month from alternat-
ing ovaries. Sometimes more than one egg is released; when this occurs, it is
possible for each egg to be fertilized, which can result in having twins or triplets.
Eggs can survive, and have the potential to be fertilized, for twelve to twenty-four
hours after ovulation. If the egg is not fertilized, it moves into the uterus and dis-
solves. Ovulation becomes less frequent as individuals age and stops entirely at
menopause.
472 Ova Donation
As the result of penile-vaginal intercourse, an ovum may be fertilized by a sperm.
In order for this to happen, the sperm needs to penetrate the outer layer of the egg
cell. To do this, the sperm cell releases specific enzymes that break down the coating
of the egg and allow the sperm to enter. If this occurs, the cells form a zygote, which
may develop into an embryo. Fertilization typically occurs in the fallopian tubes.
Some people experience difficulty becoming pregnant and so may seek out
treatments in order to improve their fertility. For people who do not wish to become
pregnant, contraceptive methods can be used. Most hormonal contraceptive methods
act by preventing ovulation, by thickening the cervical mucus to prevent sperm from
entering the female reproductive system, and/or by changing the environment in the
uterus so that if fertilization of the egg does occur, implantation does not take place.
Because ova age at the same rate as the female individual, their quality
decreases over time. This means that older individuals, those over the age of
thirty-five, often have a harder time becoming pregnant. They also experience a
higher rate of pregnancy loss or miscarriage, and there is a higher rate for chromo-
somal abnormalities in any offspring. Because of this, some people who know that
they do not want to become pregnant until later in their life may freeze some of
their eggs when they are younger in order to use them later. Some individuals may
also choose to donate their eggs to others who are unable to become pregnant on
their own, either because of infertility issues or because neither partner has their
own eggs, such as with male same-sex couples.
Heather L. Armstrong
See also: Conception; Fertility; Menopause; Ova Donation; Ovaries; Ovulation; Sex
Chromosomes; Sperm.
Further Reading
Boston Women’s Health Book Collective. (2005). Our bodies, ourselves. New York:
Scribner.
Cleveland Clinic. (2019). Female reproductive system. Retrieved from https://my
.clevelandclinic.org/health/articles/9118-female-reproductive-system
Ova Donation
Ova donation is the act of one person giving their eggs to another who is having
difficulty conceiving a child, or to scientists for stem cell research. Ova, or egg,
donors must go through a long process of screening and medical procedures and
are typically given several thousand dollars in compensation. All these factors and
more have led to major ethical debates over the procedure.
Egg donations first became commercialized in 1978, after in vitro fertilization
(IVF) produced the first successful “test tube baby” from an egg fertilized outside
a woman’s body. It was not until the 1990s, however, that use of donated eggs
became a widely acceptable part of fertility treatments for women and couples
who found it difficult or impossible to have children of their own. The market for
eggs to be used in stem cell research grew up alongside IVF, with research initially
being conducted on discarded eggs before some government agencies began pay-
ing women for their eggs directly. The latter practice remains rare, however, and
the vast majority of ova donations still are used for IVF.
Ova Donation 473
Today the market for donated eggs comes largely from women and couples who
are willing to spend thousands, or even tens of thousands, of dollars to conceive a
child. While some are simply seeking a healthy child, others pay top dollar for
eggs from donors with very specific characteristics, such as high academic test
scores, athletic abilities, or physical traits similar to themselves. Because the ova
donation industry is largely unregulated, donor consent, screening, compensation,
and follow-up care all can vary widely.
The American Society of Reproductive Medicine (ASRM) recommends that
clinics purchasing eggs compensate the donor appropriately for the “time,
inconvenience, and physical and emotional demands” associated with ova dona-
tion. According to ASRM guidelines, payments to ova donors should be limited to
$5,000, and any payment above $10,000 is inappropriate. However, advertise-
ments around college campuses commonly promise payments of $50,000 or more
for donors with specific traits.
Although most egg donors surveyed said they chose to donate mainly to help
others conceive a child, many also reported being motivated by other factors.
These primarily include financial gain, and, to a lesser degree, a desire to learn
about their own fertility or fertility treatment options or to “make up” for having
had an abortion in the past. When unemployment rose sharply in 2007 and 2008,
the Wall Street Journal reported a marked increase in women applying to donate
eggs—a trend that worried ethicists, who cite research showing that women
motivated primarily by financial gain are less able to give truly informed consent
and are more likely to regret their decision.
There is particular controversy surrounding the practice of targeting college
students for ova donation. Many medical ethicists also express concerns about
putting a price tag on human body parts, the potential for exploiting women, and
the inequalities of IVF in general, which allow only the wealthy to conceive a
child in this way.
Prior to donating eggs, women must first apply and go through an initial screen-
ing process. Although IVF donor criteria vary, in general clinics require candi-
dates to be between twenty and thirty years old and in excellent health. Candidates
must disclose their full medical histories, as well as family medical history, and
are nearly always disqualified for any incidence of sexually transmitted infec-
tions, cancer, diabetes, or mental illness, as well as for travel to certain foreign
countries. Most candidates must also consent to a long list of medical tests for
blood type, drug use, diseases, or potential genetic defects. They typically undergo
a set of mental, psychological, and personality tests as well. Even those who qual-
ify in theory may be put on a waiting list until a match is found for a woman or
couple seeking the donor woman’s particular characteristics.
If an ova donor is accepted, she then moves on to the next stage, the egg dona-
tion process itself, during which she must abstain from all smoking, alcohol,
drugs, and sex for the duration of the procedure, which takes several weeks. Sex is
typically banned because of the increased risk of unwanted pregnancy during fer-
tility treatments.
Egg donation is composed of two separate phases: ovarian hyperstimulation, in
which a series of hormonal drugs injected over several weeks prompt the ovaries
to produce multiple mature eggs in just one menstrual cycle, and egg retrieval,
474 Ovarian Cancer
which typically occurs just once. The first phase consists of three or sometimes
four stages. Some donors may first take birth control pills so that their menstrual
cycles and those of the egg recipient can sync up. The next three stages involve a
series of drug injections that (1) suppress hormone levels, causing the donor’s
body to go through “artificial menopause”; (2) stimulate the production of multi-
ple eggs; and (3) trigger the release of these matured eggs.
Between thirty-four and thirty-six hours after the final drug injection, the ova
donor undergoes egg retrieval. Typically conducted while the donor is under gen-
eral anesthesia, the surgical removal of eggs is performed by inserting an ultra-
sound probe with a suctioning needle attached. A physician guides the needle into
each ovary and suctions out mature eggs. Following this procedure, donors typ-
ically spend an additional one to two hours at the clinic before returning home to
recover. To ensure full recovery, donors usually return for a follow-up visit and
ultrasound procedure after one week. In all, screening and medical procedures for
ova donation take about sixty hours.
There has been little follow-up research on long-term side effects of ova dona-
tion, but some common risks of ovarian hyperstimulation include abdominal
swelling, tension and pressure around the ovaries, mood swings, bruising at injec-
tion sites, vaginal dryness, and hot flashes. Severe side effects appear to be rare
but may include ovarian hyperstimulation syndrome (OHSS), which leads to fluid
buildup in the chest and abdomen and enlargement of the ovaries. Severe OHSS
can cause permanent damage to ovaries, dehydration, blood clotting disorders,
kidney damage, and even death.
Side effects of egg retrieval may include mild to moderate abdominal pain,
damage to ovaries, vaginal bleeding, and infection. More serious risks include
infertility and damage to adjacent organs, including the bladder, intestines, uterus,
or blood vessels. Some doctors believe that repeatedly donating eggs may increase
risk of cancer, leading some to call for a lifetime donation limit of three cycles.
Because of the risks involved, the ASRM and medical ethicists strongly recom-
mend a lengthy process of informed consent for potential ova donors as well as
insurance coverage for any future complications related to ova donation.
Terri Nichols
See also: Assisted Reproductive Technology; Infertility; Ova; Surrogate Mothers.
Further Reading
Almeling, R. (2011). Sex cells: The medical market for eggs and sperm. Berkeley: Univer-
sity of California Press.
American Society for Reproductive Medicine. (2012). Egg donation. Retrieved from https://
www.reproductivefacts.org/globalassets/rf/news-and-publications/bookletsfact
-sheets/english-fact-sheets-and-info-booklets/egg_donation_factsheet.pdf
Cohen, C. B. (1996). New ways of making babies: The case of egg donation. Blooming-
ton: Indiana University Press.
Ovarian Cancer
Ovarian cancer is the abnormal, uncontrolled multiplication of cells within one or
both of the ovaries. Most commonly, ovarian cancer originates in the epithelial
Ovarian Cancer 475
tissue that covers the ovaries. In some cases, the cancer develops in other ovarian
tissues.
Ovarian cancer is most prevalent in women who have experienced menopause,
especially women who are older than age sixty. The disease is more prevalent
among women in developed, Western nations than in the less developed nations of
Asia and Africa. In 2014, there were about 22,000 newly diagnosed cases of ovar-
ian cancer in the United States. Some 14,000 American women died from ovarian
cancer that year.
The earlier a diagnosis for ovarian cancer is made and the earlier treatment is
begun, the more successful the outcome is likely to be. Unfortunately, this cancer
is typically diagnosed after it has spread beyond the ovaries, resulting in high
mortality rates. On average, 45 percent of women are alive five years after diagno-
sis. If the cancer remains localized in the ovaries at the time of diagnosis, the five-
year survival rate rises to about 92 percent. If the cancer has already metastasized
to distant tissues of the body at the time of diagnosis, the five-year survival rate
falls to about 22 percent.
A woman’s risk for ovarian cancer is increased by the inheritance of mutations
in either of two genes, known as BRCA1 and BRCA2. Approximately one in 200
women have at least one of these mutated genes, which also increase the risk of
breast cancer (a much more common cancer than ovarian cancer). Blood tests can
detect the presence of BRCA1 and BRCA2. A woman with either of these genes
may choose to have her ovaries or breasts surgically removed to prevent the pos-
sible development of cancer.
Only 10 percent of ovarian cancer cases are associated with the BRCA1 and
BRCA2 genes. Other cases have causes that are not fully understood. However,
factors that are believed to increase the risk of ovarian cancer include a diet high
in fat, never being pregnant, going through menopause relatively late in life
(after age fifty), and having had a relatively early onset of menstruation (before
age twelve). Some studies suggest that women who use hormone replacement
therapy to relieve the symptoms of menopause are at an elevated risk for ovarian
cancer.
Research indicates that certain factors may lower the risk of ovarian cancer.
These factors include having given birth, having breastfed the infant, and having
undergone a tubal ligation or hysterectomy. The use of oral contraceptives may
also lower ovarian cancer risk, but such use may increase breast cancer risk.
People with ovarian cancer may notice chronic pain or cramps in the abdominal
or pelvic areas as well as frequent nausea, bloating, abnormal vaginal bleeding,
and an abnormally frequent need to urinate. Such symptoms can also be associ-
ated with less serious conditions. If the symptoms are noticed almost every day
for two or three weeks, the person should see a doctor. The doctor is likely to per-
form a pelvic examination, looking for signs of abnormal lumps on the ovaries.
Lumps may also be detected with an ultrasound examination.
A suspicion of ovarian cancer is usually followed up with a blood test and
biopsy. The blood will be analyzed for elevated levels of a protein called cancer
antigen 125 (CA-125). High levels of CA-125 could suggest any of various patho-
logical conditions, including ovarian cancer, endometriosis, and uterine fibroids.
To determine the precise condition, an ovarian tissue sample must be collected for
476 Ovaries
biopsy. Additional tests, such as computed tomography, can be used to determine
the stage of cancer development.
If the presence of cancer is confirmed, surgery is usually performed to remove
one or both ovaries. In many cases, the uterus and fallopian tubes are also removed
to try to ensure that all the cancer is gone. These procedures will make it impos-
sible to have a future pregnancy, and they will cause immediate menopause if
menopause had not yet occurred.
In the most advanced cases of ovarian cancer, additional tissues may be
removed, including part of the intestines, the lining of the abdominal wall, and the
spleen. Chemotherapy and radiation therapy may also be used in a patient’s treat-
ment. Follow-up therapy often includes routine blood tests to monitor levels of
CA-125 and other substances that could indicate a recurrence of cancer.
As with breast cancer treatment, treatment for ovarian cancer sometimes results
in emotional problems regarding a woman’s perception of her body and her sexu-
ality. Thus, psychological counseling may be incorporated into follow-up
therapy.
A. J. Smuskiewicz
See also: Breast Cancer; Cervical Cancer; Oophorectomy; Ovaries; Uterine Cancer.
Further Reading
Friedman, S., Sutphen, R., Steligo, K., & Greene, M. H. (2012). Confronting hereditary
breast and ovarian cancer: Identify your risk, understand your options, change
your destiny. Baltimore: Johns Hopkins University Press.
National Cancer Institute. (n.d.). Cancer stat facts: Ovarian cancer. Retrieved from http://
seer.cancer.gov/statfacts/html/ovary.html
Ovaries
The ovaries are two oval-shaped organs that are part of the female reproductive
system. The ovaries store and release ova (egg cells) as well as the female sex hor-
mones estrogen and progesterone. There is one ovary on each side of the uterus.
At birth, each of the ovaries contains approximately 400,000–800,000 immature
eggs. The eggs begin to mature during puberty, usually between the ages of 10 and
12. Also at puberty, estrogen produced by the ovaries causes the development of
female secondary sex characteristics, such as breasts and the accumulation of fat in
the hips. One egg matures each month, from alternating ovaries, during the first half
of each menstrual cycle. Eggs stop maturing as the ovaries stop functioning during
perimenopause, which usually occurs between the ages of 45 and 55. After meno-
pause, the ovaries shrink from the size of large grapes to the size of small peas.
Near the beginning of the monthly menstrual cycle, the ovaries increase their
production of estrogen. This causes the walls of the uterus to begin building up an
extra lining of cells and blood vessels in preparation for pregnancy. The release of
an egg—ovulation—happens sometime in the middle of a menstrual cycle. Typi-
cally, the two ovaries alternate from one month to the next in performing ovula-
tion. The ovary that releases the egg also releases progesterone, which maintains
the thickened uterine lining.
Ovaries 477
Pregnancy occurs if the egg is fertilized by a sperm cell, which usually happens
in a fallopian tube, one of two tubes that lead from the ovaries to the uterus. The
fertilized egg implants itself into the uterine wall, where it develops into an
embryo. If pregnancy does not occur, the ovary stops producing progesterone,
leading to the discharge of the unfertilized egg and extra uterine lining through
the vagina.
A number of diseases can affect the ovaries, including cancer, cysts, polycystic
ovary syndrome, and premature ovarian failure. Ovarian cancer, which is most
common in women older than sixty, is a serious sometimes hereditary disease that
often goes undiagnosed until after it has spread to other parts of the body. Most
women do not suspect the disease because of the lack of early symptoms or the
resemblance of early symptoms to other conditions. Such symptoms include
abdominal discomfort and bloating, loss of appetite, and frequent vaginal bleed-
ing. A definitive diagnosis is obtained through the combination of a blood test,
which reveals elevated levels of a protein called CA-125, and a biopsy, in which
ovarian tissue is examined under a microscope. Treatment usually consists of che-
motherapy (medications) and surgical removal of the ovaries and nearby tissues,
sometimes including the uterus and fallopian tubes. Treatment for ovarian cancer
is more successful the earlier it is diagnosed. If patients are diagnosed and treated
before the cancer spreads beyond the ovaries, the five-year survival rate is about
90 percent. However, the average five-year survival rate for women with ovarian
cancer is only about 44 percent.
Ovarian cysts are fluid-filled sacs that grow on the organs. They are common
and usually harmless, often disappearing after a few menstrual cycles. However,
large cysts may cause pain in the abdomen, lower back, and thighs and interfere
with blood supply to the ovaries. Some cysts can develop into cancer. Problematic
cysts can be surgically removed.
Polycystic ovary syndrome is a painful condition usually caused by an overpro-
duction of testosterone by the ovaries or adrenal glands. This condition, which is
most common in obese women, may include the growth of several ovarian cysts,
hair growth on the face and body, irregular menstruation, and infertility. These
symptoms can be managed and reduced with certain medications.
In premature ovarian failure, the ovaries stop functioning before the normal
onset of menopause, causing infertility. Some cases are an adverse effect of medi-
cations, surgery, or radiation, while other cases are caused by certain diseases or
other factors. Some whose ovaries have stopped functioning can still become
pregnant through the use of donor eggs.
A. J. Smuskiewicz
See also: Fertility; Infertility; Menstruation; Oophorectomy; Ova; Ova Donation; Ovar-
ian Cancer; Ovulation; Polycystic Ovary Syndrome (PCOS).
Further Reading
Friedman, S., Sutphen, R., Steligo, K., & Greene, M. H. (2012). Confronting hereditary
breast and ovarian cancer: Identify your risk, understand your options, change
your destiny. Baltimore: Johns Hopkins University Press.
Vliet, E. L. (2003). It’s my ovaries, stupid. New York: Scribner.
478 Ovulation
Ovulation
Ovulation is the release of a mature ovum (egg cell) from an ovary. This release
normally happens once a month during the middle of the menstrual cycle of a
woman in her childbearing years, which typically last from approximately her
early teens to her late forties.
The released egg travels down the fallopian tube, which connects the ovary to
the uterus. If the egg is fertilized by a sperm cell, most often within the fallopian
tube, pregnancy results, and the egg implants itself into the wall of the uterus,
which has developed an extra lining of cells and blood vessels to support the
growth of the embryo. Implantation usually occurs six to twelve days after ovula-
tion. If the egg is not fertilized, it disintegrates into the thickened uterine lining,
which is discharged through the vagina as menstrual bleeding (the “period”).
At birth, the two ovaries contain a total of about eight hundred thousand imma-
ture eggs. At puberty, the eggs begin to mature. Ovulation tends to happen from
one ovary one month and the other ovary the next month at roughly the same day
each month, though the precise day of ovulation may vary over time. The monthly
maturing of eggs is triggered by the release of follicle-stimulating hormone by the
pituitary gland. That hormone activates cellular structures inside the ovary called
follicles, which contain immature eggs. A few of these eggs begin to mature.
Then, luteinizing hormone secreted by the pituitary gland causes one mature egg
to move out of the ovary and into the fallopian tube.
Ovulation happens sometime between the eleventh and twenty-first day of the
menstrual cycle (counting from the first day of the last period), with an average
ovulation time at the fourteenth day of the cycle. An egg can survive—and be
available for fertilization—for twelve to twenty-four hours after ovulation.
It is possible to track the likely time of ovulation in a number of ways, including
using a basal thermometer and examining the cervical mucus. A basal thermometer
is designed to measure tiny changes in body temperature inside the mouth at the
same time every day. A temperature spike indicates that ovulation occurred two or
three days earlier. Charting these spikes for a few months can help to create an accu-
rate prediction of ovulation times. Cervical mucus—which can be checked by
inserting a finger into the vagina—typically changes from a cloudy, sticky fluid to a
clear, slippery fluid resembling raw egg white a few days before ovulation. The last
day that the cervical fluid has such a clear appearance is usually the day that preg-
nancy is most likely to occur—the day before, or the day of, ovulation. There are
also special kits and monitors that can be purchased to help track ovulation.
The regularity of the ovulation cycle—and of the menstrual period—can be
upset by a number of factors, including illness, stress, excess exercise, alcohol or
drug abuse, and even a change in normal daily routines. Ovulation problems are
common causes of infertility and are sometimes related to malfunctions of the
pituitary gland or other glands that result in abnormal hormone levels. For
example, ovulation will not happen if the pituitary gland does not produce enough
follicle-stimulating hormone or luteinizing hormone. Polycystic ovarian syndrome
results in ovulation problems and infertility when the ovaries or adrenal glands
produce too much testosterone.
Oxytocin 479
Certain medications, such as clomiphene citrate, can be used to induce ovula-
tion in women who experience irregularities with their cycles. However, some
women with ovulation problems may need to use assisted reproductive technolo-
gies, such as in vitro fertilization or donor eggs, if they wish to become pregnant.
A. J. Smuskiewicz
See also: Cervical Mucus Method; Fallopian Tubes; Fertility; Fertility Drugs; Follicle-
Stimulating Hormone; Infertility; Luteinizing Hormone; Menstruation; Ova; Ovaries.
Further Reading
American Pregnancy Association. (2019). Understanding ovulation. Retrieved from
https://americanpregnancy.org/getting-pregnant/understanding-ovulation/
Rebar, R. W. (2019). Problems with ovulation. Retrieved from https://www.msdmanuals
.com/en-gb/home/women-s-health-issues/infertility/problems-with-ovulation
Weschler, T. (2006). Taking charge of your fertility: The definitive guide to natural birth
control, pregnancy achievement, and reproductive health (10th Anniversary Ed.).
New York: HarperCollins.
Oxytocin
Oxytocin, also called alpha-hypophamine, is a hormone produced in the brain by
the hypothalamus, especially the paraventricular nucleus, and by reproductive tis-
sues. Hypothalamic oxytocin is stored and secreted by the posterior pituitary
gland. Oxytocin circulates in the blood and binds to receptors in the amygdala and
in reproductive tissues. It is associated with sexual, pair, and group bonding; iden-
tity formation; and parental and social behaviors. Synthetic oxytocin is an obstet-
ric and psychiatric drug.
The corpus luteum, uterus, ovaries, and placenta in females, and the penis, epi-
didymis, vas deferens, testes, and prostate in males, also produce and secrete oxy-
tocin. Female receptors are concentrated in the uterus and breasts, multiply during
pregnancy, and reach their greatest number during labor, even if preterm. Oxyto-
cin production is a positive feedback cycle: rising levels stimulate further produc-
tion and receptor growth. Oxytocin works in association with estrogen,
progesterone, and prolactin.
Milk letdown is the only reproductive function that definitively requires oxyto-
cin, but many functions are strongly associated with it, including orgasm, testos-
terone production, ejaculation, and sperm transport through the male reproductive
tract, uterus, and fallopian tubes; corpus luteum shrinkage following ovulation;
prostaglandin production, uterine contraction, and fetal and placental expulsion
during birth; postbirth uterine shrinkage and hemorrhage prevention; and initia-
tion of maternal nurturing following birth or upon encountering unfamiliar young.
Oxytocin from the mother enters the fetal brain during labor, where it reduces
cortical activity, lowering physical and neurological arousal. This may protect
against perinatal hypoxia. Oxytocin in the infant is associated with recognition of
and bonding to the mother and initiation of breastfeeding.
Maternal oxytocin levels during pregnancy and the postpartum period influ-
ence bonding behaviors by mothers with their infants. Levels in infancy influence
480 Oxytocin
later social responses and parental behaviors. Early-infancy deprivation of recip-
rocal affection changes oxytocin levels and is associated with trouble forming
secure attachments in later childhood.
Oxytocin facilitates prosocial behaviors and responses, including pair bonding,
sexual arousal and receptivity, trust, individual recognition, and recognition of
and response to facial expressions and social cues. It reduces fear responses and
threat reactions and may prevent fight-or-flight reactions during labor and birth. It
is also associated with satiety, appetite suppression, and addictive behaviors.
Levels rise under both pleasant and stressful social conditions. High levels
associated with isolation and partnership stress may motivate individuals to seek
more pleasant interactions. Rises in association with cortisol may moderate stress-
induced depression, anxiety, and cardiac response.
Oxytocin administration increases trusting behaviors but only in the absence of
threatening social cues. Administration to persons in monogamous relationships
increases physical distance between the pair-bonded individual and sexually
attractive nonpartners. Genetic variation in oxytocin receptors is associated with
differing individual responses to betrayal. Elevation in males is associated with
empathy and protection of children. Oxytocin is also associated with group-
favoring and cohesion behaviors, even when such behaviors are otherwise antiso-
cial or unethical.
Pitocin, syntocinon, and carbetocin are pharmaceutical oxytocin. They are
given by injection, intravenous drip, or nasal spray for labor induction, contrac-
tion stimulation, and uterine bleeding control and shrinkage. They also encourage
lactation. Oxytocin treatment appears to enhance social cue, emotion, and facial
expression recognition in autistic persons and in patients coping with depression,
social anxiety, and schizophrenia.
Excess oxytocin in men is associated with benign prostate gland enlargement.
Lack of oxytocin receptors in the brain is one feature of Prader-Willi syndrome.
Angela Libal
See also: Attachment Theory of Love; Benign Prostatic Hyperplasia; Intimacy, Sexual
and Relational; Orgasm; Ovulation; Sex Hormones.
Further Reading
DeAngelis, T. (2008). The two faces of oxytocin. American Psychological Association
Monitor on Psychology, 39(2). Retrieved from http://www.apa.org/monitor/feb08/
oxytocin.aspx
Martin, R. D. (2015). Oxytocin: The multitasking love hormone. Psychology Today.
Retrieved from https://www.psychologytoday.com/blog/how-we-do-it/201505/
oxytocin-the-multitasking-love-hormone
P
Pansexuality
Pansexuality is a sexual orientation involving sexual or romantic attraction to all
sexes and genders or sexual and romantic attraction to individuals that is not
dependent on sex and gender. Other features, such as personality, intelligence, or
physical appearance are still important in facilitating attraction to specific roman-
tic or sexual partners. Pansexual people themselves may be of any gender or sex.
Pansexual individuals are heterogeneous and describe their sexuality in a var-
iety of ways. One commonly reported experience is where the person’s attraction
is toward another person’s features or traits regardless of the other person’s gender
or sex and that their sexual orientation transcends genders, sexes, and bodily fea-
tures (such as male or female genitals). Another commonly reported experience is
where the person can experience attraction toward men, women, and nonbinary
genders and sexes and that the person can be attracted to all configurations of bod-
ies (including genitals) and identities. A differentiation is sometimes made
between being “panromantic” (romantic attraction regardless of gender and sex)
and “pansexual” (physical attraction toward all sexes and genders). Individuals
may report being romantically attracted to all genders and sexes but sexually
attracted to only one or vice versa. Some pansexual individuals report a relative
preference for one gender or sex over others despite experiencing attraction to all
genders and sexes. Fluidity in sexual orientation, and nonidentification or rejec-
tion of existing labels and paradigms, are also commonly reported among pan-
sexual individuals. Identification with a nonbinary gender identity (e.g., “agender”)
and identification with more than one gender identity are also common in some
pansexual samples.
Pansexual individuals generally report that their ability and willingness to be
attracted to all sexes and genders is the most important aspect of their identifica-
tion with this sexual orientation. Previous sexual experiences and making a polit-
ical statement (e.g., regarding the binary and nonbinary nature of gender) are
reported as being much less important. Despite the capacity for attraction to any
gender or sex, pansexual individuals are not uniformly attracted to everyone;
qualities that are important for attraction in other orientations (e.g., personality,
intelligence, physical appearance, shared experiences and values) are also import-
ant here. Pansexual individuals, like people of other orientations, vary in how
choosy or selective they are about their partners and their interest in long-term
committed relationships. Pansexuality also does not necessarily imply higher lev-
els of sexual arousal or desire, greater promiscuity or interest in casual sex, or
engagement in polygamy or polyamory.
482 Pansexuality
Pansexuality is generally seen within the umbrella of plurisexuality or poly-
sexuality, as it involves the capacity for attraction to more than one specific gender
or sex. This is in contrast to monosexuality (e.g., gay, lesbian, straight, heterosexu-
ality, homosexuality), where capacity for attraction is focused primarily on a sin-
gle gender or sex. Bisexuality is the most well-known orientation within the
broader plurisexuality category.
Pansexuality is often described as rejecting a binary understanding of sex or
gender in contrast to bisexuality, which operates within that binary. However, it
should be noted that bisexual individuals do not always see a binary understand-
ing of gender as being important to their orientation. Some pansexual individuals
also report bisexual as a suitable alternative description of their orientation. Other
pansexual individuals report identifying as bisexual out of convenience in some
contexts, such as where “pansexual” would not be easily understood by others or
would require burdensome explanation. “Queer” and similar terms are also
alternative ways some pansexual individuals identify themselves, often to capture
both their sexual orientation and gender identity in one term.
Pansexual individuals may face discrimination outside and inside of LGBT
communities. Pansexual individuals can experience prejudice from a position of
heteronormativity (where heterosexuality is seen as the default or only acceptable
form of sexual and romantic attraction for all individuals) due to having same-sex/
gender attractions. Pansexual individuals can also experience ostracism from a
position of homonormativity (where homosexuality is seen as the default or only
acceptable form of sexual and romantic attraction for nonheterosexual individ-
uals). Pansexual individuals report that they are often seen as gay or lesbian indi-
viduals who want to maintain straight privilege or are too scared to come out or as
straight individuals who want to identify with LGBT groups or engage in indis-
criminate sexual activity when intoxicated or disinhibited. Prejudice can also be
targeted against promiscuity or polyamory and polygamy behaviors that may be
(often inaccurately) ascribed to pansexual individuals.
Some researchers have used a “borderlands” model to understand pansexu-
ality. Here, pansexuality is seen as one identity of many that emerge from the
experiences of people who do not fall within the “borders” of traditional het-
eronormative and homonormative frameworks. Pansexuality, therefore, like all
“borderlands” identities, is necessarily diverse, heterogeneous, and with fuzzy
boundaries. It forms from individuals trying to construct personal meaning
through adoption and rejection of elements from the multiple dominant paradigms
that they are exposed to but do not fully identify with.
Nevertheless, a precise and empirically supported theory for the etiology and
development of pansexuality specifically, or plurisexual orientations in general,
remains to be established. Existing research into pansexual individuals has
largely focused on young, postsecondary educated, and primarily Anglo, white,
or European samples. Information collected using anonymous online self-report
methods are most common. Further research is needed to understand if pan-
sexual identities or experiences are applicable to individuals in other popula-
tions and settings.
Silvain S. Dang
Pap Smear 483
See also: Binary Gender System; Bisexuality; Fluidity, Gender; Fluidity, Sexual;
LGBTQ+; Nonbinary Gender Identities; Queer; Romantic Attraction and Orientation;
Sexual Orientation.
Further Reading
Callis, A. S. (2014). Bisexual, pansexual, queer: Non-binary identities and the sexual bor-
derlands. Sexualities, 17, 63–80.
Flanders, C. E., LeBreton, M. E., Robinson, M., Bian, J., & Caravaca-Morera, J. A. (2017).
Defining bisexuality: Young bisexual and pansexual people’s voices. Journal of
Bisexuality, 17(1), 39–57.
Galupo, M. P., Ramirez, J. L., & Pulice-Farrow, L. (2017). “Regardless of their gender”:
Descriptions of sexual identity among bisexual, pansexual, and queer identified
individuals. Journal of Bisexuality, 17(1), 108–124.
Gonel, A. H. (2013). Pansexual identification in online communities: Employing a collab-
orative queer method to study pansexuality. Graduate Journal of Social Sciences,
10(1), 36–59.
Pap Smear
The Pap test or Pap smear was developed by Dr. George Papanicolaou (for whom
it was named, the official name being the Papanicolaou test) and is used today as a
screening test for cervical and anal cancer caused by the sexually transmitted
infection human papillomavirus (HPV).
The ideal timing for a cervical Pap smear is midcycle, between ten and twenty
days after the first day of the previous period. Before the Pap smear, any intravagi-
nal activity (sex, douching, medications, etc.) should be avoided for two days prior
to the test. A metal or plastic speculum is inserted into the vagina in order to allow
a good view of the cervix. A sample of cells is gently scraped from the inner and
outer parts of the cervix using a thin wooden or plastic spatula or brush. An anal
Pap test is similar in that a thin swab is inserted into the anus, which is then used
to collect anal cells. These specimens are either placed on a slide and chemically
fixed for examination under a microscope, or they are placed in a solution and
transported to the lab for preparation there (this liquid-based method is currently
much more common and felt to be more accurate). Using the liquid-based method
also allows for testing for HPV if this is indicated. If the cells appear abnormal,
further testing and treatment depends on the results of the HPV test and the degree
and type of abnormality found.
Current American Cancer Society guidelines for screening recommend that a
person with a cervix receive their first Pap test by age twenty-one, or within three
years of becoming sexually active, whichever is first. A Pap test should be done at
least every two years (depending on whether a liquid-based method or traditional
slide method is used) through age thirty. Certain risks would require that a Pap
test is done every year, including some previously abnormal results, human immu-
nodeficiency virus infection, or decreased immunity. If there are no previous
abnormal results, some may receive a Pap only every three years until age sev-
enty. After that time, if there has not had an abnormal result within the previous
ten years, it may be decided to stop doing Pap tests. However, if a hysterectomy
484 Pap Smear
has been done due to cervical cancer or dysplasia (abnormal Pap test results), a
yearly Pap test is recommended as long as the person is in good health.
Currently, there is no consistent guidance on frequency or need for regular anal
Pap tests. If someone is regularly engaging in receptive anal intercourse, they
should speak with their health care provider about the possibility of HPV
screening.
The Pap test has proven to be the most successful cancer screening and preven-
tion test in modern medicine. According to the Centers for Disease Control and
Prevention and National Institutes of Health, cervical cancer was the leading
cause of cancer death in women in the United States during the early and mid-
twentieth century. The Pap test became a part of routine health care in the United
States during the 1950s. From 1955 to the early 1990s, cervical cancer deaths in
the Unites States decreased by more than 60 percent, and it is now the fourteenth
most frequent cancer in women. In 2009, slightly more than 11,000 cases of cervi-
cal cancer were diagnosed in the United States, with about 4,000 deaths annually.
An additional 44,000 cases of high-grade cervical abnormality were diagnosed.
However, it is important to note that more than 55 million Pap tests are performed
in the United States every year, and roughly 3.5 million of these tests will require
medical follow-up. Clearly, the vast majority of these abnormal Pap tests are not
full-blown cancer, and many require only repeat Pap testing (without additional
treatment).
In countries where the Pap test is not part of routine health screening, cervical
cancer continues to be a significant public health crisis. Worldwide, cervical can-
cer continues to be the third most common cancer in women and the second most
common cause of cancer-related deaths. Early diagnosis made possible by Papani-
colaou’s research has made prevention of cervical cancer a reality for women who
have access to regular Pap tests. It has also provided a framework for cellular
diagnosis of many types of cancer. Papanicolaou’s test has saved the lives of
countless women, but much work continues in order to provide this low-cost, life-
saving test to women who have limited access to health care.
Anne M. Fogle
See also: Cervical Cancer; Genital Warts; Human Papillomavirus (HPV); Obstetrics and
Gynecology.
Further Reading
American College of Obstetricians and Gynecologists. (2019). Pap smear (Pap test):
Resource overview. Retrieved from https://www.acog.org/Womens-Health/Pap
-Smear-Pap-Test
Anal Cancer Foundation. (2019). About HPV/HPV & cancer. Retrieved from https://
www.analcancerfoundation.org/about-hpv/hpv-cancer/
Centers for Disease Control and Prevention. (2019). Human papillomavirus (HPV).
Retrieved from https://www.cdc.gov/hpv/
Centers for Disease Control and Prevention. (2019). HPV vaccine schedule and dosing.
Retrieved from https://www.cdc.gov/hpv/hcp/schedules-recommendations.html
Office on Women’s Health. (2019). Human papillomavirus. Retrieved from https://www
.womenshealth.gov/a-z-topics/human-papillomavirus
Paraphilias 485
University of Wisconsin Hospitals and Clinics Authority. (2016). HPV and anal Pap
testing. Retrieved from https://www.uwhealth.org/healthfacts/diagnostic-tests/7056
.pdf
Paraphilias
In 1903, Friedrich Salomo Krauss (1859–1938) devised the term “paraphilias,”
derived from the Greek word “para” meaning “beside, aside” and “philos” mean-
ing “loving.” The term “paraphilia” was not commonly used, however, until the
1950s. Paraphilia replaced the terms “perversion” and “sexual deviation” in the
third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM)
in 1980. Today, paraphilias are described as sexual interests outside of interest in
genital stimulation or foreplay with a mature consenting adult. Paraphilias are
persistent and strong but not necessarily problematic. An important distinction
was made in the fifth edition of DSM (DSM-5; 2013) between paraphilias and
paraphilic disorder. For a paraphilia to be considered a disorder, it must cause dis-
tress or functional impairment to the individual or result in harm to the self or
others. A paraphilia by itself does not equate to a mental health disorder, and
many individuals have sexual preferences that can be considered paraphilic (e.g.,
foot fetish, lingerie, bondage). As long as the preferences do not cause distress or
functional impairment, the individual and the practices should not be
pathologized.
Paraphilias are classified as their own subset of disorders within the category of
paraphilic disorders in the DSM-5. Dozens of paraphilias have been identified and
linked to paraphilic disorders; however, the DSM-5 only classifies the most com-
monly occurring and destructive in terms of legal ramifications. Eight paraphilic
disorders are identified in the DSM-5, although “other specified paraphilic disor-
der” and “unspecified paraphilic disorder” are available for clinical use if one of
the eight identified paraphilias is not appropriate. For an individual to meet cri-
teria for a paraphilic disorder, the urges, desires, or behaviors must have been
present for an estimated period of six months and must cause significant personal
distress or cause harm to the self or others.
Paraphilias are divided into two subsets: erotic targets or erotic activities. Erotic
targets refer to a sexual desire directed toward a specific group or subset. These
targets may be human or other. Pedophilic disorder, or when an individual at least
sixteen years old is attracted to a prepubescent child at least five years younger, is
an example of a human erotic target. The individual may or may not have acted on
their sexual urges and may or may not be attracted to both children and adults.
Rates of pedophilic disorder are unknown in women but estimated at 3–5 percent
among men. Nonhuman, or other, erotic targets may include fetishistic disorder or
tranvestic disorder. Fetishistic disorder is diagnosed when an individual derives
sexual pleasure from nonliving objects (e.g., socks, undergarments) or nongenital
parts of the body (e.g., feet, hair) through urges, behaviors, or desires. This disor-
der occurs almost exclusively in men, although lifetime prevalence rates are
unknown. Transvestic disorder is described as sexual arousal from dressing as the
486 Passing
other gender. This disorder may be present with fetishistic disorder if the individ-
ual is sexually aroused by the specific clothing items. Transvestic disorder is spec-
ified to occur with autogynephilia if a male individual derives sexual pleasure
from imaging himself as a female. This is different and should not be confused
with gender dysphoria, or when an individual feels a continuous disconnect
between their gender identity and biological sex. Transvestic disorder occurs more
frequently in males than females and is estimated at 3 percent among men.
The second subset of paraphilic disorders is related to erotic activities, or when
sexual desire is related to a sexual act from which an individual derives pleasure.
This subset is divided into courtship disorders and algolagnic disorders. Court-
ship disorders describe paraphilic disorders with inaccurate and exaggerated
aspects of human relationships. For example, voyeuristic disorder is when an indi-
vidual at least eighteen years of age derives sexual arousal from watching an
unknowing person who is naked, undressing, or participating in intimate acts.
Estimated prevalence rates indicate that 12 percent of males experience this disor-
der, and it is less common in women. Exhibitionistic disorder is when an individ-
ual derives sexual pleasure from genital exposure to nonconsenting people.
Lifetime estimated prevalence rate for exhibitionistic disorder in men is 2–4 per-
cent and occurs less commonly in women. Frotteuristic disorders occur when an
individual derives pleasure from touching a nonconsenting individual. Estimated
population prevalence is unknown, but research indicates that approximately
30 percent of men will engage in at least one frotteuristic act in their lifetime.
Algolagnic disorders are paraphilic disorders related to pain and suffering of
oneself or another person. Sexual masochism disorder is when an individual
derives pleasure from enduring the infliction of pain from another. Sexual sadism
disorder is when an individual derives sexual pleasure from inflicting suffering on
another person. For it to be considered a paraphilic disorder, the individual must
be distressed by the arousal or must inflict suffering on a nonconsenting
individual.
Lauren G. Masuda and Stephen K. Trapp
See also: BDSM; Exhibitionism; Fetishism; Frotteurism; Kink; Pedophilia; Transvestite;
Voyeurism.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Beech, A. R., Miner, M. H., & Thornton, D. (2016). Paraphilias in the DSM-5. Annual
Review of Clinical Psychology, 12, 383–406.
Passing
The concept of “passing” has existed in transgender communities for decades, and
the origin of the term is unclear. Generally, to “pass” means to be perceived as a
cisgender (i.e., nontrans) person of the trans person’s gender. Trans Bodies, Trans
Selves also defines passing as “the ability to present our gender in such a way that
we are consistently seen as our correct gender identity” (Erickson-Schroth, 2014).
Passing 487
That is, if a trans woman is perceived by others to be a cis woman, she can be
understood to be passing. The politics of passing have shifted throughout time as
the context in which trans individuals live has also shifted. For some, it might be
a personal desire or choice to strive to “pass,” while for others it might be neces-
sary to live safely in their community.
Passing is a concept often applied to transgender individuals but can also be
understood in other contexts—to be perceived as an identity one is not currently
or has not always been. To “pass” as a (cis) man implies that one is not genuinely
a man, for example. Passing may also be applied to a racial or disability context—
to pass as white or able-bodied when one is not. In any of these contexts, passing
might be something a person intentionally strives for, or it might be how they are
unintentionally perceived by others.
Passing can be understood to be about one’s gender expression and, more point-
edly, the perception of one’s gender rather than one’s actual gender. Trans individ-
uals whose gender expression does not align to societal expectations of their
gender might be less likely to pass. This might include butch or masculine trans
women, femme or feminine trans women, and androgynous trans people of all
genders. If a trans man’s gender expression does not fall into societal expectations
of what a man “should” look like, he might be less likely to be perceived as a
“real” or cis man. These individuals may also be referred to as “gender
nonconforming”.
Passing as a cis person is not the goal of every trans individual. For those who
do strive to pass, it might be a choice made because that is how they can most
authentically and fully live their lives or it might be a choice made for their own
physical safety. Being spotted as a trans person (also called being “clocked” or
“spooked”) can be dangerous for trans individuals, whether it be at work, while on
a date, or elsewhere. Trans people who are completely in the closet regarding
being transgender, whether it is for safety, comfort, or other reasons, might be
referred to as being “stealth” or simply remaining private about one’s transgender
status. Individuals who generally are regarded as passing may or may not also be
stealth.
In the discussion of passing, nonbinary individuals are often left out. Some
might also mistakenly assume that to “pass as nonbinary” means to have a com-
pletely androgynous gender expression. However, nonbinary individuals, like
individuals of binary genders (i.e., men and women), can have any kind of gender
expression—masculine, feminine, or other.
Some critique the concept of passing because of the implication of inauthentic-
ity or deception. For trans women in particular, this can put their lives in danger if
potential partners “discover” they are transgender, believe they have been deceived
by the trans woman, and react violently. The concept of passing might also be seen
as implying trans women are not “real” or authentic women, for example, as they
are merely passing as women. Erickson-Schroth also points out that some “trans
youth feel astounding pressure to prove [they] can fit into preexisting gender cat-
egories in our society and to prove [they] can live up to the standard of a ‘real’ man
or woman, even among other trans youth.”
Vern Harner
488 Pedophilia
See also: Gender; Gender Expression; Gender Transition; Outing; Pronoun Usage;
Transgender.
Further Reading
Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender
community. New York: Oxford University Press.
Pedophilia
Pedophilia is defined as a sexual attraction to children who are prepubescent, gen-
erally ages thirteen and younger, and is considered a paraphilia. For individuals
who are sexually attracted to children who have started puberty, the term “hebe-
philia” should be used. It is also important to know that pedophilia labels the
attraction and does not mean that a crime has been committed. If a crime has been
committed, these individuals may be referred to as sex offenders, and while sex
offenders can be diagnosed as pedophiles, not all pedophiles are sex offenders.
Pedophilia means that people have thoughts and fantasies about and are sexually
attracted to minors, but not all pedophiles have acted on these urges. It is esti-
mated that 50 percent or less of the offender population are individuals with
pedophilia.
“Pedophilia” was the diagnostic term previously used by the Diagnostic and
Statistical Manual of Mental Disorders (DSM) published by American Psychiat-
ric Association; however, in the latest version, DSM-5, it has been renamed as a
pedophilic disorder and is classified under paraphilia disorders. Paraphilias are
defined as “any intense and resistant sexual interest other than sexual interest in
genital simulation or preparatory fondling with phenotypically normal, physiolog-
ically mature, consenting human partners” (American Psychiatric Association,
2013). Paraphilias may be experienced as recurrent urges, unusual fantasies, or
atypical behaviors that are sexually arousing. In order for a paraphilia to be diag-
nosed as a paraphilic disorder, the individual must feel personal distress about
their atypical sexual interest; have a sexual attraction that causes another psycho-
logical distress, injury, or death; or have sexual behaviors that involve an unwill-
ing participant or a participant who is unable to give consent. The thoughts,
behaviors, or urges must also be present for at least six months to be diagnosed,
and in the case of pedophilic disorder, the individual must be at least sixteen years
of age and more than five years older than the child(ren) in the fantasies. An indi-
vidual with paraphilic disorder also has a higher rate of comorbidity with other
mental health diagnoses, such as anxiety, depression, mood disorders, and sub-
stance abuse.
Individuals with pedophilic attraction usually suffer from extreme distress and
have social impairments as well as difficulties holding a job. They typically have
repeated strong sexual fantasies, urges, or behaviors and may have trouble finding
satisfaction in relationships with other adults. They often suffer from low self-
esteem, and their attraction to children may dominate their life and may lead them
to live in fear and isolation.
There is no clear cause of pedophilia. Some research has suggested there may
be biological factors associated with pedophilia, but this research is still new and
Pelvic Floor Muscles 489
not certain. There has also been research that shows that often individuals with
pedophilic disorder have been sexually abused themselves during their childhood
(Psychology Today, 2019), but this is not to be seen as a clear correlation. The
majority of pedophiles are male, and it is very rare for females to be diagnosed
with pedophilic disorder.
There are a few different types of treatment for pedophilia. Behavioral and
cognitive therapy, either as outpatient or inpatient therapy, are often used and
focus on empathy training and restructuring of distorted or deviant thought pat-
terns. These types of therapy help individuals to focus on the feelings of the
victims and to understand how their actions could harm their victims Therapy
also helps individuals to understand why their thought processes could lead to
personal trouble, and it tries to help them understand their deviant thoughts.
Medications are also sometimes used in conjunction with therapy. Antiandro-
gens, medroxyprogesterone acetate, and leuprolide acetate can be used to help
lower an individual’s sex drive. A selective serotonin reuptake inhibitor may
also be prescribed to treat compulsive sexual disorders and any comorbid mood
disorders.
Amanda Baker
See also: Child Sexual Abuse; Diagnostic and Statistical Manual of Mental Disorders
(DSM); Paraphilias; Sexual Abuse.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders: DSM-5. Washington, DC: American Psychiatric Association.
Jahnke, S., & Hoyer, J. (2013). Stigmatization of people with pedophilia: A blind spot in
stigma research. International Journal of Sexual Health, 25, 169–184.
Psychology Today. (2019). Pedophilia. Retrieved from https://www.psychologytoday
.com/conditions/pedophilia
Virtuous Pedophiles. (2019). FAQ. Retrieved from http://www.virped.org/index.php/f-a-q
WebMD. (2012). What is pedophilia? Retrieved from http://www.webmd.com/mental
-health/features/explaining-pedophilia
Pelvic Floor Muscles
The pelvic floor muscles are several muscles at the bottom of the pelvis that help
support the organs of the pelvis. These organs include the large intestine, bladder,
and uterus. The pelvic floor muscles also play an important role in control over
urinary and bowel movements. Damage to the pelvic floor muscles, or a lack of
muscle tone, can result in urinary or fecal incontinence and the prolapse of organs
in the pelvis. The muscles can be strengthened by certain exercises or by surgery
in extreme cases.
The major pelvic floor muscles include the levator ani and the coccygeus mus-
cle. The associated fascia and connective tissue that help define the muscles are
also usually considered part of the pelvic floor. The total group of muscles and
tissues are sometimes called the “pelvic diaphragm,” and the term may be used
interchangeably with “pelvic floor.” Small openings in the muscles allow the ure-
thra, the anal canal, and the vagina to pass through the pelvic floor.
490 Pelvic Inflammatory Disease (PID)
All people have pelvic floor muscles, and their main function is to support the
organs located in the pelvic cavity. The muscles also play an important role in
controlling the release of urine, feces, and flatulence. When the pelvic floor mus-
cles tighten up, the internal organs are raised and sphincter muscles tighten the
openings of the vagina, urethra, and anus. When the muscles relax, the sphincter
muscles also relax, allowing urine and feces to pass through. The pelvic floor
muscles also help to push these substances out of the body. Good muscle tone of
these muscles can also improve sexual intercourse and satisfaction.
Pelvic floor muscles can suffer disorders when they become weak or damaged.
The most important problems are urinary and fecal incontinence, in which a per-
son loses control over their bladder and bowels, respectively. The other major
problem associated with the pelvic floor muscles is pelvic organ prolapse, in which
the organs drop down. In females, the organs may press against the vagina, while
males more often suffer from pressure against the anal canal. In the latter case, the
person can suffer from constipation as a result. If the pelvic floor muscles are very
tight, sexual intercourse can be painful or even impossible.
Causes of pelvic floor muscle problems range from heavy lifting to high-impact
exercise to other underlying medical conditions. Age, chronic coughing, and
chronic constipation can also reduce muscle tone. Among women, the most com-
mon causes of problems are pregnancy and childbirth. Both events can cause
damage to nerves controlling the pelvic floor muscles or even damage the muscles
themselves.
Exercises can help strengthen the pelvic floor muscles. Known as Kegel exer-
cises, the most common is a series of contracting and relaxing the muscles. Many
people have difficulty isolating the pelvic floor muscles, so experts recommend
working with a physical therapist and getting biofeedback to ensure that the exer-
cises are being done correctly.
Tim J. Watts
See also: Dyspareunia; Kegel Exercises; Vaginismus; Vulvodynia.
Further Reading
National Institutes of Health. (2019). Pelvic floor muscle training exercises. Retrieved
from http://www.nlm.nih.gov/medlineplus/ency/article/003975.htm
University of Chicago Medical Center. (2019). Pelvic floor disorders. Retrieved from
https://www.uchicagomedicine.org/conditions-services/pelvic-health/pelvic
-floor-disorders
Pelvic Inflammatory Disease (PID)
Pelvic inflammatory disease (PID) is an infection or inflammation in the upper
genital area of a woman. This disease is received through the cavities of the
cervix, uterus, fallopian tubes, and surrounding areas, ultimately affecting the
endometrium, which is the lining of the uterus. During the 1960s, PID occurred
more frequently in women who were infected with gonorrhea. In a twenty-year
time frame, 20 percent of women who were diagnosed with gonorrhea
Pelvic Inflammatory Disease (PID) 491
developed PID. During the 1980s, an even larger development was discovered.
Among women with PID, over 40 percent of cases were caused by chlamydia.
In women under twenty-five years of age, the percentage was even higher, with
60–80 percent of cases being attributed to chlamydia. Among all women, more
than half of PID cases are caused by Chlamydia trachomatis and Neisseria
gonorrhoeae; in some cases, both these sexually transmitted infections are
present
In 2001, more than 750,000 cases of PID were discovered in the United States.
However, over the past two decades in North America and western Europe, PID
has declined because of increased attempts to control Chlamydia trachomatis and
Neisseria gonorrhoeae. Regardless of the progress, PID is still a poorly controlled
disease.
The most commonly used outpatient method of treatment for PID is antibiotics
that cover a broad spectrum of pathogens, as recommended by the guidelines of
the Centers for Disease Control and Prevention. The antibiotics may include oflox-
acin, levofloxacin, ceftriaxone plus doxycycline, or cefoxitin and probenecid plus
doxycycline, all with optional chemical compounds for treating infections for full
coverage against anaerobes and bacterial vaginosis.
Another efficient way to treat PID is to be admitted into a hospital for treatment
by a doctor and other medical personnel. The “gold standard” for diagnosis is
laparoscopy, which is costly, invasive, and impractical in a general practice set-
ting. A laparoscopy is an internal abdominal examination. The outpatient method
of treatment is the most commonly used method because the disease is often
unnoticeable, and patients commonly treat themselves.
Some common symptoms associated with PID are discomfort and pain in the
lower abdomen, vaginal bleeding, vaginal discharge, and painful intercourse.
Some signs associated with PID are cervical lesions, tenderness in the abdominal
area, high temperature, uterine masses, and uterine tenderness. There is no spe-
cific diagnosis, nor is there a laboratory test for PID. Women that delay seeking
medical attention for PID are three times more likely to experience infertility or
irregular pregnancy compared to women who sought immediate medical atten-
tion. Women with untreated PID are also more prone to developing other diseases,
and PID may cause long-term reproductive disabilities.
The risk factors associated with PID are similar to those of other sexually trans-
mitted infections. The most important risk factor is having chlamydia or gonor-
rhea. Other risks include smoking, sexual intercourse with numerous people, and
not using barrier contraceptive methods like condoms.
Methods of preventing PID include practicing safer sex by using condoms,
attending comprehensive sexual education classes, and being aware of sexually
transmitted infections that lead to PID, especially chlamydia and gonorrhea. It is
also possible to have multiple PID infections, as women who have previously had
PID are more likely to be diagnosed with PID again if they have new sex partners
and do not use condoms.
Reginald Barker
See also: Chlamydia; Gonorrhea; Infertility; Sexually Transmitted Infections (STIs).
492 Penile Cancer
Further Reading
Brunham, R. C., Gottlieb, S. L., & Paavonen, J. (2015). Pelvic inflammatory disease. New
England Journal of Medicine, 2015(372), 2039–2048.
Haggerty, C. L., & Ness, R. B. (2007). Newest approaches to treatment of pelvic inflam-
matory disease: A review of recent randomized clinical trials. Clinical Infectious
Diseases, 44(7), 953–960.
Hillis, S. D., Joesoef, R., Marchbanks, P. A., Wasserheit, J. N., Cates, W., & Westrom, L.
(1993). Delayed care of pelvic inflammatory disease as a risk factor for impaired
fertility. American Journal of Obstetrics and Gynecology, 168(5), 1503–1509.
McCormack, W. M. (1994). Pelvic inflammatory disease. New England Journal of Medi-
cine, 330(2), 115–119.
Pearce, J. M. (1990). Pelvic inflammatory disease. British Medical Journal, 300(6732),
1090–1091.
Penile Cancer
Penile cancer is a cancer that can affect anyone who has a penis. It is relatively
rare, especially among men in high-income countries like the United States. The
prevalence of penile cancer is slightly higher among men from lower-income
countries and can reach up to 10 percent of total cancer cases. Although it is a rare
form of cancer, it has a high mortality. There are a variety of types of penile can-
cer and associated symptoms. There are also known risks associated with penile
cancer and several strategies for prevention.
“Penile cancer” is an umbrella term used whenever cancer cells begin to
develop on or in the penis. The most common type of penile cancer is squamous
cell carcinoma (SCC) of the penis, which is present in 95 percent of penile cancer
cases. Other types of penile cancer include melanoma, basal cell carcinoma, sar-
coma, and adenocarcinoma; however, these types are even more rare. Thus, most
of the research has been focused on the SCC cases. SCC cases can be categorized
in four different ways: verrucous, papillary squamous, warty, and basaloid. The
course of treatment is contingent on the type of penile cancer, size of the tumor,
and the location of the tumor. Tumors can arise anywhere on the penis, meaning
they can be on the surface of the skin (in situ) or invasive.
There are some common symptoms associated with penile cancer. Some of
these symptoms include, but are not limited to, a lump on the penis, inflamma-
tion, a reddish rash, a sore that bleeds, small bumps, swelling, and flat growths.
The previously listed symptoms can also be caused by infections or allergic
reactions; thus, talking to a health care provider is recommended if any of these
symptoms are present. Penile cancer is typically diagnosed after a health care
provider conducts a diagnostic biopsy. Fortunately, there has recently been more
attention drawn to these symptoms because the earlier the disease is found, the
better. If the diagnosis is discovered at an early stage, there is a better chance of
survival and recovery. There has also been work done to determine psychoso-
cial factors that influence men’s help-seeking behaviors when they identify
symptoms.
Penile cancer is more prevalent among older men (typically sixty years and
older), uncircumcised men, and men diagnosed with phimosis (when the foreskin
Penis 493
cannot be pulled back). Some other recorded risks include poor penile hygiene,
history of many sexual partners, and history of sexually transmitted infections.
There have been several studies showing that human papillomavirus (HPV) and
the human immunodeficiency virus have been associated with penile cancer.
Lastly, tobacco use has been associated with penile cancer. Those who smoke
cigarettes are at a higher risk of developing cancer, although how tobacco plays a
role is still not clear. Although these are well-known risks, the disease may also be
present in individuals who do not have these risks (i.e., circumcised, young, and
nonsmokers).
As mentioned earlier, it is important to detect penile cancer as early as possible.
If any symptoms are present, the individual must see a health care provider. The
best way to prevent developing penile cancer is by practicing good genital hygiene,
avoiding tobacco use, and avoiding sexually transmitted infections like HPV (i.e.,
having safer sex and using condoms). Research is still being conducted to learn
more about penile cancer in hopes of lowering its prevalence and its morbidity
rates.
Tori Peña
See also: Circumcision; Human Papillomavirus (HPV); Penis; Phimosis; Testicular
Cancer.
Further Reading
Bleeker, M. C. G., Heideman, D. A. M., Snijders, P. J. F., Horenblas, S., Dillner, J., & Mei-
jer, C. J. L. M. (2008). Penile cancer: Epidemiology, pathogenesis and prevention.
World Journal of Urology, 27(2), 141.
Clark, P. E., Spiess, P. E., Agarwal, N., Biagioli, M. C., Eisenberger, M. A., Greenberg, R.
E., … Ho, M. (2013). Penile cancer. Journal of the National Comprehensive Can-
cer Network: JNCCN, 11(5), 594–615.
Fish, J. A., Prichard, I., Ettridge, K., Grunfeld, E. A., & Wilson, C. (2015). Psychosocial
factors that influence men’s help-seeking for cancer symptoms: A systematic syn-
thesis of mixed methods research. Psycho-Oncology, 24(10), 1222–1232.
Larke, N. L., Thomas, S. L., dos Santos Silva, I., & Weiss, H. A. (2011). Male circumci-
sion and penile cancer: A systemic review and meta-analysis. Cancer Causes &
Control, 22(8), 1097–1110.
Pizzocaro, G., Algaba, F., Horenblas, S., Solsona, E., Tana, S., Van Der Poel, H., & Wat-
kin, N. A. (2010). EAU penile cancer guidelines 2009. European Urology, 57(6),
1002–1012.
Skeppner, E., Andersson, S.-O., Johansson, J.-E., & Windahl, T. (2012). Initial symptoms
and delay in patients with penile carcinoma. Scandinavian Journal of Urology
and Nephrology, 46(5), 319–325.
Tseng, H. F., Morgenstern, H., Mack, T., & Peters, R. K. (2001). Risk factors for penile
cancer: Results of a population-based case-control study in Los Angeles County
(United States). Cancer Causes & Control, 12(3), 267–277.
Penis
The penis is the primary male sex organ. Both urine and semen exit the body
through the penis via the urethra. A number of medical conditions can affect the
penis and may affect sexual function or the ability to urinate.
494 Penis
The head, or glans, of the penis is naturally covered with a foreskin, which may
be surgically removed during circumcision. Two columns of tissue called the cor-
pus cavernosa run along the sides of the penis. Blood vessels and small spaces in
this tissue fill with blood to cause and maintain an erection. A column of tissue
called the corpus spongiosum, running through the central region of the penis,
houses the urethra. Nerves are spread throughout the penis. The nerves are highly
sensitive, especially to stimulation during sexual experiences.
During puberty, the penis grows to its mature length and girth and becomes
fully sexually functional. This growth coincides with the sexual maturity of the
scrotum and testicles and the development of pubic hair. The male genitals typ-
ically become fully mature sometime between the ages of thirteen and eighteen.
Penis size is the result of genetic factors and has no relation to the individual’s
masculinity or sexual abilities.
When sexually aroused—either through physical touching or thoughts—the
arousal stimulates nerves to prompt the production of a substance called nitric
oxide. This chemical compound, in turn, stimulates a cascade of enzyme activity
that causes arterial muscles in the penis to relax. Blood then flows into and fills the
spaces of the corpus cavernosa. As this happens, the penis becomes larger and
firmer in preparation for sexual intercourse. Erections can happen outside of con-
scious awareness, particularly during sleep. Most young, sexually mature men
have three to five erections during sleep. During a wet dream, an erection leads to
ejaculation. Waking up with an erection is fairly common.
A number of structural and functional disorders can affect the penis. Erectile
dysfunction is a relatively common condition that affects the function of the penis.
In this condition, the penis is unable to produce or sustain an erection, usually
because of insufficient blood flow resulting from arterial malfunction. The drug
sildenafil and other phosphodiesterase inhibitors increase blood flow in the penis,
allowing for a full and sustained erection. Testosterone injections may benefit
some men with erectile dysfunction. Another structural condition, Peyronie’s dis-
ease, is an abnormal curvature of the penis that may be caused by injury or other
conditions during adulthood. Priapism is an abnormal, painful condition in which
the penis remains erect for several hours—long after sexual arousal has ended. If
this occurs, urgent medical attention is needed and injected drugs and various
surgical procedures are options for correcting this condition.
Balanitis is inflammation of the glans, usually caused by an infection. Its symp-
toms include pain, tenderness, and redness. Urethritis is a painful inflammation
and infection of the urethra, often associated with the sexually transmitted infec-
tions gonorrhea and chlamydia. Other sexually transmitted infections affecting
the penis include syphilis, herpes, and penile warts. Most penile infections can be
cured with antibiotics, though viral infections, such as herpes, require special
antiviral medications to treat symptoms. Cancer of the penis is a rare condition,
though it is more common in men who are uncircumcised.
Some males are born with defects of the penis. In hypospadias, the opening for
urine elimination occurs on the underside of the penis instead of on the tip. In
chordee, the end of the penis has an abnormal curvature, which may interfere with
urinary or sexual function. Surgery is necessary to correct these birth defects.
Performance Anxiety 495
Phimosis occurs if the foreskin covering an uncircumcised penis is too tight to
allow for retraction during an erection. Depending on the severity of the condi-
tion, stretching, surgery, or circumcision may be required to restore proper
functioning.
Another penile birth defect is micropenis, or microphallus, characterized by an
atypically small penis. This is usually caused by a hormone imbalance. Testoster-
one injections during childhood can correct this condition.
A. J. Smuskiewicz
See also: Circumcision; Erection; Foreskin; Male Sexuality; Penile Cancer; Phimosis;
Priapism; Pubic Hair; Sexual Disorders, Male.
Further Reading
Mayo Clinic. (2019). Penis health: Identify and prevent problems. Retrieved from https://
www.mayoclinic.org/healthy-lifestyle/mens-health/in-depth/penis-health/art
-20046175
National Health Service. (2018). 5 penis facts. Retrieved from https://www.nhs.uk/live
-well/sexual-health/five-penis-facts/
Planned Parenthood. (2019). What are the parts of the male sexual anatomy? Retrieved
from https://www.plannedparenthood.org/learn/health-and-wellness/sexual-and
-reproductive-anatomy/what-are-parts-male-sexual-anatomy
Performance Anxiety
Sexual performance anxiety is the inability to experience a physical or emotional
response to sexual activity due to either external or internal stressors. Sexual per-
formance anxiety can affect people of all sexual experience levels and does not
necessarily just occur among those who are sexually inexperienced. Even those
who have much experience can be overcome by anxiety associated with sexual
performance. The physical response of sexual performance can be affected by
many internal factors, including poor body image, problems within the relation-
ship, and concerns over premature or prolonged ejaculation. Sexual performance
anxiety can affect people of any gender.
The physical responses, or lack thereof, that pertain to sexual performance
anxiety come in many different forms. The most common of these is erectile dys-
function. Erectile dysfunction can occur when people with penises become
stressed about what they think their partner will think of their sexual perform-
ance. This heightened stress level narrows the blood vessels, resulting in less
blood flow to the penis, which makes it difficult to become physically aroused,
even though erection is possible in other contexts. For people with vaginas, height-
ened levels of stress can result in lubrication difficulties, which can affect the abil-
ity to have pleasurable, comfortable sex. If sexual difficulties occur as the result of
anxiety, this can create more anxiety, leading to more sexual difficulties, and,
therefore, a cycle of anxiety and dysfunction can occur.
While the physical aspects of sexual performance anxiety are often similar
across people, the effects of what is specifically causing the anxiety are more
unique to the individual. Some aspects of sexual performance anxiety include
496 Perimenopause
problems within the relationship between the individual and their partner and
concerns over prolonged or premature ejaculation. Poor body image, such as feel-
ing that one’s own body is unattractive and unappealing, is one of the leading
causes of sexual performance anxiety (Lehmiller, 2013). This can be a self-
fulfilling prophecy: if someone is lacking the confidence that they are “good
enough,” this attitude can lead to results that reflect their expectations.
There are numerous ways that people can overcome sexual performance anx-
iety. These might include behavioral techniques practiced either alone or with the
partner, focusing on the nonpenetrative aspects of sex, being “present” in the
moment (e.g., mindfulness), engaging in increased amounts of foreplay, and med-
ications to treat sexual dysfunctions. Another important aspect of sex is com-
munication. By communicating likes and dislikes, sexual partners can help to
ensure that they and their partners are having sex that feels good and that leaves
them physically and mentally satisfied. Finally, exercising is also an effective
method to help reduce sexual performance anxiety. For example, exercising just
twenty to thirty minutes a day can increase sexual stamina, which is one of the
most prevalent causes of performance anxiety. Exercise can also improve phys-
ical health and body image, which is another frequently reported cause of sexual
performance anxiety. Ultimately, exercise is a great way to both mentally and
physically change the way people feel about themselves and perform in the
bedroom.
If one experiences performance anxiety and the symptoms are frequent or seem
to progress, it is best to seek professional advice. A doctor may be able to deter-
mine if there are complicating factors such as medication side effects or other
physical ailments. Some medications that have an impact on sexual desire and
sexual performance include antidepressants, anti-inflammatory medication, high
blood pressure medications, and muscle relaxers. Speaking with a sex or relation-
ship therapist may also be useful to learn techniques to manage performance anx-
iety and to address any underlying issues in the relationship.
Casey T. Tobin
See also: Psychosexual Therapy; Sensate Focus; Sexual Dysfunction, Treatment of.
Further Reading
Gunasekaran, K. (2018). Sexual medicine. New York: Springer.
Lehmiller, J. (2013). The psychology of human sexuality. Hoboken, NJ: Wiley Blackwell.
Maier, T. (2009). Masters of sex. New York: Basic Books.
McCabe, M., Althof, S. E., Assalian, P., Chevret-Measson, M., Leiblum, S. R., Simonelli,
C., & Wylie, K. (2010). Psychological and interpersonal dimensions of sexual
function and dysfunction. The Journal of Sexual Medicine, 7(1pt2), 327–336.
Perimenopause
During perimenopause, a female body transitions from its fertile, childbearing
stage to its permanently infertile stage. Perimenopause means “around meno-
pause” and lasts for several months to several years before the final menstrual
period; it is considered over after twelve consecutive months without a menstrual
period. At that point, the individual has entered menopause.
Perimenopause 497
Perimenopause is caused primarily by fluctuating levels of estrogen and pro-
gesterone, the major female sex hormones. By the time menopause is reached, the
levels of both of these hormones have substantially and permanently declined.
The timing of perimenopause varies, though most notice the first signs and
symptoms sometime between their mid-thirties and their late forties. Certain gen-
etic factors, smoking, radiation therapy or chemotherapy for cancer, and ovarian or
uterine surgery (such as hysterectomy) may lower the age at which perimenopause
starts. Symptoms typically become more severe as menopause grows nearer.
One common symptom of perimenopause is the development of irregularities
in menstrual cycles. The cycles may become unusually long or short, the men-
strual flows may become especially heavy or light, and some periods may be
missed as ovulation fails to occur. A persistent change of seven or more days in
menstrual cycle length is characteristic of an early phase of perimenopause. A
time of sixty or more days between menstrual periods is characteristic of a late
phase of perimenopause.
Vaginal dryness can occur as the vaginal tissues begin to lose their lubrication
and flexibility. This symptom may be especially troubling during sexual inter-
course and can cause pain or irritation that can be lessened with the use of com-
mercial lubricants. The loss of tissue tone in this part of the body can also
contribute to urinary incontinence. Another sexual problem that can develop dur-
ing perimenopause is a reduction in sexual arousal and desire.
Some individuals may also experience hot flashes, night sweats, and associated
sleeping problems during perimenopause, although the intensity and frequency of
these problems will vary. Mood swings, including irritability and depression, may
also be associated with perimenopause.
Disease-related physiological changes that worsen in many women as meno-
pause approaches include the loss of bone density, the increase in low-density
lipoprotein cholesterol, and the decrease in high-density lipoprotein cholesterol.
The bone changes raise the risk of osteoporosis and fractures, and the cholesterol
changes increase the risk of cardiovascular disease.
Some learn to tolerate the changes of perimenopause without seeking profes-
sional treatment. Others, however, find the need to consult physicians—especially
those whose symptoms are unusually severe. In those cases, hormone replacement
therapy and antidepressant drugs are among the treatment options. Some physi-
cians also recommend physical exercise, dietary changes (including eating foods
high in fiber, calcium, and vitamin D), and stress-reduction techniques (such as
yoga or meditation).
A. J. Smuskiewicz
See also: Estrogen; Female Sexuality; Hormone Replacement Therapy; Hot Flashes;
Lubricants; Menopause; Menstruation; Progesterone.
Further Reading
Mayo Clinic. (2019). Perimenopause. Retrieved from https://www.mayoclinic.org/diseases
-conditions/perimenopause/symptoms-causes/syc-20354666
North American Menopause Society. (2019). Menopause 101: A primer for the perimeno-
pausal. Retrieved from https://www.menopause.org/for-women/menopauseflashes
/menopause-symptoms-and-treatments/menopause-101-a-primer-for-the
-perimenopausal
498 Perineum
Perineum
The perineum is a sensitive area of skin between the anus and the vulva or scro-
tum. This area lies below a set of muscles, called the pelvic floor muscles, that
support the bladder and bowel. The perineum contains blood vessels and nerves
that supply the urinary tract and genitals with nerve signals and blood signals.
The perineum benefits males and females in different ways. Perineal exercises
can improve urinary and fecal problems. These exercises can also help those with
erectile dysfunction and premature ejaculation as well as those with prostate prob-
lems. The best way to exercise the perineum is by attempting to stop the flow of
urination. The perineum will contract when the exercise is performed right, and it
should feel as though the muscles are moving up and down. A common way to
strengthen the perineum is by doing Kegel exercises. Kegel exercises are easiest to
perform when the bladder is empty and when sitting in a chair or standing with
legs shoulder width apart. To do a Kegel exercise, the perineum is contracted for
four seconds then released; this is known as one set. It is typically recommended
that an individual repeats their Kegel exercises ten to fifteen times (or sets), two or
three times a day. However, it is also important to speak with a doctor if experi-
encing any problems related to the pelvic floor.
Injury to the perineum can cause sexual and bladder issues. Nerves from
the perineum carry signals from the bladder to the brain and spinal cord to let the
brain know when the bladder is full. The same nerves also carry signals from the
brain to the pelvic floor muscles to hold or release urine. Injury to these nerves can
create bowel and bladder control issues. The perineum carries signals not only
between the brain and the bladder or pelvic floor muscles but also between the
brain and the genitals. As such, injury to these nerves can interfere with sexual
function. During arousal, the brain directs the smooth muscles in the genitals to
relax, which causes blood to flow to the genitals, including the penis. If these
blood vessels are damaged, this can cause erectile dysfunction, which is the inabil-
ity to have or maintain an erection firm enough to engage in penetrative sexual
activity. Damage to the perineum can also cause damage to the penis and urethra
because an internal part of the penis runs through the perineum and contains a
section of the urethra.
The perineum also plays a significant role during childbirth. During vaginal
delivery, the perineum stretches significantly to allow the baby to pass through the
vaginal opening. This can result in a perineal tear. There is a greater risk of tear-
ing when the baby is large, if a significant amount of weight was gained during
pregnancy, or if having a baby at a younger or older age. Throughout pregnancy,
people can work to stretch the perineum to help prevent tearing through regular
perineal massages. The goal of perineal massaging is to relax the pelvic floor
muscles and to stretch the vaginal opening. Often during childbirth, a doctor may
perform an episiotomy to prevent tearing. An episiotomy is an incision in the
perineum to make the vaginal opening larger for delivery. After an episiotomy,
the perineum usually heals on its own with time, but it is important to limit phys-
ical activity and use ice packs to prevent swelling.
During pregnancy, Kegel exercises, also known as pelvic floor muscle training,
are recommended to prevent urinary leakage. Kegel exercises are also recommended
Pfizer Global Study of Sexual Attitudes and Behaviors 499
to improve sexual and digestive health, as these exercises can help to control uri-
nary leakage while laughing, coughing, and sneezing and can decrease the urge to
urinate and help control stool leakage. Kegel exercises also help to strengthen the
muscles in and around the vagina. For some people, performing Kegel exercises
during sexual intercourse can lead to stronger orgasms, more pleasure, and more
arousal.
Although there are many functions of the perineum, everyone is at risk for
perineal injury, which can be acute or chronic. The most common acute perineal
injuries include perineal surgeries (such as during childbirth), straddle injuries
(where a person’s legs land on both sides of an object and the perineum forcefully
strikes an object, such as a bike), sexual abuse, and impalement. Chronic perineal
injuries, on the other hand, tend to be more severe and may result from a sport-
related practice such as bike, horseback, or motorcycle riding. When bike riding,
straddling a narrow, hard seat can pinch the blood vessels in the perineum, which
can cause severe nerve damage. Research has shown that wider seats reduce peri-
neal pressure. Constipation is also a cause of chronic perineal injury. The stool of
people who are constipated is hard, dry, and difficult to pass, and straining by
squeezing the perineum can cause damage to the blood vessels.
Most people do not often think about the perineum unless an injury has
occurred. Perineal injuries are uncomfortable and can cause pain and irritation,
but there are ways to prevent and reduce them, such as strengthening the muscles
through Kegel exercises. A strong pelvic floor is beneficial for everyone. It is also
important to keep the perineum clean and healthy to prevent irritation and
infection.
Casey T. Tobin
See also: Kegel Exercises; Pelvic Floor Muscles; Premature Ejaculation; Sexual Dysfunc-
tion, Treatment of.
Further Reading
Galan, N. (2019). The importance of the perineum in childbirth. Retrieved from https://
www.verywellhealth.com/the-perineum-2616422
Mayo Clinic. (2018). Kegel exercises: A how-to guide for women. Retrieved from https://
www.mayoclinic.org/healthy-lifestyle/womens-health/in-depth/kegel-exercises
/art-20045283
National Institutes of Health. (2014). Perineal injury in males. Retrieved from https://
www.niddk.nih.gov/health-information/urologic-diseases/perineal-injury-males
Pfizer Global Study of Sexual Attitudes and Behaviors
The Global Study of Sexual Attitudes and Behaviors (GSSAB) was a large inter-
national study sponsored by Pfizer, a multinational pharmaceutical company
headquartered in New York City. With a series of reports—the first published in
2004—the GSSAB investigated various aspects of sexual attitudes and behaviors
among 27,500 men and women aged between forty and eighty years in twenty-
nine countries on six continents. The study, which included a multinational team
of researchers, was conducted in each country by interviewing people or asking
them to fill out questionnaires and then analyzing the responses.
500 Pfizer Global Study of Sexual Attitudes and Behaviors
Much of the GSSAB analyzed the prevalence of different sexual problems,
such as erectile dysfunction, lubrication difficulties, pain during intercourse, and
lack of sexual interest. The study’s sponsor, Pfizer, manufactures one of the most
popular drugs for erectile dysfunction.
Findings from the study indicated that more than 80 percent of male partici-
pants and 65 percent of female participants reported that they had sexual inter-
course during the past year (the year before completing the survey). Of these
sexually active people, 28 percent of the men and 39 percent of the women experi-
enced at least one sexual dysfunction or problem.
Among sexually active men, the most common sexual dysfunctions were early
ejaculation (14% of respondents) and erectile difficulties (10%). Among the
women, the most common sexual problems were lack of sexual interest (21%),
inability to experience orgasm (16%), and lubrication difficulties (16%).
Among the sexually active respondents, 18 percent of the men and 18.8 percent
of the women had sought medical help for their problems, and almost 40 percent
had spoken about their sexual problem(s) with their partners. According to the
survey results, physicians asked only 9 percent of respondents about their sexual
health during routine office visits in the previous three years.
Among GSSAB participants, men generally had higher sexual well-being
scores than women. In the United States, Canada, Europe, and other Western
nations, 71 percent of men were extremely or very satisfied emotionally with their
relationships, compared with 63 percent of women. In Mediterranean nations
(such as Algeria, Egypt, Israel, and Turkey), the corresponding percentages for
relationship satisfaction were 52 percent for men and 41 percent for women, and in
China, Japan, Indonesia, and other East Asian nations, they were 30 percent for
men and 23 percent for women.
In general, the survey found that feelings of sexual satisfaction and well-being
correlated with levels of physical activity. People, especially men, who were more
physically active tended to have higher levels of sexual well-being.
Almost 50 percent of men and 32 percent of women in Western nations indi-
cated that sex was extremely or very important in their lives. Both men and women
in Mediterranean and Asian nations gave less importance to sex than in Western
nations.
Men who had multiple partners were more likely than monogamous men to
believe that sex was important, but they were less likely to be satisfied in their
relationships. Women generally placed greater importance on emotional satisfac-
tion than physical satisfaction in their relationships compared with men.
Among the conclusions reached by the GSSAB researchers were that sexual
desire and sexual activity are widespread in the forty-to-eighty age group and that
desire and activity persist into old age. Also, sexual dysfunctions tend to occur at
a relatively high rate in this age group, and the dysfunctions become more preva-
lent with increasing age, especially in men.
A. J. Smuskiewicz
See also: Sexual Disorders, Female; Sexual Disorders, Male; Sexual Dysfunction, Treat-
ment of; Sexuality among Older Adults.
PFLAG 501
Further Reading
Laumann, E. O., Paik, A., Glasser, D. B., Kang, J. H., Wang, T., Levinson, B., … & Gin-
gell, C. (2006). A cross-national study of subjective sexual well-being among
older women and men: Findings from the Global Study of Sexual Attitudes and
Behaviors. Archives of Sexual Behavior, 35(2), 145–161.
Nicolosi, A., Buvat, J., Glasser, D. B., Harmann, U., Laumann, E. O., & Gingell, C. (2006).
Sexual behaviour, sexual dysfunctions and related help seeking patterns in
middle-aged and elderly Europeans: The global study of sexual attitudes and
behaviors. World Journal of Urology, 24(4), 423–428.
Nicolosi, A., Laumann, E. O., Glasser, D. B., Moreira, E. D., Paik, A., & Gingell, C.
(2004). Sexual behavior and sexual dysfunctions after age 40: The global study of
sexual attitudes and behaviors. Urology, 64(5), 991–997.
PFLAG
PFLAG purports to be the largest nonprofit organization in the United States
working to unite families and allies with individuals from the lesbian, gay, bisex-
ual, transgender, and queer (LGBTQ) community. Prior to 2014, PFLAG as an
acronym stood for “Parents and Friends of Lesbians and Gays.” PFLAG’s strategic
vision is “PFLAG envisions a world where diversity is celebrated and all people
are respected, valued, and affirmed inclusive of their sexual orientation, gender
identity, and gender expression.” The mission of the organization is concentrated
on three major domains: support, education, and advocacy for the LGBTQ
community.
The founding of PFLAG is credited to Jeanne Manford and tied to her 1972
participation in New York City’s Christopher Street Liberation Day March (an
early precursor to modern-day LGBTQ Pride celebrations). During this time of
rampant cultural homophobia, Manford marched in the parade alongside her gay
son, Morty, while holding a protest sign that read “Parents of gays unite in support
of our children.” During the parade, Manford is said to have been approached by a
number of gay and lesbian crowd members who begged her to speak with their
non-LGBTQ-affirming parents. Following this experience, Manford decided to
begin a support group linking LGBTQ-identified individuals with heterosexual
family members and allies of the community.
The first official PFLAG meeting took place on March 26, 1973, at the
Metropolitan–Duane Methodist Church in Greenwich Village, New York City.
The group was initially referred to as Parents FLAG (Parents and Friends of Les-
bians and Gays) and had about twenty people in attendance at the first meeting. As
word about Parents FLAG began to spread, additional support groups came into
existence across the country. After the 1979 National March for Gay and Lesbian
Rights in Washington, D.C., representatives from these various groups met
together for the first time. The following year, Parents FLAG began to establish
itself as a national resource for education on the gay and lesbian community by
distributing information to educational institutions and leaders of various faith
communities. Soon thereafter, a major moment for PFLAG occurred when “Dear
502 PFLAG
Abby” mentioned the support groups in her advice column. The ,publicity report-
edly generated over 7,000 letters requesting more information about PFLAG.
In 1981, spurred by the “Dear Abby” publicity, members decided to form a
national organization, and the first PFLAG National office was created in Los
Angeles under founding president Adele Starr. The 1980s and 1990s represented a
period of significant growth for the organization, during which time it was granted
nonprofit tax-exempt status, relocated its national office several times, began to
organize itself into a chapter-based structure, and became increasingly involved in
local and national advocacy work on behalf of the LGBTQ community.
In 1993, PFLAG added the word “Families” to the name. For the first time, the
organization also specifically included bisexual people in its mission and advo-
cacy work. In 1998, PFLAG also added transgender people. In 2014, the organiza-
tion officially changed its name from “Parents, Families, and Friends of Lesbians
and Gays” to the abbreviated “PFLAG” in order to reflect growing inclusivity
related to the diverse LGBTQ community served by the organization.
PFLAG National is currently headquartered in Washington, D.C., and overseen
by both elected leadership and paid staff members. At its highest level, PFLAG is
governed by a twenty-one-member board of directors, consisting of elected volun-
teers serving three-year terms. A major responsibility of the board of directors is
to elect the PFLAG national president and executive director.
PFLAG is separated into fourteen regions throughout the United States, with
each region electing a regional director who serves a two-year term. Six regional
directors are elected to serve on the PFLAG board of directors, and these positions
act as a link between PFLAG members and the national office. On a local level,
PFLAG is organized into chapters. It currently boasts over 400 chapters and
200,000 members across all fifty states. Chapters officially consist of three or
more individuals or families working to further the vision and mission of PFLAG
and have significant autonomy with regard to planned member activities and
events.
PFLAG’s first foray into national advocacy occurred in the 1980s when the
organization became involved in opposing Anita Bryant’s crusade against gay
rights. In the 1990s, local Massachusetts PFLAG chapters helped pass the first
Safe Schools legislation in the country. Also during this time, a PFLAG-affiliated
family was involved in the Department of Education’s ruling that Title IX protects
gay and lesbian students from harassment based on sexual orientation. More
recently, PFLAG’s advocacy work has included significant involvement in the U.S.
marriage equality rulings, support for the Equality Act, legislative bans on con-
version therapy for LGBTQ youth, federal employment protections for transgen-
der people, and working with Congress to promote LGBTQ rights as a global
foreign policy priority.
Jennifer A. Vencill
See also: Gay-Straight Alliance (GSA); LGBTQ+.
Further Reading
PFLAG. (2019). About PFLAG. Retrieved from https://pflag.org/about
Pheromones 503
Pheromones
Pheromones are chemical substances that are released into the environment by
many species of animals as communication signals that influence the behavior of
other members of their species. These signals are usually in the form of chemicals
that can be smelled, tasted, or detected by a special structure called the vomerona-
sal organ (VNO). Animals known to communicate with pheromones include
insects, mollusks, reptiles, rodents, dogs, cats, hogs, and monkeys. A few plants
are known to release pheromone-like chemicals when grazed upon (prompting the
production of other chemicals in surrounding plants of the same species that make
them less tasty to animals). The existence of pheromone communication among
human beings has long been suspected, but it has been difficult to prove scientifi-
cally that such chemicals influence human behavior.
Pheromones play a number of important social roles in animal species, includ-
ing territory marking, threat warnings, and the attraction of mates and other
reproduction-related purposes. Many kinds of male mammals, such as wolves,
tigers, monkeys, and deer, mark the boundaries of their territories with oily liquid
secretions containing pheromones. These chemicals serve as signals to attract
females and repel other males. The chemicals also serve to protect food resources
within the animal’s territory.
Warning-type pheromones are released by certain kinds of ants, snails, and
mice when they are injured or threatened by enemies. When the airborne chemi-
cal signals are detected by other members of the species, they have the effect of
driving those individuals out of the area.
Animal pheromones serve various purposes related to mating and reproduc-
tion. Queen bees (the females that reproduce in bee colonies) secrete pheromones
that block the sexual development of other females in a colony, causing them to
become worker bees instead. Female silk moths secrete a powerful pheromone
that can attract male moths from several miles away. Female tree snakes emit
pheromones that prompt both the start and end of male courtship behaviors. Some
male mice secrete pheromones that speed the development of puberty in young
female mice. Pheromones released by some female mice, hamsters, and other
rodents attract and sexually arouse males of their species. In hogs, the smell of a
boar’s saliva can prompt a sow to stand in a mating position.
Many researchers suspect that the sweaty secretions of armpits, the groin area,
and other body regions contain pheromones that influence human sexual and
reproductive behaviors as well as other emotions and behaviors.
Some research suggests that pheromones released into the air by ovulating
women cause testosterone levels to increase in nearby men. Many observations
indicate that women who spend a lot of time together—such as women who live
together in college dormitories—tend to develop menstrual cycles that become
increasingly in synch over time. Some unusual research has demonstrated that the
smell of the sweat of people who have just jumped out of airplanes with para-
chutes makes other people more attentive to details—suggesting a type of chemi-
cal alarm signal might be contained in the sweat.
504 Phimosis
In other perspiration research, the smell of men’s sweat has been shown to
make some women feel more relaxed. In addition, women were found to prefer the
smell of sweaty T-shirts that had been worn by men who had versions of a gene
called MHC that were different than their own MHC genes. That finding implied
that a pheromone in men’s sweat might guide women to select mates who would
enhance the genetic diversity, and thus the health, of their future offspring.
Research published in 2011 indicated that pheromone odors released by glands
in a mother’s nipples help guide newborns to the breasts to suckle for milk. Other
research suggests that pheromones released by breastfeeding women can alter the
moods of nearby women who do not have children, increasing their sexual desire.
Despite the many observations that suggest important social and behavioral
roles for human pheromones, none of these observations have been confirmed by
large-scale, placebo-controlled scientific studies. The complexity of human behav-
ior, compared to the relatively simple behaviors of most animals, further compli-
cates the scientific evaluation of pheromone influences on people. In addition,
although some people have tiny VNO ducts behind their nostrils—similar to the
pheromone-detecting VNOs of animals—not all people have such structures, and
the structures, when present, have not been shown to actually function.
Moreover, unlike the specific chemical compounds that have been identified as
pheromones in animals—such as bombykol in female silk moths and androste-
none in boar saliva—no particular chemical substances have been confirmed as
human pheromones. The best candidate for a human pheromone is androstadie-
none, a compound in sweat that the body makes from testosterone—the scent of
which has been shown to alter brain activity in people. However, more research is
needed before androstadienone can be proven to consistently function as a
behavior-modifying pheromone.
A. J. Smuskiewicz
See also: Arousal; Menstruation; Ovulation; Sex Hormones.
Further Reading
Hadhazy, A. (2012, February). Do pheromones play a role in our sex lives? Scientific
American. Retrieved from https://www.scientificamerican.com/article/pheromones
-sex-lives/
Wyatt, T. D. (2003). Pheromones and animal behaviour: Communication by smell and
taste. Cambridge: Cambridge University Press.
Yuhas, D. (2014). Are human pheromones real? Scientific American. Retrieve from
https://www.scientificamerican.com/article/are-human-pheromones-real/
Phimosis
Phimosis is a condition in which the foreskin (prepuce) cannot retract over the
glans (head) of the penis. It is normal among male children before adolescence.
Attempting to retract the foreskin before the foreskin releases from the glans can
cause pain and scarring. Medical personnel advise treatment only when phimosis
affects sexual relations. A variety of treatments are available, ranging from con-
servative, noninvasive actions to radical circumcision.
Physical Attractiveness 505
At birth, the foreskin is adhered to the glans of the penis. This developmental
phimosis is normal and in most cases will disappear as the child matures. “Patho-
logical phimosis” is the term used when an uncircumcised adult male’s foreskin
will not retract. The most common cause is that the tip of the foreskin is too nar-
row to pass over the glans. The condition is relatively rare and occurs in only 1–5
percent of uncircumcised males. The most common and conservative treatment is
the application of topical steroidal medications to the tip of the foreskin. This
medication will accelerate growth of the tip of the foreskin, making it larger and
allowing it to pass over the glans. This treatment is often accompanied by dilation
and stretching. This can be done through manual stretching or the use of medical
devices. Constant tension will cause the skin to grow new cells, making the fore-
skin larger. Steroids and stretching are both painless and have a rate of success of
around 85 percent. They also preserve the foreskin tissue, which protects nerves
that gives heightened pleasure during intercourse.
More extreme treatments include several types of surgery, known as preputio-
plasty. One version involves a slit in the foreskin parallel to the length of the penis.
The opening is then closed in a transverse manner, making the foreskin looser.
This operation is less painful and requires less recovery time than a circumcision.
Traditional surgical treatment for phimosis was total circumcision, which was
more painful and ran the risk of greater infection than modern preputioplasty. In
addition, the loss of the foreskin may result in decreased sensitivity during
intercourse.
Tim J. Watts
See also: Circumcision; Foreskin; Penis.
Further Reading
Better Health Channel. (2014). Foreskin care. Retrieved from https://www.betterhealth
.vic.gov.au/health/conditionsandtreatments/foreskin-care
National Health Service. (2018). Tight foreskin (phimosis and paraphimosis). Retrieved
from https://www.nhs.uk/conditions/phimosis/
UCSF Department of Urology. (2019). Phimosis. Retrieved from https://urology.ucsf.edu
/patient-care/children/phimosis
Physical Attractiveness
There are many things that can make people seem attractive. Some people are
attracted to others’ intelligence, or to their kindness, or to their sense of humor.
Oftentimes, people are attracted to others who share similar attitudes and values.
Being attracted to a person has been reported as the number one reason why
people have sex, and physical attractiveness plays a major role.
Physical attractiveness is important to overall attractiveness when selecting a
partner, and it tends to be most important during a first meeting or when making
a first impression of a potential partner. In addition, physical attractiveness may
be especially important when considering a short-term sexual partner as com-
pared to a long-term relationship. Physical attractiveness is important to both
males and females, although some gender differences have been noted. In general,
506 Physical Attractiveness
among heterosexual individuals, men tend to place more importance on physical
attractiveness than women.
What is considered physically attractive varies by culture and changes over
time. And, while physical attractiveness is ultimately subjective to the individual—
what one person finds physically attractive is often different from what another
person finds attractive—there are some general consistencies.
In terms of facial attractiveness, people tend to rate faces that are symmetrical
and those that are “averaged” as most attractive. It is important to note that “aver-
aged” in this context means that all facial features are proportionate to each other.
The eyes are neither too close together nor too far apart, and the ears and nose are
neither too big nor too small. All features are balanced and “averaged.” This pref-
erence for symmetry and “averaged” faces has been shown to be present among
men and women and across a variety of cultures. Female faces that are considered
to have more feminine traits, such as large eyes, are also generally considered to
be more attractive.
In terms of bodily attractiveness, body mass index (BMI) and waist-to-hip
ratios have been the most studied. BMI is a value that considers the individual’s
height and mass. Someone who is tall and has a lower body mass has a lower BMI
than someone who is short and has a higher body mass. Waist-to-hip ratios con-
sider the diameter of someone’s waist in relation to the diameter of their hips.
Someone with a waist smaller than their hips has a waist-to-hip ratio less than 1.0,
whereas someone whose waist is larger than their hips has a waist-to-hip ratio
greater than 1.0. In current Western culture, female bodies that are lower than
average with respect to BMI and waist-to-hip ratios tend to be rated as more
attractive; however, those that are much lower or much greater than average are
generally rated as less attractive than those that are closer to the average. Among
male bodies, lower levels of body fat and higher rates of muscle are generally con-
sidered more attractive, as are waist-to-hip ratios that are less than but nearer to
1.0. Cultural differences in preferred BMI and waist-to-hip ratios have been noted.
Ultimately, physical attractiveness is subjective, and different people are
attracted to different physical characteristics in their partners. Some people find
height attractive, while other people prefer a short partner. Some people find
blonde hair attractive, while others prefer those with brown hair. And while phys-
ical attractiveness is important, especially when considering a casual sex partner,
it is not the only characteristic that is considered, and it generally becomes less
important when considering a long-term romantic relationship partner.
Heather L. Armstrong
See also: Desire; Evolutionary Perspectives on Gender and Sexual Behavior; Romantic
Attraction and Orientation; Same-Sex Attraction and Behavior.
Further Reading
Apicella, C. L., Little, A. C., & Marlowe, F. W. (2007). Facial averageness and attractive-
ness in an isolated population of hunter-gatherers. Perception, 36, 1813–1820.
Little, A. C., Jones, B. C., & DeBruine, L. M. (2011). Facial attractiveness: Evolutionary
based research. Philosophical Transactions B, 366, 1638–1659.
Planned Parenthood 507
Luo, S., & Zhang, G. (2009). What leads to romantic attraction: Similarity, reciprocity,
security, or beauty? Evidence from a speed-dating study. Journal of Personality,
77(4), 933–963.
Marlowe, F., & Wetsman, A. (2001). Preferred waist-to-hip ratio and ecology. Personality
and Individual Differences, 30(3), 481–489.
Meston, C. M., & Buss, D. M. (2007). Why human have sex. Archives of Sexual Behavior,
36, 477–507.
Smith, K. B. (2017). Attraction, intimacy, and love. In C. F. Pukall (Ed.), Human sexuality:
A contemporary introduction (2nd ed.). Don Mills, ON: Oxford University Press.
Planned Parenthood
Planned Parenthood Federation of America (PPFA), usually shortened to Planned
Parenthood, is a nonprofit organization that offers reproductive and other health
services, sexuality education, and advocacy for reproductive justice. It is the larg-
est U.S. provider of reproductive health care. PPFA’s services include screening
for cancer; testing, counseling, and treatment for sexually transmitted infections;
contraception; and abortion. Contraception accounts for about one-third of PPFA’s
services, and testing and treatment for sexually transmitted infections accounts
for 42 percent. PPFA provides nearly 300,000 abortions each year among the
2.7 million people it serves with health care annually.
According to their mission statement, “Planned Parenthood believes in the fun-
damental right of each individual, throughout the world, to manage his or her
fertility, regardless of the individual’s income, marital status, race, ethnicity, sex-
ual orientation, age, national origin, or residence.”
The organization began in Brooklyn, New York, when Margaret Sanger opened
the first birth-control clinic in 1916. She founded the American Birth Control
League in 1921, which became part of Planned Parenthood Federation of America
in 1942. Since then, PPFA has expanded and contracted in size. As of 2015, it had
sixty-one locally governed affiliates nationwide. The affiliates operate approxi-
mately 700 health centers. In addition, Planned Parenthood affiliates provide edu-
cational programs to 1.5 million young people and adults. PPFA is an affiliate of
the International Planned Parenthood Federation.
When Margaret Sanger opened the first clinic in Brooklyn, poor women often
suffered serious health problems from multiple pregnancies and having more chil-
dren than they were able to support. Information about birth control was judged
“obscene,” and Sanger was arrested eight times as she advocated for its use.
Planned Parenthood has been attacked for Margaret Sanger’s early support of
negative eugenics, in which she said that there were irresponsible and reckless
people whose religious scruples “prevent their exercising control over their num-
bers.” She said, “There is no doubt in the minds of all thinking people that the
procreation of this group should be stopped.” Her strategy was that they should be
offered birth control.
Others have opposed the work of Planned Parenthood by suggesting that the
organization targets African American communities in an attempt at genocide.
508 Planned Parenthood
They point to the percentages of African American women who get abortions as
compared to white women. A major factor for all women seeking abortion is eco-
nomics, and according to the Pew Research Center, “the median wealth of white
households is 18 times that of Hispanic households and 20 times that of black
households” (Kochhar, Fry, & Taylor, 2011).
Again, some of these attacks on PPFA stem from the belief that Margaret
Sanger wanted to employ eugenics on the African American population. In 1930,
she opened a birth control clinic in Harlem at the request of black leaders and
staffed it with African American doctors and nurses. Martin Luther King Jr. com-
mended Sanger in his acceptance speech for an award named in her honor.
In 1948, PPFA provided a small grant to Dr. Gregory Pincus to explore the pos-
sibility of a hormonal contraceptive. In 1953, based on Dr. Pincus’s encouraging
research, Sanger persuaded philanthropist Katherine Dexter McCormick to
underwrite the development of a birth control pill, which resulted in Enovid, the
first oral contraceptive. It was approved by the U.S. Food and Drug Administra-
tion in 1960 and had a profound effect on society. Within five years, one out of
every four married women in the United States under the age of forty-five had
used the pill.
In 1970, President Richard Nixon signed into law Title X of the Public Health
Service Act. This made contraceptives available to low-income women and pro-
vided funding for educational programs to reduce teenage pregnancy. Planned
Parenthood affiliates were recipients of these funds, enabling them to provide
birth control to poor women and young people. In 1973, the Supreme Court deci-
sion in Roe v. Wade overturned state laws that outlawed abortion. Planned Parent-
hood began offering abortion services at several of their affiliates and increasingly
advocated for reproductive justice.
The Planned Parenthood Action Fund, the nonpartisan advocacy and political
arm of PPFA, publicizes issues and organizes people to support “women’s full
equality in health care access.” This includes the right to abortion, and opponents
of abortion have long criticized PPFA for offering this service. In the 1980s and
1990s, Planned Parenthood affiliates were subject to murders of staff, clinic bomb-
ings, arson attacks, and anthrax scares. Abortion rights continue to be a signifi-
cant part of PPFA’s advocacy agenda. Lawmakers regularly propose laws to
restrict access to abortion, and Planned Parenthood and other organizations work
to ensure that women are able to get an abortion when they need one. In addition,
PPFA works “for commonsense policies that foster the sexual and reproductive
health and rights of individuals, families, and communities” (Planned Parenthood,
2014).
Michael J. McGee
See also: Abortion Legislation; Contraception; Family Planning Clinics; Planned Parent-
hood v. Casey; Roe v. Wade; Sanger, Margaret; Sexual Health; Sexual Rights.
Further Reading
Chesler, E. (1992). Woman of valor: Margaret Sanger and the birth control movement in
America. New York: Simon & Schuster.
Planned Parenthood v. Casey 509
Kochhar, R., Fry, R., & Taylor, P. (2011, July 26). Wealth gaps rise to record highs between
Whites, Blacks, Hispanics. Pew Social Trends. Retrieved from http://www.pew
socialtrends.org/2011/07/26/wealth-gaps-rise-to-record-highs-between-whites
-blacks-hispanics/
Planned Parenthood Federation of America. (2014). 2013–2014 Annual Report. New York:
Author.
Planned Parenthood Federation of America. (2019). Planned Parenthood. Retrieved from
http://www.plannedparenthood.org/
Sanger, M. (1921, November 18). The morality of birth control. Retrieved from https://
www.nyu.edu/projects/sanger/webedition/app/documents/show.php?sangerDoc
=238254.xml
Planned Parenthood v. Casey
Planned Parenthood v. Casey was a 1992 Supreme Court decision about abortion
rights. An earlier landmark Supreme Court case, Roe v. Wade, had made abortion
legal in the United States in 1973. However, in the 1980s, a group of Pennsylvania
laws were passed that required a woman to notify her spouse before obtaining an
abortion. In addition, her doctor had to provide her with specific information that
might change her mind, and she had to wait at least twenty-four hours before the
procedure could take place. If she was a minor, she needed to get the consent of at
least one of her parents or permission from a judge to have the abortion. Further,
the Pennsylvania law said that a woman could only get an abortion if it was a med-
ical emergency. Finally, the law imposed certain reporting requirements on facil-
ities providing abortion services. Before any of these laws could take effect,
Planned Parenthood of Southeast Pennsylvania, five abortion clinics, and a physi-
cian representing himself and other doctors who provided abortions brought the
case against the state, led by governor Robert Casey. The plaintiffs said these laws
were unconstitutional. The district court agreed that the provisions of the law were
unconstitutional and stopped their enforcement. The court of appeals later
affirmed some of the provisions but struck down the husband notification provi-
sion. In some ways, these laws were a challenge to the findings in Roe v. Wade.
Since the Roe decision, many states have tried to overturn it or to limit women’s
access to abortion by putting restrictions on the procedure.
When the Planned Parenthood v. Casey case came to the Supreme Court, the
court reaffirmed Roe but upheld most of the Pennsylvania provisions. For the first
time, the justices imposed a new standard to determine the validity of laws
restricting abortions. It asked if a state regulation imposes an “undue burden,”
which is defined as a “substantial obstacle in the path of a woman seeking an abor-
tion before the fetus attains viability” (Wharton, Frietsche, & Kolbert, 2006).
Under this standard, the only part of the law to fail the undue burden test was the
husband notification requirement. The court said that the rest of the provisions
were constitutional and were not an “undue burden.”
Casey ruled that states may regulate abortions so as to protect the health of the
mother and the life of the fetus and may outlaw abortions of “viable” fetuses. This
510 PLISSIT Model of Sex Therapy
means that the state could enact laws prohibiting abortions if the fetus was
developed enough to live outside the woman’s body. Casey held that states could
now pass regulations about the first trimester (before the fetus is viable) but only
to protect a woman’s health, not to limit a woman’s access to abortion. The court
also said that, with newer life-preserving medicines and technology, the point at
which a fetus might become “viable” (the point at which states may constitution-
ally outlaw abortions) could now be earlier than six months into the pregnancy.
The court ruled that the mandatory twenty-four-hour waiting period was not an
undue burden and was thus constitutional. They said the provision’s purpose, to
promote well-considered abortions, was legitimate and only slightly limited
access to abortions. They also ruled that the spousal consent provision was an
undue burden because husbands could resort to abuse and obstruction when they
learned of the woman’s abortion plans. The court upheld the remaining portion of
the law, including a parental consent provision for minors.
Casey v. Planned Parenthood, though less famous than Roe v. Wade, is actually
a more important case. Casey not only affirmed Roe’s abortion right but also
broadened the states’ authority to regulate it. The Casey decision crafted a new
undue burden analysis and, for the first time, made it the controlling standard for
evaluating all abortion restrictions. The decision remains as controversial as Roe.
Many legal scholars think the “undue burden” test is more ambiguous and diffi-
cult to apply. The justices’ decision was intended to provide a level of protection
for the abortion right that was consistent with Roe’s main objective of “ensur[ing]
that the woman’s right to choose not become so subordinate to the State’s interest
in promoting fetal life that her choice exists in theory but not in fact” (Nossiff,
2007). As Supreme Court justices change over time, this standard may mean that
future legal challenges to abortion rights may succeed and that access to safe and
legal abortion may be diminished.
Michael J. McGee
See also: Abortion, Elective; Abortion Legislation; Planned Parenthood; Roe v. Wade.
Further Reading
CQ Almanac. (1992). Supreme Court’s decision on Pennsylvania case. In CQ Almanac
1992 (48th ed., 30-E-34-E.). Washington, DC: Congressional Quarterly. Retrieved
from http://library.cqpress.com/cqalmanac/cqal92-845-25185-1106699
Nossiff, R. (2007). Gendered citizenship: Women, equality, and abortion policy. New Pol-
itical Science, 29(1), 61–76.
Wharton, L. J., Frietsche, S., & Kolbert, K. (2006). Preserving the core of Roe: Reflec-
tions on Planned Parenthood v. Casey. Yale JL & Feminism, 18, 317.
PLISSIT Model of Sex Therapy
The PLISSIT model of sex therapy represents points of intervention created to
assist health care providers in providing a sex-positive space for patients while
simultaneously aiding in the shaping of more positive health behaviors. Adults
and adolescents alike frequently possess concerns related to their sexual health
and sexual trajectory and the ways in which physical and mental factors can
PLISSIT Model of Sex Therapy 511
influence their sex lives. Various physical and psychological conditions (such as
diabetes, cancer, neurological disease, depression, anxiety, and grief) can nega-
tively affect sexual health and sexual satisfaction. In addition, factors such as lack
of training to address sexual health issues, biases related to sexual and sexuality-
related concerns, or discomfort around discussing sexuality-related topics with
patients act as barriers to individuals receiving information that will aid in increas-
ing their sexual autonomy and chances of engaging in sexual health–promoting
behaviors.
The first stage of the PLISSIT model is “permissions.” The act of gaining per-
mission from a patient to administer assistance regarding sexual concerns is a
crucial step used to reinforce the basic autonomy a patient should feel in making
their sexual decisions. Seeking permission from a patient is used as a way to avoid
offending the patient at any point of assessment. Furthermore, granting the patient
permission works to normalize the patient’s sexual fantasies, desires, behaviors,
and boundaries while screening for engagement in any behaviors that may be
harmful to self or others. Ways clinicians can foster permission in the treatment
setting are to engage in routine questioning, generalizing and normalizing
patients’ experiences, and asking open-ended questions to further assess patients’
symptoms.
The second stage of the PLISSIT model is “limited information.” The sharing
of limited information emphasizes the caring professional as a point of informa-
tional resource for the patient. Information that caregivers can provide includes,
but is not limited to, male, female, and nonbinary anatomy and physiology; the
impact of various diseases on sex drive and sexual function; information on gen-
der, gender expression, sexual orientation, and modes of sexual expression; and
avenues of sexual exploration that may be open to patients. While the health pro-
fessional wants to provide a wealth of information, it is important to note that this
information should be centered around the patient’s primary concern(s) so as not
to overburden the patient with information that may not address their needs.
The third stage of the PLISSIT model is “specific suggestions.” If patients
respond positively to the permission and limited information phases of the model,
caregivers may want to provide the patient with specific suggestions on how to
address their concerns. These suggestions may involve reading printed materials
related to the concern, engaging in a behavior that exposes the patient to the con-
cern, or working with the patient to consider medicinal options that may address
the concern. Specific suggestions are not rules for the patient to follow but are
instead tools the patient may or may not choose to use.
The final stage of the PLISSIT model is “intensive therapy.” The level of inten-
sive therapy in the PLISSIT model usually involves an expert or highly trained
therapist, counselor, social worker, or psychiatrist. This level of the PLISSIT
model is reserved for more complex concerns the patient may be experiencing.
Some of the interventions that could be involved in this step could potentially
include trauma-informed therapies, aggressive medication management, or other
therapeutic treatment that may intervene in more crisis-related health concerns.
Many investigations of the PLISSIT model highlight it as a tool to assist
patients in navigating their sexualities when they have experienced some sort of
512 Polyamory
physical or mental health trauma. This model has been used to assist health care
providers in administering competent care when patients have encountered sex-
ual difficulties related to interactions with cancers, diabetes, emotional trauma,
grief, and other health issues. The PLISSIT model can also be used with adoles-
cents to assist in clarifying their concerns around sexual identities and sexual
decision making.
Shadeen Francis and Patrick R. Grant
See also: Disabilities, Sexual Function and; Psychosexual Therapy; Sexual Dysfunction,
Treatment of; Sexual Health.
Further Reading
McInnes, R. (2003). Chronic illness and sexuality. The Medical Journal of Australia,
179(5), 263–266.
Nusbaum, M. R. H., & Hamilton, C. D. (2002). The proactive sexual health history. Amer-
ican Family Physician, 66(9), 1705.
Polyamory
“Polyamory,” also known as “poly,” comes from the Greek and Latin languages
and means “many loves.” Polyamory is a relationship style that reflects shared
intimacy, emotion, friendship, or sexual connectedness between two or more
people. Though the dynamic most often seen is couples having other relationships
outside of the duo, within polyamory, the person does not have to be partnered
with another person but can give and receive love, care, intimacy, and emotional
support as a single person with multiple people. Other examples of relationship
styles within polyamory include polyfidelity (“in which two people, possibly two
or more couples, form a sexually exclusive group”) and open marriages (Easton &
Hardy, 2009, p. 275). Polyamory gives people an alternative relationship configu-
ration to monogamy, where two people are committed to each other in their rela-
tionship (hence polyamory sometimes being called nonmonogamy). People who
choose to be involved in a polyamorous relationship vary in sex, gender, gender
expression, and sexual orientation.
Though there is no one significant incident that sparked polyamory as it is seen
and negotiated today, there have been many reasons for this idea to grow: whether
through the attempts to personalize expressions of love for more than one person,
dismantle larger systems of patriarchy and capitalism, or to rearrange these same
systems to benefit the needs of women. Though making sexual and emotional
connections with people outside of primary relationships has been happening
since relationships existed, the organized and structured idea of nonmonogamy
began to take shape in the 1960s in the United States. From the mentality of the
1950s, where sex outside of monogamous relationships was cheating but more
acceptable for men who were “sowing wild oats” as opposed to women being
“loose,” the blossoming idea in the 1960s of open marriages, polyamory, and free
love became an alternative. Sexual and social revolutions (including feminism and
anarchy), particularly in the United States and Europe (where much of the research
and information has been focused), were movements that not only changed
Polyamory 513
attitudes toward social justice, equality, and the self but also expanded the search
for authenticity, claiming autonomy, and resisting authority.
“Swinging” was one of the first organized forms of nonmonogamy for people
who identified as heterosexual and bisexual. Swinging, the practice of couples
exchanging partners, usually for sexual pleasure, can be seen within the Holly-
wood scene in the 1930s and 1940s. Researchers also note swinging among Air
Force pilots and their wives during World War II at military installments. Their
research shows that swinging was used as a way for wives to be supported by the
surviving pilots due to the fatality rate during the war. This practice of nonmo-
nogamy still exists today among couples trying to explore different sexual orien-
tations as well as kink and BDSM (bondage/domination, sadism/masochism)
practices with others.
Due to there being at least two or more people involved within this relationship
dynamic, it is important to have a foundation of, or skills to build a foundation of,
communication, honesty, trust, and boundaries. Good communication prevents
assumptions around the needs of each person in the relationship. Exploration
around what the individual person or multiple people want may include discus-
sions of how many people are going to be involved in the relationship(s), how time
will be managed and valued among those involved, what intimacy looks like with
each person, and so on. From these conversations, boundaries may be generated to
protect and respect the wants, desires, needs, and sensitivities of the individuals
and to prevent unwanted hurt or emotional pain as best as possible. This is to say
that communication and boundaries do not always avoid emotional pain, as words,
gestures, and nuances can be misunderstood, but these qualities are a start in
building a solid foundation in polyamorous relationships for all to be heard.
Two concepts that are a part of conversations in polyamory but constantly mis-
conceived are jealousy and compersion. Jealousy is an emotion usually brought up
by “expression of insecurity, fear of rejection, fear of abandonment, feeling left
out, feeling not good enough, feeling inadequate, [and/or] feeling awful” (Easton
& Hardy, 2009). Even though jealousy is usually an emotion people try to avoid
feeling, it is a feeling that may come up for some people if they are involved with
another person or multiple people. For example, if Billy is in a polyamorous rela-
tionship with Steve and Jamie, Jamie may get jealous of the time Steve is spending
with Billy, vice versa, or it can be experienced by all. Again, with communication,
honesty, trust, and boundaries, partners can further discuss where those feelings
are coming from to help alleviate or redirect the emotion. Compersion, on the
other hand, is the positive expression a person feels toward their partner about
their partner’s romantic or intimate interest in another. Steve, for example, may be
excited that Jamie and Billy are going to the movies together since Steve is not
interested in participating in that activity.
A concern that comes with being physically intimate with multiple partners is
the fear of spreading sexually transmitted infections (STIs) among partners. There
are several ways this can be resolved, mostly using the foundation of communica-
tion. Some, or all, of the partners within the relationship may choose to use bar-
riers such as condoms, dental dams, or rubber gloves. Partners may also use some
form of birth control to prevent unintended pregnancies.
514 Polyamory
Some, or all, partners who are sexually active may also practice a method called
“fluid bonding” or “fluid monogamy,” where the partners will engage in sexual
activity without barriers. Before this method of intimacy is practiced, all individ-
uals are tested for STIs and HIV so the health status of all participants is known.
Continued conversations among the partners involved help them to decide what
boundaries are placed around sexual activities for the safety of all.
Though polyamory is usually seen as a way for two or more people to coordi-
nate their love and commitment to one another, polyamory can also be seen as a
way to build and support families while distributing resources such as money,
energy, and time among the group, even without sex being involved. For example,
in the Nandi communities in Kenya (and also South Africa), the females took on
“female husbands” (defined as women who are “promoted” to the status of “man”
through their marriages to other women). This had not only the benefits of negat-
ing gender roles but also the wife of a female husband “is free to engage in sexual
liaisons with men of her own choosing”; as such, she has the advantage of sexual
freedom (Murray & Roscoe, 1998). Though these relationships are still within the
structure of marriage, they also show the freedom negotiated in relationships in
order to meet sexual and economic needs to sustain the community. The practice
has now grown throughout communities as a way to sustain partnerships, raise
children, and create individual freedoms of loving for people of all genders and
sexual orientations.
Currently, nonmonogamy in all forms is expanding and being given more visi-
bility, even within the media, to challenge the traditional idea of monogamy. Lit-
erature by authors such as Tristan Taormino (Opening Up—A Guide to Creating
and Sustaining Open Relationships, 2008), Wendy-O Matik (Redefining Our
Relationships, 2002), and the well-known resource The Ethical Slut by Dossie
Easton and Janet Hardy (1997), give people who identify as nonmonogamous a
guide related to their lifestyle. These books contain a wide variety of information
to help answer questions and ease anxiety around topics such as how to deal with
jealousy, STIs and safer sex, coming out to family members and friends, family
planning, and speaking to one’s children about nonmonogamy and family
structure.
The internet is also a source for general information about nonmonogamy and
is often used to find “meet-ups,” such as LovingMore.com and Polyamory.org.
Spokespeople such as Anita Wagner Illig for practicalpolyamory.com, and
organizations such as the Woodhull Freedom Foundation, have committed their
mission to educating and supporting people within various types of nonmonog-
amous relationships and advocating for their rights (Woodhull Freedom Foun-
dation, 2019). These resources, as well as TV shows such as Polyamory: Married
and Dating, help the experienced and curious person alike to offset the negative
views and stigma attached to relationships outside of the traditional two-person
dynamic.
Shane’a Thomas
See also: Communication, Sexual; Monogamy; Open Marriage; Polygamy; Sexual Revo-
lution; Swinging.
Polyandry 515
Further Reading
Easton, D., & Hardy, J. W. (2009). The ethical slut: A practical guide to polyamory, open
relationships & other adventures (2nd ed.). New York: Celestial Arts.
Munson, M., & Stelboum, J. P. (1999). Introduction: The lesbian polyamory reader: Open
relationships, non-monogamy, and casual sex. In M. Munson & J. P. Stelboum
(Eds.), The lesbian polyamory reader: Open relationships, non-monogamy, and
casual sex (1–7). New York: Harrington Park Press.
Murray, S. O., & Roscoe, W. (1998). Boy-wives and female husbands: Studies in African
homosexualities. New York: St. Martin’s Press.
Taormino, T. (2008). Opening up: A guide to creating and sustaining open relationships.
San Francisco: Cleis Press.
Woodhull Freedom Foundation. (2019). Home page. Retrieved from https://www.woodhull
foundation.org
Polyandry
“Polyandry” is a broad term used to refer to the cultural practice in which one
woman is simultaneously married to two or more men. Polyandry is a relatively
rare custom in contemporary societies but is thought to have been somewhat more
common in the past. At any rate, polyandry has been found around the world,
most often in egalitarian societies.
Polyandry is a variety of polygamy, where an individual may have more than
one spouse at a time. Polygamy is often confused with polygyny, where it is cus-
tomary for a man to have more than one wife at a time. Polyandry is sometimes
practiced alongside polygyny in a society, which forges a system referred to as
polygynandry. These cultural practices can result in less partitioning of family
land holdings and other assets, restricted population growth, and expanded oppor-
tunities with respect to domestic economic activities.
Polyandry is generally understood to have an economic basis rather than a
status or sexual basis. It is most often associated with extreme conditions, such as
severe poverty, which might frequently be correlated with the practice of female
infanticide. That sort of situation produces a surplus supply of males for whom
mates can be rather difficult to find. A similar result can be produced in polyan-
drous societies that do not commit adequate resources to caring for female chil-
dren, apparently in response to poor probabilities of their being able to marry.
Endemic warfare, such as that reported among the Yanomama Shirishana of Bra-
zil, can also create an unbalanced sex ratio, which might lead to the practice of
intermittent polyandry. Male absenteeism, such as that associated with prolonged
military service or priestly duties, is another factor commonly associated with the
cultural practice of polyandry. In a polyandrous marriage, the woman does not
acquire extra husbands for sexual satisfaction, nor does she gain any additional
status for the number of husbands she has. The woman usually has little to no say
over whether or not to take on additional husbands in a polyandrous marriage.
Fraternal polyandry is the most common variant of polyandry that has been
documented ethnographically and historically. For instance, the Nyinba of north-
western Nepal, who are culturally similar to many Tibetan ethnic groups, practice
516 Polycystic Ovary Syndrome (PCOS)
fraternal polyandry, as do many of their Tibetan neighbors. In these cultures, most
men who have brothers marry polyandrously, and all the brothers tend to remain
in these marriages for the rest of their lives to maintain coresidence patterns asso-
ciated with their system of property inheritance and succession to positions of
household authority. A sociobiological explanation for fraternal polyandry that
has been suggested is that since brothers demonstrably have more genetic material
in common with each other than with others they are not related to, raising the
children of one’s brother is a way to ensure that your gene pool is more likely to
survive. Fraternal polyandry is frequently associated with the belief in partible
paternity, which holds that a child can possibly have more than one biological
father. At any rate, brothers who can keep all their family resources together by
being in a polyandrous marriage are clearly able to maintain greater collective
wealth than those who divide resources and establish separate family units.
An alternative variant of polyandry involves a woman who has two or more
husbands who are not related. This type of polyandry has been reported, for
example, among the Nayar of Kerala, India. The Nayars are a caste among whom
a man’s property is inherited by the children of his sisters, not by his own biologi-
cal children. Under this polyandrous system, only the women know who are their
biological children. It is thought that polyandry among the Nayar arose in response
to men being employed in the military; this could have created a shortage of labor-
ers to work on family farms, with polyandry developing as a cultural adaptation.
Other castes in Kerala who practiced this form of polyandry include the Kamma-
lans and the Thiyyas.
Victor B. Stolberg
See also: Marriage; Marriage, Cross-Cultural Comparison of; Polygamy; Polygyny.
Further Reading
Beall, C. M., & Goldstein, M. L. (1981). Tibetan fraternal polyandry: A test of sociobio-
logical theory. American Anthropologist, 83, 5–12.
Levine, N. E. (1988). The dynamics of polyandry: Kinship, domesticity, and population on
the Tibetan border. Chicago: University of Chicago Press.
Peters, J. F., & Hunt, C. H. (1975). Polyandry among the Yanomama Shirishana. Journal
of Comparative Family Studies, 6, 197–207.
Raha, M. K., & Coomar, P. C. (1987). Polyandry in India. Delhi: Gian Publishing House.
Polycystic Ovary Syndrome (PCOS)
Polycystic ovary syndrome (PCOS) is a condition in which multiple fluid-filled
follicles, called cysts, develop within the ovaries, resulting from an imbalance in
hormones. People with PCOS generally have higher levels of androgen hormones
(otherwise known as male hormones) such as testosterone. Every person with
PCOS is affected differently and demonstrates an array of different symptoms.
Those diagnosed with PCOS are often prescribed oral birth control pills to aid
with the symptoms.
The causes of PCOS are unknown. There is a debate as to whether PCOS may
be a product of environmental factors, such as hormone-containing preservatives
Polycystic Ovary Syndrome (PCOS) 517
within foods, or genetic factors, such as the hereditary passage from mother to
daughter. Other factors that seem to be related to the development of PCOS are
obesity and insulin resistance. Insulin is secreted by the pancreas and is used to
help absorb glucose (sugar) into cells from the blood stream. When a person has
insulin resistance, the level of glucose increases in the bloodstream. High insulin
production may also affect the endocrine system by promoting the production of
androgens that lead to hormone imbalance and thus relate to PCOS.
There are a variety of symptoms associated with PCOS. One of the most com-
mon symptoms is irregularities in the menstrual cycle. People with PCOS may
have fewer than nine menstruations within a year, absent menstruations, or heavy
bleeding. Other symptoms of PCOS include adult acne, excessive body hair
growth (hirsutism), and weight gain that often leads to obesity. In addition, PCOS
is related to high blood pressure, sleep apnea, depression, uterine bleeding, endo-
metrial cancer, and infertility. PCOS may contribute to the development of type II
diabetes or heart disease. It is important to know that people with PCOS are
affected differently and may each demonstrate a different combination of
symptoms.
There is no single test for PCOS. Doctors often diagnose PCOS through a list of
criteria that includes hyperandrogenism, ovulatory dysfunction, and polycystic
ovaries. Patients must exhibit two out of the three criteria to be diagnosed. Tests
that will aid in diagnosis include physical exams, pelvic exams, various blood
tests, and ultrasounds. The quickest way to identify PCOS is through an ultra-
sound, which will show the cysts within the ovaries on the screen of the machine.
However, it is important that doctors first rule out hyperthyroidism and hypothy-
roidism, both of which can cause similar symptoms and conditions to PCOS. Doc-
tors use the physical and pelvic exams to look for symptoms such as excessive hair
growth and adult acne. Doctors may also inquire as to the patient’s medical hist
ory as well as the medical history of the patient’s mother and grandmother due to
the potential hereditary aspects of the syndrome.
There is no treatment for PCOS that will rid the ovaries of their follicles and
correct the hormone imbalance. However, there are treatments to aid with the
symptoms of PCOS. The most common treatment prescribed by doctors is birth
control. Oral birth control pills with estrogen and progestin aid with regulating
menstrual cycles and help to lower the androgen. Lower androgen levels help
eliminate acne and excessive hair growth. Other forms of birth control, such as the
vaginal ring, can also be used.
Metformin may be prescribed to help lower insulin levels and to aid in regu-
lation of the menstrual cycle and weight loss. People who want to become
pregnant but are experiencing issues related to PCOS may be prescribed clomi-
phene, follicle-stimulating hormone and luteinizing hormone, spironolactone, or
steroids.
There are no techniques to prevent PCOS. However, for people with a family
history of PCOS, living a healthy lifestyle that encompasses a low-carbohydrate
diet and daily moderate to vigorous activity levels may help with related
symptoms.
Camilla Loggins
518 Polygamy
See also: Androgens; Birth Control Pills, Estrogen-Progestin; Estrogen; Infertility; Men-
struation; Ovaries; Testosterone.
Further Reading
American College of Obstetricians and Gynecologists. (2017). Polycystic ovary syndrome
(PCOS). Retrieved from http://www.acog.org/-/media/For-Patients/faq121.pdf?dm
c=1&ts=20150930T0048253696
Mayo Clinic. (2019). Polycystic ovary syndrome (PCOS). Retrieved from http://www
.mayoclinic.org/diseases-conditions/pcos/basics/definition/con-20028841
Sheehan, M. T. (2004). Polycystic ovarian syndrome: Diagnosis and management. Clini-
cal Medicine & Research, 2, 13–27.
Polygamy
Polygamy is the cultural practice of having more than one spouse at a time. Essen-
tially polygamy is the form of marriage that permits an individual to have more
than one husband or wife at the same time. There are two basic forms of polygamy:
polygyny, in which a man can have more than one wife, and polyandry, in which a
woman can have more than one husband at a time. Polygyny is far more common
than polyandry, but collectively polygamy is more prevalent than monogamy.
Monogamy, the practice of having one spouse at a time, is the predominant pat-
tern in modern Western societies, but across cultures and over time, polygamy is
the most widely preferred marriage form.
The term “polygamy” comes from two Greek words: “polloi” meaning “many”
and “gamos” meaning “marriage.” Thus, the literal meaning of polygamy is mar-
riage to several mates at once.
Certain religions permit the practice of polygamy, generally polygyny. Accord-
ing to the Quran and sanctioned under Sharia law, Islam allows a man to take as
many as four wives. Hinduism has no limit on the number of wives a man can
have. Buddhism does not prohibit polygamy. Ancient Judaism, as described in the
Old Testament, allowed kings, princes, and other male members of the upper
classes to have multiple wives (Deuteronomy 21:15; Judges 8:30; II Samuel 3:2–5;
I Kings 11:1–3). Up until it was banned in 1890, the Church of Jesus Christ of
Latter-Day Saints, or the Mormons, openly practiced polygyny, which they erro-
neously referred to as polygamy, resulting in confusion to this day; splinter Mor-
mon sects and other Christian fundamentalist groups still practice polygynous
marriages, although the U.S. Congress passed a law prohibiting polygyny in 1862.
The custom of taking multiple wives was practiced in pre-Communist China
and continues today in many countries, primarily in Africa, the Middle East, and
Asia. For example, Thailand legally accepted polygyny up until 2010, and it is still
legal in neighboring Myanmar (Burma). In fact, polygyny was practiced in many
places up until modern times, including Ireland, Japan, Oceania, and Turkey.
Polygamy remains legal in over 150 countries around the world. Polyandry, the
custom of a single wife with two or more husbands at a time, was practiced by
peoples like the Inuit, many Native Americans, the Todas of India, and some
groups in Nepal and Tibet.
Polygyny 519
There is generally an economic rationale behind polygamy. Multiple spouses
can clearly expand the resources available. For example, when the Blackfoot of
North America switched from beaver to buffalo fur trading, cowives made more
sense as buffalo skin tanning was a labor-intensive task exclusive to women, and
more wives dramatically increased a man’s financial potential. Similarly, Sinuai
women in the Solomon Islands take on the primary responsibilities for raising
pigs, a major signifier of wealth; thus, more wives help generate more wealth.
There can be strong political and economic factors supporting polygamy, includ-
ing the establishment of alliances and supporting descent ties between groups.
Other factors are also involved; in some societies, if there was a shortage of men,
such as resulting from warfare, then polygyny might be more likely, such as is the
case among the Yanomamo of southern Venezuela and northern Brazil; con-
versely, if there was a shortage of women, such as associated with female infanti-
cide, then polyandry might be a cultural response.
Victor B. Stolberg
See also: Marriage; Marriage, Cross-Cultural Comparison of; Monogamy; Polyamory;
Polyandry; Polygyny.
Further Reading
Chagnon, N. A. (1977). Yanomano: The fierce people. New York: Holt, Rinehart and
Winston.
Conaty, G. T. (1995). Economic models and Blackfoot ideology. American Ethnologist,
22(2), 403–409.
Gordon, S. B. (2003). The Mormon question: Polygamy and constitutional conflict in
nineteenth-century America. Journal of the Supreme Court History, 28(1), 14–29.
Hayase, Y., & Liaw, K.-L. (1997). Factors on polygamy in sub-Saharan Africa: Findings
based on the demographic and health surveys. The Developing Economies, 35(3),
293–327.
Rehman, J. (2007). The Sharia, Islamic family laws and international human rights law:
Examining the theory and practice of polygamy and talaq. International Journal
of Law, Policy and the Family, 21(1), 108–127.
Polygyny
Polygyny is a marital pattern in which a man has more than one wife at a time.
Polygyny and polyandry are different forms of polygamy. Polygyny is practiced
by the majority of societies around the world, particularly in non-Western
countries.
Polygyny was a dominant practice across many ancient societies. In this regard,
polygyny featured prominently among peoples discussed in the Old Testament.
The patriarchs, such as Abraham (Genesis 16:1–16) and Jacob (Genesis 29:20–29)
were polygynous; Abraham had three wives, and Jacob had four. In ancient Israel,
kings and other male members of the upper social classes in particular were per-
mitted more than one wife (Deuteronomy 21:15; Judges 8:30). The most famous
kings of ancient Israel, David (I Samuel 25:39–44; I Samuel 27:3; II Samuel 3:2–5)
and Solomon (I Kings 11:12), were polygynous in the extreme. The harem of
520 Polygyny
Solomon surpassed that of even his father (I Kings 11:1–8); Solomon is said to
have had seven hundred wives and three hundred concubines (I Kings 11:3).
Rehoboam, Solomon’s son, continued the family tradition, as he had eighteen
wives and sixty concubines, who collectively bore him twenty-eight sons and
sixty daughters (II Chronicles 11:21). Polygyny was practiced by kings of other
ancient Near Eastern kingdoms as well, including the Sumerians, Babylonians,
Assyrians, Hittites, and Egyptians. Many reasons were given to explain polygyny
in ancient times, including love, procreation, trade alliances, and political
diplomacy.
It is estimated that about 70 percent of the world’s cultures permit polygyny.
This, of course, does not mean that 70 percent of the world’s population practice
polygyny. In fact, even in societies that allow polygyny, most men only have one
wife at a time. There are many reasons polygyny is not the most common form of
marriage, even where it is permitted. Only a small proportion of men in societies
that say they prefer polygyny actually are able to practice it due, in no small meas-
ure, to the economic burden of acquiring and maintaining more than one wife. In
addition, in societies that permit polygyny, there is inequality in the ability of a
man to sexually reproduce.
Polygyny is more common in societies with marked age stratification, as older
males with more status and wealth acquire wives as a way to demonstrate this. On
the other hand, polygyny is also more common in societies where women exert
more control over resources and thus are less dependent on male parental
investments.
Polygynous marriages often require financial support and approval from a large
group of kin. Substantial bridewealth, the compensation expected by the family of
the bride from the groom and his family, is often necessary to acquire a bride. In
many pastoral societies, for example, several head of livestock are commonly
expected for the “purchase” of a bride. Most potential grooms must draw on the
resources of extended kin groups to accumulate sufficient bridewealth. Kin in
polygynous societies are less likely to contribute to paying bridewealth for addi-
tional wives. Unless a man is very successful financially and has considerable
status, it may be considered culturally inappropriate for him to seek an additional
wife. In some polygynous societies, a man must be able to provide and maintain
separate households for each wife, which can present considerable financial
demands. It has also been found that in some societies where women are seen as
an economic liability, where men do the majority of the work, that polygyny is
less common. For instance, among the Sinuai of the Solomon Islands, women do
much of the work of raising pigs, a highly valued resource, and also contribute to
labor in the gardens; consequently polygynous households tend to have more pigs
and thus greater economic resources, granting more status to polygynous
husbands.
Another factor contributing to the difficulties of polygynous marriages is the
interpersonal dynamics of balancing the demands of multiple wives. Considerable
administrative skills may be needed to manage two or more wives and their
children and households. If the relationships between cowives are not congenial,
this can add to the stressors upon a polygynous husband. There may need to be
Pornography 521
complex calculations made as to things like which wife a man sleeps with, whom
to eat food from, and whose children to allocate resources to.
There are other social pressures restricting polygyny, even where it is possible.
For example, a study of retired Zulu migrant workers in South Africa found that
although polygyny is considered to be the culturally preferred practice, the major-
ity of Zulu men are monogamous. White South Africans and largely white Chris-
tian churches promote socially dominant values in opposition to polygyny, to
which many Zulu decide to conform.
In addition to the disadvantages of polygyny, there are also several advantages
cited. As mentioned, a polygynous husband typically acquires higher status and
more social prestige by having more wives. Having multiple wives is often a signi-
fier of wealth and power. A wife’s status also often increases as her husband
acquires more wives. Contrary to what might be assumed, polygyny can naturally
contribute to population control. For example, among the Shipibo of the Amazon
in Peru, polygyny allows women to have longer intervals between birthing chil-
dren when paired with postpartum sexual abstinence; this practice also lowers
infant mortality as mothers can breastfeed longer with the net result of suppressed
birthrates. Some cultures practice sororal polygyny where a man marries sisters
or other closely related females, which may help lessen jealousy between cowives
and also maintains closer kinship relationships for offspring. In some cultures, the
senior wife wields relative authority over junior wives, which can aid in maintain-
ing smoother dynamics as she can often help mediate conflicts and disputes
between cowives. Many ethnographic studies report on the degree of cooperation
and harmony between cowives who can assist each other in the performance of
labor-intensive activities.
Victor B. Stolberg
See also: Marriage; Marriage, Cross-Cultural Comparison of; Monogamy; Polyamory;
Polyandry; Polygamy.
Further Reading
Hern, W. M. (1992). Family planning, Amazon style. Natural History, 101(12), 30–37.
Moller, V., & Welch, G. J. (1990). Polygamy, economic security, and well-being of retired
Zulu migrant workers. Journal of Cross-Cultural Gerontology, 5(3), 205–216.
Oliver, D. (1955). A Solomon Island society. Cambridge, MA: Harvard University Press.
Tonkinson, R. (1978). The Mardudjara aborigines: Living the dream in Australia’s desert.
New York: Holt, Rinehart and Winston.
Pornography
The earliest use of the word “pornography” in the United States was in 1843 in
a book that described pictures of naked women in ancient Rome. Today, por-
nography is defined as the depiction of sexual material that is intended to be
sexually arousing. The word “pornography” is often used to describe sexual
content in a negative way. Erotica, on the other hand, is a more positively
evaluated form of sexual content and comes from a Greek word meaning “love
poem.”
522 Pornography
Sometimes people equate pornography and erotica with obscenity. “Obscenity”
is a legal term, and while there is subjectivity in its application, it describes
material that, applying contemporary community standards, appeals to the pruri-
ent interest; depicts or describes, in a patently offensive way, sexual conduct spe-
cifically defined by the applicable state law; and lacks serious literary, artistic,
political, or scientific value. Sexually explicit material that meets those conditions
is illegal. Many pornographic materials that were once deemed in court to be
obscene were later appealed and found to be acceptable under the First Amend-
ment, freedom of speech.
The first pornographic book printed on a printing press, I Modi, was published
in Rome in 1527 and included sixteen sonnets about various sexual positions that
were accompanied by engraved illustrations. The first pornographic novel, Mem-
oirs of a Woman of Pleasure, or Fanny Hill, was written in England in 1758 and is
one of the most banned books in history. When it was published in the United
States in the 1960s, it was banned, but when the case was appealed to the Supreme
Court, it was found that it did not meet the standard of obscenity.
Pornography in the United States became a big business in the 1840s. Prior to
then, erotic books and pictures were imported from France and England. Begin-
ning in 1846, a New York publisher, William Haines, who had previously imported
sexual materials began to produce them. By the time he died in 1872, he had pub-
lished 320 pornographic books. Haines was the most successful publisher of por-
nography of the time, but he was hardly alone. Thousands of books, magazines,
pamphlets, and photographs of explicit sexual content were produced in New York
City throughout the nineteenth century and distributed nationally through the
mail.
The proliferation of these materials and their delivery through the mail
prompted the first federal obscenity law, the Comstock Act of 1873. The law made
it illegal to send through the mail erotica, contraceptives, abortifacients, sex toys,
or any information about these items. The Comstock Act was named for Anthony
Comstock, an antivice reformer from New York whose job became to monitor the
mail and confiscate and destroy obscene materials. He was very effective in his
work, and due to his efforts, the flourishing pornography trade in New York City
declined, only to be taken up in Philadelphia, St. Louis, Chicago, and San
Francisco.
Shortly after the motion picture was developed, French producers made short
films of women taking off their clothes. With profits to be made, producers in
many countries began to make pornographic films. Men who could afford the
projector bought the “stag films” discreetly and showed them at private parties.
Eventually, pornographic movies would be distributed to adult theaters, and then,
in the 1970s, made available on videotape, which consumers could view in the pri-
vacy of their homes.
Nowadays, sexually explicit material is available in magazines on newsstands,
in bookstores, on television and DVDs, and, most pervasively, on the internet. It is
estimated that, in the United States, pornography revenues equal $13 billion annu-
ally. A book series known for its erotic storyline, 50 Shades of Grey, has sold over
Pornography 523
125 million copies, and a follow-up book sold another million copies within days
of its release.
With so much consumption of pornography, many people are concerned about
its effects. Among mental health professionals, there is debate about whether or
not pornography use is harmful to healthy sexual development and intimate rela-
tionships. Many professionals view its use as problematic because some people
use it compulsively, others experience relationship difficulties when one partner
feels left out or inadequate because of their partner’s porn use, or an individual
feels a lack of satisfactory sexual performance when comparing real life with the
fantasies portrayed in pornography.
There has been a long-standing argument that exposure to pornography
increases violence against women. However, Milton Diamond’s analysis of data
from around the world shows that as pornography becomes more available, sex
crimes either decrease or remain constant. Sexually explicit material has wide
acceptance and use and is tolerated for adults. Among the studies on attitudes
about pornography, the only constant finding is that adults want to prevent its
exposure to children. One researcher suggests that sexually explicit material func-
tions in a variety of ways, such as increasing the consumer’s knowledge, illustrat-
ing a range of intimate behaviors, helping to develop a sexual identity, and offering
a context for expressing gender and sexuality.
As with all representations of sexuality in the media, explicit content expresses
a set of values and a point of view. In most pornography, the people portrayed are
highly sexual and available for sexual behavior at any time. The focus is typically
on pleasure (most often the male’s) rather than on the relationship between the
characters. The bodies of the people in the story, picture, or video are most often
idealized, and models with attractive attributes are used as the talent. In the case
of professionally produced films, lighting, music, camera angles, and editing are
skillfully combined to create the most arousing effects. Critics of pornographic
films point out that the fantasy aspect of the content leads viewers, especially
younger viewers, to expect that this is how shared sexual behavior is or should be.
Research also suggests that unhappy adults who use sexually explicit media are
most likely to be negatively influenced by it. Because so much pornography pres-
ents an extremely casual view of sex, consumers without a steady partner may
view sexual behavior without being in a relationship as desirable. The risk for
these people is that they are more likely to engage in casual sex with people not
known to them, and there is an increased potential for sexual aggression, contract-
ing sexually transmitted infections, and being part of an unintended pregnancy.
The casual view of sex in pornography is also a factor in young people’s expec-
tations of what they might anticipate as they begin dating. Among early adoles-
cents, exposure to sexually explicit media is an important factor in sexual
socialization and leads to more permissive, earlier sexual behavior. Among teen
boys who consume pornography, three-quarters report committing some form of
sexual harassment. A strategy that parents and youth serving professionals can
take to diminish the impact of exposure to porn is to provide comprehensive sexu-
ality education in conjunction with media literacy education. Adults can help
524 Pornography
young people to view all media with a critical eye and to understand that it is cre-
ated in particular ways for profit and influence.
Research suggests that as consumers of sexually explicit material get used to a
particular type of porn, they seek novelty by viewing more intense or unusual
behaviors that can lead to “porn addiction.” The next step in the process suggests
that users get habituated to the new, more intense content and wind up back where
they started, seeking yet another, more intense behavior. At this point, they begin
acting out sexually, as they no longer get satisfaction from viewing porn. Whether
or not this theory is accurate is a matter of debate.
Much of the concern about porn is that it will cause someone to behave in
unhealthy, addictive, or relationship-damaging ways. In a review of the research,
analysts found that more porn use is related to higher levels of libido or sexual
arousal. Individuals who report being more aroused by porn also use it more and
report higher levels of sexual desire. Thus, a higher need or desire for sensation
predicts more frequent use of porn in both adolescents and adults. It is valuable for
all users of sexually explicit material to consider their motivation to use it and to
work to understand its role in their life. Developing a healthy relationship to fan-
tasy and pornography is an indicator of sexual maturity.
The first peer-reviewed journal about the study of pornography, Porn Studies,
began publication in 2014.
Michael J. McGee
See also: Advertising, Sex in; Arousal; Commission on Obscenity and Pornography;
Media and Sexuality; Miller v. California; Pornography Addiction; Sex Education.
Further Reading
Attwood, F. (2005). What do people do with porn? Qualitative research into the consump-
tion, use and experience of pornography and other sexually explicit media. Sexu-
ality and Culture, 9(2), 65–86.
Attwood, F., & Smith, C. (2014). Porn studies: An introduction. Porn Studies, 1(1–2), 1–6.
Brown, J. D., & L’Engle, K. L. (2009). X-rated: Sexual attitudes and behaviors associated
with U.S. early adolescents’ exposure to sexually explicit media. Communication
Research, 36(1), 129–151.
Dennis, D. (2009). Licentious Gotham: Erotic publishing and its prosecution in
nineteenth-century New York. Cambridge, MA: Harvard University Press.
Diamond, M. (2009). Pornography, public acceptance and sex related crime: A review.
International Journal of Law and Psychiatry, 32(5), 304–314.
D’Orlando, F. (2011). The demand for pornography. Journal of Happiness Studies, 12(1),
51–75.
Hardingham-Gill, T. (2015, June 23). The new Fifty Shades of Grey novel has already
smashed UK book sales records. Retrieved from http://metro.co.uk/2015/06/23/
the-new-fifty-shades-of-grey-novel-has-already-smashed-uk-book-sales-records
-5261225/
Ley, D., Prause, N., & Finn, P. (2014). The emperor has no clothes: A review of the “por-
nography addiction” model. Current Sexual Health Reports, 6(2), 94–105.
Library of Congress. (1873). American memory from the Library of Congress. Statutes at
Large: U.S. Congressional Documents. Retrieved from http://memory.loc.gov/
ammem/amlaw/lwsl.html
Pornography Addiction 525
Maltz, W., & Maltz, L. (2008). The porn trap: The essential guide to overcoming prob-
lems caused by pornography. London: HarperCollins.
Slade, J. W. (2006). Eroticism and technological regression: The stag film. History &
Technology, 22(1), 27–52.
Smith, W., & Anthon, C. (Eds.). (1843). A dictionary of Greek and Roman antiquities.
New York: American Book Company.
Wright, P. J. (2015). A longitudinal analysis of US adults’ pornography exposure. Journal
of Media Psychology, 24(2), 67–76.
Wright, P. J., Tokunaga, R. S., & Bae, S. (2014). More than a dalliance? Pornography con-
sumption and extramarital sex attitudes among married US adults. Psychology of
Popular Media Culture, 3(2), 97.
Pornography Addiction
Pornography involves the depiction of sexual behaviors in ways intended to cause
sexual arousal or satisfaction. Common forms of pornography include pictures,
videos, and written accounts of sexual features or behaviors. At present, pornog-
raphy is primarily accessed by users in North America through the internet,
though print magazines and sexually explicit films remain available. Problematic
pornography use is sometimes referred to as “pornography addiction” or “pornog-
raphy compulsion,” though the use of these terms varies among professionals.
Problematic pornography use may cause relational, occupational, legal, financial,
spiritual, and mental health distress.
The American Society of Addiction Medicine defines addiction as “a primary,
chronic disease of brain reward, motivation, memory and related circuitry. Dys-
function in these circuits leads to characteristic biological, psychological, social
and spiritual manifestations. This is reflected in an individual pathologically pur-
suing reward or relief by substance use and other behaviors.” According to this
model, an individual with pornography addiction will find it very difficult or
impossible to avoid pornography use, will crave the activity, and will often have
difficulty acknowledging the damage done to personal relationships (such as those
with a romantic or sexual partner, children, extended family, or friends) or other
areas of functioning. Addiction models employ a medical model and view the
behavior as chronic, involving cycles of relapse and remission. Addiction is often
seen as progressive, worsening over time if the individual does not participate in
recovery and treatment activities.
While an addiction model may be an appropriate one to apply to some individ-
uals’ use of pornography, the bulk of the research on pornography use indicates
that most users of pornography do not experience clinically significant distress
and impairment in biological, psychological, or social domains of functioning as a
result of pornography use. There is also some disagreement among mental health
professionals about whether problematic pornography use is better understood in
terms of an addiction model or a compulsion model. In a compulsion model, an
individual repeatedly engages in behaviors that they feel driven to perform in
response to another stressor, such as anxious thoughts. Some clinicians prefer to
use a compulsion model to describe problematic pornography use because it better
526 Pornography Addiction
fits the symptoms reported by their clients. Finally, an individual may experience
problems related to pornography use that do not fit either an addiction or compul-
sion model, such as relationship strain due to pornography use, even if the use is
infrequent or time-limited.
Research suggests that there is no single cause for problematic pornography
use. It is often more helpful to look at several biological, psychological, social,
and spiritual contributors to this and other problematic behaviors. Some sex
researchers have focused on the important role of an individual’s arousal tem-
plate in pornography use. The template is the individual’s pattern of sexual
arousal in response to internal stimuli (such as thoughts and images) and external
stimuli (the sights, sounds, smells, tastes, and touches that the individual finds
arousing). It is likely the product of biological predispositions and both classical
and operant conditioning during adolescence and early adulthood. Early expos-
ure to pornography may significantly shape an individual’s arousal template in
terms of what they find arousing later in life; also, an individual may specifically
seek out pornography to find the features of a sexual scenario that they find
arousing, particularly if it is difficult to find those features in a face-to-face rela-
tionship or encounter.
Assessment of pornography use can be difficult for many reasons. Individuals
are often reluctant to disclose the frequency and duration of pornography use as
well as the specific content of what is used. Individuals often underreport pornog-
raphy use due to embarrassment, concerns about judgment from the assessor, or a
lack of awareness of the scope of the pornography use. Further, the individual may
see it as a more or less problematic behavior than the assessor. For example, men
often report that pornography use is less problematic compared to women’s
descriptions of the same behaviors. Some individuals see any pornography use as
inherently problematic, while a sex therapist or educator may view the
individual’s behavior as normal. The DSM-5 does not include a diagnosis for a
pornography-related disorder among its descriptions of substance-related and
addictive disorders, though some individuals may display symptoms consistent
with an unspecified paraphilic disorder.
Several brief assessments of pornography problems are available, such as the
Internet Sex Screening Test. A consultation with a mental health professional that
specializes in sexual concerns is recommended before determining if an individ-
ual has a pornography problem. Treatment often focuses on anxiety management,
depression treatment, conflict resolution, and identifying face-to-face means of
meeting sexual needs and interests. Treatment may be offered in inpatient hospital
settings, outpatient counseling, twelve-step groups, and online programs.
Elizabeth A. Maynard
See also: Compulsivity, Sexual; Online Sexual Activity; Out-of-Control Sexual Behavior;
Pornography.
Further Reading
American Psychiatric Association. (2011). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Association.
American Society of Addiction Medicine. (2019). Retrieved from www.asam.org
Preejaculate Fluid 527
Cooper, A. (Ed.). (2013). Cybersex: The dark side of the force (special issue). Journal of
Sexual Addiction and Compulsivity, 19(1–2), 1–160.
Grant, J. E., Potenza, M. N., Weinstein, A., & Gorelick, D. A. (2010). Introduction to
behavioral addictions. The American Journal of Drug and Alcohol Abuse, 36(5),
233–241.
Twohig, M. P., & Crosby, J. M. (2010). Acceptance and Commitment Therapy as a treat-
ment for problematic Internet pornography viewing. Behavior Therapy, 41(3),
285–295.
Preejaculate Fluid
Preejaculate fluid (preseminal fluid, precum) is a fluid created mainly by the bul-
bourethral glands (Cowper’s glands). The Cowper’s glands are two small glands
along the urethra. This fluid is necessary to reduce the acidity of the urethra and
provides lubrication for the ejaculate. Discharged from the urethra during fore-
play, masturbation, and sexual arousal, most men are unable to control the release
of preejaculate fluid and do not feel it happening. This fluid is known as preejacu-
late because it occurs before orgasm and ejaculation.
For sperm to survive, it must be in a neutral or alkaline environment. Preejacu-
latory fluid neutralizes the urethra, which can be an acidic environment due to the
presence of urine, increasing the viability of sperm. Like the urethra, the vagina is
also an acidic environment and is hostile toward sperm. Preejaculatory fluid may
neutralize the vagina, increasing sperm’s survival and motility. Along with neu-
tralizing the urethra and vagina, preejaculatory fluid may be a lubricant for the
glans (head of the penis) and aid in penetration.
Preejaculate fluid is clear, colorless, and chemically different from semen. The
amount of fluid an individual produces varies widely, with some individuals not
producing any. Some individuals are uncomfortable or embarrassed by the amount
of preejaculate they produce. This overproduction of preejaculate is rare and might
be treatable with an alpha-5-reductase inhibitor. Preejaculate, like semen, can
contain sexually transmitted infections (STIs), including HIV, that can be trans-
mitted to uninfected people if barrier methods, such as condoms or dental dams,
are not used.
A widely debated topic regarding preejaculate is whether or not this fluid con-
tains sperm. The quick answer is it is unlikely that preejaculatory fluid contains
viable sperm; however, it is possible, so precautions should be taken. Research
into whether preejaculatory fluid contains sperm has produced mixed results with
some studies showing that no viable sperm are present in preejaculate and other
studies showing many viable sperm in preejaculate samples. If there is semen
present in the urethra from a prior ejaculation, it is possible for sperm to enter the
preejaculatory fluid and be released from the urethra before climax and ejacula-
tion. Some sexuality and health educators advise people to urinate after ejacula-
tion to remove semen from the urethra, reducing the possibility of the preejaculate
fluid containing sperm.
Some individuals use the knowledge that it is unlikely that preejaculate fluid
contains sperm as reason to use the withdrawal method (coitus interruptus,
528 Pregnancy
pull-out method) as a form of pregnancy prevention. In the event that preejacula-
tory fluid does not contain sperm, the withdrawal method may still not be the most
reliable birth control option because not everyone can determine when they will
ejaculate, and therefore they may not pull out in time. This method also leaves
people susceptible to STI and HIV infection as these diseases can be transmitted
via preejaculatory fluid. It is advised that individuals use barrier methods to pro-
tect themselves against disease transmission and to reduce the risk of pregnancy.
Damiene Denner
See also: Bulbourethral Glands; Ejaculation; Semen; Sexually Transmitted Infections
(STIs); Withdrawal Method.
Further Reading
American Pregnancy Association. (n.d.). Can you get pregnant with pre-cum? Retrieved
from http://americanpregnancy.org/getting-pregnant/can-you-get-pregnant-with
-precum/
Herbenick, D. (2005). Q&A: Can you get pregnant from pre-cum? Kinsey Confidential.
Retrieved from http://kinseyconfidential.org/can-you-get-pregnant-from-pre-cum/
Killick, S. R., Leary, C., Trussell, J., & Guthrie, K. A. (2011). Sperm content of pre-
ejaculatory fluid. Human Fertility, 14(1), 48–52.
Pregnancy
The thought of having a baby might excite some people, scare some people, or do
both for some people. Some people may decide not to continue a pregnancy, and
sometimes a pregnancy ends in an unexpected miscarriage. If the pregnancy con-
tinues for a full forty weeks, though sometimes sooner, a baby is born through a
process called birth. Birth happens via vaginal delivery or through cesarean sec-
tion. Not everyone who is pregnant becomes the parent of a baby after they give
birth to the baby, as some people may place the baby for adoption or may be acting
as surrogates for other people. However, most people who give birth to a baby
become the parent of that child.
Only people with uteruses can become pregnant. An egg from an ovary and a
sperm from a testicle need to combine to begin a pregnancy. The egg is fertilized
by the sperm, and this creates something called a zygote. A zygote has all the
genetic information about the person the sperm came from and the person the
egg came from in addition to the blueprints for continuing to grow. This zygote
then grows enough to be called a blastocyst. When the blastocyst attaches to the
uterus, it can then be called an embryo. The embryo is called a fetus when it
grows for a few more weeks. This fetus then continues to grow for about another
six months before it is born. Full gestation is considered forty weeks or roughly
nine months.
People often become pregnant while in a relationship with another person. The
most common way a pregnancy occurs is through penis-in-vagina sex, though this
is not the only method. Some people become pregnant through other methods of
bringing sperm and eggs together, often called assisted reproductive technology,
so that the zygote can implant into a uterus and grow.
Pregnancy 529
People often learn that they are pregnant from a pregnancy test. Many people
take a home pregnancy test where they place urine on a device that tests for some-
thing called human chorionic gonadotropin (hCG). A pregnant person’s body
starts to produce hCG about two to three weeks after conception (or about four
weeks since the beginning of the last menstrual period). When taking a pregnancy
test, it can be useful to take the test first thing after waking up in the morning
because hCG concentrations will be highest after not urinating for a while. If a
test comes back positive, meaning the person is pregnant, that is almost always the
case as there are very few false positives. However, false negatives are more com-
mon, so if a home pregnancy test is negative, the person can try again in a week to
be sure. Some people also do urine tests at doctors’ offices instead of on their own
at home. Blood tests by a doctor are not more accurate and cannot be done any
earlier than a home pregnancy test using urine. If an at-home test is positive, the
person should schedule an appointment with a doctor. If they expect to continue
the pregnancy, all alcohol, substance, tobacco, and hormonal birth control use
should be stopped.
It is not always easy for someone to become pregnant, and sometimes repeat-
edly trying to conceive changes the way someone feels about their body and sexu-
ality. When people are trying to conceive, doctors often prescribe medications to
increase the chances of an egg and a sperm combining and for a blastocyst to
attach to the uterus. These medications often cause other changes to the way a
person’s body feels and whether they are in the mood to sexually connect with a
partner. Trying to conceive might also include one or more miscarriages for the
people trying to become parents. Almost always, a miscarriage is completely
unavoidable and is not anyone’s fault. Sometimes people do not tell others they are
pregnant for the first twelve weeks, or the first trimester, as the first trimester has
the highest chances of a miscarriage occurring. Trying to conceive is a great time
for couples to talk about what they most enjoy during sex and ways to continue
having sex that is fun for everyone involved.
There are many changes that occur to the pregnant person’s body as the fetus
grows. Some of these changes affect the way a person experiences and expresses
their sexuality. For example, breasts feel fuller, clothing no longer fits the same
way, some people get upset stomachs almost daily, most pregnant people are very
tired, and the pregnant person usually notices they can feel movement from the
fetus inside their uterus. Many people talk about feeling uncomfortable being sex-
ual while a fetus is developing inside their uterus. Sometimes people are afraid
penetrative sex might be dangerous to the fetus or painful. Vaginal sex will not
contact the fetus. Very early on in a pregnancy, a barrier develops to block off the
uterus from the vagina. In general, sex should not cause undesired pain, so if a
pregnant person notices pain, they should contact their doctor.
During the first trimester, or the first twelve weeks of the pregnancy, many
changes occur. Often, people will be unaware that they are pregnant until after
they miss a period and take a pregnancy test, which usually happens around weeks
four or five. Some people will have no pregnancy symptoms at all. Others
may experience early pregnancy symptoms, which may include sore breasts, nau-
sea or morning sickness, mood swings, tiredness, headaches, food cravings, a
530 Pregnancy
heightened sense of smell, vaginal discharge, a need to urinate more frequently,
cramping, changes to hair and skin, and feeling boated. During this stage, the
zygote grows from being just a few cells to being a fetus about two inches long. In
addition, the fetus’s nervous system and brain develop, the heart forms and starts
to beat, other internal organs form, and facial features and limbs start to develop.
During the second trimester, weeks thirteen to twenty-seven, the pregnant per-
son forms a small bump in their midsection that continues to grow for the duration
of the pregnancy. Breasts also start to enlarge, and the placenta forms around
week fourteen. Usually the symptoms of pregnancy are less severe in the second
trimester. In addition to the symptoms noted above, some people may also experi-
ence trouble with their gums; aches and pains, especially around the belly; nose-
bleeds; gastric complaints; trouble sleeping; and bladder or vaginal infections,
among others. The fetus is continuing to grow and develop during this phase and
will grow from about 2.5 inches long to about 14.4 inches long. It also becomes
possible for the pregnant person to feel the fetus moving inside them.
During the third and final trimester, the fetus continues to grow, and the preg-
nant person’s body readies itself for birth. Commonly, people in the third trimes-
ter of pregnancy may experience heartburn and indigestion, aches and pains, and
tiredness. Other symptoms mentioned above may still be present. Toward the end
of the trimester, people may begin to feel Braxton-Hicks contractions, or a tight-
ening of the muscles of the uterus. The fetus continues to grow and gain weight
until birth. It continues to be active and can respond to sound and light. At week
thirty-seven, the fetus is considered to be full term, meaning it’s likely big enough
and developed enough to survive in the outside world without medical interven-
tion should it be born. Most births occur during weeks thirty-nine to forty-one.
Typically babies are about twenty inches long when they are born and often
weigh around seven to eight pounds, although some can be much lighter or much
heavier.
Being a parent also affects how individuals might be able to sexually connect
with each other. It is often very difficult to find time and energy to have sex when
caring for an infant who wakes up every two hours and needs regular feeding and
diaper changes. Most parents work full-time jobs and worry about how to finan-
cially afford this new addition to their family. Some new parents also suffer from
postpartum depression, which causes feelings of deep sadness and hopelessness.
Doctors and therapists can help people with postpartum depression. Very little
alone time, not enough sleep, and lots of stress do not help people have sex. It is
very important for new parents to set aside time to go on regular dates once the
baby is old enough to be cared for by someone other than a parent.
Rosara Torrisi
See also: Assisted Reproductive Technology; Fertility; Infertility.
Further Reading
Boggs, B. (2016). The art of waiting: On fertility, medicine, and motherhood. Minneapo-
lis: Graywolf Press.
Cavallucci, D., & Fulbright, Y. K. (2008). Your orgasmic pregnancy: Little sex secrets
every hot mama should know. Alameda, CA: Hunter House Publishers.
Premarital Sex 531
Kerner, I., & Raykeil, H. (2009). Love in the time of colic: The new parents’ guide to get-
ting it on again. New York: William Morrow Paperbacks.
National Health Service. (2020). Week-by-week guide to pregnancy. Retrieved from
www.nhs.uk/start4life/pregnancy/week-by-week/
Tsiaras, A. (2010). Conception to birth. Presented at INK Conference TED Talk. Retrieved
from https://www.ted.com/talks/alexander_tsiaras_conception_to_birth_visualized
?language=en
Premarital Sex
Premarital sex is sex that takes place before marriage. Survey results from the
early 2010s indicate that around 90 percent of ever-married Americans under the
age of forty-five years had sex before they married. Nearly half of American high
school students admit to having engaged in sexual intercourse. Discussions of
youthful premarital sex, in particular, often focus on topics such as immorality
and emotional immaturity. There are negative consequences to society in terms
of unwanted pregnancies and the spread of sexually transmitted infections
(STIs).
Premarital sex most often takes place after puberty when hormonal changes
greatly escalate the sex drive, the desire for sexual activity. The age at which
puberty occurs varies by individual but is typically before or during the early teen
years. Menarche is the onset of menstrual periods. Scientists have found that the
average age at which girls experience menarche declined from around sixteen
years old during the early 1900s to less than thirteen years old in the early 2000s.
Research suggests that boys are also beginning puberty at earlier ages than in dec-
ades past. The reasons for this trend are not yet clear.
The U.S. Census Bureau collects detailed data about the marital status of Amer-
icans. One statistic of particular interest is the age at first marriage. Between 1970
and 2009, the median age at first marriage for women increased from twenty-one
to twenty-seven years; the median age for men increased from twenty-three to
twenty-eight years. In 1970, nearly half (42%) of women marrying for the first
time were teenagers; by 2009, that number had dropped to only 7 percent. Overall,
the data indicate that Americans are marrying for the first time at older ages than
in the past.
The combination of younger puberty ages and older ages at first marriage trans-
lates to a longer time period during which premarital sex can occur. This wide
window of opportunity is a modern phenomenon. In ancient times, girls first mar-
ried around or even before the onset of puberty. This greatly reduced the chances
of premarital sex taking place. There are still societies in the twenty-first century
in which child brides or young teen brides are common, primarily parts of Africa
and Asia.
The U.S. Centers for Disease Control and Prevention (CDC) conducts surveys
in which it asks Americans about their marital status and sexual history. During
surveys conducted from 2011 to 2013, the CDC found that 89 percent of ever-
married women aged fifteen to forty-four years and 92 percent of ever-married
532 Premarital Sex
men aged twenty to forty-four years said they had engaged in premarital sexual
intercourse.
Every two years, the CDC conducts a national Youth Risk Behavior Survey
(YRBS) in which it surveys students in ninth through twelfth grades in U.S. pub-
lic and private schools. Results indicate that in 2017, 39.5 percent of the students
said they had engaged in sexual intercourse. This percentage is down from 54
percent in 1991.
The YRBS data specifies premarital sex rates by race and ethnicity. In 2017,
black or African American teens had the highest rate of premarital sex at 45.8
percent. They were followed by Hispanic or Latino teens (41.1%) and white teens
(38.6%). According to the YRBS, a small fraction (3.4%) of all the ninth to twelfth
graders asked in 2017 said they had sexual intercourse for the first time before
they were thirteen years old. This compares with 10 percent in 1991. Another sub-
ject addressed in the YRBS is number of sexual partners. Some 9.7 percent of the
ninth to twelfth graders surveyed in 2017 said they had engaged in sexual inter-
course with at least four people. This percentage is down from 19 percent in 1991.
Having multiple sexual partners is considered risky because it raises the chances
of unwanted pregnancies and STIs.
Attitudes about premarital sex are often driven by religious beliefs or cultural
sensibilities. Sex outside of marriage (and hence premarital sex) is deemed
immoral in religions such as Christianity, Islam, and Judaism. In some cultures,
premarital sex is considered inappropriate not because of religious restrictions but
because it violates long-standing cultural traditions regarding marriage. In addi-
tion, there is widespread belief that youths lack the maturity needed to make
rational decisions about engaging in sex and the possible consequences of doing
so. Physical intimacy often adds psychological complexity to a relationship. This
may be difficult for teenagers to process emotionally; for example, they may con-
fuse sexual passion with love.
Premarital sex can result in pregnancy. According to the CDC, unmarried teen-
age girls accounted for nearly 195,000 U.S. births during 2017. This equated to a
rate of around 18.8 births per 1,000 unmarried girls in this age range. However,
the teen birth rate has declined dramatically since the early 1990s. YRBS survey
data indicate that more than half (53.8%) of the sexually active ninth to twelfth
graders surveyed in 2017 said they used a condom during their most recent sexual
intercourse, and 20.7 percent said they used birth control pills. However, 13.8 per-
cent of the sexually active teens reported using no method of birth control.
The spread of STIs is a major public health problem. People who have sex with
multiple partners have the greatest risk of contracting these diseases. Preteens and
teens who engage in premarital sex are high-risk groups because they begin hav-
ing sex at such a young age. This increases the likelihood that they will have mul-
tiple partners during their sex lives. According to the CDC, during the early 2010s,
there were 10 million new STIs among persons aged fifteen to twenty-four years
in the United States. These youths accounted for 50 percent of all new infections,
even though they comprised just over a quarter of the sexually active population.
Kim Masters Evans
Premature Ejaculation 533
See also: Casual Sex; Dating, Cross-Cultural Comparison of; Hookup Culture; Marriage;
Religion, Diversity of Human Sexuality and; Teen Pregnancy.
Further Reading
Copen, C. E., Daniels, K., Vespa, J., & Mosher, W. D. (2012). First marriages in the United
States: Data from the 2006–2010 National Survey of Family Growth. National
Health Statistics Reports, 49, 1–21.
Kann, L., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., Queen, B., ... Ethier,
K. A. (2018). Youth risk behavior surveillance—United States, 2017. MMWR Sur-
veillance Summaries, 67(8), 1–114.
Martin, J. A., Hamilton, B. E., Osterman, M. J., Curtin, S. C., & Matthews, T. J. (2015).
Births: Final data for 2013. National Vital Statistics Reports, 64(1), 1–65.
U.S. Centers for Disease Control and Prevention. (2016). Trends in the prevalence of sex-
ual behaviors and HIV testing: National YRBS: 1991–2013. Retrieved from http://
www.cdc.gov/healthyyouth/data/yrbs/pdf/trends/us_sexual_trend_yrbs.pdf
U.S. Centers for Disease Control and Prevention. (2017). Key statistics from the National
Survey of Family Growth: Premarital sex. Retrieved from http://www.cdc.gov/
nchs/nsfg/key_statistics/p.htm#premarital
U.S. Centers for Disease Control and Prevention. (2017). Sexually transmitted diseases:
Adolescents and young adults. Retrieved from http://www.cdc.gov/std/life-stages
-populations/adolescents-youngadults.htm
U.S. Centers for Disease Control and Prevention. (2019). Reproductive health: Teen preg-
nancy. Retrieved from https://www.cdc.gov/teenpregnancy/index.htm
U.S. Centers for Disease Control and Prevention. (2019). Teen births. Retrieved from
http://www.cdc.gov/nchs/fastats/teen-births.htm
Premature Ejaculation
Premature ejaculation (PE, also known as rapid ejaculation, premature climax, or
early ejaculation) occurs when someone uncontrollably ejaculates before or
immediately upon sexual penetration, often with minimal sexual stimulation.
While this primarily affects males, some females also experience PE. PE is fairly
common and is more likely to occur in younger males. It is estimated that PE
affects most men at some point in their life.
Diagnostic criteria for PE include ejaculation within one minute of penetration,
the inability to delay ejaculation all or nearly all the time, and the feeling of dis-
tress and frustration that may lead to the avoidance of sexual intimacy. PE can be
primary or secondary. Primary PE is lifelong, beginning with the individual’s first
sexual encounter, and occurs nearly all the time. Secondary PE is acquired and
develops after the individual has had sexual experiences without ejaculatory
issues. Symptoms of PE do not always meet diagnostic criteria and may be cat-
egorized as natural variable PE instead. Natural variable PE occurs when an indi-
vidual has periods of premature ejaculation and normal ejaculation.
Premature ejaculation often has no clear cause. Certain situations, such as a
new partner or a long time since last ejaculation, may increase the potential for
PE. For some individuals, PE may only occur in specific sexual situations.
534 Premature Ejaculation
Early sexual experiences are thought to establish sexual patterns that often per-
sist into adult life and can be difficult to change. When individuals are hurried to
reach climax or associate feelings of guilt that lead to a tendency to rush to orgasm
and end sexual activities, PE can result. Relationship problems may also contrib-
ute to PE. Anxiety, especially anxiety regarding sexuality or sexual performance,
can affect ejaculation. If an individual is anxious about prematurely ejaculating,
this anxiety can increase the chances of future PE. Anxiety regarding erectile
dysfunction (having or maintaining an erection) may create a pattern of rushed
ejaculation because the individual tries to climax before losing their erection.
Rushing to ejaculation is not always something the individual knows they are
doing, making it difficult to identify.
PE can have biological causes, including abnormal hormone and neurotrans-
mitter levels. The ejaculatory system is a reflex, and this reflex can become dam-
aged, causing PE. Inflammation and infection of the prostate or urethra and nerve
damage may also affect ejaculation.
Embarrassment concerning PE is common and can impede individuals from
seeking medical and therapeutic assistance. Sexual experience and age can help
individuals learn how to delay ejaculation and, in many instances, PE will resolve
itself over time. Some individuals may be relieved to know that PE is common and
treatable.
Gaining more control over an individual’s orgasm can decrease the instances of
PE. Masturbating to climax an hour or two before partnered sexual activities may
allow an individual to better control their orgasm during sex. Reducing or elimin
ating the use of alcohol, tobacco, and recreational drugs may also improve an
individual’s control. Communicating with a partner to slow or stop stimulation
when ejaculation is approaching, using different positions during sexual activ-
ities, and using condoms and medications that reduce sensation may allow an indi-
vidual to better control ejaculation. Certain creams, gels, and sprays (topical
anesthetics) that are applied before sexual activities to reduce sensation can be
used to delay ejaculation, although these should be discussed with a medical pro-
fessional before use. Some of these medications may also transfer to the individu-
al’s partner(s) during sexual activity and reduce the partner’s sensation. Methods
that reduce sensation may also reduce sexual pleasure.
Use of the pause-squeeze technique may be an effective therapy to delay ejacu-
lation. To do this technique, sexual activity should begin as usual up until the
point where the individual is about to ejaculate. At this point the penis should be
compressed between the shaft and head for several seconds until the urge to ejacu-
late subsides. After the squeeze is released, the individuals should wait roughly
thirty seconds before continuing sexual activity. Repeat the squeeze technique
again when the individual feels like they are about to ejaculate. This technique can
be repeated as many times as necessary until the individual is able to enter their
partner without ejaculating.
Reducing anxiety associated with ejaculation is another possible treatment,
especially because these thought patterns can lead to more episodes of PE. Think-
ing of nonsexual matters and using relaxation techniques may delay ejaculation.
Focusing on other types of sexual activity, apart from penetrative sex, may reduce
Premenstrual Dysphoric Disorder (PMDD) 535
pressure and anxiety associated with sexual activity. Counseling and behavioral
therapy may also be useful in reducing anxiety that is related to PE.
Damiene Denner
See also: Ejaculation; Performance Anxiety; Retrograde Ejaculation; Sexual Disorders,
Male; Start-Stop Technique.
Further Reading
Harvard Health Publishing. (2017). Premature ejaculation. Retrieved from https://www
.health.harvard.edu/a-to-z/premature-ejaculation-a-to-z
Mayo Clinic. (2018). Premature ejaculation. Retrieved from https://www.mayoclinic.org/
diseases-conditions/premature-ejaculation/symptoms-causes/syc-20354900
NHS. (2019). Ejaculation problems. Retrieved from https://www.nhs.uk/conditions/
ejaculation-problems/
Premenstrual Dysphoric Disorder (PMDD)
Premenstrual dysphoric disorder (PMDD) is a depressive disorder characterized
by a severe form of premenstrual syndrome (PMS) in which mood swings, depres-
sion, irritability, or anxiety significantly impair everyday functioning. Both PMS
and PMDD have physical and emotional symptoms. However, PMDD causes
extreme mood shifts that can disrupt the individual’s work and relationships. In
both PMS and PMDD, symptoms typically begin seven to ten days before the
menstrual period starts and continue for the first few days of the period. Both
PMS and PMDD can cause fatigue, bloating, breast tenderness, and changes in
sleep and eating patterns. However, in PMDD, at least one of the following emo-
tional or behavioral symptoms stands out: extreme moodiness, marked irritability
or anger, overwhelming sadness or hopelessness, and extreme anxiety or tension.
According to the fifth edition of the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-V), women can be diagnosed with PMDD if they exhibit a
pattern of symptoms during the final week before the onset of their menstrual
cycle. The symptoms should start to improve within a few days after the onset of
the menstrual cycle and be minimal or absent in the following week. These symp-
toms include marked mood swings, irritability, anger, and increased interpersonal
conflicts. They also include depressed mood, feelings of hopelessness, anxiety,
feelings of being “on edge,” and decreased interest in usual activities. Other symp-
toms may include difficulty concentrating, a lack of energy, a change in appetite
or sleep pattern, breast tenderness, food cravings, weight gain, and a sense of
being overwhelmed. These symptoms must be significantly distressing and impair
the individual’s ability to function in important areas of life. Finally, this condition
cannot have been caused by substance use, medical conditions, or other mental
disorders.
Just as with PMS, the cause of PMDD is not well understood. As with other
mental disorders, several factors appear to be involved. First among these are hor-
mones. Hormonal changes during the menstrual cycle can trigger some of the
symptoms of this disorder. In addition, changes in levels of serotonin, a neuro-
transmitter thought to regulate mood, can trigger these symptoms. For instance,
536 Premenstrual Syndrome (PMS)
low levels of serotonin can cause premenstrual depression, fatigue, and sleep
problems. Other factors include stress, which can increase symptom intensity, and
poor nutrition. Eating highly salty foods can cause fluid retention, while consum-
ing alcohol and caffeine can cause moodiness and fatigue. Low levels of vitamins
and minerals and a previous history of depression may also increase the likeli-
hood of having PMDD.
Medications, counseling, or psychotherapy have a place in treating PMDD.
Commonly prescribed medications include selective serotonin reuptake inhibi-
tors, which can help with the symptoms of depression, fatigue, sleep problems,
and food cravings. Over-the-counter pain medications can ease cramping and
breast tenderness. Diuretics can reduce swelling and bloating. Oral contraceptives
can stabilize hormonal swings, and hormone injections or contraceptive inject-
ables can temporarily stop menstruation and the accompanying pain. Psychother-
apy can also help those with this disorder to develop more effective coping
strategies. The use of stress management and mindfulness practices can increase
relaxation, acceptance, and living in the present.
Len Sperry
See also: Diagnostic and Statistical Manual of Mental Disorders (DSM); Menstruation;
Premenstrual Syndrome (PMS); Sex Hormones.
Further Reading
Huston, J. E., & Fujitsubo, L. C. (2002). PMDD: A guide to coping with premenstrual
dysphoric disorder. Oakland, CA: New Harbinger Publications.
Sperry, L. (Ed.). (2015). Mental health and mental disorders: An encyclopedia from
androgyny to zolpidem. Santa Barbara, CA: Greenwood.
Premenstrual Syndrome (PMS)
Premenstrual syndrome, often referred to as PMS, is a combination of psycho-
logical and physiological symptoms that occur in relation to a person’s menstrual
cycle. PMS symptoms can begin up to two weeks prior to the menstrual cycle.
Once the person’s period starts, the symptoms typically end within four days or
less. These premenstrual symptoms can be so severe that they interfere with how
the person is able to interact with their daily activities. There is a wide range of
experiences with PMS. Some individuals barely notice symptoms, while others
suffer debilitating symptoms. PMS is most common among individuals between
twenty and forty years old. Premenstrual syndrome has a wide range of psycho-
logical and physical symptoms, and each person’s experience is different. PMS is
typically diagnosed when an individual has psychological and physical symptoms
five days before their period for three consecutive menstrual cycles.
Physiological symptoms of PMS include, but are not limited to, fatigue, bloat-
ing and/or weight gain, skin issues (i.e., acne), abdominal pain (i.e., cramping),
breast tenderness, headaches and migraines, general aches and pains throughout
the body, constipation or diarrhea, and vomiting.
PMS can also affect one’s cognitive processes and emotional state. Often these
psychological shifts are negative and cause distress. These symptoms of psycho-
logical distress could be incorrectly attributed to other external stimuli outside of
Priapism 537
PMS. Psychological symptoms of PMS include, but are not limited to, hostility or
irritability, exhaustion, food cravings, depression, mood swings, change in libido,
anxiety, insomnia, and social withdrawal.
Currently, there is no research that has proven the cause of PMS; however, it is
thought to be due to changes in hormone levels that occur throughout menstrua-
tion and ovulation. Stress may be an additional contributor to the intensity of the
symptoms of PMS.
If an individual experiences PMS, it is best for them to consult with their health
care provider to find a treatment that works best for their body. Hormone and
symptom levels are different for each individual; therefore, there is no one-
size-fits-all solution. That said, there are some home remedies that can reduce the
symptoms from PMS. Medication used to treat symptoms of PMS include hor-
monal contraceptives, nonsteroidal anti-inflammatory drugs (e.g., ibuprofen),
antidepressants, and diuretics (i.e., water pills). There are also lifestyle adjust-
ments that may help alleviate the uncomfortable symptoms presented with PMS,
including eating a well-balanced diet; decreasing sugar, salt, and caffeine con-
sumption; getting seven to eight hours of sleep every night; and participating in
regular exercise, as exercise helps to release endorphins, which can help psycho-
logical symptoms such as depression and anxiety. Individuals may also benefit
from activities that help to reduce stress, such as meditation, yoga, massage ther-
apy, and other forms of relaxation therapy.
Overall, living a well-balanced and healthy lifestyle can help treat many
unwanted physical and psychological symptoms caused by PMS. If changes in
lifestyle do not help with painful and distressing PMS symptoms, then further
medication and medical advice from a health care provider may be required.
Nicole Williams
See also: Menstruation; Premenstrual Dysphoric Disorder (PMDD); Sex Hormones.
Further Reading
American College of Obstetricians and Gynecologists. (2015). Premenstrual syndrome
(PMS). Retrieved from https://www.acog.org/Patients/FAQs/Premenstrual
-Syndrome-PMS
Freeborn, D., Revino, H., & Burd, I. (2019). Premenstrual syndrome (PMS). Retrieved
from https://www.urmc.rochester.edu/encyclopedia/content.aspx?contenttypeid
=85&contentid=p00581
Mayo Clinic. (2018). Premenstrual syndrome (PMS). Retrieved from https://www.mayoclinic
.org/diseases-conditions/premenstrual-syndrome/symptoms-causes/syc-20376780
National Institutes of Health. (2019). Premenstrual syndrome. Retrieved from https://
medlineplus.gov/premenstrualsyndrome.html
Office on Women’s Health. (2018). Premenstrual syndrome (PMS). Retrieved from https://
www.womenshealth.gov/menstrual-cycle/premenstrual-syndrome
Priapism
A priapism is a persistent, painful, and unwanted erection of the penis. Priapism
causes erections that are not the result of sexual desire or arousal. Typically, the
engorged portions of the penis become tender and painful during a priapism, and
538 Priapism
the symptoms can last a few hours, days, or weeks. Priapism is rare and most
often occurs in children between five and ten years old and adults between twenty
and fifty years of age. Clitoral priapism can occur in females when the clitoris
becomes engorged with blood for prolonged periods of time, resulting in a tender,
painful, and unwanted erection of the clitoris.
There are two kinds of priapism: ischemic (low flow) and nonischemic (high
flow). Ischemic priapism is characterized by blood not being able to leave the
penis and is the most common kind of priapism. Nonischemic priapism occurs
when there is too much blood flowing into the penis. This kind of priapism is often
less painful than ischemic priapism. Prognosis for priapism is often good; how-
ever, the longer medical attention is delayed, the greater the risk for permanent
injury.
There are several causes of priapism, including nervous system disorders,
mechanical disorders, alcohol and other drug use, prescription medication, blood
disorders, and injury. Nervous disorders that can lead to priapism include disor-
ders of the spinal nerves or peripheral nerves that lead to the reproductive tract.
Syphilitic involvement of the nervous system can also cause priapism in children
and adults. Mechanical causes of priapism include obstructions in the penis, such
as blood clots or tumors, and occasionally prolonged and rough sexual activity in
the case of chronic priapism. Causes of priapism in children may include local
irritation, prolonged masturbation, and a full bladder. Congenital syphilis, leuke-
mia, sickle cell anemia, and infections of the reproductive tract can also lead to
priapism in children.
Priapism that lasts longer than four hours requires immediate treatment. If left
untreated, priapism can lead to urine retention in the bladder, kidney disease,
penile disfigurement, and permanent impotence (inability to achieve or maintain
an erection). Priapism that lasts less than four hours does not require immediate
medical assistance but should be brought to the attention of a doctor so future epi-
sodes can be prevented and the cause can be determined.
Ischemic and nonischemic priapism are treated differently. Nonischemic pria-
pism is often treated with a watch-and-wait approach because this kind of pria-
pism can be resolved with no treatment and poses little risk to the penis. In the
event that treatment is needed, surgery to put material in the body that blocks the
flow of blood to the penis may be recommended. The application of pressure and
ice to the perineum and penis to reduce swelling may also be an effective treat-
ment for nonischemic priapism.
There are several ways to treat ischemic priapism. Aspiration, the draining of
blood from the penis via syringe, may relieve pain and stop the erection. Medica-
tion that constricts blood vessels, such as phenylephrine, can be injected into the
spongy tissue of the penis (corpus cavernosum) to increase the flow of blood out of
the penis. Surgery that reroutes blood using a device (shunt) implanted in the penis
may also be helpful in treating priapism. Treatment of sickle cell anemia, leuke-
mia, and damaged arteries and tissue may also be necessary for successful treat-
ment of priapism.
Damiene Denner
Progesterone 539
See also: Erection; Penis.
Further Reading
American Urological Association. (2010). Priapism. Retrieved from https://www.auanet
.org/guidelines/priapism-guideline
Mayo Clinic. (2019). Priapism. Retrieved from https://www.mayoclinic.org/diseases
-conditions/priapism/symptoms-causes/syc-20352005
National Health Service. (2017). Priapism (painful erections). Retrieved from https://
www.nhs.uk/conditions/priapism-painful-erections/
Progesterone
Progesterone is a hormone produced primarily in female bodies by the ovaries
and, during pregnancy, by the placenta. Small amounts of progesterone are also
produced by the adrenal glands and by male testicles. Progesterone is classified as
belonging to a group of steroid hormones called progestogens.
The main role of progesterone is to prepare the uterus for pregnancy. During
the middle of the menstrual cycle, one of the two ovaries releases an egg. Immedi-
ately after this ovulation, the corpus luteum (the structure left in the ovary after
the egg is released) begins secreting large amounts of progesterone into the blood-
stream. These secretions continue for approximately ten to twelve days, causing
the endometrium (the lining of the interior walls of the uterus) to develop a thick-
ened layer of blood vessels, cells, and glands.
Should the released egg be fertilized by a sperm cell, the fertilized egg implants
itself into this thickened uterine lining. As the endometrium is penetrated, tissues
from the embryo become intertwined with tissues from the uterus, forming the
placenta, which carries food and oxygen to, and waste away from, the embryo
(and, later, the fetus). The large amount of progesterone secreted by the placenta
keeps the uterine muscle relaxed during pregnancy, preventing the baby from
being born prematurely. The progesterone from the placenta works with other
hormones to induce development of cells in the breasts that secrete milk and to
strengthen the pelvic wall in preparation for birth. Immediately after birth, pro-
gesterone levels begin to decline.
If the egg is not fertilized and pregnancy does not occur, the extra lining of the
uterus and the corpus luteum are discharged through the vagina in menstrual
bleeding (commonly called a period). Whether or not pregnancy occurs, the
monthly increase in progesterone levels may cause body temperature to increase
and breasts to enlarge and become more sensitive.
Progesterone plays important roles in the nervous system for all people. It helps
to protect nerve cells, including the neurons of the brain, and to regulate the trans-
mission of nerve impulses by interacting with proteins at sites on nerve cells called
receptors. Progesterone aids the normal development of brain neurons, and it may
help to protect the brain against traumatic injury by reducing inflammation.
Additional functions of progesterone are associated with regulation of blood
clotting, cellular oxygen levels, conversion of fat into energy, and insulin secretion
540 Pronoun Usage
by the pancreas. It also plays a role in keeping the bronchial tubes of the lungs
open and clear.
Progesterone, or synthetic versions of it known as progestin, is used as medica-
tion to treat certain conditions involving the female reproductive system, includ-
ing menstrual bloating, irregular menstruation, and premenstrual syndrome
(characterized by a variety of physical and psychological symptoms that may
occur up to two weeks before menstruation). Some people take progestin as part
of hormone replacement therapy (HRT) to manage the symptoms of menopause;
estrogen is usually also part of HRT. Progesterone-based medications are some-
times prescribed as part of treatment for breast, uterine, or kidney cancer, and for
weight loss related to cancer or AIDS. The hormone is typically taken in pill form.
Progestin is also used in birth control pills, either by itself or combined with
estrogen. Progestin-only pills are commonly called the minipill because they con-
tain a lower dose of the hormone than the progestin-and-estrogen combination
pill. The pills work mainly by thickening the mucus of the cervix (the neck of the
uterus) to block sperm from entering and by suppressing ovulation. The
progestin-only pill generally carries less risk of adverse effects, such as stroke and
uterine cancer, than the combination pill, though it is somewhat less effective at
preventing pregnancy. Progestin is the active ingredient in the injectable contra-
ceptive (medroxyprogesterone acetate) and in many intrauterine devices.
Topical cream or gel products containing progesterone are sold for a variety of
purposes, including as treatments for menopausal symptoms, osteoporosis, aller-
gies, headaches, and irritability. However, there is conflicting scientific evidence
regarding the effectiveness of such products.
Because of its role in neuron protection, researchers are investigating the use of
progesterone in treating patients with nervous system disorders, such as multiple
sclerosis.
A. J. Smuskiewicz
See also: Birth Control Pills, Estrogen-Progestin; Birth Control Pills, Progestin-Only;
Contraceptive Implants; Contraceptive Injectables; Contraceptive Patch; Estrogen; Hor-
mone Replacement Therapy; Intrauterine Device (IUD); Ovulation; Pregnancy; Sex
Hormones.
Further Reading
Goldstein, S. R. (2019). Progesterone. Retrieved from http://www.healthywomen.org/
condition/progesterone
ScienceDirect. (2019). Progesterone. Retrieved from https://www.sciencedirect.com/
topics/neuroscience/progesterone
Pronoun Usage
A pronoun is a word used in place of a noun to refer to a specific subject. When
pronouns are used to refer to people, they create linguistic and mental shortcuts
related to the perception of a person’s gender identity, which then informs how
others refer to them. In the English language and using societal conventions, a
Pronoun Usage 541
person’s gender and pronouns are often assumed from a person’s looks and behav-
iors, and these assumptions are often based on a binary understanding of gender
(exclusively male or masculine and female or feminine). For example, one may use
the masculine pronoun “he” for someone assumed to be a male or man, whereas
the feminine pronoun “she” may be used for someone assumed to be a female or
woman. Gendered assumptions and expectations may be imposed onto others
(whether intentionally or not) by assuming a person’s pronouns and using the
assumed pronouns to reference the person. It is important to ask people what their
personal pronouns are instead of using pronouns based on gendered assumptions.
Pronouns are important to some individuals and may be one way a person may
assert their own gender identity.
Of note, labels for gender identity (e.g., transgender, genderqueer, agender) are
growing and changing quickly. “Cisgender” is a term describing individuals
whose gender identity is congruent with their birth-assigned sex. Individuals who
identify as cisgender may feel comfortable with pronouns that are associated with
societal expectations (i.e., a person assigned male at birth feeling comfortable
being referenced with pronouns “he, him, or his”). For individuals who identify
within the transgender and gender-nonconforming community, as well as for
some cisgender individuals (such as cisgender individuals whose gender expres-
sion does not align with societal expectations), using pronouns associated with
their birth-assigned sex may cause discomfort or even distress. When a person is
called by a pronoun with which they do not identify, the person may feel invisible,
frustrated, sad, upset, annoyed, and so on. Also, a person who repeatedly asks
others to use the pronouns they identify with or who frequently educates others
about pronoun usage may experience tiredness and exhaustion.
Similar to gender identity labels, pronouns are changing and frequently being
created, meaning some people may be unfamiliar with the use of these words.
Some individuals are comfortable using binary pronouns to indicate feminine
(e.g., she, her, hers, herself) and masculine (e.g., he, him, his, himself) identities.
In the English language, some individuals use pronouns that neutralize gendered
language (e.g., they, them, their, theirs, themself). For example, instead of saying,
“She went by herself to the store,” one would say, “They went by themself to the
store.” Some individuals who do not identify with binary or they, them, their,
theirs, and themself pronouns may use other gender neutral pronouns like ze, hir,
hirs, hirself or xe, xem, xyr, xyrs, and xemself. Moreover, some individuals may
prefer to not use any pronouns and would rather just have others use their name
when referring to them.
G. Nic Rider and Leonardo Candelario-Pérez
See also: Binary Gender System; Gender; Gender Expression; Gender Identity; Gender
Transition; Nonbinary Gender Identities; Transgender.
Further Reading
Bongiovanni, A., & Jimerson, T. (2018). A quick and easy guide to they/them pronouns.
Portland, OR: Limerence Press.
Gender Neutral Pronoun Blog. (n.d.). The need for a gender-neutral pronoun. Retrieved
from https://genderneutralpronoun.wordpress.com/
542 Prostate
Prostate
The prostate, also called the prostate gland, is a walnut-sized organ that is part of
the male reproductive system. It is located below the bladder, just in front of the
rectum.
A whitish fluid that makes up much of semen is produced in the prostate. This
fluid contains proteins, fats, minerals, and other substances that provide nourish-
ment to the sperm cells. Other parts of the seminal fluid—which provides a med-
ium in which the sperm can be transported out of the body—are produced in
glands called seminal vesicles and bulbourethral glands (also called Cowper’s
glands).
After sperm cells are produced in the testicles, they travel to the prostate
through the vas deferens tubes. The sperm then becomes mixed with the fluid
from the prostate and the other glands. In ejaculation, the semen passes out of the
body via the urethra, a tube that runs from the bladder and prostate through the
penis. The urethra is the same tube that carries urine out of the body.
Physical stimulation of the prostate can play a role in sexual arousal, leading to
orgasm and ejaculation. The prostate is most effectively stimulated by massaging
the skin around the anus or the skin between the anus and testicles. This stimula-
tion can be performed with fingers, a penis, or a sex toy, such as a vibrator or
“p-spot” massager.
The prostate commonly becomes enlarged in men who are older than fifty. In
some cases, the enlarged gland puts so much pressure on the urethra that the indi-
vidual feels a frequent urge to urinate, though it may be difficult to urinate when
they try to do so. Treatment for an enlarged prostate depends on the severity of
the symptoms and whether the enlargement is benign (noncancerous) or the result
of cancer. In cases of benign enlargement, called benign prostatic hyperplasia,
many patients can be treated successfully with medications, such as alpha-block-
ers. If symptoms persist, all or part of the gland may be removed in surgery.
Treatment of prostate cancer typically consists of surgical removal of the entire
gland and radiation therapy. Medications that reduce levels of testosterone may
also be used because prostate cancer cells use this hormone to grow. Prostate can-
cer usually grows slowly before it reaches a fatal stage. Thus, many physicians
recommend that older men avoid surgery and radiation, which each carries certain
risks, while continuing to have the growth of the cancer monitored.
Prostate cancer is the most common cancer among men, and more men die of
prostate cancer than any other form of cancer except lung cancer. There is a gen-
etic basis to prostate cancer, with greater risk among those who have a family
history of the disease. African American men are at the greatest risk. Treatment
has a high success rate if it is started before the cancer spreads beyond the pros-
tate, with almost all patients alive five years after diagnosis. However, after the
cancer has spread to lymph nodes, bones, or other tissues, five-year survival rates
drop to less than 30 percent.
Many physicians recommend that middle-aged and older men get annual tests
to detect early signs of prostate cancer. One such test is a digital rectal examina-
tion, in which the doctor feels the gland with a finger inserted into the anus,
Prostate Cancer 543
checking for a lump or hard spot that may be indicative of cancer. In another test,
called the prostate-specific antigen (PSA) test, levels of the PSA protein are meas
ured in a blood sample. Higher-than-normal levels may indicate cancer.
Prostatitis is an inflammation of the prostate that may be caused by an infec-
tion. Treatment for this condition often involves the use of antibiotics.
A. J. Smuskiewicz
See also: Benign Prostatic Hyperplasia; Prostate Cancer; Prostatectomy; Prostatitis; Semen.
Further Reading
Carter, H. B., & Couzens, G. S. (2013). The whole life prostate book: Everything that
every man—At every age—Needs to know about maintaining optimal prostate
health. New York: Free Press/Simon & Schuster.
Cohen, J. S. (2014). Prostate cancer breakthroughs 2014: New tests, new treatments, bet-
ter options: A step-by-step guide to cutting-edge diagnostic tests and 12 medically
proven treatments. Del Mar, CA: Oceansong Publishing.
Walsh, P. C. (1995). The prostate: A guide for men and the women who love them. Balti-
more: The Johns Hopkins University Press.
Prostate Cancer
Prostate cancer is the abnormal, uncontrolled multiplication of cells within the
prostate. This cancer is the most common cancer among men, and it kills many
men every year. However, if diagnosed and treated early, it is one of the more cur-
able forms of cancer.
In 2020, it has been estimated that there will be 191,930 new cases of prostate
cancer diagnosed in the United States, representing 10.6 percent of all new cancer
cases. It is also expected that more than 33,000 Americans will die of the disease
in 2020, representing 5.5 percent of all cancer deaths. Prostate cancer is responsi-
ble for more deaths among American men than any other form of cancer except
lung cancer.
All ethnic groups can get prostate cancer, but African American men are at the
highest risk. This cancer is rarely diagnosed before age forty-five, though African
Americans are at risk around age forty. Prostate cancer is most commonly diag-
nosed between the ages of sixty-five and seventy-four.
Prostate cancer has a lower mortality rate than most cancers. If diagnosed and
treated early, people with prostate cancer have a good chance of long-term sur-
vival. The average five-year survival rate for patients with prostate cancer is 99
percent. If treatment is begun very early, this rate rises to 100 percent. However, if
the cancer is not diagnosed and treated until after it has spread to other parts of the
body, the five-year survival rate drops to 28 percent.
The risk of prostate cancer steadily increases with age, especially after age
forty-five. By age eighty, about 80 percent of men have some cancer cells in their
prostate.
Prostate cancer runs in families. Men who have relatives who have had prostate
cancer are at elevated risk for the disease themselves. This risk more than doubles
for men who have fathers or brothers diagnosed with prostate cancer.
544 Prostate Cancer
Heredity factors alone cannot explain most cases of prostate cancer. There are
other factors that increase risk, though these factors are little understood. A high-
fat diet, smoking, and exposure to certain environmental toxins (such as heavy
metals) are suspected of increasing risk.
Early stages of prostate cancer produce few if any symptoms. Those with more
advanced prostate cancer may experience pain or discomfort in the pelvic area,
lower back, ribs, or upper thighs, as well as an abnormally frequent urge to uri-
nate. However, passing urine may be difficult. These symptoms are caused by the
abnormal enlargement of the prostate gland, which puts pressure on the bladder
and the urethra.
Physicians can perform tests to check for prostate enlargement and to deter-
mine if this enlargement is the result of cancer or some other, less serious condi-
tion. In a digital rectal examination, the patient’s prostate is felt by the physician’s
finger, which is inserted into the rectum. Abnormal hardness or lumps suggest the
presence of cancer. In a test known as prostate-specific antigen (PSA) test, the
blood is analyzed for levels of the PSA protein. Elevated levels of this protein are
indicative of cancer.
If cancer is suspected based on these tests, an ultrasound examination is usu-
ally conducted to produce a detailed image of the prostate. Using this image, the
physician inserts needles through the rectum wall to obtain tissue samples from
the prostate. Microscopic examination of these biopsy samples will reveal if the
tissue is malignant or benign. If malignant, further tests are performed to deter-
mine the stage of cancer development—whether the cancer is confined to the
prostate or if it has metastasized to other parts of the body.
If the cancer is confined to the prostate, surgical removal of the gland and/or
radiation therapy can often cure the patient. These procedures may lead to urinary
incontinence and/or sexual impotence in patients. Some advanced surgical pro-
cedures may be able to remove the cancerous tissue while preserving nerves
necessary for sexual functioning.
If the cancer has spread to tissues and organs beyond the prostate, additional
treatments beyond prostate surgery and radiation therapy are necessary. These
treatments may include orchiectomy (removal of the testes) and administration of
certain hormones or other medications. These treatments lower the levels of the
male hormones that “feed” the growth of prostate cancer cells.
The earlier treatment for prostate cancer is initiated, the more successful the
treatment is likely to be. To catch this cancer in an early, curable stage of develop-
ment, many doctors recommend that men over age forty get annual digital rectal
examinations and PSA tests. PSA tests are able to detect smaller, earlier growths
of cancer than rectal exams. Some doctors recommend routine rectal exams but
not routine PSA tests, because PSA tests may reveal small cancers that grow so
slowly that they will never become life-threatening. Treatment for such small can-
cers could lead to unnecessary potential complications for patients. Thus, when
small cancers are detected in the prostate, some doctors recommend waiting to
see if the cancer spreads before beginning treatment.
A. J. Smuskiewicz
See also: Penile Cancer; Prostate; Prostatectomy; Testicular Cancer.
Prostatectomy 545
Further Reading
National Cancer Institute. (2020). Cancer stat facts: Prostate cancer. Retrieved from http://
seer.cancer.gov/statfacts/html/prost.html
Walsh, P. C., & Worthington, J. F. (2012). Dr. Patrick Walsh’s guide to surviving prostate
cancer. New York: Grand Central Life & Style.
Prostatectomy
Prostatectomy is the partial or total removal of the prostate gland. The prostate
gland is part of the reproductive system, and it secretes prostate fluid found in
semen. The muscles of the prostate gland also help to project the seminal fluid into
the urethra during ejaculation. Not all of the functions of the prostate are known.
The prostate is located directly below the bladder, and the urethra, the tube-like
structure that carries urine from the bladder during urination, passes through the
center of the prostate gland.
Prostatectomies are typically performed as part of the treatment plan for pros-
tate cancer and can be performed along with several other treatments, including
chemotherapy, hormone therapy, and radiation. The procedure of a prostatectomy
involves removing the prostate, or part of the prostate, any cancerous tissue,
nearby lymph nodes, and the seminal vesicles. A radical prostatectomy is the
removal of the entire prostate and more related tissues, while a simple prostatec-
tomy is used more to treat obstructive lower urinary tract symptoms produced by
benign prostatic hyperplasia.
A radical prostatectomy can be performed by three different methods: robot-
assisted radical prostatectomy, open radical prostatectomy, and laparoscopic radi-
cal prostatectomy. The robot-assisted radical prostatectomy uses a robotic device
guided precisely by a surgeon at a remote console that displays a 3-D view of the
prostate and surgical field by feeding specialized instruments through the small
incisions in the lower abdomen. The open radical prostatectomy is retropubic sur-
gery, where a surgeon makes one incision in the lower abdomen and accesses the
prostate manually through that incision site. The laparoscopic radical prostatec-
tomy is where the surgeon again makes small incisions in the lower abdomen and
uses highly specialized tools to move through those incisions and remove the
prostate. The risks of any of the radical prostatectomy methods include bleeding,
urinary tract infection, urinary incontinence, impotence, narrowing of the urethra
or bladder, lymphoceles, possible change in the length of the penis, and sterility.
Each method has its own benefits and disadvantages and requires thoughtful dis-
cussion and consideration with a physician and social support system to decide the
method best suited to the individual.
Prostatectomies are done under general anesthesia, and antibiotics are typically
given immediately prior to surgery in order to prevent infection. A urinary cath-
eter, a flexible tube placed within the urethra to allow urine flow to avoid obstruc-
tion while in recovery, is typically placed after a prostatectomy and kept in place
for five to ten days postoperation. After the procedure, pain medications are
administered intravenously, and patients are encouraged to walk the day of the
surgery. It is common for patients to be discharged from the hospital the day after
546 Prostatitis
the procedure with outpatient postoperative visits as needed. It may take several
months to a year for sexual function to return to normal after a prostatectomy.
Though semen will continue to be produced, it is simply reabsorbed harmlessly by
the body and will not be able to be projected through the urethra without the pros-
tate gland’s assistance. Prostatectomies are useful and effective interventions to
remove and treat prostate cancer but are invasive and carry lifelong changes that
must be considered before proceeding with this intervention.
Cassia Araujo-Lane
See also: Benign Prostatic Hyperplasia; Prostate; Prostate Cancer; Prostatitis; Seminal
Vesicles.
Further Reading
Johns Hopkins Medicine. (2019). Radical prostatectomy. Retrieved from https://www
.hopkinsmedicine.org/health/treatment-tests-and-therapies/radical-prostatectomy
Kim, E. H., Larson, J. A., & Anriole, G. L. (2016). Management of benign prostatic hyper-
plasia. Annual Review of Medicine, 67(1), 137–151.
Mayo Clinic. (2019). Prostatectomy. Retrieved from https://www.mayoclinic.org/tests
-procedures/prostatectomy/about/pac-20385198
Rincones, O., Sidhom, M., Mancuso, P., Wong, K., Berry, M., Forstner, D., … Girgis, A.
(2019). Robot or radiation? A qualitative study of the decision support needs of
men with localised prostate cancer choosing between robotic prostatectomy and
radiotherapy treatment. Patient Education and Counselling, 102(7), 1364–1372.
Prostatitis
Prostatitis is an infection involving the prostate. The disease can be subdivided
into two types: acute bacterial prostatitis and chronic bacterial prostatitis. Most
infections are bacterial in origin and are caused by the movement of bacteria into
the prostate via the urethra; however, bacteria may also be introduced via surgery
or manipulation of the surrounding structures. The most common agents involved
in prostatitis are gram-negative bacteria, including Escherichia coli, Enterococ-
cus, and Proteus species. Prostatitis may also be caused by Chlamydia trachoma-
tis and Trichomonas vaginalis.
Acute bacterial prostatitis (ABP) may present with lower abdominal pain, pain
with urination, frequent urination, urinary urgency, painful erections, fever, blood
in the ejaculate fluid, and chills. Characteristics that increase the risk for infection
include diabetes, having a chronic indwelling catheter, and performing self-
catheterization. On examination, the prostate may be tender and swollen. Special
care needs to be taken with prostate exams, as excessive massage of the prostate
may lead to spread of the bacteria, resulting in sepsis (when an infection spreads
to the bloodstream). Evaluation may be performed with a gram stain or urine cul-
ture to uncover the causative organism. While a blood culture is not often called
for, it may be used if someone presents with systemic symptoms such as low blood
pressure, as this may be a sign of sepsis. Blood cultures can also be performed for
people with a high risk of developing sepsis or severe infections, such as heart
lesions. ABP is treated with antibiotics. A potential complication of this infection
is urinary retention.
Prostitution 547
Chronic bacterial prostatitis (CBP) may develop from ABP that is not treated
appropriately or if bacteria is spread to other areas through the blood into the pros-
tate, if it is refluxed into the prostate with urine during recurrent urinary tract
infections, or if an ascending infection occurs through the urethra. On rare occa-
sions, infections may be caused by fungi or Mycobacterium tuberculosis. Smok-
ers and individuals with diabetes may have a higher risk. Otherwise, the risk
factors mostly mirror those associated with ABP. Often, individuals with CBP
may be asymptomatic or have symptoms similar to a mild urinary tract infection
(pain with urination, urinary urgency, increased frequency, or abdominal pain).
Laboratory evaluation is performed by testing the urine or prostatic fluid, and
treatment requires an extended course of antibiotics (more than six weeks).
Chronic pelvic pain may also occur as a result.
Rachel Snedecor
See also: Benign Prostatic Hyperplasia; Prostate; Prostate Cancer; Prostatectomy; Sexu-
ally Transmitted Infections (STIs).
Further Reading
Chuang, A. Y., Tsou, M. H., Chang, S. J., Yang, L. Y., Shih, C. C., Tsai, M. P., ... Hsueh, P. R.
(2012). Mycobacterium abscessus granulomatous prostatitis. The American Jour-
nal of Surgical Pathology, 36(3), 418–422.
Dickson, G. (2013). Prostatitis: Diagnosis and treatment. Australian Family Physician,
42(4), 216–219.
Meyrier, A., & Fekete, T. (2019). Acute bacterial prostatitis. Retrieved from https://www
.uptodate.com/contents/acute-bacterial-prostatitis
Schaeffer, A. J. (2006). Clinical practice: Chronic prostatitis and the chronic pelvic pain
syndrome. New England Journal of Medicine, 355, 1690–1698.
Yoon, B. I., Kim, S., Han, D. S., Ha, U. S., Lee, S. J., Kim, H. W., ... Cho, Y. H. (2012).
Acute bacterial prostatitis: How to prevent and manage chronic infection. Journal
of Infection and Chemotherapy, 18(4), 444–450.
Prostitution
Prostitution is generally recognized as the practice of performing sexual acts in
exchange for monetary payment, be it sexual intercourse or other forms of nonco-
ital sex. Prostitutes are sex workers and are pejoratively referred to as “hookers”;
customers are typically called “Johns,” referring to the term “John Doe.” The legal
status of prostitution varies within and across countries around the world. In the
United States, prostitution is predominantly considered a crime, except for some
counties in Nevada, but exists in other places of the world as a regulated profes-
sion or a permissible but unregulated offense. Like many other types of sex work,
this profession is typically degraded and considered obscene or immoral. This
may be due to religious convictions surrounding sexual deviance and monogamy,
individual or collective erotophobia, an association with premarital and extramar-
ital sex, or even more practical concerns regarding the spread of sexually trans-
mitted infections. There are many reasons people solicit the services of prostitutes
and other sex workers, as commercial sex is often easily accessible, sexually grati-
fying, and customizable (i.e., physical characteristics or interest in a particular
act).
548 Prostitution
Informally referred to as “the oldest profession in the world,” the exchange of
sex for resources is present throughout human history, and the practice has even
been reported in various animal species. Currently measured as a worldwide
billion-dollar industry, prostitution continues to thrive. That is not to say this per-
ceivably natural phenomenon has existed without challenge. Christian traditions
and sexuality beliefs during the Middle Ages in Europe were challenging for pros-
titution. Interestingly, prostitution was openly condemned but frequently valued
in juxtaposition by the church as a “necessary evil” to preserve the proper sanctity
of marriage. The persistent advertisement of a clear division between dishonor-
able sexuality and wholesome reproduction within the household inspired Sig-
mund Freud’s theory of the Madonna/whore dichotomy and many of Michel
Foucault’s philosophical ponderings. The proposed discrepancy was so pervasive
that medieval medical models of the prostitute began to emerge describing sex
workers as infertile. This concept was meant to explain a lack of recurring gesta-
tion based on the notion that a womb was inhospitable to pregnancy when it
became too “slippery” to allow for conception (as per indiscriminate and transient
sexual encounters). These presumptions were inaccurate and failed to account for
the regular use of contraception or the enlistment of abortion procedures.
Such dehumanizing constructs vastly differ from the respected high-class trad-
itions of the Eastern world and earlier periods of antiquity when prostitution was
more welcome as a form of commerce or even prestigiously anointed. Sacred
prostitution among temple priestesses of ancient Mesopotamia, the “living art-
work” of the Japanese geisha, and the hetaerae of ancient Greece are all examples
of coveted sexual exchange. Inanna, the Sumerian goddess of love, was seen as
patron of ritual sexuality, brothels, and male prostitution. The craft of the Japan-
ese geisha is still practiced today, adored as an artisan of beauty and desire,
although their services are not always associated with sexual interactions. Report-
edly more autonomous than their Eastern counterparts were the renowned courte-
sans of ancient Greece. Not to be confused with common “pornai,” hetaerae were
economically independent and regularly took part in the city symposia. Unable to
marry, the hetaerae maintained lower social status but were the most educated and
influential women in all of Greece.
Today, prostitution is typically viewed as demeaning regardless of professional
ranking. Modern prostitution in the United States is generally composed of street-
walkers, those who work in massage parlors or brothels, and call girls or escorts.
Streetwalking is the most stigmatized form of prostitution and often the most dan-
gerous. Visible to the public, streetwalkers are more likely to be arrested and to
experience physical violence and sexual abuse. Little control over their working
conditions leaves streetwalkers faced with dangerous hazards such as kidnapping,
robbery, and rape. Brothel and massage parlor workers are safer in their reliable
working spaces. Working in these establishments reduces the likelihood of arrests,
as sensuous massage parlors may limit or disguise services advertised to avoid
legal difficulties, and brothels are legal where permitted by law. Brothels are also
usually equipped with safety features like panic buttons, surveillance devices,
support staff, and prophylactics, and they require regular employee medical
exams. While many customers enjoy frequenting these businesses, some prefer
Prostitution 549
the privacy of arranging appointments with professional escorts. Call girls may be
independently managed or have appointments arranged by employers who adver-
tise their services. High-end call girls are considered the highest-ranking form of
prostitution because they serve wealthier clientele and can charge higher fees than
the average sex worker.
The “fast cash” appeal of the sex industry is not the only reason people become
sex workers and is definitely not exclusive to women. While most prostitutes are
female, both men—sometimes referred to as gigolos—and trans individuals are
also drawn to sex work. Not all who are involved in prostitution are motivated by
socioeconomic issues, drugs, or homelessness, although these are common incen-
tives. Some also genuinely enjoy being paid for sex. However, not everyone who
engages in sex work actively chooses to do so. In the United States, coercive par-
ties have been known to “groom” vulnerable adolescents by providing gifts and
attention only to eventually exploit them sexually. In many countries, people,
many of whom are minors, may be deceived with seemingly harmless work oppor
tunities in order to be trafficked or may be blatantly kidnapped and sold into sex
slavery. While voluntary participation (of those meeting the lawful age of consent)
in sex tourism markets is often legal, the forced labor of commercial sex exploita-
tion is explicitly illegal worldwide. Although nonconsensual sex work will most
likely always remain illegal, advocacy efforts to legalize consensual prostitution
continue in many places where it is currently not permitted.
Due to advancing research, modern debate surrounding the legalization of
prostitution is evolving. Regardless of moral conviction, greater attention to the
benefits of prostitution is being objectively explored. Commercial regulation of
prostitution has the potential to provide safer conditions for both clients and sex
workers, legal access for sexually marginalized communities such as the disabled
when professional sexual surrogacy is inaccessible, and a general normalization
of human sexual needs. Historically, the assistance of sex workers has also played
a significant role in a wide range of scientific research, particularly in the field of
sexology. When members of the general population may be apprehensive to par-
ticipate in investigative physiological reports or sexual history surveys for research
projects, adequate compensation of sex workers allows for readily available par-
ticipant samples. Clearly, the relationship between modern society and prostitu-
tion is complex and multifaceted.
Ilyssa Boseski
See also: Age of Consent; Madonna/Whore Dichotomy; Religion, Diversity of Human
Sexuality and; Sex Tourism; Sex Work; Sex Workers, Male; Sexual Slavery; Sugar
Daddies and Sugar Babies.
Further Reading
Bullough, V. L. (1994). Science in the bedroom: A history of sex research. New York:
Basic Books.
Charnov, E. L. (1982). The theory of sex allocation. Monographs in Population Biology
(MPB-18). Princeton, NJ: Princeton University Press.
International Labour Organization, International Labour Office. (2009). Executive sum-
mary of 2009 Global Report on Forced Labour “The cost of coercion.” Retrieved
from http://www.ilo.org/global/docs/WCMS_106387/lang--en/index.htm
550 Psychosexual Therapy
Lacquer, T. (1990). Making sex: Body and gender from the Greeks to Freud. Cambridge,
MA: Harvard University Press.
Lovelock, B. (2013). The ethics of tourism: Critical and applied perspectives. New York:
Routledge Taylor & Francis Group.
National Center for Victims of Crime. (2012). Grooming dynamic. Retrieved from https://
www.victimsofcrime.org/media/reporting-on-child-sexual-abuse/grooming
-dynamic-of-csa
Pomeroy, S. (1995). Goddess, whores, wives, and slaves: Women in classical antiquity.
New York: Schocken Books.
Ringdal, N. J. (2005). Love for sale: A world history of prostitution. New York: Gross Press.
Yarber, W. L, Sayad, B. A., & Strong, B. (2010). Human sexuality: Diversity in contempo-
rary America (7th ed.). New York: McGraw-Hill.
Psychosexual Therapy
Psychosexual therapy assists with sexual difficulties and dysfunctions, including
erectile concerns, loss of sexual desire, sexual avoidance, and fear of sex. Sexual
difficulties and dysfunctions vary in complexity and severity and can be the result
of physical or psychological illness as well as emotional and relational distress.
Psychosexual therapy focuses on psychoeducation, bolstering communication
skills, intimacy development, implementing behavioral techniques, and utilizing
self-monitoring techniques to systematically desensitize anxious responses that
may occur during sexual situations. Traditional psychosexual therapy focuses pri-
marily on sensitization and desensitization techniques to lower anxiety related to
sexual experiences. In particular, the focus is on verbal and nonverbal communi-
cation with the intent of improving intimacy, dispelling negative thoughts, and
potentially temporarily abstaining from sexual intercourse in order to reduce
anxiety.
The effective implementation of psychosexual therapy is strongly based on the
initial evaluation and assessment of an individual or couple. Due to the intimate
nature of psychosexual therapy, it is essential that a strong therapeutic alliance is
formed, focused on promoting unconditional positive regard and genuineness. As
the therapist begins the assessment process, special attention is paid to collecting
a detailed sexual history. The alliance built in the beginning of therapy will be
utilized during the evaluation and assessment process to develop a comfortable
environment where sexual issues can be explored. Rao and colleagues (2018)
speak to the importance of confidentiality during this stage of therapy, as a lack of
privacy regarding sexual concerns may impede accurate history taking. Psycho-
sexual history should include assessment of current complaints, duration of the
issue, associated symptoms, onset, frequency, and severity of the issue or issues.
In addition, sexual practices, intimacy and relationship problems, and current sex-
ual functioning must be addressed. After thorough assessment and evaluation,
tenets of psychosexual therapy may be implemented.
Numerous models of psychosexual therapy exist to best serve clients as specific
needs arise, including treatment modalities focused on systemic therapy and sex-
ology. One modality, the Sexual Wellness Enhancement and Enrichment Training
Psychosexual Therapy 551
model, proposes a mind-body skills interaction aiming to improve sexual wellness
through adequate and educational self-care. The PLISSIT model of psychosexual
therapy addresses permission, limited information, specific suggestion, and inten-
sive sexual therapy to improve communication and arousal behaviors between the
client couple. Other forms of psychosexual therapy incorporate aspects of cogni-
tive behavioral therapy, mindfulness, and psychoeducation.
Clinical results of psychosexual therapy allege differences in treatment efficacy
outcomes. Frühauf, Gerger, Schmidt, Munder, and Barth (2013) propose that
psychological interventions may especially improve female hypoactive sexual
desire disorder and female orgasmic disorder. However, further updated outcome
studies are needed to assess efficacy in treating other sexual dysfunctions and the
long-term effects of psychosexual therapy. O’Donoghue (1996) suggests various
obstacles to treatment when practicing psychosexual therapy. While the process
can improve sexual performance, efficacious outcomes rely heavily on couple
dynamics and involvement. Obstacles to treatment may include, but are not lim-
ited to, sexual dysfunction in extramarital affairs, lack of partner involvement,
ethical concerns, past sexual history (rape, sexual abuse, etc.), religious beliefs,
and reproduction conflicts. Another concern is the efficacy of therapy when used
with diverse populations, such as LGBTQ+ persons or young adults. Binik and
Meana (2009) assert that psychosexual therapy falls short of standards for
evidence-based practice.
Further considerations for the future include changing the vehicle through
which therapy is delivered. Hall (2004) conducted a pilot study exploring the effi-
cacy of online psychosexual therapy. Feedback provided by participants included
increased self-awareness, greater sexual knowledge, and an improvement in sex-
ual dysfunction. While challenges remain in conducting psychosexual therapy
online, Hall provides a framework from which to work. In the age of technology,
this may be a strong option for accessing psychosexual therapy.
Kyndel L. Tarziers and Franco Dispenza
See also: Performance Anxiety; PLISSIT Model of Sex Therapy; Sensate Focus; Sexual
Disorders, Female; Sexual Disorders, Male; Sexual Dysfunction, Treatment of.
Further Reading
Baker, A. C., & Absenger, W. (2013). Sexual Wellness Enhancement and Enrichment
Training (SWEET): A hypothetical group model for addressing sexual health and
wellbeing. Sexual & Relationship Therapy, 28(1–2), 48–62.
Binik, Y. M., & Meana, M. (2009). The future of sex therapy: Specialization or marginal-
ization? Archives of Sexual Behavior, 38(6), 1016–1027.
Frühauf, S., Gerger, H., Schmidt, H., Munder, T., & Barth, J. (2013). Efficacy of psycho-
logical interventions for sexual dysfunction: A systematic review and meta-
analysis. Archives of Sexual Behavior, 42(6), 915–933.
Hall, P. (2004). Online psychosexual therapy: A summary of pilot study findings. Sexual
& Relationship Therapy, 19(2), 167–178.
Markovic, D. (2012). Psychosexual therapy in sexualised culture: A systemic perspective.
Sexual & Relationship Therapy, 27(2), 103–109.
Masters, W. H., Johnson, V. E., & Kolodny, R. C. (1988). Masters and Johnson on sex and
human loving. Boston: Little, Brown and Company.
552 Puberty
O’Donoghue, F. (1996). Psychological management of erectile dysfunction and related
disorders. International Journal of STD & AIDS, 7(Suppl. 3), 9–12.
Rao, T. S. S., Maheshwari, S., George, M., Chandran, S., Manohar, S., & Rao, S. S. (2018).
Psychosocial interventions for sexual dysfunction in addictive disorders. Indian
Journal of Psychiatry, 60, S506–S509.
Ridley, J. (2006). The subjectivity of the clinician in psychosexual therapy training. Sex-
ual & Relationship Therapy, 21(3), 319–331.
Puberty
Puberty is the beginning of the process of a child growing into an adult. There are
many physical, mental, and social changes that occur during this time.
Puberty begins when the maturing pituitary gland sends a signal to the body to
start producing sex hormones; for people assigned male at birth this includes tes-
tosterone and some estrogen, and for people assigned female at birth this includes
estrogen, progesterone, and some testosterone. These hormones affect the adoles-
cent body in many ways, both physically and mentally.
For all genders, puberty is a process that takes place over several years. For
folks assigned female at birth, puberty often begins between the ages of nine and
fifteen but can sometimes occur earlier or later. For folks assigned male at birth,
puberty usually begins a little later, most often between the ages of eleven and
sixteen. The age of the onset of puberty may depend on a number of factors,
including heredity (the age at which one’s parent or other family members began
puberty), body weight, racial background, environment, and other influences. His-
torically, all genders are reaching puberty at younger ages than in previous dec-
ades, which some experts believe may be due to changing environmental
influences.
Some of the physical changes that occur during puberty happen for all genders.
Everyone will grow taller, although some folks may have a more significant height
increase than others. An increase in natural oil production also takes place, which
can cause the hair and scalp to become more oily and lead to acne (pimples) on the
face and upper body. Changes in the tone of voice also happen during this time.
This is most noticeable for adolescents who were assigned male at birth, as their
voices may deepen significantly, and they may experience several stages of embar-
rassing voice-cracking and squeaking in the process. Though less noticeable, the
voices of folks who were assigned female at birth change slightly as well.
Another change that affects all genders is the development of body hair. For
people with more testosterone, this includes a thickening of the hair on the legs
and arms, hair around the genitals, underarm hair, and sometimes new hair growth
on the chest, stomach, back, and face (though this may occur much later). For
people who have more estrogen, hair growth includes the legs, underarms, around
the genitals, and sometimes on the face as well.
In addition to the many physical changes that puberty brings, there are also
mental changes. The onset of puberty jump-starts additional brain development,
which allows adolescents to understand and engage in much more abstract, com-
plex, and new ways of thinking. The hormonal surges and fluctuations can also
Puberty 553
bring about sudden shifts in moods and emotional reactions. The sex hormones
that are instrumental in puberty may also contribute to adolescents becoming nat-
urally more curious about sex and sexuality, thinking sexual thoughts, and becom-
ing sexually excited.
Puberty often brings about some social changes as well. In addition to becom-
ing more curious about sexuality, some adolescents may begin experimenting
sexually with each other. Youth at various stages of puberty also tend to become
much more self-conscious than previously and sometimes feel quite awkward and
clumsy as they adjust to all the changes happening inside and outside their bodies.
Close, intimate friendships also become very important and common during this
time. Along with this, some young adults may become even more concerned with
fitting in with their peers than previously, and bullying may also become more of
a concern during these years.
The bodily changes that occur during puberty for people who have a uterus
usually begin with the development of breast buds that will later become breasts.
The growth of body hair (legs, underarms) and pubic hair (hair around the geni-
tals) often follows. Vaginal discharge is also common during the year leading up
to a person’s first menstrual period, which often occurs within around a year or
two of developing breast buds. During this time, many people will also begin to
gain some extra “padding” of fat around the hips, buttocks, and thighs, and the
bones of their hips and pelvis may also begin to widen in order to allow a baby to
safely pass through the pelvis during childbirth in the future. Usually, the most
notable stage of puberty for people who have a uterus is the first menstrual period
(menarche). A period comes in the form of blood and tissue from the uterus that
pass out of the body through the vaginal opening. Although someone with ovaries
is born with all their eggs (ova) already in the ovaries, they do not start releasing
these eggs until puberty, when sex hormones trigger the first ovulation (release of
an egg). This begins the menstrual cycle that marks a person’s new capability to
become pregnant. A person’s first period can be both frightening and exciting,
depending largely on how well prepared and informed they are before experienc-
ing their first period. Many young folks’ periods will be irregular and sporadic at
first, usually becoming more regular (occurring about every twenty-eight days or
so) over the next several years.
For people who have a penis, puberty often begins with an increase in height,
developing body hair and pubic hair, and possibly growing some facial hair,
though this often develops a few years later. Around this time, their voices may
also begin to deepen. In addition to growing taller, they also gain an increase in
muscle mass. The sex hormones involved in puberty begin the production of
sperm cells in a person’s testicles, which will allow them to begin ejaculating and
therefore also makes them capable of contributing to beginning a pregnancy.
About half of all adolescents with penises will experience nocturnal emissions
during puberty as the body releases an overproduction of semen during sleep in
the form of an ejaculation. Like a first period, nocturnal emission may also be a
frightening experience if a person is not prepared or if they are unaware that this
is a normal occurrence. Once masturbation or sexual activity is initiated, noctur-
nal emissions tend to cease. Nearly all young people who have a penis will also
554 Puberty, Delayed
experience spontaneous erections during puberty. This is where the spongy tissue
of the penis fills with blood and becomes firm (erect). During puberty, some ado-
lescents may be thinking sexual thoughts or become sexually excited more easily,
which can contribute to frequent erections, but often this happens for no apparent
reason at all. This can be an embarrassing situation but is extremely common and
completely normal. This may also happen to adult males, though significantly less
often.
Puberty is often celebrated in many different cultures as the beginning of a
young person’s journey into maturity, new responsibilities, and adulthood. Other
cultures simply consider it to be a private event and prefer to keep it hidden and
not spoken of, while some societies view the onset of puberty with much stigma
and superstition, particularly for girls experiencing menarche. In U.S. society,
many schools include puberty education as part of health class, though often well
after many young people have already begun experiencing the changes of puberty.
There are still many schools that do not include lessons on puberty at all, or leave
out important information. Many adolescents in the United States receive a major-
ity of their reproductive health information from peers or from the internet, which
are not always reliable sources.
Lyndsay Mercier
See also: Adolescent Sexuality; Adrenarche; Breast, Female; Menarche; Menstruation;
Nocturnal Emissions; Ovulation; Pubic Hair; Semen; Sex Hormones.
Further Reading
Boston Women’s Health Book Collective. (2005). Our bodies, ourselves. New York:
Scribner.
Harris, R. H. (2018). It’s perfectly normal: Changing bodies, growing up, sex, and sexual
health. Somerville, MA: Candlewick Press.
Puberty, Delayed
Delayed, or late, puberty refers to the lack of sexual maturation (evidenced by
bodily changes occurring during the transition from childhood to adulthood) in a
young adolescent. In most cases, the delay is not caused by illness or disease and
is simply a late start in the onset of adolescence. Sometimes, however, delayed
puberty is caused by medical conditions, medicines, or malnutrition. Treatment
options vary based on the cause of the delay.
An increase in the production of sex hormones (testosterone in males and estro-
gen in females) is responsible for the onset of puberty, or sexual maturation. In
female adolescents, these hormonal changes result in a growth spurt, the develop-
ment of breasts and pubic hair, and the onset of menstruation. Male adolescents
begin to grow pubic and facial hair, have a growth spurt, their testicles and penis
get larger, and the body becomes more muscular. These changes take place over a
number of years, and the age at which it starts and ends varies widely. Puberty
generally begins between the ages of seven and thirteen for girls and between the
ages of nine and fifteen for boys. Delayed puberty occurs when the signs of sexual
maturation exceed this age range.
Pubic Hair 555
Roughly estimated to occur in about 3 percent of children, delayed puberty can
have several causes. In over 90 percent of cases, delayed puberty is due to what is
known as a constitutional delay in growth and puberty (being a late bloomer), a
condition ten times more common in boys than in girls. This type of delay tends
to run in families, and affected children are usually shorter in stature than their
peers. Sometimes delayed puberty and growth can be secondary to a chronic ill-
ness, such as diabetes (high blood sugar), cystic fibrosis (an illness affecting the
lungs and digestive system), and celiac disease, a digestive intolerance to a protein
found in wheat, barley, and rye. Also, some young girls who undergo intense
physical training for a sport start puberty later than usual. Another culprit is mal-
nutrition, which may be due to an eating disorder such as anorexia. In other cases,
the delay in puberty occurs because of a long-term medical condition known as
hypogonadism, in which the sex glands (the testes and ovaries) produce few or no
hormones or the parts of the brain involved in sending hormones to the sex
glands—the hypothalamus and pituitary—fail to function properly.
Treatment is usually a matter of watching and waiting with regular checks on
height, weight, and levels of relevant hormones. In some instances, medication
such as testosterone injections, skin patches, or gels, or estrogen in skin patch or
pill form, can jump-start puberty. Growth hormones may also be prescribed if the
pituitary is not working well enough. Whatever the cause, if the delay causes
psychological or emotional stress, medical professionals can offer children ways
to cope and manage the delay more effectively.
Linda Tancs
See also: Adrenarche; Hypogonadism; Puberty; Sex Hormones.
Further Reading
Ann & Robert H. Lurie, Children’s Hospital of Chicago. (2019). Late puberty. Retrieved
from https://www.luriechildrens.org/en/specialties-conditions/delayed-puberty/
Mayle, P. (1975). What’s happening to me? A guide to puberty. New York: Kensington
Publishing.
Pubic Hair
Pubic hair develops for people of all genders during puberty. In addition to pro-
tecting the skin from friction during sex, it may also help trap bacteria and other
pathogens before they reach the reproductive organs.
Social trends and preferences for pubic hair styling vary greatly across time
and by culture. In contemporary Western societies, it has been noted that females
with visible body hair, including hair in the pubic region, can incur social castiga-
tion and be positioned as aggressive, less sociable, less happy, and less sexually
attractive. The regime of removing part or all of the pubic hair (particularly for
females) has differing historical roots. Some researchers claim that pubic hair
shaving had all but ceased in the latter part of the nineteenth century in Western-
ized societies, with natural pubic hair being the norm in terms of genital appear-
ance. Nevertheless, this practice reemerged in the 1980s and ranges from removal
of hair from the bikini line (outer pubic hair) to the Brazilian (a small strip of
556 Pubic Hair
central pubic hair remains) to the complete removal of all pubic hair. This cultural
change has largely been influenced by pornography and the prevalence of social
norms around the removal of all pubic hair, which are often seen in the media.
This regime is mirrored within online pornography, where films of females who
have not shaved are considered a sexual preference “specialty” in terms of appear-
ance and appeal.
Reflecting this trend is the rising amount of research into why females choose
to remove all or most of their pubic hair, with research participants citing
hygiene, aesthetics, and sexual attraction as primary driving forces, particularly
within heterosexual relationships. It has been noted that alternative identities
such as older females, feminists, and lesbians may actively abstain from pubic
hair removal. Nevertheless, the cultural dominance of hair removal has led some
to claim that “it is now unusual for a clinician . . . to examine any woman under
the age of 30 who still has all her pubic hair” (Riddell, Varto, & Hodgson,
2010).
With respect to males, pubic hair removal and grooming appear to have less
importance, but research by Hildebrandt (2003) claims the display of natural pubic
hair between males and females may be narrowing. Male body hair has been
socially constructed as a visible sign suggesting virility and masculinity, but some
recent research suggests that it is becoming more of a social norm for males to
trim and tidy up around the genital region, but it is still not the social norm for
complete pubic hair removal (although pornographic imagery can display men
with no visible pubic hair).
Lesley-Ann Smith
See also: Femininity; Masculinity; Media and Sexuality; Pornography; Puberty.
Further Reading
Boroughs, M., Cafri, G., & Thompson, K. J. (2005). Male body depilation: Prevalence and
associated features of body hair removal. Sex Roles, 52(9–10), 637–644.
Braun, V., Tricklebank, G., & Clarke, V. (2013). It shouldn’t stick out from your bikini at
the beach: Meaning, gender and the hairy/hairless body. Psychology of Women
Quarterly, 37(4), 478–493.
Caselli, D. (2006). “The wives of geniuses I have sat with”: Body hair, genius and moder-
nity. In K. Lesnik-Oberstein (Ed.), The last taboo: Women and body hair (18–47).
Manchester, UK: Manchester University Press.
Fahs, B. (2014). Genital panics: Constructing the vagina in women’s qualitative narratives
about pubic hair, menstrual sex and vaginal self-image. Body Image, 11, 210–218.
Fahs, B. (2014). Perilous patches and pitstaches: Imagined versus lived experiences of
women’s body hair growth. Psychology of Women Quarterly, 38(2), 167–180.
Fahs, B., & Delgado, D. (2011). The specter of excess: Constructing race, class, and gen-
der in women’s body hair narratives. In C. Bobel & S. Kwan (Eds.), Embodied
resistance: Breaking the rules, challenging the norms (13–25). Nashville, TN:
Vanderbilt University Press.
Hildebrandt, S. (2003). The last frontier: Body norms and hair removal practices in con-
temporary American culture. In H. Tschachler, M. Devine, & M. Draxlbauer
(Eds.), The embodyment of American culture (59–73). Munster, Germany:
Litverlag.
Pubic Lice 557
Ramsey, S., Sweeney, C., Fraser, M., & Oades, G. (2009). Pubic hair and sexuality:
A review. The Journal of Sexual Medicine, 6, 2102–2110.
Riddell, L., Varto, H., & Hodgson, Z. G. (2010). Smooth talking: The phenomenon of
pubic hair removal in women. The Canadian Journal of Human Sexuality, 19(3),
121–130.
Toerien, M., Wilkinson, S., & Choi, P. Y. L. (2005). Body hair removal: The “mundane”
production of normative femininity. Sex Roles, 52(5), 399–406.
Pubic Lice
A common name for pubic lice is crabs, because under magnification, they look
very much like crabs. Pubic lice are organisms that are similar to those organisms
that cause scabies, body lice, and head lice, and they all live on the human body
and consume human blood.
Pubic lice are tannish to grayish-white, six-legged ectoparasitic organisms
(parasites that live on the host surface) that are approximately two millimeters by
two millimeters in size. Their scientific name is Pediculosis phthirus pubis. Lice
are found worldwide and are not racially discriminatory. They are known to infest
the hair of the pubic area primarily, which includes the groin, genitalia, and ano-
genital region (space between anus and genitalia). However, pubic lice can infest
facial hair if there is intimate contact, such as during oral sex. If pubic lice are
found in the eyebrows or eyelashes in children, it is important to realize that this
may be a sign of sexual abuse.
Pubic lice have three forms: the egg (also called a nit), the nymph, and the adult.
The nits are lice eggs, often challenging to see but found firmly attached to the
hair shaft. Adult female lice typically lay about thirty eggs in their nearly month-
long life span. The nits are oval and usually yellow to white in color. Pubic lice
nits take approximately six to ten days to hatch. When the nits hatch, they become
nymphs, which are immature lice. A nymph looks like an adult pubic louse but
smaller. After hatching, the pubic lice nymphs take about two to three weeks to
mature into adult lice. The pubic lice are capable of reproducing only in their adult
form, not as nymphs. In order for a nymph to survive, it must feed on the blood of
the human host via burying its head in the skin, similar to the action of a tick.
When the nymph matures into an adult, the adult female is larger than the male
louse. Pubic lice have a broader body than head lice. The pubic louse has two front
legs that are very large and look like the pincher claws of a crab, which is how they
received their nickname “crabs.” Within twenty-four hours of mating, the mature
female louse begins laying seven to ten eggs (nits) daily, and repeated fertilization
is not required. If the louse falls off a person and does not land on another human
host, it will die within one to two days.
The biggest differences between scabies, pubic lice, and body and head lice are
how they are acquired and their locations on the body. Scabies are known to reside
in the webs between the fingers and under the fingernails, but if someone scratches
their groin on a regular basis, they can be transmitted to the groin and genital
regions. Body lice usually reside in hairy regions, like armpits, the chest if hair is
558 Pubic Lice
present, and in areas of tight-fitting clothes. Body lice are typically passed by
sharing unwashed clothes from person to person.
Pubic lice are the only organisms in this family that are known to be transmit-
ted by sexual contact. And if a person has acquired pubic lice, though lice are not
specific carriers for disease, the individual should be evaluated for other sexually
transmitted infections (STIs). It is important to realize that STIs frequently occur
simultaneously, as they have the same mode of transmission, and the majority of
STIs can be asymptomatic. Therefore, any time a person is diagnosed with one
STI, they should be tested for all of them.
Risk factors for acquiring pubic lice include poor hygiene, having intercourse
with a person infected with pubic lice, having multiple sexual partners, and shar-
ing bedding, towels, or clothing with an infected person. Despite much concern
about the spread of STIs through public restrooms, public spread of pubic lice
rarely occurs.
Once this parasite takes hold, it is easily transmitted from person to person.
The infection can be extremely uncomfortable, with intense itching that is often-
times worse at night. This itching sensation may start soon after being infected, or
it may start as late as two to four weeks after contact. In addition to the itch, there
is often a reaction to the parasite consuming the blood, which causes the skin to
turn bluish-gray in color. Vigorous scratching often leads to sores and secondary
bacterial skin infections.
The treatment for pubic lice is not intense, but it can be laborious, and it must
be performed and completed to fully treat the infection. All partners should be
treated at the same time to avoid passing the infection back and forth. All the indi-
viduals’ clothing and bedding, as well as any cloth or fabric items they may have
come in contact with within their homes, should be treated.
Topical treatments are the mainstay of treatment. Shampoos with 1 percent per-
methrin are the favorite treatments used for the elimination of pubic lice and can
be purchased over the counter (OTC). Other products include OTC therapies like
antilice shampoo or a mousse substance containing pyrethrins and piperonyl
butoxide. Another option, if the OTC medications do not help, is to contact a doc-
tor for a prescription of 0.5 percent malathion lotion, or lindane shampoo, which is
an option for therapy. This treatment is usually reserved for later use because of
the potential neurotoxic side effects on the brain, especially in infants and preg-
nant people. The final medication option known at this time is oral ivermectin (a
broad-spectrum antiparasitic medication used all over the world for parasitic
infections), which can kill the adults and nymphs but cannot kill the nits. In addi-
tion to medications, those with pubic lice must use a fine-toothed comb to comb
through pubic hair and remove nits.
People may believe that if they have a cleanly shaven pubic region, this elimin-
ates either the risk of acquiring pubic lice or serves as a treatment to eliminate the
lice after infestation has occurred, but these are myths. After acquiring pubic lice,
trimming pubic hair can help treatment but is not necessary. The trimming aids in
eliminating the nits but does not eliminate the adults or nymphs. Trimming allows
for ease in the application of medication and better visualization of the louse. If a
Public Displays of Affection 559
person shaves after infestation, they run the risk of leaving the head of the louse in
the skin, which can end up causing a superficial skin infection.
Usually a single course of treatment is all that is needed. But if another treat-
ment is necessary or recommended, then one should contact their doctor, and the
subsequent treatment should be done four days to one week after the previous.
Howard W. MacLennan Jr.
See also: Pubic Hair; Scabies; Sexually Transmitted Infections (STIs).
Further Reading
Grimes, J. A., Smith, L. A., & Fagerberg, K. (2013). Sexually transmitted disease: An
encyclopedia of diseases, prevention, treatment, and issues. Santa Barbara, CA:
Greenwood.
McAnulty, R. D., & Burnette, M. M. (Eds.). (2006). Sex and sexuality. Santa Barbara, CA:
Praeger.
Newton, D. E. (2009). Sexual health: A reference handbook. Santa Barbara, CA:
ABC-CLIO.
Public Displays of Affection
Public displays of affection (PDA) are characterized by physical acts of intimacy
in a public setting. Although PDAs are often associated with conventional social
settings such as schools and parks, PDA can also take place in cyber social spaces.
Social media provides a communication platform in which individuals often
develop and maintain their relationships, including romantic ones.
PDA can take place in both romantic and nonromantic relationships and ranges
from platonic displays such as holding hands, hugging, and putting one’s arm
around someone else’s shoulder, to more intimate acts such as kissing and posting
pictures on social media demonstrating physical intimacy or closeness with a
romantic partner. Although intimate acts of affection take place in both the public
and private spheres, researchers argue that in the public sphere these acts have the
intentional effect of demonstrating the intimate status of the individuals’ relation-
ship to others.
There are significant cultural differences that inform how PDA is displayed
and interpreted. As explained by social scientists, these differences are better
understood by how cultures express communication in their relationships, or
high-context versus low-context communication. In high-context cultures, verbal
communication is less explicit, and greater emphasis is placed on physical contact
such as closeness and touch. In lower-context cultures, verbal communication is
more explicitly expressed, and individuals derive meaning from the words found
in messages. It is important to note that the context of cultures is not static. For
instance, Finland has traditionally been considered a high-context culture, but
researchers have recently observed that this trend is changing.
Cultural attitudes about race and PDA can intersect. For example, interracial
couples in the United States are less likely to engage in PDA due to the stigma sur-
rounding interracial relationships. Compared to intraracial couples, studies have
560 Purity Pledges
found that adolescents in interracial romantic relationships engage in less PDA,
suggesting that individuals learn at a young age what kinds of PDA are culturally
acceptable and valued.
Gender and gender expression play an integral part in PDA. In many societies,
same-sex and same-gender PDA is stigmatized, prohibited, and even punishable
by law. Therefore, due to stigma and the fear of violence, some scholars have
found that PDA is less common among same-sex and same-gender couples. Those
who decide to engage in PDA have to be very strategic about simple acts such as
holding hands in order to protect themselves from retaliation and hate crimes. It
should be noted, however, that same-sex and same-gender PDA is perceived dif-
ferently in various cultures. For example, although in many Arab countries same-
sex romantic relationships are prohibited, two men holding hands is not perceived
to be romantic.
The stigmatization of same-sex and same-gender PDA is learned at an early
age. For example, schools in the United States disproportionately punish lesbian,
gay, bisexual, transgender, and queer (LGBTQ) youth for engaging in PDA. This
form of discrimination toward LGBTQ youth leads to consequences such as
expulsion from school and contributes to increased mental health concerns in
LGBTQ youth. More broadly, this double standard is indicative of negative cul-
tural beliefs and attitudes toward the LGBTQ community in the United States.
To sum, PDA is a phenomenon that is observed across diverse groups of indi-
viduals worldwide. However, there are differences in terms of culture, gender,
gender expression, and sexual identity, among others, that must be considered in
how PDA is interpreted.
Roberto L. Abreu and Jacob Huff
See also: Dating, Cross-Cultural Comparison of; Gender Expression; Heterosexism;
Kissing; Media and Sexuality; Touching, Sexual Arousal and.
Further Reading
Charton, L., & Boudreau, J. A. (2017). “We or them,” “you and I,” and “I”: Spaces of inti-
macy and (not so) public displays of affection in Hanoi. Gender, Place & Culture,
24, 1303–1322.
de Oliveira, J. M., Costa, C. G., & Nogueira, C. (2013). The workings of homonormativ-
ity: Lesbian, gay, bisexual, and queer discourses on discrimination and public dis-
plays of affections in Portugal. Journal of Homosexuality, 60, 1475–1493.
Seidman, G., Langlais, M., & Havens, A. (2019). Romantic relationship-oriented Face-
book activities and the satisfaction of belonging needs. Psychology of Popular
Media Culture, 8(1), 52.
Vaquera, E., & Kao, G. (2005). Private and public displays of affection among interracial
and intra-racial adolescent couples. Social Science Quarterly, 86, 484–508.
Purity Pledges
Purity pledges, also known as virginity pledges or abstinence pledges, are com-
mitments made by people—usually young women—not to have sex until married.
Most purity pledges are religious in nature, even if they are not directly involved
Purity Pledges 561
with a particular church. Although many cultures have similar expectations about
remaining sexually chaste until married, purity pledges are unique in that they
involve an explicit vow and often mark those vows with a ring. The pledges are
most common in the United States, although they can also be found in some South
American countries as well.
In addition to purity rings, other artifacts or events can mark purity pledges. In
the United States, greeting cards and religious pamphlets are often produced for
parents to use as part of the purity pledge process. Prewritten contracts can also
be downloaded online or purchased from vendors that outline the details of the
pledge. Some families or groups of families hold purity balls, sometimes-
elaborate ceremonies where daughters take the vow in front of friends and fami-
lies. In some purity balls, daughters bring their fathers as dates and pledge that
until they have another man in their life—specifically, a husband—they will avoid
sex and sexual activity. As such, many people—especially those outside of Evan-
gelical Christian communities—have critiqued purity pledges as a sexist practice
that is especially focused on girls and young women.
Many families and individuals point to religious convictions as the reason for
having their children make purity pledges. Particularly, they argue that cultural
sexual mores and rituals are out of line with traditional Christian practices. To that
end, most pledges involve religious language in the purity contract and the use of
prayer to ask for the pledge to be successful. Even though some critique purity
pledges as old-fashioned and counterculture, advocates of purity pledges point
to how many U.S. celebrities—most notably, the Jonas Brothers and Jessica
Simpson—have publicly worn purity rings. Fathers often espouse that they see it
as their duty to protect the sexuality of their daughters, as do mothers; and, thus,
the pledges are encouraged. Children, especially daughters, often report that they
are happy to make the pledges because they mean so much to their parents and, to
a lesser degree, because they also believe in the principles that the pledge
represents.
Research has revealed that, despite their popularity, purity pledges do not tend
to have any impact on whether or not someone will have sex before marriage. If a
child introduces the idea of the pledge to the family, then it is more likely that the
pledge will be successful. Overall, however, there is no compelling scientific evi-
dence that purity pledges have any effect on choices to not be involved in sexual
relationships. A relationship has been established, however, between taking purity
pledges and not being prepared for safer sexual activity. Links between being bul-
lied and wearing purity rings have also been established. Still, many families con-
tend that even if pledges are not efficacious, they represent shared values and
meaning between family members.
Jimmie Manning
See also: Adolescent Sexuality; Abstinence; Religion, Diversity of Human Sexuality and;
Virginity.
Further Reading
Bruckner H., & Bearman P. S. (2005). After the promise: The STD consequences of ado-
lescent virginity pledges. Journal of Adolescent Health, 36, 271–278.
562 Purity Pledges
Gardner, C. J. (2011). Making chastity sexy: The rhetoric of evangelical abstinence cam-
paigns. Berkeley: University of California.
Manning, J. (2014). Exploring family discourses about purity pledges: Connecting rela-
tionships and popular culture. Qualitative Research Reports in Communication,
15(1), 92–99.
Rosenbaum, J. E. (2009). Patient teenagers? A comparison of the sexual behavior of vir-
ginity pledgers and matched nonpledgers. Pediatrics, 123, 110–120.
Q
Queer
“Queer” is a word that broadly refers to sexual and gender minorities. A queer
person, then, is someone who is not heterosexual (attracted to people of a different
sex) or is not cisgender, meaning a typically masculine male or a typically femi-
nine female. Queer is often considered to be an identity, one that can be claimed
by a person or that is placed on another person. Queer is highly contextual, mean-
ing that the way it is interpreted often depends on context cues such as surround-
ing words and sentences as well as nonverbal cues such as tone of voice. Although
frequently used to identify lesbian, gay, bisexual, or transgender (LGBT) people,
queer can indicate any gender or sexuality that is not the norm.
The word “queer” originally had nothing to do with sex or gender but instead
was a word that meant peculiar, weird, or strange until the late 1800s. Then the
word started being used to identify and antagonize people who were attracted to
the same sex. As that suggests, even though “queer” can be a positive word that
empowers people, some use it in a negative way as a put-down even today. That is
why the word is often contested, or debated, among LGBT people. Some feel that
because it is rooted in a negative use, it is not a good way to refer to those who are
LGBT. That sentiment is becoming less common, especially among younger
people who grew up with the word being used in a positive context.
One way that the word “queer” became transformed into a positive identity
marker was its use by political activists. This use was especially evident in the
United States in the late 1980s and early 1990s when the AIDS crisis had many
people frustrated that the government was not helping sick gay men. One group
named itself Queer Nation, noting that the word “queer” in their title made their
name more noticeable and directly confronted the stigma and prejudice aimed at
sexual minorities. Members of Queer Nation would rally and chant, “We’re here!
We’re queer! Get used to it!” as a way of making people take notice that queer
people and their rights were being ignored. This activist use of “queer,” as well as
others, became a radical way of asserting rights. Many continued to use the word
“queer” in this sense; in the present day, it is less radical but still noticeable by
people.
Around the time activists started to use “queer,” a similar movement developed
in colleges and universities as many professors, especially those in women’s stud-
ies, began to use the word. Queer theory developed as an intellectual movement
that theorized about heteronormativity, the idea that societies construct the ways
that gender and sexuality are supposed to be and that people who do not follow
those norms should not be oppressed or shamed. Queer theory continues to be
564 Questioning
developed by scholars, often involving research that examines how heteronorma-
tivity is unrealistic, problems related to sexuality or gender and privacy, and cul-
tural pressures for people to assimilate into cisgender or heterosexual roles and
behaviors.
Jimmie Manning
See also: Gay Rights Movement; Gender; Genderqueer; LGBTQ+; Pronoun Usage; Sex-
ual Identity; Sexual Rights.
Further Reading
Lovaas, K. E., Elia, J. P., & Yep, G. A. (2006). Shifting ground(s): Surveying the contested
terrain of LGBT studies and queer theory. Journal of Homosexuality, 52, 1–18.
Manning, J. (2009). Because the personal is the political: Politics and unpacking the rhet-
oric of (queer) relationships. In K. German & B. Dreshel (Eds.), Queer identities/
political realities (1–12). Newcastle: Cambridge.
Rand, E. J. (2014). Reclaiming queer: Activist and academic rhetorics of resistance. Tus-
caloosa: University of Alabama.
Sedgwick, E. K. (1990). Epistemology of the closet. Berkeley: University of California.
Questioning
“Questioning” is a term used to discuss how individuals explore and wonder about
their sexual orientation, sexual identity, or gender identity. “Questioning” can be
used to refer to the process of such exploration and potential change in orientation
or identity. “Questioning” can also be used by an individual as an identity during
this process, or at times to express rejection of trying to fit one’s individual experi-
ence into existing identity labels.
The process of questioning, and identifying as questioning, is often discussed
in the context of teens and adolescents, for whom navigating emerging roles and
identities is particularly salient. Physiological changes associated with pubertal
development, emerging and crystallizing sexual interests, changes in peer inter-
actions (e.g., start of dating and partnered sexual activity), and changes in gen-
dered social expectations and roles are all potentially relevant factors during this
entry into adulthood. However, questioning of sexuality or gender may be relevant
for individuals of any age. For some, this can reflect a lifelong process of flexibil-
ity and change in their orientation and identity.
Questioning represents an important part of development of gay, lesbian, bisex-
ual, and other sexual minority orientations and identities. Adoption of a gender
minority identity, such as a transgender identity, or transitioning from one gender
to another, often starts with a process of questioning. Our society has a baseline
presumption that people are heterosexual and cisgender, and questioning often
involves the individual realizing that society’s expectations are not consistent with
their own experience. They often must actively seek out information and navigate
the challenges associated with differing from the heteronormative and cisnorma-
tive mainstream. This can include coping with distress as the result of discrimin-
ation directed toward LGBT individuals. Questioning can also involve navigating
self-acceptance and integration of a nonheterosexual and noncisgender identity,
Questioning 565
where internalized homophobia or transphobia can be a significant source of dif-
ficulty for some individuals.
Questioning can be especially complex among individuals whose experiences
do not fit easily into existing categories of the gender binary (male versus female)
or gendered attractions (heterosexual versus homosexual). They can face pressure
from both outside and inside the LGBT community to decide on a category or
label. For example, an individual may be expected to decide if they are definitively
male or female, when their actual gender identity involves both masculine and
feminine features. Some individuals may find less common but more applicable
identities for themselves (e.g., pansexual, agender), while others may decide
against labeling themselves at all.
Questioning can overlap with sexual orientation and identity formation in sex-
ual and gender minority individuals, but it is not synonymous with having an
“unformed” or “developing” identity. Indeed, heterosexual cisgender individuals
may also engage in questioning their gender and sexual identities. In some cisgen-
der heterosexual university samples, about half of the men and two-thirds of the
women reported having questioned their sexual orientation in the past. However,
after a process of questioning and exploration, these individuals returned to a het-
erosexual orientation as the best descriptor of their own sexuality.
Recently, there has been an increase in adolescents who are less interested in
maintaining a specific gender or sexual identity. This may be associated with
increasing societal acceptance of gender fluidity and sexual minorities. Question-
ing youth include those who see that there are a large number of ways people can
label and understand their sexual and gender identities, and they are consequently
not interested in foreclosing on a specific identity (without more experience and
information). For some individuals, questioning becomes a lifelong process in rec-
ognition of how gender and sexual identities can change in response to changing
stages, circumstances, and relationships across the life span.
The process of questioning can take on many forms and involve different
behaviors. Introspection and reflection on one’s motivations, feelings, thoughts,
and sense of self are common. For example, individuals consider which people
and groups they have (or do not have) romantic and sexual attractions to. They
may also compare their relative levels of attraction toward one gender or sex ver-
sus another. Individuals may also notice experiences such as an intrinsic sense of
“maleness” or “femaleness” or other sexual/gender identities. A person may
become aware of a sense of difference from societal norms or expectations, such
as difference from heteronormative romantic or sexual attractions, or a lack of fit
with expectations and roles prescribed to their assigned gender. For some, this
may be accompanied by significant distress and dysphoria; for others, it may be a
sense of “lack of fit” with a heterosexual or cisgender identity.
New sexual behaviors or gender presentation may also be explored. For
example, individuals questioning sexual orientation may reflect on whether past
sexual and romantic activities with different genders or sexes were enjoyable,
repulsive, or neutral. Individuals questioning gender identity may experiment
with different aspects of gender presentation (e.g., hairstyle, clothes, names, pro-
nouns) in private or public and whether these behaviors feel more or less
566 Questioning
congruent with their internal sense of self. Prospective behaviors may also be
explored through hypothetical thinking and perspective taking. This can include
imagining engaging in sexual activities with different genders and sexes or imag-
ining living or presenting as a different gender (or gender fluid) and noting posi-
tive, negative, or ambivalent or neutral reactions within oneself.
Exposure to information related to other identities and orientations, and inter-
actions with individuals with those identities and orientations, can have a signifi-
cant impact on questioning individuals. Learning about other orientations and
identities in sex education class, through the media, from family and peers, and
from other sources can be crucial for helping questioning individuals identify
and contextualize their own experiences. For youth, opportunities to meet and
engage with diversity in sexuality and gender, such as through gay-straight alli-
ance organizations in school, is often reported to be important for supporting
questioning individuals. Having a trusted mentor who has similar experiences
with sexual or gender identity can also be valuable for questioning youth as a
source of support and information. With the proliferation of the internet, question-
ing individuals also have more opportunities to seek out information and support-
ive communities online.
Questioning identity can map onto several existing models of identity develop-
ment. Some models are based on developmental stages, and questioning often rep-
resents the early stages of these models. For example, Cass’s (1979) model of
homosexual identity development states that sexual identity is acquired and pro-
gresses linearly through six distinct stages: identity confusion, identity compari-
son, identity tolerance, identity acceptance, identity pride, and identity synthesis.
For emerging gay or lesbian individuals, questioning can map onto the stages of
identity confusion (where the individual realizes that their experiences are incon-
gruent with heteronormative expectations) and identity comparison (where the
individual examines whether a gay or lesbian identity may be suitable for them).
Other models are based on developmental processes rather than stages. For
example, Cox and Gallois’s (1996) social identity model highlights two major pro-
cesses involved in identity development: self-categorization (which involves self-
labeling with a group and adoption of norms and values of a group) and social
comparisons (which involves varying levels of dependence on having a group
membership and contrasts between values and norms of different groups). Both
appear important in the questioning process; questioning involves exploration of
which social groups the individual fits into and the social impacts of adopting cer-
tain identities. For example, questioning involves widening the range of self-labels
and groups that are available to the individual. The questioning process may also
become more complicated or protracted if adoption of a new gender or sexual
identity or orientation will precipitate conflict with other important group mem-
berships (e.g., family, existing peer groups).
Some authors have used an intersectionality approach to examine questioning.
This paradigm emphasizes how sexuality and gender exist within a broader socio-
cultural and individual interpersonal context, which include factors such as cul-
tural values and norms, socioeconomic status, education, age, and personal
relationships and life experience. Questioning is then a reflection of the dynamic
Questioning 567
interaction between an individual’s self-identity within this broader context. This
approach also emphasizes that sexuality and gender, although conceptually differ-
ent, are often interactive and interrelated. Questioning of one may lead to new
experiences and subsequent further questioning of the other. Questioning can
become a lifelong process that allows greater flexibility and fluidity in response to
changing individual circumstances and often involves rejection of clear labels and
categories in favor of a more personally relevant and integrated sense of
self-identity.
Silvain S. Dang
See also: Adolescent Sexuality; Binary Gender System; Coming Out; Fluidity, Gender;
Fluidity, Sexual; Gender Dysphoria; Gender Identity; Gender Identity Development;
Gender Roles, Socialization and; Gender Transition; Genderqueer; Homophobia, Inter-
nalized; LGBTQ+; Queer; Sexual Identity; Sexual Orientation.
Further Reading
Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of
Homosexuality, 4(3), 219–235.
Cox, S., & Gallois, C. (1996). Gay and lesbian identity development: A social identity
perspective. Journal of Homosexuality, 30(4), 1–30.
Diamond, L. M., & Butterworth, M. (2008). Questioning gender and sexual identity:
Dynamic links over time. Sex Roles, 59, 365–376.
Hollander, G. (2000). Questioning youth: Challenges to working with youths forming
identities. School Psychology Review, 29, 173–179.
Morgan, E. M., Steiner, M. G., & Thompson, E. M. (2010). Processes of sexual orientation
questioning among heterosexual men. Men and Masculinities, 12(4), 425–433.
Morgan, E. M., & Thompson, E. M. (2011). Processes of sexual orientation questioning
among heterosexual women. Journal of Sex Research, 48(1), 16–28.
Steinmetz, K. (2017, May). Beyond “he” or “she”: The changing meaning of gender
and sexuality. Time. Retrieved from http://time.com/4703309/gender-sexuality
-changing/
R
Rape
Rape involves the penetration of a person’s bodily orifice, which includes the oral
cavity, vagina, or anus. It can involve any object, but the typical instrument of
insertion is a penis. Rape exists when consent is not present. People traditionally
viewed rape as only involving women as victims. However, modern legal statutes
in many countries acknowledge that men experience rape. This changing concep-
tion of victimization relates to shifts in cultural beliefs and values of gender and
sexuality.
The concept of rape has existed since the beginning of recorded history. Greek
mythology notes several instances of rape. Interestingly, several stories have
themes related to bestiality, with gods taking the form of animals to engage in
forced copulation with women. This includes the story of Europa. Zeus took the
form of a bull, embedded himself in a herd belonging to her father, and raped her.
Other ancient accounts of rape exist in the Code of Hammurabi and the Bible.
Throughout time, rape has been a part of cultures in various ways. This includes
bridal arrangements between families, carnal rewards associated with war victo-
ries, and slavery. A commonality with these examples involves patriarchal stan-
dards of male aggression and ideas that women are the property of males. Gender
equality has changed much of this. Consider that in the United States it used to be
legal for husbands to rape their wives, sometimes referred to as marital rape. All
states had removed laws involving marital rape exemptions by 1993. Recent move-
ments within the United States have even advocated the existence of “rape cul-
ture.” This involves social settings where rape is prevalent, partly because popular
culture and the media excuse themes associated with it. The argument is that rape
culture thrives when the use of misogynistic language and the objectification of
women’s bodies is acceptable. For example, consider the debate around Robin
Thicke’s song “Blurred Lines.”
There are several different forms of rape. Molestation concerns an adult using
a child for sexual stimulation. It is not just family related and can occur in a var-
iety of settings, including educational and religious contexts. Dynamics involving
people in positions of power over children and the inability for children to provide
legal consent are key. Statutory rape involves the prohibition of intercourse
between people of a specified legal age regardless of consent. The age of consent
in most areas of the United States is between fourteen and eighteen. Acquaintance
rape involves someone the victim knows. Research shows that one-quarter of
women report at least one rape experience. Up to 95 percent of those women
570 Rape
indicate the assailant was an acquaintance. Rape by an acquaintance is more likely
with adolescents. Scholars are skeptical of statistics in this area, and with rape in
general, since surveys indicate only 4 percent of rape victims report the crime to
law enforcement. Date rape is a type of acquaintance rape involving situations
where the victim agreed to accompany the perpetrator to an entertainment-based
event, social gathering, or dining encounter. The perpetrator may establish sex as
a necessary exchange for paying for the date. Other themes involve the encourage-
ment of intoxication, the use of drugs to limit the victim’s mental capacity, and
social isolation to reduce detection. Group rape involves fraternities, athletic
teams, and gangs. These are all-male groups that promote masculine, physical
aggression in their behaviors and have an elevated sense of group identity. Dynam-
ics involve advanced planning by a group leader, victim selection, victim humili-
ation, and systematic coverup if the event becomes public knowledge. Some
theories argue that homoerotic tendencies are involved in group rape. Western
culture has traditionally frowned on homosexual contact between groups of males
with close emotional ties. Therefore, a group rape involving a female victim pro-
vides males with an indirect outlet for sexual contact with other males. Criminal
convictions for group rape are uncommon.
In the United States, there is legal variation with the term “rape.” In some
states, statutes refer to sexual assault instead of rape. Sexual assault involves
actions against a victim’s will or without consent, using force or threats related to
force, and/or manipulation. Other acts involving sexual motivation not falling
under the traditional definition of rape can apply. This includes consensual sex
between two people of legal age where one is an authority figure working in an
official capacity for the government. Consider a teacher or juvenile detention offi-
cer having a sexual relationship with someone eighteen years or older. Some states
simply use the words “rape” and “sexual assault” interchangeably. Once under
prosecution, research shows that rapists will defend themselves in ways that refo-
cus responsibility to the victim. This includes claiming that the victim’s seduction
was irresistible, the victim wanted it despite saying “no,” the victim enjoyed it, or
the victim has a history of promiscuity, making the likelihood of rape impossible.
These motives often emerge after the assault to justify the crime and are not
necessarily rationalizations that provide good legal standing during court pro-
ceedings. However, literature implies that in cases involving female victims,
whether or not the person was engaging in what culture defines as wholesome
activities before an assault can make a difference with some judges and juries.
Sexual assault penalties vary in the United States, with most having one- to two-
year minimum sentences. Mitigating and aggravating circumstances, such as the
number of previous offenses, influence punishment. Castration is an option for
some offenders. This is more likely to involve a chemical component that lowers
testosterone levels, but some offenders have volunteered for physical castration.
Critics argue that rape can be more about power and control and less about sexual
gratification. In turn, physical castration might limit the ability of a rapist to use
his penis for penetration, but the possibility of using other objects still exists.
Upon release from prison, over 50 percent of convicted rapists commit some crim-
inal offense within five years.
Rape, Abuse and Incest National Network (RAINN) 571
Due in part to the influence of the feminist movement in the early 1970s, the
public, and more importantly the legal system, started paying attention to the
aftermath of rape. Rape crisis centers emerged, and the idea of addressing psych-
ological reactions to rape became relevant. Associated with posttraumatic stress
disorder, “rape trauma syndrome” entered the lexicon of clinical fields associated
with sexual assault responses. It involves symptoms including, but not limited to,
shock, nausea, headaches, stomach pains, sleep irregularity, trouble eating, cry-
ing, being startled easily, radical lifestyle changes, substance abuse, and suicidal
tendencies.
Jason S. Ulsperger
See also: Date Rape; Rape, Abuse and Incest National Network (RAINN); Rape Shield
Laws; Rape Trauma Syndrome; Sexual Abuse; Sexual Assault; Statutory Rape.
Further Reading
Cocca, C. (2004). Jailbait: The politics of statutory rape laws in the United States. Albany:
State University of New York Press.
Denton, M. (2018). Rape culture: How can we end it? New York: Lucent Press.
Horeck, T. (2014). #AskThicke: Blurred lines, rape culture, and the feminist hashtag take-
over. Feminist Media Studies, 14(6), 1105–1107.
Reddington, F., & Kreisel, B. (2017). Sexual assault: The victims, the perpetrators, and
the criminal justice system. Durham, NC: Carolina Academic Press.
Smith, M. (2018). Encyclopedia of rape and sexual violence. Santa Barbara, CA:
ABC-CLIO.
Rape, Abuse and Incest National Network (RAINN)
The Rape, Abuse and Incest National Network, also known as RAINN, is one of
the United States’ largest anti-sexual-violence agencies. It created and runs the
National Sexual Assault Telephone Hotline and National Sexual Assault Online
Hotline, which are composed of independent RAINN affiliates answering a
twenty-four-hour hotline that can be reached via phone or the internet (800-656-
HOPE and online.rainn.org). RAINN also provides education about sexual vio-
lence, leads efforts to prevent sexual violence, and helps to improve services to
victims throughout the United States.
Scott Berkowitz cofounded RAINN in 1994, along with Tori Amos, who was
the organization’s first national spokesperson. RAINN was founded through mon-
etary help from Atlantic Records and Warner Music Group. At the time of its
founding, RAINN was composed of 347 centers across the United States that
helped provide victim support. RAINN has continually grown and now has more
than 1,100 affiliated centers. Scott Berkowitz is still the president of RAINN, and
Christina Ricci is currently RAINN’s national spokesperson.
RAINN manages two different hotlines, the National Sexual Assault Hotline
and the National Sexual Assault Online Hotline, and since opening in 1994, the
organization has helped more than two million people. RAINN is able to provide
this support by partnering with more than 1,100 local sexual assault agencies
across the nation to bring free and confidential services twenty-four hours a day,
572 Rape Shield Laws
seven days a week. Individuals who contact the national hotline phone number
will be routed to sexual assault service providers in their area.
RAINN expanded its services in 2007 by starting the first confidential online
instant messaging program that enabled individuals to talk with trained staff
members through a secure and confidential web-based interface. The plan to go
digital was due to the fact that half of sexual assault victims are younger than
eighteen, and this age group is more likely to embrace online technology than to
make a phone call. Both hotlines provide confidential support, referrals for med-
ical help, resources, and legal information. The hotline can be contacted by vic-
tims or loved ones looking for information about sexual violence.
The U.S. Department of Defense (DoD) has also contracted RAINN to operate
the DoD Safe Helpline. This helpline is solely for members of the Department of
Defense community and can be reached via phone or the internet. Individuals
trained specifically on topics of military sexual assault operate these hotlines and
provide appropriate help and services based on the caller’s request. The DoD Safe
Helpline is also confidential, and identifying information will not be shared with
the DoD.
RAINN also works closely with the entertainment industry to help educate
people and prevent sexual violence. RAINN provides information and educa-
tional statistics to news junkets across the United States and also runs television
ads with the help of celebrities. These celebrities offer monetary support to
RAINN to help keep their services going. Above all is their informative and
educational website, RAINN.org, that provides not only statistics on sexual vio-
lence but also information on the effects of sexual assault along with other
important educational information. RAINN’s website also provides lists of local
services and tips on how to be safer in public and on the internet. RAINN’s mis-
sion is to help decrease the number of sexual violence incidents across the
nation, and it continually provides new information and support to make this
happen.
Amanda Baker
See also: Date Rape; Incest; Rape; Sexual Abuse; Sexual Assault.
Further Reading
DoD Safe Helpline. (n.d.). About Safe Helpline. Retrieved from https://www.safehelpline
.org/about
Finn, J., & Hughes, P. (2008). Evaluation of the RAINN National Sexual Assault Online
Hotline. Journal of Technology in Human Services, 26(2–4), 203–222.
RAINN. (2019). About RAINN. Retrieved from https://rainn.org/about-rainn
RAINN. (2019). About the national sexual assault telephone hotline. Retrieved from
https://rainn.org/get-help/national-sexual-assault-hotline
Rape Shield Laws
The term “rape shield law” refers to a set of conventions guiding the disclosure of
information about the background of a person who is alleging a sexual assault.
Colloquially, “rape shield law” can be used to describe two different things:
Rape Trauma Syndrome 573
disclosure of a victim’s background in the press or exposure of a victim’s back-
ground during the prosecution of the assailant.
While there is no set law prohibiting the press from disclosing personal infor-
mation about someone alleging a sexual assault, popular convention has deterred
the publication of a victim’s name or likeness. Many media outlets avoid publish-
ing any type of information that could potentially identify an alleged rape victim.
The widespread expansion of news and social media facilitated by the explosion
of wireless and internet technology can affect the trend of protecting rape victims’
identities, and this becomes amplified if it is a high-profile case, such as if a celeb-
rity is being accused.
There are laws governing the use of the victim’s background in the prosecution
of a sexual assault case, and these laws can vary jurisdictionally (Galvin, 1986).
The name of a complaining witness is usually a part of the accusatory instrument,
and thus a part of the case, but there are different guidelines regarding the use of
information about a victim’s past sexual history. The prejudicial nature of this evi-
dence can outweigh its evidentiary value.
While many jurisdictions prohibit the introduction of evidence of a victim’s past,
there are circumstances under which information about a victim’s sexual past may
be introduced as evidence. One is if the victim and the defendant have been intimate
prior to the alleged incident, such as if they were in a sexual relationship or married.
Another is if the victim has had a past conviction of a sex crime, notably a prostitu-
tion offense. A sex work conviction may be introduced as evidence, regardless of its
connection to the current case or the time since the conviction. Another exception to
rape shield laws is if there is evidence that may be used to impeach a witness or
prove perjury. This can occur in a rape prosecution if the complainant asserts they
have never had sex before and the prosecution has a credible witness who testifies
that they had sex with the complainant. Here, the testimony is used to challenge
credibility, but it also has the effect of introducing information about the complain-
ant’s sexual past. Evidence may also be introduced if it can show that forensic evi-
dence found on the victim originated from someone other than the defendant.
Rachel Kalish
See also: Date Rape; Rape; Sexual Assault.
Further Reading
Anderson, M. J. (2002). From chastity requirement to sexuality license: Sexual consent
and a new rape shield law. George Washington Law Review, 70, 51.
Galvin, H. R. (1986). Shielding rape victims in the state and federal courts: An approach
for the second decade. Minnesota Law Review, 70, 763.
Haddad, R. I. (2005). Shield or sieve? People v. Bryant and the rape shield law in high
profile cases. Columbia Journal of Law and Social Problems, 39, 185.
Rape Trauma Syndrome
“Rape trauma syndrome” was coined by two therapists, Ann Burgess and Lynda
Holmstrom, to refer to a series of symptoms that are commonly experienced by
rape victims. Since this syndrome has been named, it has been used in countless
574 Rape Trauma Syndrome
trials to help survivors have a voice. Rape trauma syndrome is a collection of
emotional, physical, and behavioral reactions that are experienced by victims of
attempted or completed rape. Burgess and Holmstrom identified two stages: the
first, known as the acute phase, is the immediate phase of disruption and disorga-
nization; the second phase is the long-term process of reorganization. A third
phase, known as the underground phase, has since been recognized. Phase length
varies, and individuals may go back and forth between the phases. The names of
the stages have also changed over time and may differ depending on the source of
information. This article uses the language used by the creators.
The acute stage occurs immediately after the assault. The physical and emo-
tional reactions in this stage are intense, and sometimes victims are in disbelief or
shock because of what has happened to them. Other emotions that may be experi-
enced include fear, humiliation, shame, guilt, self-blame, anger, and revenge. Due
to the range of emotions, the victims may demonstrate this stage in a variety of
ways, from crying to a composed calmness. Physically, the victim may feel sore-
ness all over the body, generalized pain, and bleeding. They may react with fear
and confusion and have difficulty completing daily tasks. This phase usually lasts
from a few days to a few weeks.
The underground phase follows the acute stage. During this phase, the victim
tries to return to what their life was prior to the rape, and often they may try to act
as if nothing has happened. Throughout this phase, they may not want to discuss
what has happened or to have reminders of the incident. Individuals can remain in
this stage for years and may give off the appearance that they are over what hap-
pened to them.
The final stage is the reorganization stage. This stage is often started off by a
trigger and returns the victim to a phase of emotional turmoil. This process is
often long term and may require outside help and therapy. Through this phase, the
individual can become very frightened of returning to the stage of emotional pain.
Fears and phobias can develop; fantasies of revenge may also come up, and the
individual may experience eating and sleeping disturbances. As this stage develops,
the individual will hopefully be able to work through these difficult emotions and
behaviors and toward returning to a life where the rape is not at the forefront. The
context of the assault, such as the individual’s developmental stage in life, who
committed the assault, cultural background, and the nature of the assault, can have
a significant effect on the process through the reorganization stage.
Amanda Baker
See also: Child Sexual Abuse; Date Rape; Rape; Rape, Abuse and Incest National Net-
work (RAINN); Sexual Abuse; Sexual Assault.
Further Reading
Burgess, A. W. (1983). Rape trauma syndrome. Behavioral Sciences & the Law, 1(3),
97–113.
Burgess, A. W., & Holmstrom, L. L. (1974). Rape trauma syndrome. American Journal of
Psychiatry, 131(9), 981–986.
Rape Crisis Cape Town Trust. (2019). Rape trauma syndrome (RTS). Retrieved from
http://rapecrisis.org.za/information-for-survivors/rape-trauma-syndrome/
Reimer, David 575
Reimer, David
David Reimer was the child at the center of the controversial “John/Joan” gender
experiment conducted by Dr. John Money, a celebrated psychologist in practice at
Johns Hopkins Gender Identity Clinic in Baltimore, Maryland.
Reimer was an identical twin. The infants were born August 22, 1965, in Win-
nipeg, Manitoba, Canada, and named Bruce Peter Reimer and Brian Henry
Reimer. At eight months old, Bruce’s penis was completely severed during a
botched circumcision. After the accident, the twins’ parents, Ron and Janet
Reimer, were referred to Dr. Money for advice on how to care for their son after
his accident.
A well-known sexologist and researcher, Dr. Money believed that human gen-
der identity is malleable and can be instructed or influenced by outside factors. He
is, in fact, credited with coining the term “gender role,” meaning the behavior
“learned by a person as appropriate to their gender, determined by the prevailing
cultural norms.”
Meeting the Reimer family inspired Money to devise an experiment to prove
his theory. With an identical twin to serve as the control, the circumstances
seemed nearly perfect. Money encouraged Reimer’s parents to authorize sex reas-
signment surgery on the baby, raise him as a girl, and never tell either of the twins
(or anyone else) what had happened.
Reimer was the first documented case of sex reassignment of a child born
developmentally normal. Over the course of more than a decade, Money subjected
the Reimer twins to a number of sexually explicit exercises and activities, some of
which were photographed and/or witnessed by half a dozen colleagues or more.
Throughout the experiment, Money continued to report that Brenda (formerly
Bruce) had transitioned successfully and was doing just fine as a girl. He gained
more and more power and fame for his work, and his findings were discussed in
medical textbooks and psychology lectures worldwide.
In reality, however, nothing was further from the truth. Both twins struggled
with depression and anxiety. Brenda, consistently sullen and angry, experienced
severe gender dysphoria and was bullied in school for being too masculine. At age
thirteen, Brenda threatened to commit suicide if made to see Money again.
The twins were fifteen when Ron Reimer finally told his sons what had hap-
pened. Immediately, Brenda assumed the name David and began living as male.
David attempted to put the past behind him, but he remained tortured by the
trauma. He attempted to end his life on more than one occasion, and he so longed
for revenge that he went so far as to buy an unregistered handgun with the inten-
tion of killing the doctors involved. By age twenty-two, he had begun testosterone
therapy and had undergone chest reconstruction surgery to remove the breasts that
had resulted from the estrogen pills he had been subjected to since he was eleven
years old. David later went on to have additional surgical procedures to construct
a penis. In 1997, he married Jane Fontane, who had three young children.
The truth about David’s experience was uncovered by another sex researcher,
Dr. Milton Diamond of the University of Hawaii, who wanted to know what had
become of the twins who had likely entered adulthood. He also wondered why
576 Religion, Diversity of Human Sexuality and
Money had not published or spoken of the twins’ case for more than a decade.
Intrigued, Dr. Diamond hunted down the Reimers and soon learned the real story
and published an article refuting Money’s claims.
The media eventually caught wind of the study gone awry, and David’s life
became front-page headlines. After they hit it off during an interview, David
agreed to let Rolling Stone reporter John Colapinto write his life story. Published
in 2000, the resulting book As Nature Made Him: The Boy Who Was Raised as a
Girl, shined a very unflattering light on the now-infamous story of Dr. Money’s
experiment.
In 2002, David’s brother Brian died after overdosing on antidepressant medica-
tion. David was struggling financially, and he had grown quite weary of the inva-
sion to his privacy. In May 2004, his wife, Jane, told him she wanted a divorce.
Two days later, David shot himself.
Money’s lies had ramifications far beyond just the Reimer family. His reports
were used by the medical community as justification for sex reassignment surger-
ies for thousands of children born with ambiguous genitals or other intersex con-
ditions; this is a nonconsensual practice that has only recently begun to wane after
significant work by intersex community advocates.
C. Michael Woodward
See also: Circumcision; Diamond, Milton; Gender Dysphoria; Gender Identity; Gender
Roles, Socialization and; Money, John; Sex Reassignment Surgery.
Further Reading
Colapinto, J. (2000). As nature made him: The boy who was raised as a girl. New York:
HarperCollins Publishers.
Gaetano, P. (2017, November 15). David Reimer and John Money gender reassignment
controversy: The John/Joan case. Retrieved from https://embryo.asu.edu/pages/
david-reimer-and-john-money-gender-reassignment-controversy-johnjoan-case
Religion, Diversity of Human Sexuality and
There are many philosophical perspectives from which to examine the intersec-
tion of religion and sexuality. A French philosopher, Michel Foucault (1978), dis-
cusses sexuality as socially constructed and suggests that its meaning is derived
from the language that is used to discuss it. When institutions dialogue about sex
and sexuality, John Gagnon (1990) describes this reality as having an instructional
system around sexuality. Religion is one such institution or system.
Religion can be defined as an organized system of beliefs based on a worldview
about the relational interconnectedness between humans, nature, the universe,
creation, or a divine presence. Some key components of religion include commun-
ity, group worship, a set of dogma or doctrine, a set of moral values, rituals, and a
creation story about how the world came to be to help explain the universe and
humanity’s relationship to it. Religions also have what is called a metanarrative, or
a story from which the religious system stems that differentiates it from other reli-
gious systems. In Christianity, this is the story of the passion, death, and resurrec-
tion of Jesus from the Christian Bible; for Islam, it is the story of Muhammad told
Religion, Diversity of Human Sexuality and 577
in the Qur’an; in Buddhism, the metanarrative is the story and life of Siddhartha
Gautama, or the first Buddha. All these aspects are crucial in the interpretation of
the religion. These interpretations then affect the institution’s view of the human
condition, part of which is sexuality.
Because of the various worldviews and experiences that led to the creation of
multiple religions, it follows that each religion has a different way of viewing
human sexuality. How a religion views the purpose of our existence will affect
how it is believed we should operate around sexuality. The view of how humans
relate to the Divine or the universe is called a theological or cosmological
anthropology.
As religion attempts to make sense of various human experiences, it has inevit-
ably been met with the reality of sexuality. Many ancient religions understood that
fertility was a natural human process that exhibited great power. The creation and
perpetuation of humanity quite literally depended on fertility. Fertility of humans,
fertility of land and soil after the dawn of agriculture, and fertility of livestock
were all seen as powers of nature so great that many religions have specific fertil-
ity deities. Prayers, sacrifice, and service were all paid to these deities to appease
them so that nature would work in their favor. Many ancient rituals involved retell-
ing or reenacting stories of fertility to bring about good fortune or luck to situa-
tions in which fertility was unsure or not guaranteed. Differences in fertility
practices or sexual behaviors were often a point of pride for a new religion as it
emerged and distinguished itself and its doctrines from the surrounding religious
systems.
One of the ways religion attempts to make sense of sexuality is by having codes
or rules and regulations around sexual behavior. Because religion is concerned
with how humans relate to the world, it often has proscriptions on how to live in it
as well. Most societies throughout history have had some rules on what was con-
sidered acceptable and unacceptable sexual behavior. While the overall view can
range from seemingly negative views of human sexuality to viewing sexuality as
an ultimate form of divine love, sexuality has been present in much of the dia-
logue around morality.
Within religions, the purpose of humanity is often closely tied to what is sexu-
ally right and wrong. For example, in some religious belief systems, the body is
viewed as bad or weak compared to the soul. This sense of dualism affects how
the religion views sexual pleasure or the effects of procreation. In Christianity, St.
Augustine of Hippo, influenced by Manicheism (a dualistic religion that stresses a
dichotomy between light and dark), felt that sexual intercourse even for procre-
ation is still sinful. The Christian view that sexuality is for procreation stems from
the metanarrative in which God tells Abraham to be fruitful and multiply. The
official Christian church did not accept Augustine’s teaching that all sexual activ-
ity was sinful, but his sentiments of sexuality being innately harmful have per-
sisted throughout history.
In other religions, sexuality can be more readily seen as a holistic part of the
human experience. In these religions, rules of sexual morality may focus more on
appropriate times in life to be sexual or understand a multiplicity of ways to be
sexual. In Hinduism, the understanding of sexual orientation and gender identities
578 Religion, Diversity of Human Sexuality and
guides what is or is not moral based on the fact that there is a place in society for
those with differing sexual experiences and identities.
The word “pornography” is an excellent example of how sexual morality works
in society. The Greek word “porneia” means “illicit” or “illegal sex.” This refers
to any sexual behavior that is deemed wrong or inappropriate for society. In a reli-
gious context, primarily the Christian Bible, this word is translated to mean forni-
cation, adultery, or otherwise sexually immoral behavior.
Rituals are extremely important to religious systems. Many religions today
have rituals around sexuality, just as they might have rituals around initiation or
death. Sexual rituals involve a symbolic act or recognition of power. Some reli-
gions, like Judaism, have rituals around circumcision or menstruation. Other reli-
gions have specific prayers for sexual intercourse between spouses or special
rituals for accessing various sexual energies. For example, religions that focus on
psychic energy and the role of sexuality in that view of humanity may engage in
sex magic—a harnessing of sexual energy to transcend the average human
experience.
People may ascribe to a religion for many reasons: because it resonates most
with their worldview, answers questions, gives them security, supplies them with
a space that feels sacred, gives them a community, has been what their family
practiced, or provides a feeling of closeness to a Divine presence and more con-
nection than another system of belief. Whatever the reason, one’s religious and
sexual identities will likely intersect. For some individuals, navigating this inter-
section is simple and aligns with their experience of sexuality. For others, how-
ever, this intersection can be a point of contention, pain, or sexual discomfort or
dysfunction. A Christian raised with the understanding that sex before marriage is
bad may have internalized this message so much that sex after marriage may be
difficult or impossible because of sexual aversion. A Jewish rabbi who feels pres-
sured to get married may feel so overwhelmed by the implicit sexual obligations
of marriage that they avoid the topic all together. Topics of sexual orientation,
gender identity, differences in sexual development, marital structures and life-
styles (monogamy, nonmonogamy, polyamory, etc.), and sexual development or
behaviors are all places that this dissonance can occur.
The cognitive dissonance that can come with having a sexual identity contrary
to what one’s religion may identify as morally good can be difficult to reconcile.
Some people may seek the help of their religious leaders or religiously sensitive
counselors and therapists. When this identity discord arises, learning about one’s
own religious system and cosmological or theological anthropology can help iden-
tify and resolve the internal and external issues present in the situation.
The concept of sexuality being socially constructed is only one paradigm or
philosophical disposition about the nature of sexuality. Many religions view sexu-
ality as essential—an integral part of the human experience, whether or not it is
discussed on a societal level. The true nature of sexuality is seen to be discover-
able or able to be uncovered by society. In such a view, it is often seen as the
responsibility of the religious leader, theologian, or philosopher to describe that
nature and help others in society strive toward what is morally good. The rituals,
prayers, rules, and regulations are all in existence because somewhere throughout
Reparative Therapy 579
history it was thought to be a good idea to institute such practices. When examin-
ing other codes of sexual morality, it is helpful to know the cosmological or theo-
logical anthropology from which a system works in order to identify why it is held
to be the morally good option. The diversity of the ways religions deal with human
sexuality is vast. A common theme, however, has been that sex and sexuality have
been important enough to make rules about and even honor in certain ways. In our
present society, the intersection of how various cultures and religions deal with
sexuality can be seen in the hotly debated topics of abortion, premarital sex, sex-
ual pleasure, masturbation, and sexuality education. Each voice in these dis-
courses comes from a position that is possibly connected to a religious identity
trying to resolve dissonance.
Mark A. Levand
See also: Antigay Prejudice; Circumcision; Fertility; Menstruation; Reparative Therapy;
Roman Catholic Church Sexual Abuse Scandal; Tantric Intercourse.
Further Reading
Foucault, M. (1978). The history of sexuality: Volume 1, an introduction (R. Hurley,
Trans.). New York: Pantheon.
Gagnon, J. H. (1990). The explicit and implict use of the scripting perspective in sex
research. Annual Review of Sex Research, 1, 1–43.
Reparative Therapy
Reparative therapy (also known as gay conversion therapy or sexual reorientation
therapy) is intended to convert individuals having a homosexual orientation to a
heterosexual one. Targeted primarily toward white male homosexuals, these pro-
grams are based on the assumptions that same-sex attraction is a pathological or
deviant condition and that this orientation can be changed. Beginning in the
1990s, reparative therapies underwent extensive scrutiny as to their theoretical
validity, effectiveness, and potential to inflict harm. These practices are currently
opposed by all major mental health and medical organizations and are banned in
some states, with increasing support for national prohibition. In the face of this,
many organizations that had offered these therapies have closed. Nonetheless,
some reparative therapy programs continue to operate with primary support from
conservative religious organizations.
Discussion of reparative therapies has existed since the 1920s, and over time,
treatments utilized to “cure” homosexuality have included brain surgery, medical
hormonal castration, and behavioral aversion therapy pairing homoerotic images
with sensations of pain or nausea. More recently, less intrusive and more traditional
talk therapy approaches including visualization and skills training have been
emphasized in conversion programs, as have spiritually based interventions.
Historically, proponents of reparative therapy based their theoretical founda-
tion for this treatment on psychoanalytic theory. Reasoning that abnormal develop-
ment patterns resulted in male homosexuality, early indications of homosexual
orientation were thought to be evidenced through an abnormally large amount of
time spent with one’s mother and a lack of interest in sports, physical
580 Reparative Therapy
confrontations with other males, and flirtation and sexual harassment of females.
Ironically, this interpretation’s use of psychoanalytic theory is at odds with the
opinion voiced by Sigmund Freud that homosexuality was not a feature that could
be, or perhaps should be, changed. It is also inconsistent with other psychoanalytic
interpretations of male homosexual identity development.
Theoretically, reparative therapy conflicts with mainstream beliefs in two ways.
First, it views homosexuality as pathological and in some cases even criminal or
immoral. In contrast, homosexual orientation has not been considered a disorder
by professional mental health organizations since 1973 and has also received
increasing social and political acceptance. Second, there is no theoretical or
empirical support for viewing homosexual orientation as changeable rather than
innate to the individual. There are no empirical studies indicating these programs
are successful in changing sexual orientation. Results reported by programs are
also questionable in that they often measure success based on reported homosex-
ual activity rather than sexual orientation so that a lack of homosexual activity
would be considered a success. Further, many programs believe that a homosexual
cannot have sex with an other-sex partner, so engaging in heterosexual sex indi-
cates a successful conversion. Finally, participant reports indicate coercive factors
may influence reported results as participants may indicate changes to please pro-
gram therapists or to avoid alienation or exclusion from group affiliations, such as
expulsion from schools.
Beyond failing to change sexual orientation, reparative therapy programs can
cause harm to participants. Programs may not ethically inform participants that
this therapy is deemed ineffective and banned by mental health organizations and
that their assumptions are at odds with majority views on the nature of homosex-
uality as reflecting normal versus pathological development. They may provide
misinformation as to the connection of homosexual orientation to other patholo-
gies, fail to allow for informed consent, and create false impressions of program
effectiveness. As a result of the misinformation and intervention approaches used
in reparative therapy, participants may suffer from depression and suicidal ide-
ation, anxiety, reduced self-esteem, relational disruption, feelings of alienation
and isolation, and identity confusion.
Given that the professional literature is rich with information that is critical of
reparative therapy, the lack of theoretical or research foundation for these pro-
grams supports criticism that they are based on personal opinion and social bias
rather than scientific evidence. The content of websites promoting reparative ther-
apy offer two main justifications for the treatment. The first is that of professional
therapists who feel those who want this type of treatment have a right to have it,
regardless of the negative evaluation of this therapy in the professional commun-
ity. The second is that of religious counselors who believe homosexuality is sinful
and should be changed on moral grounds. Those reparative therapy programs that
continue to operate tend to have religious themes and emphasize the belief that
homosexuality can be changed yet stress the responsibility of the participant for
results and make no promises for change.
Mary McClure
Reproductive Coercion 581
See also: Antigay Prejudice; Gay Affirmative Therapy; Homophobia; Homosexuality;
Religion, Diversity of Human Sexuality and; Sexual Identity; Sexual Orientation.
Further Reading
Arthur, E., McGill, D., & Essary, E. H. (2014). Playing it straight: Framing strategies
among reparative therapists. Sociological Inquiry, 84(1), 16–41.
Bright, C. (2004). Deconstructing reparative therapy: An examination of the processes
involved when attempting to change sexual orientation. Clinical Social Work
Journal, 32(4), 471–481.
Haldeman, D. C. (1994). The practice and ethics of sexual orientation conversion therapy.
Journal of Consulting and Clinical Psychology, 62(2), 221–227.
Shidlo, A., & Schroeder, M. (2002). Changing sexual orientation: A consumers’ report.
Professional Psychology: Research and Practice, 33(3), 249–259.
Reproductive Coercion
Reproductive coercion, also called coerced reproduction, is a form of domestic
violence that occurs when a sexual partner destroys, or fails to use, a form of con-
traception without telling their partner; threatens a partner who does not want to
become pregnant; forces a partner to carry a pregnancy against their wishes; or
forces a partner to terminate a pregnancy. Essentially, one partner is preventing
the other from making their own reproductive decisions. While reproductive coer-
cion can happen in relationships of all genders, sexes, and sexual orientations, it is
most frequently seen in mixed-sex couples in which the male partner inflicts
reproductive coercion on their female partner. During reproductive coercion, cer-
tain reproductive health behaviors are used to maintain power and control over
another person in the relationship in an attempt to keep them in an abusive rela-
tionship. The behaviors can include intimidation, verbal threats, or acts of vio-
lence that are used to influence a person’s reproductive decision making with the
intent to pressure or coerce a partner into becoming a parent or ending a
pregnancy.
These behaviors generally take three forms: pregnancy pressure, pregnancy
coercion, and birth control sabotage. Pregnancy pressure and coercion occur when
one partner is pressured or coerced by the other partner to have unprotected sex to
get pregnant, to continue an unwanted pregnancy, or to terminate a pregnancy.
Birth control sabotage can be verbal or behavioral and is defined as pressure to
become pregnant or not to use birth control. Verbal sabotage includes statements
such as “You would have my baby if you loved me,” or “I’ll leave you if you don’t
get pregnant.” Behavioral sabotage includes acts such as poking holes in or break-
ing a condom, throwing away birth control pills and replacing them with place-
bos, hiding or destroying birth control, removing a condom during intercourse
without the other partner knowing, or the forceful removal of contraceptive
devices such as vaginal rings or intrauterine devices. It may also include the use of
force to have unprotected sex.
The direct relationship between physical violence and reproductive coercion is
not entirely known, and birth control sabotage does not occur solely in violent
582 Retrograde Ejaculation
relationships, but several studies have demonstrated a strong link between domes-
tic violence and birth control sabotage. The risk of unintended pregnancy increases
dramatically for women in physically abusive relationships. If a woman has a
physically abusive partner, that partner is likely to engage in reproductive coer-
cion as well. And this coercion affects women across the socioeconomic and edu-
cational spectrum. An important strategy to help reduce reproductive coercion is
to focus on the training of health care providers, and in particular OB/GYNs, to
recognize victims of reproductive coercion and direct these patients to agencies
and hotlines, such as the National Domestic Violence Hotline, that help women
who are abused.
Currently in the United States, it is not a crime to destroy birth control pills or
a condom. However, it is a crime to force a woman to ingest a substance or a pill
that induces an abortion without her knowledge.
Amy Reynolds
See also: Contraception; Pregnancy; Rape, Abuse and Incest National Network (RAINN);
Sexual Abuse; Sexual Rights.
Further Reading
Murray, R. (2013, June). More men are sabotaging women’s birth control to get them
pregnant: ACOG. NY Daily News. Retrieved from http://www.nydailynews.com/
life-style/health/men-sabotaging-women-birth-control-article-1.1361932
Trawick, S. M. (2012). Birth control sabotage as domestic violence: A legal response.
California Law Review, 100(3), 721–760.
Retrograde Ejaculation
“Retrograde ejaculation” (RE) refers to the backward movement of semen into the
bladder as opposed to the typical movement expulsion pattern via the urethra dur-
ing ejaculation. This results in what is referred to as a “dry orgasm” or “dry ejacu-
lation,” where little to no semen is externally released. RE is not a physically
harmful or painful condition but may be permanent depending on its cause and
other contributing factors. Infertility is common among those with RE, and addi-
tional treatment may be required in order to conceive. Although RE may feel as
pleasurable as a typical orgasm, psychological issues may arise if the individual
experiences feelings of inadequacy derived from social expectations placed on
masculinity and sexual performance.
Antegrade or forward-moving ejaculation (AE) occurs when sperm is trans-
ported from the testes to the prostate via the muscular vessel referred to as the vas
deferens. Once in the prostate, the sperm mixes with prostatic secretions and sem-
inal fluid to produce the male ejaculate known as semen. This ejaculate is then
propelled through the urethra before exiting the penis externally. For this function
to be performed, the muscle located at the opening of the bladder, otherwise
known as the bladder neck, closes to prevent the entry of semen into the bladder.
During RE, these muscles fail to contract, allowing for semen to enter the bladder
instead of traveling through the urethra. This dysfunction can be attributed
to anatomical, surgical, neurological, or drug-induced causes and will vary
Retrograde Ejaculation 583
according to each case. Signs indicative of RE include urine that appears to be
cloudy after orgasm, expelling little or no semen from the penis during ejacula-
tion, and infertility among different-sex couples trying to conceive.
The most common causes of RE include medications and surgical procedures
that relax the bladder neck. If a person believes they are experiencing RE due to
medication, they may consult with a physician regarding the discontinuation or
alteration of their medication. Neurological issues related to RE include, but are
not limited to, spinal cord injury, diabetes, and multiple sclerosis. Certain surger-
ies surrounding the prostate, urethra, and bladder may also lead to RE by causing
damage to the prostatic muscles responsible for contracting and the bladder neck.
Retroperitoneal lymph node dissection (RLND), for example, is common among
people with RE. RLND is a surgical procedure that is used to identify and treat
testicular cancer. During this surgery, the nerves that control the bladder neck
may be injured, leading to ejaculatory dysfunction. Of the several notable causes
mentioned, RE induced by medication tends to be the easiest to treat and shows
the most successful reversal rate.
RE is not physically harmful, nor does it cause physical pain or discomfort in
most cases. While the ejaculatory fluid does not physically exit from the penis,
having an orgasm is entirely possible, and the sensation typically resembles that of
an orgasm with AE. Although a person may be physically healthy, it is important
to consider the emotional and psychological implications that may result from
feelings of inadequacy or emasculation. These feelings are likely to be derived
from issues pertaining to infertility and concerns about sexual performance.
Cognitive awareness and subjective perception of self are highly influential
while evaluating RE and how it affects quality of life. A man’s relationship with
his sexuality is often heavily influenced by societal standards and expectations
surrounding masculinity. The often strong correlation between masculinity and
the ability to reproduce may leave one feeling as though they are evolutionarily
inferior and incomplete in their masculinity. This unfortunate misconception may
then lead to issues such as performance anxiety or distress, leading to a decrease
in sexual satisfaction. Inaccurate associations surrounding personal and partnered
relationships with sex and intimacy is another possible result.
If infertility is a concern, there are viable options that allow for the successful
retrieval of sperm. Postejaculation sperm retrieval followed by a postejaculate
urine analysis is a noninvasive and promising option for many experiencing RE.
Since the seminal fluid is redirected to the bladder during orgasm, a urine sample
containing the semen can be collected post ejaculation. This method can be com-
pleted in a few easy steps with the guidance of a physician and is the most favor-
able option due to its noninvasive nature. Artificial stimulation of emission and
ejaculation is a less favorable option as it is more invasive and requires anesthetic.
Artificial stimulation is typically recommended for individuals with RE stem-
ming from a spinal cord injury.
Although RE is noted as a common form of ejaculatory dysfunction in males,
the topic is rarely discussed or researched from an evidence-based standpoint. It
is, however, known that RE poses no physical threat and does not have to deter an
individual from having a fulfilling sexual, intimate, and social life. Infertility
584 Roe v. Wade
resulting from RE is a prominent concern, and modern methods used to retrieve
sperm for artificial insemination purposes have proven to be hopeful and viable
options. Overall, people experiencing RE may suffer from both medical and
psychological concerns. The extent of distress experienced by the individual is
dependent on both the cause of the dysfunction as well as social and emotional
stressors associated with male sexuality and performance.
Cheyenne Taylor
See also: Ejaculation; Infertility; Male Sexuality; Masculinity; Performance Anxiety;
Premature Ejaculation; Semen; Testicular Cancer.
Further Reading
Harvard Health Publishing. (2018). Retrograde ejaculation. Retrieved from https://www
.health.harvard.edu/a_to_z/retrograde-ejaculation-a-to-z
Kamischke, A., & Nieschlag, E. (2002). Update on medical treatment of ejaculatory dis-
orders. International Journal of Andrology, 25(6), 333–344.
Mayo Clinic. (2019). Retrograde ejaculation. Retrieved from https://www.mayoclinic.org/
diseases-conditions/retrograde-ejaculation/symptoms-causes/syc-20354890
Mehta, A., & Sigman, M. (2015). Management of the dry ejaculate: A systematic review
of aspermia and retrograde ejaculation. Fertility and Sterility, 104(5), 1074–1081.
Memorial Sloan Kettering Cancer Center. (2018). Retrograde ejaculation. Retrieved from
https://www.mskcc.org/cancer-care/patient-education/retrograde-ejaculation
Metro Vancouver Urology. (2013). Retrograde ejaculation and anejaculation. Re-
trieved from http://www.metrovanurology.com/content/retrograde-ejaculation-and
-anejaculation
Yavetz, H., Yogev, L., Hauser, R. Lessing, J. B., Paz, G., & Homonnai, Z. T. (1994).
Retrograde ejaculation. Human Reproduction, 9(3), 381–386.
Roe v. Wade
Roe v. Wade is a landmark legal decision issued on January 22, 1973, in which the
U.S. Supreme Court struck down Texas laws banning abortion. This decision in
effect legalized the procedure for all of the United States.
In the early nineteenth century, a woman could get a legal abortion. It was legal
if it was done before “quickening,” when the woman felt the fetus move, usually
about the fourth month of pregnancy. Over time, states made it illegal in response
to women dying from abortions that were done by untrained people or under
unsafe conditions. In the late 1850s, the new American Medical Association began
calling for laws against abortion. This was partly to eliminate doctors’ competi-
tion from midwives and homeopaths who performed the procedure. In 1873, Con-
gress passed the Comstock Law, which made it illegal to distribute birth control
and abortion-inducing drugs through the U.S. mail. Eventually abortion was ille-
gal in all the states.
In the 1960s, the sexual revolution and women’s rights movement resulted in
public pressure to make abortion laws less restrictive. Some women resorted to
illegal, dangerous, “back-alley” abortions or aborted the fetus themselves. In the
1950s and 1960s, the estimated number of illegal abortions in the United States
Roe v. Wade 585
ranged from 200,000 to 1.2 million per year. When a few states began to relax
abortion restrictions, some women found it relatively easy to travel to a state
where the laws were less stringent. Some women could find a doctor who was
willing to certify that there was a medical necessity for an abortion. Poor
women, however, often could not afford to travel outside their state for the pro-
cedure. The state laws that were in place were often unclear, so doctors did not
really know whether they were committing a serious crime by providing an
abortion. In this time of social change, government interference in sexual mat-
ters was beginning to be questioned by people who were shifting their concep-
tion of privacy.
The Roe v. Wade case began in 1970 when “Jane Roe,” a fictional name used to
protect the identity of the plaintiff, Norma McCorvey, filed suit against Henry
Wade, the district attorney of Dallas County, Texas. The case challenged the state
law banning abortion. McCorvey was young, unmarried, poor, and pregnant for
the third time. Two recent law school graduates, Sarah Weddington and Linda
Coffee, took her case and won it. After the district court found the Texas law
unconstitutional, Wade appealed to the Supreme Court.
Sarah Weddington argued the case in the higher court as well. In the Roe deci-
sion, Justice Blackmun’s majority opinion explicitly rejected a fetal “right to life”
argument. He wrote that these Texas laws in most cases violated a woman’s con-
stitutional right of privacy. He found it to be implicit in the liberty guarantee of the
due process clause of the Fourteenth Amendment (“nor shall any state deprive any
person of life, liberty, or property, without due process of law”). The court also
said that this right must be balanced against the state’s interests in regulating abor-
tions, protecting women’s health, and protecting the potential for human life.
There is no right to privacy explicitly guaranteed in the Constitution, but the
Supreme Court has long recognized some right to privacy. Starting in the 1960s,
the court’s position on privacy came to be seen as a right connected to a person
rather than to a location. The change in conceptions of privacy can be seen in the
landmark decision of Griswold v. Connecticut (1965). The Supreme Court ruled
that a Connecticut statute outlawing access to contraception violated the U.S.
Constitution because it invaded the privacy of married couples to make decisions
about their families. Since 1973, many court cases in the states have narrowed the
scope of Roe v. Wade but have not overturned it. In Planned Parenthood v. Casey
(1992), the Supreme Court established that restrictions on abortion are unconstitu-
tional if they place an “undue burden” on a woman seeking an abortion before the
fetus is viable (able to live outside the woman’s body). Advocates both for and
against abortion rights continue to debate the issue, and many people are con-
cerned about changes in the makeup of the Supreme Court that could alter the law
in one direction or the other.
Michael J. McGee
See also: Abortion Legislation; Planned Parenthood v. Casey.
Further Reading
Gold, R. B. (2003). Lessons from before Roe: Will past be prologue? Guttmacher Report
on Public Policy, 6(1), 8–11.
586 Roman Catholic Church Sexual Abuse Scandal
Reagan, L. J. (1997). When abortion was a crime: Women, medicine, and law in the
United States, 1867–1973. Berkeley: University of California Press.
Torr, J. D. (2006). Abortion: Opposing viewpoints. Farmington Hills, MI: Greenhaven
Press/Thomson Gale.
Roman Catholic Church Sexual Abuse Scandal
The Roman Catholic Church sexual abuse scandal was named a scandal for the
way that American Catholic bishops handled sexually offending priests. In 2002,
a series of stories surfaced of people being sexually abused as minors by Catholic
priests. Many bishops had a common practice of removing offending priests from
one parish and placing them in another parish, with further opportunity to offend.
The legality of these cases could often be overlooked because many of the victims
never formally brought charges against offending priests. The stories of abuse ori-
ginated in the archdiocese of Boston and created a space for other victims to tell
their stories.
Awareness of sexual abuse in the Catholic Church had been growing steadily
over the years leading up to the scandal. In 1992, the archbishop of Chicago, Car-
dinal Joseph Bernardin, commissioned a board of primarily nonclerical (lay)
Catholics to review charges brought against bishops and priests. Another recogni-
tion of the sexual misconduct of priests was the creation of the VIRTUS program
by the National Catholic Risk Retention Group in 1998. This program was
designed to inform people of what the organization calls human relationship,
including relationships between adults and children as well as other vulnerable
populations. Ultimately, in January 2002, the Boston Globe began publishing stor-
ies of people who were sexually abused by priests. Thousands of other articles
began arising all over the country. People who had been abused as minors finally
had a space and a community to go to with their stories that they had not had
before. Later that year, in Dallas, the U.S. bishops had a general meeting at which
they approved the Charter for the Protection of Children and Young People. This
charter created a board that commissioned the John Jay College of Criminal Jus-
tice to conduct a study to help understand the causes and context of the scandal.
This report became known as The Causes and Context of Sexual Abuse of Minors
by Catholic Priests in the United States, 1950–2010, or The John Jay Study.
As a result of the scandal, many other Catholic organizations around the world
began examining their own policy around priests that have sexually abused
minors. After a similar scandal took place in Ireland in the spring of 2010, Pope
Benedict XVI wrote a pastoral letter to the Catholics of Ireland expressing feel-
ings of true sorrow and apologizing for the sinful and criminal mistakes made by
members of the church.
The John Jay Study came under attack from both Catholic and non-Catholic
sources for having authority limitations. In addition, an unusually high number of
sexual abuse incidences in the report (about 40%) seemed to take place within a
six-year time span, from 1975 to 1980. The report did, however, make a point to
dispel the myth that if a priest is gay, he has a higher likelihood of sexually abus-
ing a minor.
Romantic Attraction and Orientation 587
Pope Francis I approved a specific tribunal (a church committee) to hear the
cases of bishops accused of failing to protect minors in which high-ranking church
members will be held accountable for their cover-ups. The scope of this tribunal
will be to address the specific cases of high-ranking clerics who had been virtu-
ally immune to repercussions for their actions.
Mark A. Levand
See also: Child Sexual Abuse; Religion, Diversity of Human Sexuality and; Sexual
Abuse.
Further Reading
Dempsey, J. Q., Gorman, J. R., Madden, J. P., & Spilly, A. P. (1992). The cardinal’s com-
mission on clerical sexual misconduct with minors. Chicago: Archdiocese of
Chicago.
National Catholic Risk Retention Group. (1999). Taking bigger and bigger steps. Com-
municare, 1(1), 1–4.
Pope Benedict XVI. (2010). Pastoral letter of the Holy Father Pope Benedict XVI to the
Catholics of Ireland. Retrieved from http://w2.vatican.va/content/benedict-xvi/
en/letters/2010/documents/hf_ben-xvi_let_20100319_church-ireland.html
Roberts, T. (2011). Critics point to John Jay study’s limitations. National Catholic
Reporter. Retrieved from http://ncronline.org/news/accountability/critics-point
-john-jay-studys-limitations
Terry, K. J., Smith, M. L., Schuth, K., Kelly, J. R., Vollman, B., & Massey, C. (2011). The
causes and context of sexual abuse of minors by Catholic priests in the United
States, 1950–2010: A report presented to the United States Conference of Catholic
Bishops by the John Jay college research team. Washington, DC: United States
Conference of Catholic Bishops.
Romantic Attraction and Orientation
Romantic attraction and orientation are concepts similar to sexual attraction and
orientation. Just as people can be sexually attracted to others of the same sex/gen-
der, another sex/gender, both same and other sexes/genders, or not at all, people
can be romantically attracted to others of the same sex/gender, another sex/gender,
both same and other sexes/genders, or not at all.
Many people, including scientific researchers, use the term “sexual orientation”
to account for all types of attraction (e.g., romantic, sexual) to other people. How-
ever, some biological and psychological research has indicated that sexual attrac-
tion (who people want to have sex with) and romantic attraction (who people want
to love or be in a romantic relationship with) are two different constructs with
different brain systems.
For most people, it is expected that their romantic attraction and orientation
matches with their sexual attraction and orientation. In other words, individuals
who are sexually attracted to other-sex/gender individuals (e.g., people who are
heterosexual or straight) are also romantically attracted to other-sex/gender indi-
viduals or that people who are sexually attracted to same-sex/gender individuals
(e.g., people who are gay or lesbian) are also romantically attracted to same-
sex/gender individuals. However, this is not always the case.
588 Romantic Attraction and Orientation
Some bisexual individuals report being sexually attracted to both men and
women but only romantically attracted to one sex/gender or the other. Alterna-
tively, some may be romantically attracted to both sexes/genders but may only
experience sexual desire for either the same or other sex/gender.
The construct of romantic attraction and orientation may be especially relevant
to people with an asexual sexual orientation. People with an asexual sexual orien-
tation report a lack of sexual attraction to other people, regardless of sex or gen-
der. However, not all people with an asexual sexual orientation report a lack of
romantic attraction. Some asexual individuals desire and want to be in intimate
and romantic relationships with other people. Further, these people could be
romantically interested in the same sex/gender (homoromantic), other sex/gender
(heteroromantic), or any sex/gender (biromantic, panromantic). If a person experi-
ences neither sexual attraction nor romantic attraction, they may identify as asex-
ual and aromantic.
Interestingly though, given that sexual attraction and romantic attraction are
two distinct constructs, this means that people who experience sexual attraction
(i.e., those with a sexual orientation other than asexuality) can potentially also be
aromantic. For these people, they may desire to have a sexual relationship with a
single person or with multiple people, but they do not desire to, or are unable to,
experience a romantic connection with their partner(s).
Given that most research on attraction and sexual orientation assumes that
romantic attraction is a component of sexual orientation, more research on the
distinction between sexual attraction and romantic attraction, and the outcomes
when these two concepts do not align, is needed.
Heather L. Armstrong
See also: Asexuality; Bisexuality; Kinsey’s Continuum of Sexual Orientation; Sexual
Identity; Sexual Orientation.
Further Reading
Bogaert, A. F. (2015). Understanding asexuality. Lanham, MD: Rowman & Littlefield.
Diamond, L. M. (2003). What does sexual orientation orient? A biobehavioral model dis-
tinguishing romantic love and sexual desire. Psychological Review, 110(1),
173–192.
Fisher, H. E., Aron, A., Mashek, D., Li, H., & Brown, L. L. (2002). Defining the brain
systems of lust, romantic attraction, and attachment. Archives of Sexual Behavior,
31(5), 413–419.
S
Safer Sex
“Safer sex” is an umbrella term for a range of practices that people can employ to
reduce the risk of contracting or transmitting a sexually transmitted infection
(STI) during consensual sexual encounters. STIs are infections that can be passed
on through genital contact, body fluids, or, sometimes, skin-to-skin contact. Sex
has, of course, risks that are not just physical, such as emotional and relational
risks. However, “safer sex” is a term commonly used to refer to the management
of physical risks associated with sexual practices, mainly the transmission of
STIs, including HIV.
One of the main practices under the safer sex umbrella is the use of condoms
for insertive and receptive sexual activities. To be effective, condoms need to be
used from the beginning of sexual contact—for example, before inserting a penis
into a vagina or anus. Condoms can be insertive—that is, placed on the penis or
toys that are then inserted into an orifice, such as the mouth, vagina, or anus. This
is the most common type of condom, which is usually distributed in safer sex kits
and can be easily found in a range of stores, from pharmacies to gas stations.
Receptive condoms are less popular, as they have only been in use since the early
1990s. They are placed in the vagina or anus and are commonly known as female
condoms. Condoms are available in both latex and nonlatex materials, and using
lube at the same time reduces friction and thus the risk of breaking the condom
during sexual intercourse. Condoms are for single use only, which means that
multiple condoms can be used in a single sexual encounter, if there are multiple
insertions. Condoms can also be used on toys to decrease exposure to other peo-
ple’s bodily fluids when switching toys between partners or in sexual encounters
with multiple people. The use of condoms reduces the risk of pregnancy and STI
transmission, even though those risks can never be completely eliminated during
a sexual encounter with another person.
The choice and use of sex toys also need to be considered for safer sex. Some
sex toys are made from porous materials, which might encourage the pooling of
harmful bacteria, and some are made from toxic materials, which should not come
into contact with genitals. Generally, silicone, glass, and metal sex toys are the
safest and easier to clean, including the ability to sterilize them through boiling. It
is important to not insert a toy in the anus first and then into the vagina, even
when masturbating or when inserting it in the same person, given that the bacteria
in the anus can cause infection in the vaginal area.
Safer sex practices can include the use of contraceptives, such as oral hormonal
pills, intrauterine devices, diaphragms, spermicides, contraceptive sponges, vagi-
nal rings, implants, and so on. However, those methods only reduce the risk of
590 Same-Sex Attraction and Behavior
pregnancy and do not stop the transmission of STIs, including HIV. Regular HIV
and STI testing is also part of safer sex practices, especially when a higher number
of sexual partner is involved or when new sexual partners are introduced.
Alex Iantaffi
See also: Barrier Contraceptive Methods; Condoms, Female (Receptive); Condoms, Male
(Insertive); Contraception; Intercourse; Sex Toys; Sexual Health; Sexually Transmitted
Infections (STIs); Testing, STI.
Further Reading
Farr, G., Gabelnick, H., Sturgen, K., & Dorflinger, L. (1994). Contraceptive efficacy and
acceptability of the female condom. American Journal of Public Health, 84(12),
1960–1964.
Stabile, E. (2013). Getting the government in bed: Regulating the sex toy industry. Berke-
ley Journal of Gender, Law & Justice, 28, 161–184.
Steiner, M., Piedrahita, C., Glover, L., Joanis, C., Spruyt, A., & Foldesy, R. (1994). The
impact of lubricants on latex condoms during vaginal intercourse. International
Journal of STD & AIDS, 5(1), 29–36.
World Health Organization. (2007). Global strategy for the prevention and control of
sexually transmitted infections: 2006–2015: Breaking the chain of transmission.
Geneva: World Health Organization.
Same-Sex Attraction and Behavior
Same-sex attraction and same-sex behavior are two components of what is com-
monly referred to as “sexual orientation.” “Sexual orientation” refers to an indi-
vidual’s pattern of sexual desire for others, their sexual behavior in relation to
others, and their sexual identity or label; it is a predominantly Western way to
understand sexual diversity. For most people, their sexual behavior, attraction, and
identity label all align; however, this is not always the case. For example, some
people may self-identify as “straight” but may have same-sex attraction or behav-
ior. Many bisexual people who are in committed, monogamous relationships
experience bisexual attraction and may self-identity as “bisexual,” but they may
only have sex with one person and therefore one sex or gender.
Alfred Kinsey (1948) conceptualized sexual orientation as a single behavioral
continuum ranging from “exclusively heterosexual” to “exclusively homosexual.”
Subsequent models of sexual orientation have considered additional dimensions,
such as sexual attraction, sexual fantasies, emotional preference, social prefer-
ence, and self-identity. Various scales have been developed to measure these
components—for example, the Klein Sexual Orientation Grid. Quite recently,
sexuality theorists have posited new models for understanding sexual orientation
that consider partnered sexualities (gender or sex and partner number).
Most of the scales developed to measure sexual orientation were and continue
to be based on a binary gender/sex system. This binary gender or sex system has
been problematized by queer theorists in the West. Historical and modern studies
of non-Western cultures document different frameworks and conceptualizations
Same-Sex Attraction and Behavior 591
of gender or sex and sexual orientation that have been devalued and erased via
European colonization. For most of human history, the concept of sexual orienta-
tion as it is understood today did not exist, and the acceptability of same-sex sex-
ual behavior and attraction has varied with time and place. In what is now North
America, many indigenous peoples recognized two-spirit individuals, a term that
encompasses a diversity of gender/sex identities and roles. Prior to colonization,
similar attitudes were found among many indigenous peoples; for example, same-
sex relationships were accepted and relatively common among the Maori, the
indigenous people of New Zealand.
In Europe, a strong Christian tradition resulted in any sexual activity other than
procreative sex within marriage being seen as sinful. Sodomy in particular,
regardless of the gender/sex of the individuals involved, was considered to be
against the “natural law” that governed human behavior and was therefore illegal
as well as immoral. With the development of modern Western medical practices—
including psychiatry—in the nineteenth century, however, these views shifted,
and sexual orientation was framed first as a matter of health or illness and then as
an inherent and fixed characteristic and a key feature of an individual’s sexual
self. Previous understandings of same-sex attraction and behavior were replaced
by this new conceptualization.
Within this current Western framework, a number of theories have been pro-
posed to explain the development of sexual orientation. Masters and Johnson
(1979) suggested a behavioral explanation, that sexual orientation is determined
by the reinforcement or punishment of same-sex or different-sex sexual behavior
via pleasurable sexual experiences or unpleasant ones. Subsequent behavioral
research conducted within this theoretical framework has provided mixed results;
it seems that experience may have some influence on sexual orientation, but it is
likely not the only factor.
Biological theories focus on genetics, hormones, and physiology as the poten-
tial causes of nonheterosexual sexual orientations. Studies with identical and fra-
ternal twins indicate a possible genetic component: individuals whose identical
twin is gay or lesbian are more likely to be gay or lesbian themselves, although
this has been examined far more in gay men than in women, and the limited evi-
dence regarding this phenomenon in women is not as strong. In addition, the fact
that not all identical twins have the same sexual orientation suggests that other
factors may play a role. Exposure to differing levels of hormones during prenatal
development as well as the anatomy of specific brain structures have been sug-
gested as additional influences, although the mechanism of these influences is not
yet clear. The connection between orientation and brain anatomy in particular has
not been satisfactorily determined; it is not known whether these anatomical dif-
ferences determine sexual orientation or whether sexual orientation may result in
these differences developing later in life.
In contrast to biological theories, social constructionist theories emphasize
that the categories and frameworks used to understand sexual orientation are
socially constructed while recognizing the significant impact that categories
such as gay, lesbian, bisexual, and heterosexual have on individuals’ lives. In his
592 Same-Sex Attraction and Behavior
key work The History of Sexuality, Michel Foucault outlined the substantial
shifts in how sexuality has been viewed across time and place, arguing that
sexuality is not an inherent characteristic of individuals but rather is defined by
cultures through the delineation of certain kinds of relationships and behaviors
as sexual, specifically as “heterosexual” or “homosexual.”
Regardless of the underlying cause(s) of sexual orientation, the social catego-
ries and valuing of alignment between attraction, behavior, and identity further
marginalize, pathologize, and cause distress for people and communities with
diverse experiences and social locations. In her sexual configurations theory, van
Anders (2015) summarized a number of shortcomings in existing theories and
research related to sexual orientation, such as the implication that sexual orienta-
tion is about attraction to biological sex rather than gender; the privileging of het-
erosexuality as a desired, natural default; and the failure to account for the fact
that attraction and behavior are not always fixed and may shift over the course of
an individual’s lifetime. In addition, she provides a framework that includes sex-
ual attraction, behavior, and identity as well as a diversity of partnered sexualities
with regard to sex/gender and relationship structure. The variations in alignment
between sexual identity label, sexual attraction, and sexual behavior as well as the
fluid nature of these constructs have been noted by Diamond (2016) and others
and may be more common than previously thought.
Nathan Lachowsky and Karyn Fulcher
See also: Binary Gender System; Biological Theories of Sexual Orientation; Kinsey’s
Continuum of Sexual Orientation; Sexual Orientation.
Further Reading
Aspin, C., & Hutchings, J. (2007). Reclaiming the past to inform the future: Contempo-
rary views of Maori sexuality. Culture, Health & Sexuality, 9(4), 415–427.
DeLamater, J. D., & Hyde, J. S. (1998). Essentialism vs. social constructionism in the
study of human sexuality. Journal of Sex Research, 35(1), 10–18.
Diamond, L. M. (2016). Sexual fluidity in males and females. Current Sexual Health
Reports, 8, 249–256.
Epstein, R., & Robertson, R. E. (2014). How to measure sexual orientation range and why
it’s worth measuring. Journal of Bisexuality, 14(3–4), 391–403
Fausto-Sterling, A. (2000). Sexing the body: Gender politics and the construction of sexu-
ality. New York: Basic Books.
Foucault, M. (1980). The history of sexuality. Volume one: An introduction. (R. Hurley,
Trans.) New York: Vintage Books.
Galupo, M. P., Lomash, E., & Mitchell, R. C. (2017). “All of my lovers fit into this scale”:
Sexual minority individuals’ responses to two novel measures of sexual orienta-
tion. Journal of Homosexuality, 64(2), 145–165.
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human
male. Oxford: Saunders.
Masters, W. H., & Johnson, V. E. (1979). Homosexuality in perspective. Boston: Little,
Brown.
Van Anders, S. (2015). Beyond sexual orientation: Integrating gender/sex and diverse
sexualities via sexual configurations theory. Archives of Sexual Behaviour, 44,
1177–1213.
Same-Sex Marriage 593
Same-Sex Marriage
“Same-sex marriage” refers to the legal union of two individuals of the same
sex—in other words, the marriage of two men or two women. These marriages
can occur in civil (i.e., nonreligious) or religious ceremonies. Same-sex marriage
has long been a topic of political, social, and religious debate, with opponents con-
trasting it to a “traditional” or heterosexual marriage between one man and one
woman.
Same-sex unions are not new, and records dating from ancient Greece, Rome,
and China show loving relationships, sometimes formalized through ritual pro-
ceedings, between two men and two women. However, while same-sex unions
have been recorded across varying times and cultures, legal recognition of these
unions is relatively new. In 2001, The Netherlands became the first country to
legalize same-sex marriages, followed by Belgium (2003) and Spain (2005) in
Europe, and Canada (2005) in North America. As of summer 2020, twenty-nine
countries now perform same-sex marriages, including much of Europe, all of
North America, several in Central and South America, Australia, New Zealand,
and South Africa. The United States extended the right to marry to all citizens
with a historic Supreme Court ruling on June 26, 2015. Several additional coun-
tries recognize marriages performed internationally and/or allow for civil unions
between same-sex couples.
Marriage offers numerous benefits to committed couples, both mixed-sex and
same-sex. Married couples are immediately entitled to practical, legal benefits
such as family law, adoption, pension and health benefits, tax benefits, immigra-
tion, and inheritance and power of attorney. Without these rights, same-sex cou-
ples have been denied the ability to start families and to care for their loved ones
during sickness and death. Same-sex marriage also provides social support for
couples, with recently married couples reporting greater acceptance of relation-
ships by family and friends. Legalization of same-sex marriage also increases
social support on a greater scale, with public support of same-sex marriage sig-
nificantly increasing after laws are passed. This greater social acceptance may
also contribute to decreases in internalized homophobia, which in turn is associ-
ated with better mental and physical health outcomes for gay, lesbian, and bisexual
individuals. In addition, gay and bisexual men living in Massachusetts reported
significantly fewer medical and mental health care visits and decreased health
care costs following the legalization of same-sex marriage in that state, regardless
of their own marital status, suggesting that same-sex marriage may benefit all
sexual minority individuals. Finally, marriage also contributes to greater relation-
ship satisfaction. After being married, same-sex couples tend to report increased
commitment and connection as well as greater feelings of love and closer emo-
tional bonds toward their partners.
Given the recent legalization of same-sex marriage in the United States, it is
likely that research into the effects of marriage on individuals, couples, families,
and society at large will expand over the next few years. Studies on same-sex
divorce may also be forthcoming.
Heather L. Armstrong
594 Sanger, Margaret
See also: Antigay Prejudice; Civil Union; Gay Rights Movement; Marriage; Marriage,
Cross-Cultural Comparison of.
Further Reading
Alderson, K. (2004). A phenomenological investigation of same-sex marriage. The Cana-
dian Journal of Human Sexuality, 13, 107–122.
Hatzenbuehler, M. L., O’Cleirigh, C., Grasso, C., Mayer, K., Safren, S., & Bradford, J.
(2012). Effect of same-sex marriage laws on health care use and expenditures in
sexual minority men: A quasi-natural experiment. American Journal of Public
Health, 102, 285–291.
Lannuti, P. J. (2008). “This is not a lesbian wedding”: Examining same-sex marriage and
bisexual-lesbian couples. Journal of Bisexuality, 7, 237–260.
MacIntosh, H., Reissing, E. D., & Andruff (Armstrong), H. (2010). Same-sex marriage in
Canada: The impact of legal marriage on the first cohort of gay and lesbian Cana-
dians to wed. The Canadian Journal of Human Sexuality, 19, 79–90.
Newcomb, M. E., & Mustanski, B. (2010). Internalized homophobia and internalizing
mental health problems: A meta-analytic review. Clinical Psychology Review, 30,
1019–1029.
Ramos, C., Goldberg, N. G., & Badgett, M. V. L. (2009). The effects of marriage equality
in Massachusetts: A survey of the experiences and impact of marriage on same-
sex couples. Los Angeles: The Williams Institute, UCLA.
Sanger, Margaret
Margaret Higgins Sanger (1879–1966) was a nurse, activist, sexuality educator, and
advocate for birth control. She was born in Corning, New York, to Michael Higgins,
an Irish immigrant stonemason, and his wife, Anne. The sixth of their eleven chil-
dren, she always believed her mother’s death at fifty was due to having had eighteen
pregnancies and caring for so many children. Margaret learned self-reliance early
when she had to leave school at sixteen to take care of her dying mother.
After her mother’s death, Margaret studied nursing at White Plains Hospital. In
1902, she married William Sanger, an architect. They had three children. Sanger
worked as a visiting nurse and midwife on the Lower East Side, where she saw the
struggles of immigrant women in poor health who had too many children to pro-
vide for.
At this time, there were few options for preventing pregnancy, and it was illegal
to even give information about “any drug or medicine, or any article whatever, for
the prevention of conception.” This was the Comstock Law, enacted by Congress
in 1873. Anthony Comstock, a crusader “for the suppression of vice” in New York
City, drafted the law. In his role as special agent in the U.S. Post Office, he was
able to confiscate “immoral” materials sent through the mail and arrest those who
sent them.
Despite the law, Margaret Sanger published a monthly newsletter, The Woman
Rebel, which advocated for women’s right to control their own bodies. She pro-
moted the term “birth control,” which spoke directly to preventing pregnancy. At
the same time, she wrote “Family Limitation,” a sixteen-page pamphlet that
described specific methods of contraception.
Sanger, Margaret 595
Under the Comstock Law, Sanger was arrested in 1914 for publishing The
Woman Rebel. While awaiting trial, she fled to Europe and remained there until
October 1915. She learned more from experts in Holland and England about con-
traceptives and human sexuality. During her ten months in Europe, William
Sanger was tricked into selling a copy of “Family Limitation” to a Comstock
cohort. He was arrested and spent thirty days in jail. His arrest prompted influen-
tial newspapers to print more stories about Margaret and contraception. Public
opinion was turning. In February 1916, the charges against her were dropped.
The following October, Margaret Sanger opened the first birth control clinic in
the United States, staffed by herself; Ethel Byrne, her sister who was a registered
nurse; Fania Mindell, a volunteer who spoke three languages; and Elizabeth
Stuyvesant, a social worker. Ten days after the clinic opened, the vice squad
arrested Sanger and Mindell. After paying a fine, they were released and promptly
reopened the clinic, only to be arrested again with Ethel. While the clinic was
open, they saw 464 women.
Several weeks later, Ethel Byrne was tried, convicted, and sentenced to a month
in the Blackwell’s Island workhouse. She went on a hunger strike, and four days
later the police began to force-feed her through a tube, a historical first. Publicity
about Ethel’s imprisonment further influenced public opinion about women’s
rights. The trials of Margaret Sanger and Fania Mindell began in January 1917.
Sanger was convicted but offered a more lenient sentence if she promised to not
break the law again. She said, “I cannot respect the law as it exists today” and
spent thirty days in jail.
She appealed the conviction, and in 1918, the court ruled partly in her favor,
that doctors could prescribe contraception for medical purposes. This victory
enabled Margaret Sanger to found the American Birth Control League in 1921
and the Clinical Research Bureau in 1923. Both organizations gained support
from middle-class and wealthy donors and advocates. She worked successfully to
convince physicians to endorse family planning.
To change the laws regarding access to contraceptives, she ordered diaphragms
from Japan, knowing the authorities would confiscate them. In 1936, the govern-
ment’s case against her resulted in a decision to overturn the Comstock Law. The
following year, the American Medical Association accepted contraception as a
normal part of clinical practice.
In 1942, the organizations that Margaret Sanger founded were renamed Planned
Parenthood Federation of America. Four years later, she helped found the Interna-
tional Planned Parenthood Federation. Sanger was the organization’s first presi-
dent and continued in that role until she was eighty years old.
In the 1920s, Sanger had begun to propose that mentally disabled women not be
allowed to have children, and she became involved in the eugenics movement,
whose goal was to improve the genetic quality of the human race. She was also
accused of trying to limit births in the African American population, though she
maintained that her goal was to provide better birth control to better the lives of
African American women and their families.
She died in 1966 in Tucson, Arizona. People opposed to abortion, as well as
those who are in favor of abortion rights, have criticized her views on race and
596 Satcher, David
eugenics. Nonetheless, Margaret Sanger is regarded as a leader of the American
reproductive and woman’s rights movements.
Michael J. McGee
See also: Contraception; Planned Parenthood; Sexual Rights.
Further Reading
Chesler, E. (1992). Woman of valor: Margaret Sanger and the birth control movement in
America. New York: Simon & Schuster.
Coates, P. W. (2008). Margaret Sanger and the origin of the birth control movement,
1910–1930: The concept of women’s sexual autonomy. Lewiston, NY: Edwin Mel-
len Press.
Dennis, D. (2009). Licentious Gotham: Erotic publishing and its prosecution in
nineteenth-century New York. Cambridge, MA: Harvard University Press.
Satcher, David
Dr. David Satcher, MD, PhD (1941–) was the U.S. surgeon general from 1998 to
2002. He was the sixteenth surgeon general and is the only person in history to be
surgeon general and assistant secretary for health simultaneously. In 2001, he
issued a report titled “The Call to Action to Promote Sexual Health and Respon-
sible Sexual Behavior.” The purpose of the report was to address the public health
challenges surrounding Americans’ sexual health and to promote responsible sex-
ual behavior. At the time the report was published, there were approximately
12 million new cases of sexually transmitted infections (STIs) each year in the
United States (Office of the Surgeon General, 2001) and approximately 800,000
persons living with HIV. In addition, 22 percent of women and 2 percent of men
were victims of a forced sexual act.
The mission of the report was to start an open and honest discussion about
sexuality and sexual health within the nation. The report explained that sexual
health is intimately tied to a person’s mental and physical health. In the same man-
ner that mental and physical illnesses can affect sexual health, sexual issues often
affect mental and physical health. The report discussed the benefits of healthy
sexual interactions, which include bonding, intimacy, pleasure, and reproduction.
In the report, several terms were defined. “Sexual health” was defined as being
broader than just the absence of disease and dysfunction. It is defined as the ability
to make informed sexual decisions in a responsible manner without the presence
of sexual abuse or discrimination. Sexual responsibility requires that individuals
be aware of their level of sexual development and their personal sexuality. In addi-
tion, individuals should have the information and skill set needed to estimate the
risk of a situation and the possible outcomes. Respect for self and partner is essen-
tial, and there should be tolerance for different sexual orientations. The impor-
tance of ensuring that pregnancies occur in a welcoming environment was also
addressed.
The report came forth at a time where it took courage to talk about sexuality in
American culture. The previous surgeon general, M. Joycelyn Elders, had taken
the risk to discuss masturbation and suffered political backlash. Elders was the
Satcher, David 597
fifteenth surgeon general and was the first African American surgeon general. In
December 1994, at a United Nations conference on AIDS, she was asked whether
it would be appropriate to teach schoolchildren about masturbation, to which she
replied that masturbation was a part of human sexuality. President Bill Clinton’s
administration requested that Elders step down from her post on December 9.
Despite being fully aware of what had occurred to the surgeon general just before
him, Satcher let his mission of greater health for all Americans guide him to pub-
lishing his report on sexual health.
A native of Anniston, Alabama, Satcher has extensive experience with health.
At two years old, he contracted whooping cough and became severely ill. His fam-
ily was unable to take him to the local hospital because it did not admit African
Americans. However, they were able to reach an African American physician,
Dr. Fred Jackson, who traveled to tend to the toddler’s illness. At age six, Satcher
decided he wanted to follow in Jackson’s footsteps and become a physician. He
attended Morehouse College, where he was class president. At Morehouse, he
often attended lectures by Dr. Martin Luther King Jr. that inspired him to play an
active role in the civil rights movement. He attended Case Western Reserve Uni-
versity, where he earned a MD and PhD.
In 1993, Satcher became director of the Centers for Disease Control and Pre-
vention (CDC) and administrator of the Agency for Toxic Substances and Dis-
ease Registry. He was in that position for five years. During his time at the CDC,
he focused on continuing the public health gains in HIV/AIDS, cervical and
breast cancer screening, and childhood vaccinations. In addition, he addressed
the emerging epidemic of obesity that was overtaking the nation. At the same
time he was addressing these issues, he was strengthening the infrastructure of
the CDC.
Satcher and his wife, Nola Satcher, are parents to four children. Satcher is cur-
rently founding director and senior adviser of the Satcher Health Leadership Insti-
tute at Morehouse School of Medicine in Atlanta, Georgia. He was previously
president of Morehouse School of Medicine from 2004 to 2006 and president of
Meharry Medical College in Nashville, Tennessee, from 1982 to 1993.
Renée M. Haynes
See also: Sexual Health.
Further Reading
Creelan, M. (2013). David Satcher (b. 1941). New Georgia Encyclopedia. Retrieved from
https://www.georgiaencyclopedia.org/articles/science-medicine/david-satcher
-b-1941
Jehl, D. (1994, December). Surgeon general forced to resign by White House. New York
Times. Retrieved from http://www.nytimes.com/1994/12/10/us/surgeon-general
-forced-to-resign-by-white-house.html
Office of the Surgeon General (US). (2001). The Surgeon General’s call to action to pro-
mote sexual health and responsible sexual behavior. Rockville, MD: Office of
Population Affairs (US).
Satcher, D. (2007). CDC’s 60th anniversary: Director’s perspective: David Satcher, M.D.,
Ph.D., 1993–1998. MMWR, 56(23), 579–582. Retrieved from http://www.cdc.gov/
mmwr/preview/mmwrhtml/mm5623a3.htm
598 Savage, Dan
Schemo, D. J. (2001, June). Surgeon General’s report calls for sex education beyond absti-
nence. New York Times.
U.S. Department of Health and Human Services. (2007). David Satcher (1998–2002).
Retrieved from https://www.hhs.gov/surgeongeneral/not-found/about/previous
/biosatcher.html
Savage, Dan
Dan Savage is a gender and sexuality advocate, a writer, a father, a husband, and
an outspoken gay man who has used his words to change history. Whether it is
sexual or political, Dan Savage has exercised his ability to write and seek clarity
for the masses.
He is a modern-day Dear Abby or Ann Landers, advising for almost thirty
years with Savage Love, an internationally syndicated weekly sex advice column
with a focus on relationships, sex toys, and sexual freedom. Writing this column
began as a joke and was only supposed to last six months. The joke was that Dan
Savage wanted to use the same gay rhetoric imposed on gay communities on
straight communities. He is continuously surprised and humbled to receive the
gravity of questions he has over the past three decades. He has been quoted as say-
ing that he will never stop writing his column and that “it will be pried out of his
dying hands.” He uses humor, reality, and snark heavily in his column. Ironically,
he writes his column on the desk of Anne Landers, as he had purchased it from
her estate.
Dan Savage was born in Chicago, Illinois, in 1964 and attended the University
of Illinois at Urbana-Champaign, where he received a bachelor of fine arts in act-
ing. His parents had encouraged him to enter religious life, as they had both been
very active within their Roman Catholic community; his father was a deacon and
his mother a lay minister.
He adopted his son DJ in 1999 with his boyfriend, Terry Miller, through open
adoption, and they were married in 2015 immediately as the legalities allowed. He
has been electrically vocal on how these moments have shaped his life.
In an infamous quote exemplifying his stance on cultural religiousness versus
indoctrinated religious behavior, Dan said, “We can learn to ignore the bullshit in
the Bible about gay people. The same way we have learned to ignore the bullshit
in the Bible about shellfish, about slavery, about dinner, about farming, about
menstruation, about virginity, about masturbation.”
In 2010, Dan and Terry created a notable reflection of honesty, empathy, and
mental health awareness entitled “It Gets Better” in reaction to the suicide of a
young queer person. This reflection is a collection of user-submitted YouTube vid-
eos to document how life can get better, help to erase any pain, manage loneliness,
eliminate bullying, and expose gender and sexuality stigmas. This social media
platform has given Savage the opportunity to reach an audience of fearful and
impressionable LGBTQ+ youth and provides optimistic examples, mentors, and
mental health resources to help curb the epidemic of suicides and self-harming
behaviors.
Scabies 599
Savage has written and collaborated on several books, notably Savage Love,
The Kid, Skipping Towards Gomorrah, The Commitment, It Gets Better, and
American Savage. He continues to open and have conversations related to reli-
gious intolerance, sexual stigma, heteronormative ideologies, and political
injustice.
Michele Montecalvo
See also: LGBTQ+; Media and Sexuality.
Further Reading
Savage, D. (2019). Savage love. Retrieved from https://www.thestranger.com/savage-love
Savage, D. (2019). Savage lovecast [podcast]. Retrieved from https://www.savagelovecast
.com
Savage, D., & Miller, T. (2019). It gets better project. Retrieved from https://itgetsbetter
.org/
Scabies
Scabies is a very itchy, highly contagious skin infection caused by the mite (para-
site) Sarcoptes scabiei. This mite exclusively lives and grows in humans and is
spread from person to person (through any type of direct skin-to-skin contact).
However, it can live without a human host for up to thirty-six hours, or even lon-
ger when in a cold environment. As such, more infections are seen in the winter
than in the summer. Scabies are very small and usually cannot be seen by the
human eye. They cause a skin reaction by burrowing underneath the surface of
the skin and laying their eggs in a tunnel. The itching that is characteristic of this
infection is thought to be due to an allergic reaction against the mite, its feces,
and eggs.
Scabies causes an intensely itchy skin reaction consisting of small red bumps
located in specific parts of the body. The symptoms are worst at nighttime. The
most common locations are between and on the sides of fingers, the buttocks,
waist, armpits, bottom of feet, upper thighs, along the skin folds of the elbows,
knees, and wrists; on the penis and scrotum, and around the nipples.
Scabies is usually not seen on the face or head. Occasionally, people can see the
tunnels that the mites made as they travel under the skin. The tunnels appear as
brown-gray lines that can be up to 0.6 inches (1.5 centimeters) long. Less com-
monly, people can get large, itchy, red, round, dome-shaped bumps, known as
nodules, in the groin or armpits.
People who have weak immune systems, such as those with human immunode-
ficiency virus (HIV), can develop a very contagious form of scabies called crusted
scabies. A person with crusted scabies typically has large, red, itchy, and crusty-
looking skin patches or bumps that are usually on the hands, feet, or head.
Scabies is passed from person to person through direct contact, including
genital-genital or genital-skin contact. This infection is a commonly known sexu-
ally transmitted infection (STI), especially among young adults across the world.
However, it is not exclusively sexually transmitted, as any skin-to-skin contact,
600 Scabies
regardless of the body part infected, can lead to infection in another person. Infec-
tions are commonly spread throughout entire families once one family member is
infected. The infection is very contagious, and close contact for just fifteen to
twenty minutes is enough time for it to move from one person to another. Scabies
is different from many other STIs because (although less common) a person can
also get the infection from touching clothing, bedding, furniture, or other objects
that have the mites on them (e.g., by wearing the same shirt that someone with an
active scabies infection just wore). There is a higher risk of getting scabies from
direct skin-to-skin contact than from object-skin contact because there are usually
more mites on a person’s skin than on clothes. Symptoms usually start developing
about three to six weeks after a person has been infected. A person who gets rein-
fected with scabies can develop symptoms much sooner—within three to five
days after infestation.
A doctor can diagnose scabies based on someone’s symptoms (including informa-
tion about any close contacts with scabies) and exam, and if a burrow or tunnel is
seen on exam, this makes the diagnosis more certain. Sometimes a doctor can per-
form a skin scraping or an adhesive tape test to look for mites or eggs. Although these
tests can confirm a diagnosis, they are not necessary for diagnosis. In fact, a result
that is negative for mites does not prove against scabies as the cause of infection.
Scabies can be treated and potentially cured with proper use of medication and
cleaning techniques at home. Standard treatment is with permethrin cream. The
steps for applying the cream must be strictly followed. The cream must be applied
to every inch of skin from the neck down and kept on overnight, or between eight
and fourteen hours, and then washed off. The treatment must be repeated one
week later. Any close contacts (family members, dorm roommates, sexual part-
ners), even those who do not have symptoms, also must receive the same medical
treatment. There is also a pill—ivermectin—that is just as effective as the cream.
One pill is taken to initiate treatment, and a second dose is taken fourteen days
later. Ivermectin is used to treat crusted scabies. The pill may be harder to find,
and more costly, and so this option should be discussed with a doctor.
Even after treatment, itching may still continue for two weeks. This lingering
symptom can be treated with allergy medications, also known as antihistamines,
such as over-the-counter diphenhydramine or loratadine.
To prevent reinfecting oneself or infecting close contacts, all clothing, bedding,
and cloth products or toys that were used in the week prior to starting treatment
should be washed in hot water and then dried in a hot dryer. If something cannot
be washed, it should be placed in a airtight sealed plastic bag for three days. Floors
should be vacuumed. Even if only one partner is infected, sex should be post-
poned until both partners complete treatment; otherwise the infection will just
continue to be passed back and forth between partners.
Condoms do not prevent against transmission of scabies but should still be used
to prevent the transmission of other STIs.
There is no vaccine to prevent scabies. One way to decrease the risk of getting
it is by limiting the number of sexual partners.
Mona Dalal
Scrotum 601
See also: Pubic Lice; Sexually Transmitted Infections (STIs).
Further Reading
Grimes, J. A., Smith, L. A., & Fagerberg, K. (2013). Sexually transmitted disease: An
encyclopedia of diseases, prevention, treatment, and issues. Santa Barbara, CA:
Greenwood.
McAnulty, R. D., & Burnette, M. M. (Eds.). (2006). Sex and sexuality. Santa Barbara, CA:
Praeger.
Newton, D. E. (2009). Sexual health: A reference handbook. Santa Barbara, CA:
ABC-CLIO.
Scrotum
The scrotum is an external sac of skin that holds the testes in some male mam-
mals, including humans. Its placement is apparently an evolutionary development
intended to keep the sperm produced by the testes cooler than the normal body
temperature. For humans, sperm develops and matures best at a temperature sev-
eral degrees below normal body temperature. An external location for the testes
may also prevent inadvertent emptying of the testes before sperm is mature due to
normal contraction and relaxing of the abdominal muscles. Common medical
problems associated with the scrotum include the development of masses, which
may impair reproductive function.
The scrotum is located in human males between the penis and the anus. It is
composed of a thin layer of skin over smooth muscle and includes a large number
of oil-producing and sweat glands. The scrotum is divided into two compartments
by a ridge known as the raphe, which connects to a muscular internal partition
that separates the compartments. Within each compartment are the testes, the epi-
didymis, and a large number of nerves and blood vessels. The muscles in the scro-
tum help to regulate the temperature of the testes. In cold conditions, the muscles
contract, drawing the scrotum closer to the abdomen to increase its temperature.
Under warmer conditions, the muscles relax, allowing the scrotum to lengthen
and more air to circulate around it. Higher temperatures around the scrotum cause
the male’s fertility to decrease.
The scrotum is vulnerable to blisters caused by chafing and scratching, espe-
cially when damp. Skin irritation may also occur because of exposure to soaps,
detergents, and other irritants. Scrotal masses may also develop. Symptoms
include unusual lumps, sudden pain, dull aching pain, tender or swollen testicles,
and nausea or vomiting. Fever, frequent urination, and pus or blood in the urine
may also be indications of problems with the scrotum. Regular self-examinations
are important to identify problems at an early stage. Common causes of scrotal
masses include testicular cancer, spermatocele, and epididymitis. Inguinal hernias
may also occur when part of the small intestine pushes through the abdominal
wall into the groin.
Tim J. Watts
See also: Epididymis; Testicles; Testicular Cancer.
602 Semen
Further Reading
Harvard Health Publishing. (2016). Lumps or pain within the scrotum. Retrieved from
https://www.health.harvard.edu/decision_ guide/lumps-or-pain-within-the
-scrotum
Jewell, T. (2018). Scrotum overview. Retrieved from https://www.healthline.com/human
-body-maps/scrotum
Mayo Clinic. (2019). Scrotal masses. Retrieved from https://www.mayoclinic.org/diseases
-conditions/scrotal-masses/symptoms-causes/syc-20352604
Semen
Semen (seminal fluid) is produced by the male reproductive system and is a fluid
that may contain spermatozoa (sperm). Composed of several kinds of fluid and
components, semen provides a protective and nutritive environment for sperm and
aids in the fertilization of an ovum, or female egg. In order for fertilization to
occur, sperm (with pH 7.2 to 8.0) must survive in the acidic environment of the
female reproductive organs and reach an ovum in the fallopian tubes. Semen
increases the viability of sperm and is comprised of fructose, prostaglandins,
enzymes, and other substances that create a more alkaline environment for the
sperm. These fluids also enhance sperm’s motility, increasing the possibility that
a sperm will reach an egg. The seminal vesicles, prostate gland, and bulbourethral
glands (Cowper’s glands) contribute the various fluids that comprise semen.
Sperm, produced in the testes, makes up less than 5 percent of semen, and there
are roughly 200 million to 500 million sperm in a single ejaculate. The average
ejaculate is roughly one teaspoon (approximately three to five milliliters) in vol-
ume; however, this volume is affected by several factors, such as hydration, age,
and the length of time since last ejaculation. After a vasectomy, ejaculate will be
roughly the same volume because sperm is only a small part of the composition of
semen.
Typically, semen is translucent and tinted a white, gray, or yellowish color.
Semen also has a distinct smell and flavor. A very strong odor or unusual color
could signal a medical problem, such as a prostate infection, and may require a
doctor. Upon ejaculation, semen is a gel-like consistency because it begins to
coagulate. After a period of fifteen to thirty minutes, the semen becomes a liquid
again due to prostate-specific antigen, which causes decoagulation. Researchers
believe semen coagulates upon ejaculation so it is less susceptible to gravity and
can remain in the vagina for longer, increasing the possibility of fertilization.
Semen is safe to ingest; however, it can transmit sexually transmitted infections
(STIs) such as herpes, human papillomavirus, chlamydia, gonorrhea, and HIV.
Transmission of STIs is a risk if individuals are engaging in unprotected oral sex.
Infection of the genitals (vagina, penis, anus) is also possible when contact with
semen occurs. It is recommended that individuals use a barrier method for protec-
tion, such as a condom or dental dam, during any sexual act that might put them at
risk for disease transmission.
Although rare, some individuals are allergic to semen. Known as human semi-
nal plasma sensitivity, this allergy is characterized by a localized allergic response
Seminal Vesicles 603
when the individual comes in contact with seminal fluid. Desensitization treat-
ment has been found to be successful for human seminal plasma sensitivity.
Semen cryopreservation is a process that stores semen for several years and
allows sperm to retain its fertility. The fertility of semen is assessed by a sperm
count that determines how many viable sperm are in the semen sample. With this
technology, sperm can be kept viable outside of the human body for a long period
of time and used for fertilization of an ovum.
Damiene Denner
See also: Bulbourethral Glands; Ejaculation; Prostate; Seminal Vesicles; Sexually Trans-
mitted Infections (STIs); Sperm.
Further Reading
Human Fertilization & Embryology Authority. (n.d.). Sperm freezing. Retrieved from
https://www.hfea.gov.uk/treatments/fertility-preservation/sperm-freezing/
Joannides, P. (2013). Guide to getting it on (7th ed.). Waldport, OR: Goofy Foot Press.
Mandal, A. (2019). What is semen? Retrieved from http://www.news-medical.net/health/
What-is-Semen.aspx
Seminal Vesicles
The seminal vesicles are two glands in the human male as well as many other
mammals. They help produce semen used in reproduction. Fluid from the seminal
vesicles provides nutrients for sperm as well as helping make conception possible.
Seminal vesicles sometimes are affected by congenital deformities as well as cer-
tain diseases, including tuberculosis.
Seminal vesicles are associated with the vas deferens. They are elongated, sac-
like glands that are about two to three inches long. They sit below the urinary
bladder and above the prostate gland, and their ducts, along with those of the vas
deferens, form the ejaculatory ducts that place semen in the urethra. A muscular
lining of smooth muscle contracts during ejaculation to force the contents of the
seminal vesicles into the urethra. Inside the seminal vesicles, a lining of convo-
luted, folded tissue is found. This lining secretes a fluid that joins the sperm and
other fluids from the vas deferens to form semen that is ejaculated by the male.
The fluid from the seminal vesicles constitutes up to 60 percent of the volume of
the semen that is ejaculated. This yellowish fluid is composed partially of fruc-
tose, which provides energy for the sperm. It also includes proteins, citric acid,
phosphorus, potassium, and prostaglandins. The semen is slightly alkaline, which
helps counteract the acidity of the vagina and improves the survival rate of the
sperm. The semen also includes clotting factors, which makes it thicker and sticky.
This factor allows the semen to cling to the walls of the female reproductive tract
and increases the ability of the sperm to make their way to the ovum (egg).
Few abnormalities are associated with the seminal vesicles. Congenital cysts
sometimes develop in the seminal vesicles and the prostate, but they are normally
small and do not cause problems. A more serious problem is associated with cystic
fibrosis. The seminal vesicles in this case are usually malformed or completely
absent. As a result, the male is sterile. In other cases, the ducts may become
604 Seminiferous Tubules
blocked, either from trauma or from calcification. Infection from tuberculosis may
spread to the seminal vesicles as well, causing scarring or alterations in shape that
prevents the glands from working.
Tim J. Watts
See also: Ejaculation; Semen; Vas Deferens.
Further Reading
ScienceDirect. (2019). Seminal vesicles. Retrieved from https://www.sciencedirect.com/
topics/neuroscience/seminal-vesicle
Seladi-Schulman, J. (2018). What are the seminal vesicles and what is their purpose?
Retrieved from https://www.healthline.com/human-body-maps/seminal-vesicles/
male
Seminiferous Tubules
The seminiferous tubules are located in the male testes and are coiled, long, thin,
ramen noodle–like tubules. They are made up of a variety of cells and are the site
of germination, maturation, and transportation of sperm cells. The outside of the
tubules is made of stem cells that will divide into two separate cells through mito-
sis. As the stem cells divide, they move inward and create the inside walls of the
tubules. Within the tubules are Sertoli cells, which are column-like cells that line
the wall of the tubules. The tubules also contain spermatogenic cells, which will
later turn into sperm cells. These cells allow for spermatogenesis, the process that
creates mature sperm.
To create sperm cells, the spermatogenic cells divide twice into four separate
cells within the tubules. The early-stage spermatozoa, otherwise known as the
spermatogonia, will flow throughout the tubules for around sixty days, passing
through the central tubule as they head to the rete testis. The rete testis is a net-
work of delicate tubules located on the upper back portion of each testicle. The
sperm then flow through the efferent ducts to the epididymis to be stored until
they are passed to the vas deferens. During the sperm’s travel through the seminif-
erous tubules, the spermatogonia mature and receive nutrients from the Sertoli
cells. By the end of their trip, the spermatogonia transition into spermatozoa, or
mature sperm cells; however, they will still need to develop their tails.
Seminiferous tubules go through many changes as the individual grows from
birth to adulthood. In newborns, the seminiferous tubules only contain spermato-
gonia and Sertoli cells. Around the time of puberty, the seminiferous tubules
begin to produce sperm. After this point, the testes begin to enlarge due to the size
increase of the seminiferous tubules. The seminiferous tubules also contain over
200 compartments that are divided by walls that belong to the corpora cavernosa
of the penis.
There are two different kinds of tubules. Convoluted tubules are located on the
lateral side of the testes, while straight tubules occur when the tubule begins to
connect and form the duct that leads to the outside of the testis. The tubules are
formed from the testis cord that is developed from the gonadal cords. This gonadal
cord is formed from the gonadal ridge during embryonic development.
Sensate Focus 605
Sperm are very fickle, and they must have regulated temperature. Spermato-
genesis works best at a temperature slightly less than core body temperature. Due
to this fact, the scrotum will move toward or away from the body to maintain a
temperature of about 95 degrees Fahrenheit. The movement of the scrotum is
administered by the cremaster muscle. When the testicles need to be closer to the
body, the cremaster muscle contracts. When the testicles need to be farther from
the body, the cremaster muscle relaxes. The cremaster muscle also responds to
stress. For example, if an individual is in a threatening situation, the testicles may
move closer to the body so that they are protected.
Casey T. Tobin
See also: Epididymis; Sperm; Testicles.
Further Reading
Barclay, T. (2015). Seminiferous tubules. Retrieved from http://www.innerbody.com/
anatomy/male-reproductive/seminiferous-tubules
Jones, R. E., & Lopez, K. H. (2014). Human Reproductive Biology. San Diego, CA: Aca-
demic Press.
Marieb, E. N., & Hoehn, K. (2016). The reproductive system. In Human anatomy and
physiology (10th ed., 1029–1030). London: Pearson Education.
Sensate Focus
Many couples seek couples therapy and sex therapy to improve their relationships.
Sensate focus is a specific technique utilized by sex therapists to aid in improving
the sexual relationship between two people.
Sex researchers William Masters and Virginia Johnson first described sensate
focus in 1970. Helen Singer Kaplan, a sex therapist, developed it further in 1974.
Sensate focus involves a series of exercises that systematically desensitize partici-
pants’ sexual anxiety and negative associations to sex.
Sensate focus exercises span several weeks and are done in specific steps.
These exercises require one partner to be the “giver” and one partner to be the
“receiver.” Both partners will experience being the “giver” and “receiver” as they
switch roles halfway through each sensate focus experience they have together.
Each exercise should be done about three times a week until the exercise does not
elicit anxiety (usually one to two weeks). Each partner should take a turn as the
“giver” and as the “receiver,” spending about twenty minutes in each role. Typi-
cally, intercourse is prohibited until the completion of the exercises.
The first phase of sensate focus exercises involves the giver touching their part-
ner’s body without touching the breasts or genitals. This involves different types
of touch using the hands and mouth. The goal of this phase of sensate focus is to
explore different types of touch and sensation, not to sexually arouse one’s part-
ner. Though sexual arousal often occurs, it is not the purpose of the exercise, and
one should not try to have an orgasm or give their partner an orgasm.
In the second phase of the exercises, touching that occurred in phase one is still
encouraged. In addition, breast and genital exploration is permitted. However, as in
phase one, orgasm is not the goal and should not be attempted. Intercourse is not
606 Sensate Focus
allowed during this phase, and touching that would lead to an orgasm is not permit-
ted. In the third phase, mutual touching will occur simultaneously as opposed to tak-
ing turns as the giver and receiver. Stage four begins with incorporating elements
from all the prior phases. In addition, the couple may begin to rub their genitals
together and eventually have intercourse. Orgasm is permitted during this phase.
If an erection is achieved during phases one to three, stimulation should be
halted until the penis returns to a flaccid state. The purpose of this is to aid in
reducing anxiety about losing an erection and not being able to obtain one again.
During all phases of the exercises, communication is important. Focusing on one’s
own pleasure is of utmost importance.
Sensate focus exercises are often employed during sex therapy when one or
both partners experience sexual anxiety. The exercises may help treat erectile dys-
function that is often a result of psychological stress or anxiety. Sensate focus
works by helping to alleviate anxiety and obsessive thoughts that may prevent
someone from obtaining or maintaining an erection. By introducing the individ-
ual slowly and without pressure to different forms of stimulation, anxiety may
lessen and sexual functioning may be restored.
In addition, sensate focus exercises may help improve sexual communication
as they encourage couples to feel more comfortable discussing their sexual likes
and dislikes. Couples may experience different sensations and have a forum to
explore their sensuality. Sensate focus allows both partners to understand their
body and their partner’s body better, which can improve overall sexual satisfac-
tion. Couples learn to give and receive pleasure in a relaxed environment without
any pressure to perform sexually. The increased communication and sensual
experiences a couple experience together may lead to an increase in emotional and
sexual intimacy.
There are nine primary functions of engaging in sensate focus exercises:
1. It helps individuals understand their body more thoroughly and the sensations
that are desired.
2. It has each partner focus on their own pleasure as opposed to worrying about
the pleasure of their partner, which may cause anxiety.
3. It enhances sexual communication.
4. It helps partners understand their partner’s sexual needs more.
5. It expands sexual exploration.
6. It allows each partner to appreciate sensual and sexual touch without the need
for orgasm.
7. It helps create a positive relationship and relational expression.
8. It aids in building sexual desire.
9. It enhances feelings of closeness, intimacy, caring, and love in a relationship.
Amanda Manuel
See also: Communication, Sexual; Johnson, Virginia; Kaplan, Helen Singer; Masters,
William H.; Masters and Johnson Four-Stage Model of Sexual Response; Performance
Anxiety; Psychosexual Therapy; Sexual Dysfunction, Treatment of.
Serial Monogamy 607
Further Reading
Hertlein, K. M., Weeks, G. R., & Gambescia, N. (2009). Systemic sex therapy. New York:
Routledge.
Long, L. L., Burnett, J. A., & Thomas, R. V. (2006). Sexuality counseling: An integrative
approach. Upper Saddle River, NJ: Pearson/Merrill Prentice Hall.
Serial Monogamy
“Serial monogamy” refers to the practice of having a succession of romantic or
sexual relationships with one individual at a time. Each relationship lasts for a
relatively long period compared with a “hookup” or a brief, casual dating relation-
ship. For example, a woman may have a pattern of dating one man exclusively for
several weeks or months before breaking up with him to date another. Or a man
may be married to a series of women, remaining faithful to each woman for years
before the marriage ends in divorce.
Precise definitions of serial monogamy, as well as estimates of its prevalence,
vary. However, many people practice serial monogamy, and, according to some
definitions and estimates, it is actually the most prevailing style of romantic and
sexual relationship in the United States and other Western countries today.
A key aspect of serial monogamy is that the individual tends to spend as little
time as possible being alone or single; they typically move into a new relationship
as soon as the previous relationship is over. Psychologists note that this tendency
may suggest a form of personal insecurity in which the individual fears to spend
much time alone. Perhaps constantly being in one relationship or another serves as
a distraction from having to think about or deal with unpleasant aspects of the
individual’s personal life. Or perhaps the relationships give the individuals a tem-
porary sense of self-confidence that they lack on their own.
Serial monogamy might also imply a genuine desire to be faithful to a loved
one but a simultaneous fear of remaining seriously committed to that person for
very long. Some psychologists note that the relationships in serial monogamy
could offer certain individuals a good compromise—the relationships provide a
sense of stability, love, and limited commitment while at the same time avoiding
permanent commitment.
The chances of pregnancy and sexually transmitted infections are generally
easier to control in a serial monogamous relationship than in relationships in
which multiple partners are involved. Both partners in a serial monogamous rela-
tionship typically are aware of each other’s birth control and safer sex practices.
A. J. Smuskiewicz
See also: Dating; Dating, Cross-Cultural Comparison of; Hookup Culture; Monogamy;
Polyamory.
Further Reading
Andersson, C. (2015). A genealogy of serial monogamy: Shifting regulations of intimacy
in twentieth-century Sweden. Journal of Family History, 40(2), 195–207.
Ben-Zeév, A. (2008, October). Is serial monogamy worth pursuing? Psychology Today.
Retrieved from https://www.psychologytoday.com/blog/in-the-name-love/200810/
is-serial-monogamy-worth-pursuing
608 Sex Chromosomes
Sex Chromosomes
A sex chromosome is a type of chromosome (a thread-like structure made up of
DNA that maps the human body) that participates in one’s determination as either
biologically male or female. Generally occurring in a pair, they carry not only the
genes that determine male and female traits but also those for some other charac-
teristics. An abnormal number of sex chromosomes results in disorders that can
interfere with normal growth.
Humans and most other mammals have two sex chromosomes, known as the X
and Y chromosomes. Females have two X chromosomes, and males have an X
chromosome and a Y chromosome. A female’s egg cells always have one X chro-
mosome, while a male’s sperm cells may carry either an X or a Y chromosome.
This arrangement means that it is the male cell that determines the sex of the off-
spring when fertilization occurs. The joining of a female X chromosome with a
male X chromosome will result in a female child, and the joining of a female
X chromosome with a male Y chromosome will result in a male child.
Both X and Y chromosomes determine characteristics other than sex. The X chro-
mosome is large, containing about 1,098 genes. Most of these genes code for some-
thing other than female anatomical traits. In fact, many of the non-sex-determining
X-linked genes are responsible for a variety of conditions. Some of the most common
human genetic disorders are red-green color blindness (a color vision deficiency in
which an individual cannot perceive red and green in the same way as people with
normal vision) and male pattern baldness. Another condition linked to X genes is
hemophilia, a blood-clotting disorder resulting in prolonged bleeding from even
minor cuts and injuries. Duchenne muscular dystrophy, a gradual and irreversible
wasting of skeletal muscle, is also linked to the X chromosome. Contrary to the X
chromosome, the much smaller Y chromosome has only twenty-six genes, and one is
responsible for male anatomical traits. Most of the remaining Y chromosome genes
are involved either with cellular health or sperm production. When any of the genes
involved in sperm production are missing or defective, the result is usually very low
sperm counts and subsequent fertility challenges or infertility.
Other disorders are linked to the quantity or quality of the chromosomes. Two
of the most common conditions are Turner syndrome and Klinefelter syndrome.
Turner syndrome occurs when one of a female’s two X chromosomes is abnormal
or missing, causing short stature and developmental problems with the ovaries
and production of sex hormones. Although there is no cure, treatment includes
human growth hormone and estrogen hormone replacement therapy. Another con-
dition affecting about one in one thousand females is triple X syndrome, a condi-
tion in which a female has three X chromosomes instead of two. This condition
usually results from an error in the formation of an egg cell, a sperm cell, or an
embryo. Symptoms vary in severity and may include developmental delays. Males
with Klinefelter syndrome are born with an extra X chromosome (XXY instead of
XY), which can slow sexual development because of lowered testosterone and can
cause increased breast growth. Depending on its severity, the condition is treat-
able with testoterone replacement therapy, breast reduction, and counseling.
Linda Tancs
Sex Differentiation of the Brain and Sexual Orientation 609
See also: Biological Sex; Chromosomal Sex; Gender; Klinefelter Syndrome; Turner Syn-
drome; X Chromosome; Y Chromosome.
Further Reading
Easter, C. (n.d.). Sex chromosomes. Retrieved from https://www.genome.gov/genetics
-glossary/Sex-Chromosome
ScienceDirect. (2019). Sex chromosome. Retrieved from https://www.sciencedirect.com/
topics/biochemistry-genetics-and-molecular-biology/sex-chromosome
Weingarten, C. N., & Jefferson, S. E. (2009). Sex chromosomes: Genetics, abnormalities,
and disorders. Hauppauge, NY: Nova Science Publishers.
Sex Differentiation of the Brain and Sexual Orientation
Sex differentiation, the process of developing as male, female, or somewhere on
the intersex spectrum, begins in the sixth week of pregnancy. Embryos that con-
tain a Y chromosome typically develop testes, while embryos with two X chromo-
somes typically develop ovaries. After fetal gonads (testes or ovaries) are
developed, other organs in the body also start to develop male or female charac-
teristics, including the brain. While the mechanisms for many sex-linked charac-
teristics continue to be studied, it is now widely accepted that the complex
interactions between brains, genes, hormones, and the intrauterine environment
(the womb) underlie the development of not only sex but also sexual orientation.
To understand the development of sexual orientation, it is necessary to under-
stand that the development of sex is a complex biological process that affects the
development of not only the body but also the brain. Indeed, sex arises from a
complex interaction between a mother’s womb, a baby’s genes, hormones (such as
estrogen and testosterone), and the immune systems of both mother and child.
Interactions between these factors cause the brains of males and females to change.
This is despite conflicting results in studies examining specific sex differences in
the brain. Indeed, given (1) the many ways that male and female brains could be
compared (e.g., volume, mass, connectivity), (2) the large number of comparable
brain structures, and (3) the wide variation in these structures within each sex, it is
difficult to fully characterize the differences between male and female brains.
Furthermore, differences in the brains of adult men and women do not necessarily
arise from biological sex alone. It is also possible that environmental influences,
such as gendered roles for boys and girls, also influence how the brain develops.
Nevertheless, despite the difficulties associated with this research, sex differ-
ences in how the brain works and how people behave are widely recognized. Like-
wise, there is now lots of evidence that shows brains also differ by sexual
orientation and not just biological sex. These studies mirror those that compare
physical differences between homosexual and heterosexual subjects by demon-
strating differences in the brain structure and function between homosexual and
heterosexual individuals. For example, on average, the part of the brain in gay
men that is associated with male-typical sexual behavior (the anterior hypothala-
mus) has more similarities with the female brain relative to heterosexual men. It
has been suggested that the “feminization” of this structure may lead homosexual
610 Sex Education
men to, among other things, respond similarly to women when exposed to male
body odors. Aside from the hypothalamus, other differences in the brain have also
been identified, and the existing evidence from this body of literature strongly
supports other findings that suggest sexual orientation, like sex, is related to
changes that fetuses undergo while in their mother’s womb.
Kiffer G. Card
See also: Biological Theories of Sexual Orientation; Gender; Sex Hormones; Sexual
Dimorphism; Sexual Orientation.
Further Reading
Balthazart, J. (2011). The biology of homosexuality. New York: Oxford University Press.
Fisher, A. D., Ristori, J., Morelli, G., & Maggi, M. (2018). The molecular mechanisms of
sexual orientation and gender identity. Molecular and Cellular Endocrinology,
467, 3–13.
Garcia-Falgueras, A., & Swaab, D. F. (2010). Sexual hormones and the brain: An essential
alliance for sexual identity and sexual orientation. Pediatric Neuroendocrinology,
17, 22–35.
LeVay, S. (2016). Gay, straight, and the reason why: The science of sexual orientation
(2nd ed.). New York: Oxford University Press.
McCarthy, M. M., Nugent, B. M., & Lenz, K. M. (2017). Neuroimmunology and neuro-
epigenetics in the establishment of sex differences in the brain. Nature Reviews
Neuroscience, 18(8), 471–484.
Ngun, T. C., Ghahramani, N., Sánchez, F. J., Bocklandt, S., & Vilain, E. (2011). The genet-
ics of sex differences in brain and behavior. Frontiers in Neuroendocrinology,
32(2), 227–246.
O’Hanlan, K. A., Gordon, J. C., & Sullivan, M. W. (2018). Biological origins of sexual
orientation and gender identity: Impact on health. Gynecologic Oncology, 149(1),
33–42.
Roselli, C. E. (2018). Neurobiology of gender identity and sexual orientation. Journal of
Neuroendocrinology, 30(7), e12562.
Ruigrok, A. N. V., Salimi-Khorshidi, G., Lai, M.-C., Baron-Cohen, S., Lombardo, M. V.,
Tait, R. J., & Suckling, J. (2014). A meta-analysis of sex differences in human
brain structure. Neuroscience and Biobehavioral Reviews, 39(100), 34–50.
Savic, I. (2014). Pheromone processing in relation to sex and sexual orientation. In
C. Mucignat-Caretta (Ed.), Neurobiology of chemical communication. Boca Raton,
FL: CRC Press/Taylor & Francis. Retrieved from http://www.ncbi.nlm.nih.gov
/books/NBK200984/
Sex Education
The history of sex education in the United States is quite short, beginning in 1913
when schools began to teach sex education. By the 1930s, most secondary schools
provided some sort of sex education, but it was not mandatory nor regulated by the
federal or state governments. Whether or not students were taught about sex was
not an issue for state governments until the emergence of HIV/AIDS in the early
1980s. At this time, states mandated that schools teach about HIV/AIDS and how
to stop it from spreading in order to curb the sudden outbreak. It was required that
Sex Education 611
schools help stop the rapid spread of HIV, but the government did not provide a
specific way to do so. Groups pushing for abstinence-based programs had existed
since the 1960s as a way to counteract the Supreme Court cases Griswold v. Con-
necticut, which made contraception legal in 1965, and Roe v. Wade, which made
abortion legal in 1973. These groups believed that the Supreme Court rulings sig-
nified an end to sexual purity in the United States, and they sought to protect stu-
dents’ innocence. The existence of these groups prior to states requiring some
form of sex education in the 1980s influenced how students were taught about sex.
In the late 1980s, another enthusiastic push for abstinence-only education came
as more teenagers became pregnant, resulting in high numbers of single mothers
and abortions. This perpetuated the belief that the United States’ moral fabric was
unraveling. Pro-abstinence-only groups dominated the emerging political conver-
sation about sex education at this time and lobbied for more control. This resulted
in the federal and state governments giving schools across the country about $1.5
billion from 1996 to 2007 under Title V of the Social Security Act to support and
develop abstinence-only curriculum.
During this time, many countries around the world, and especially in Europe,
were implementing a different kind of sex education, one that was comprehensive
and included information about anatomy, sexual development, sexually transmit-
ted infections (STIs), contraception, pregnancy, childbirth, abortion, and healthy
relationships. This type of fact-based education teaches students from elementary
school through high school about different aspects of sex and sexuality from dif-
ferent perspectives and gradually builds in content as the students get older. Not
surprisingly, countries with this approach have lower rates of unplanned pregnan-
cies, abortions, and STIs, and rates continue to decrease. Meanwhile, the U.S.
rates are significantly higher.
In 2010, as part of the Affordable Care Act, the U.S. government passed the
Personal Responsibility Education Program in an effort to expand sex education
curriculum past abstinence-only curriculum to include teaching students about
the various forms of contraceptives available and how to use them. This is the first
federally funded sex education curriculum that combines abstinence-only teach-
ings with fact-based curriculum. This is one step that the United States has taken
to try to improve the nation’s ineffective sex education. Unfortunately, even
though this legislation was passed by both political parties, schools across the
country have consistently rejected the funds from the program in order to keep
teaching students the abstinence-only curriculum.
Not only is the sex education curriculum in the United States outdated in the
ideals about sex, but the programs do not effectively prevent teenage pregnancies
or STIs. The teenage birth rate in the United States is three times higher than in
France, four times higher than in Germany, and five times higher than in the Neth-
erlands. Similarly, the United States does not have the best statistics regarding
STIs. According to the Centers for Disease Control and Prevention, young adults,
ages fifteen to twenty-four, are at a higher risk of acquiring STIs than older gen-
erations. As of 2015, all the nationally reported STIs (chlamydia, gonorrhea, and
syphilis) have seen increases between 6 percent and 19 percent in the number of
infections reported. The U.S. youth population is about six times more likely to be
612 Sex Guilt
diagnosed with HIV/AIDS than in Europe, and U.S. youth are far less likely to use
any contraception. The lack contraception use in the United States is not surpris-
ing seeing that abstinence-only education wrongly teaches that condoms do not
work. We even see differences in these statistics within in different U.S. states. In
states where sex education is more comprehensive, as opposed to the abstinence-
only approach, there are lower rates of unplanned pregnancies and STIs.
A positive consequence of teaching children about sexuality is that it builds a
foundation for future learning and growth. As students age, their sex education
needs change. For example, teaching about the physical, mental, and emotional
changes that happen during puberty helps students understand that what is hap-
pening is supposed to happen. When young people do not properly understand
what is to be expected during puberty, it can lead to eating disorders, excessive
use of anabolic steroids, depression, and increased use of legal and illegal sub-
stances. Understanding the changes in their bodies helps build confidence in talk-
ing about these changes, which promotes communication between students and
trusted adults if something is wrong or if they have questions.
Research shows that the majority of people in the United States prefer that
schoolchildren receive a complete and comprehensive sex education similar to
programs found in Europe. Many teachers, parents, doctors, and politicians are
trying to replace abstinence-only programs based on the research showing it is
ineffective, looking to Europe’s more comprehensive sexuality education
approach. However, there are still many deep-seated religious ideals and miscon-
ceptions about the science of adolescent development that are held by many Amer-
icans and continue to perpetuate outdated curriculum.
Former president Barack Obama proposed eliminating a $10 million-a-year
grant that funds abstinence-only sex education. However, the Republican-led Sen-
ate and House of Representatives extended federal funding through the beginning
of the next presidency, giving control of the budget to the Donald Trump adminis-
tration. President Trump proposes to increase support for abstinence-only sex
education by nearly $300 million.
Carson Clark and Karen S. Beale
See also: Abstinence; Contraception; Puberty; Religion, Diversity of Human Sexuality
and; Sexual Health; Sexual Learning; Teen Pregnancy.
Further Reading
Guttmacher Institute. (2019). Sex and HIV education. Retrieved from https://www
.guttmacher.org/state-policy/explore/sex-and-hiv-education
Ponzetti, J. J., Jr. (2016). Evidence-based approaches to sexuality education: A global
perspective. New York: Routledge/Taylor & Francis Group.
Sex Guilt
Sex guilt is the feeling of regret or remorse after engaging in a sexual activity. It can
occur after engaging in any sexual activity, including masturbation, but it is typi-
cally discussed in regard to sexual intercourse. It is often confused with sex anxiety
or sexual shame. Sex anxiety is the feeling of apprehension or worry that may occur
before a sexual encounter or about anything sex related. Sexual shame comes from
Sex Hormones 613
the fear of disgrace or humiliation from others about sex or a sex-related behavior.
Simply put, sex guilt is privately experienced based on a specific behavior, sexual
shame is more publicly oriented, and sex anxiety is a more generalized emotion.
The feelings of regret and remorse following a sexual encounter are experi-
enced by an individual if they believe that they have acted contrary to their beliefs
or values. For example, sex guilt may be experienced by a person raised in a strict
religious environment who engaged in sex before marriage. However, sex guilt
can also be experienced for other reasons, such as because they cheated on their
significant other, because they had sex with someone they didn’t love, because
they were intoxicated during the sexual encounter, or because they engaged in a
sex behavior that they did not want to. Sex guilt is reported more often by women,
likely due to the sexual double standard.
Scientific research on sex guilt really began in the 1960s and 1970s, likely due
to researchers trying to understand the phenomenon of “free love” and the sexual
revolution. In the 1980s and 1990s, there was very little research published on this
topic, but recently, more researchers are beginning to study it again to try to better
understand why it occurs and the effects it can have on an individual and their
relationships.
Sex guilt can cause cognitive dissonance (an unpleasant feeling when one’s
beliefs or values do not match their behaviors). Because cognitive dissonance is so
emotionally painful, people experiencing it must make a choice: they must either
change their behavior, by no longer engaging in the sexual activity, or they must
change their beliefs or values about sex. Sex guilt can also lead to decreased self-
esteem, increased sex anxiety, and decreased sexual satisfaction in relationships.
Extreme cases can lead to sexual dysfunction and depression.
Because sex guilt stems from the mismatch between a person’s behaviors and
their beliefs or values, it can be particularly difficult to overcome and avoid nega-
tive results. Many people seek help from a counselor, a minister, a sex educator, or
a trusted friend. Working through these feelings is very important in order to
maintain sexual health.
Rachael Zaffiro and Karen S. Beale
See also: Cheating and Infidelity; Double Standards, Sexual; Performance Anxiety; Pre-
marital Sex; Religion, Diversity of Human Sexuality and.
Further Reading
Hackathorn, J., Ashdown, B., & Rife, S. (2016). The sacred bed: Sex guilt mediates religi-
osity and satisfaction for unmarried people. Sexuality & Culture, 20(1), 153–172.
Janda, L. H., & Bazemore, S. D. (2011). The Revised Mosher Sex-Guilt Scale: Its psycho-
metric properties and a proposed ten-item version. Journal of Sex Research, 48(4),
392–396.
Sex Hormones
Sex hormones are any of several chemical substances secreted by various glands
that are responsible for human sexual and reproductive characteristics and behav-
iors. While typically classified as male and female, all people have varying levels
of each of the sex hormones. The main male sex hormones are testosterone,
614 Sex Hormones
androsterone, and other androgens. The main female sex hormones are estrogen
and progesterone. Sex hormones are steroids, fat molecules that have a core struc-
ture made of three rings of six carbon atoms and one ring of five carbon atoms.
Besides their natural functions, sex hormones and synthetic versions of them have
a number of medical uses.
Testosterone is the most active and powerful male sex hormone. Most testoster-
one is produced by the connective tissue cells surrounding the sperm-producing
tubules in the testes, or testicles. Small amounts of testosterone are also secreted
by the adrenal glands, on top of the kidneys, and by the ovaries.
Androsterone plays a supportive role for the functions of testosterone, and it also
plays roles in other physiological processes. Androsterone and certain other
androgens—including androstenedione, dehydroepiandrosterone (DHEA), and
dehydroepiandrosterone sulfate (DHEA sulfate)—are produced mainly in the adre-
nal cortex, the outer portion of the adrenal glands. The testes and ovaries also pro-
duce some of these hormones, and DHEA and DHEA sulfate can be converted into
testosterone or androstenedione in adipose (fat) tissues and other body tissues.
Testosterone and androgen levels increase in males during puberty, typically
starting between the ages of twelve and fourteen. As the testes release testosterone
into the bloodstream, it flows throughout the body, prompting the development of
physical and behavioral characteristics that mark male sexual maturity. These
characteristics include the growth of hair on the face and body, the buildup of
muscle mass, the growth of the penis and testes, and the deepening of the voice.
Testosterone and other androgens promote male sexual arousal and general
aggressiveness, peaking during sexual interest and arousal. Healthy forms of
aggressiveness, such as a competitive drive and high motivation and energy, are
associated with high testosterone levels. Some research has found associations
between high testosterone levels and criminal sexual aggression, including rape, in
certain men. Other functions of testosterone, for all people, include the promotion of
cognitive functions—such as thinking ability, memory, concentration, and focus—
and spatial awareness. Testosterone also helps the ovaries produce estrogen.
In cases in which boys or men do not produce sufficient amounts of androgens,
testosterone or androgen replacement therapy can promote the development and
functioning of male reproductive organs and normal sperm cells. Trans men opt-
ing for gender transition may also take testosterone or androgen therapy in order
to promote masculinization of their physical features. Synthetic versions of these
hormones may be administered as injections, pills, creams, gels, patches, or
implants. Androgen replacement is also used as treatment for men who have low
sex drives.
Androgens can be used to treat people who have other disorders, including
breast cancer, anemia, skin problems, and abnormally delayed growth. Androgen
drugs known as “anabolic steroids” are used by some athletes to build muscle
strength. However, such use can result in serious physical and psychological side
effects, including cardiovascular problems, liver damage, testicular shrinkage,
and excessive aggression.
Estrogen begins to be secreted in large amounts by the ovaries at the start of
puberty, usually between the ages of ten and twelve. Among the various forms of
estrogen, the strongest and most important is estradiol. As these hormones flow
Sex Hormones 615
through the bloodstream, they produce physical changes that mark female sexual
maturity. These changes include the development of breasts, rounded hips, and
mature vaginal and clitoral tissues.
Estrogen also stimulates the beginning of the menstrual cycle, in which, once a
month, an ovary releases a mature egg. During the menstrual cycle, estrogen
works in conjunction with progesterone to thicken the lining of the uterus in prep-
aration for pregnancy. If pregnancy occurs, the hormones continue to be produced
in large amounts, maintaining the uterine lining and prompting the various devel-
opments of pregnancy. If pregnancy does not occur, the hormone levels decrease,
leading to the shedding of the thickened uterine lining in menstruation.
During middle age, usually between the ages of about forty-five and fifty-five,
the secretion of estrogen by the ovaries gradually decreases. When estrogen levels
in the blood become suitably low, ovulation and menstrual periods stop, and
menopause beings. Postmenopausal women can no longer become pregnant.
In addition to the estrogen secreted by the ovaries, smaller amounts of estrogen
are secreted by the adrenal glands and the testes. Small amounts are also produced
in adipose tissue and other tissues, through the metabolic conversion of other hor-
mones. The functions of estrogen in men are not clearly understood, though it
likely plays a role in promoting blood clotting and strengthening bones.
Progesterone is secreted primarily by the ovaries and, during pregnancy, by the
placenta. Like estrogen, small amounts of progesterone are also produced by the
adrenal glands and the testes.
As previously indicated, during the menstrual cycle, one of the ovaries releases
an egg and begins secreting large amounts of progesterone. These secretions cause
the endometrium (the lining of the interior walls of the uterus) to develop a thick-
ened layer of blood vessels, cells, and glands. Should the released egg be fertilized
by a sperm cell, the fertilized egg develops into an embryo, which implants in the
uterine lining. Tissues from the embryo become intertwined with tissues from the
uterus, forming the placenta. Large amounts of progesterone secreted by the pla-
centa keep the uterine muscle relaxed during pregnancy, preventing the fetus from
being born prematurely. The placenta’s progesterone works with other hormones
to induce development of milk-secreting cells in the breasts and to strengthen the
pelvic wall in preparation for birth. Immediately after birth, progesterone levels
begin to decrease.
If the egg is not fertilized and pregnancy does not occur, menstruation occurs
and progesterone levels immediately decline. Whether or not pregnancy occurs,
the monthly increase in progesterone levels may increase body temperature and
cause the breasts to enlarge and become more sensitive.
In addition to its sexual and reproductive functions, progesterone, in all people,
helps to regulate the transmission of nerve impulses; aids in the development and
protection of brain neurons; and plays roles in the regulation of blood clotting, cel-
lular oxygen levels, conversion of fat into energy, and insulin secretion by the
pancreas.
Drugs made with synthetic estrogen, sometimes mixed with synthetic proges-
terone (progestin), are used in oral contraceptives (birth control pills). Estrogen-
progestin pills are known as “the combination pill,” while progestin-only pills are
commonly called “the minipill.” The combination pill contains a higher dose of
616 Sex Reassignment Surgery
progestin than the minipill. These pills prevent pregnancy by blocking ovulation,
thinning the uterine lining, and thickening the mucus of the cervix.
Estrogen and progestin pills, creams, patches, implants, and injections are also
used in hormone replacement therapy (HRT) to reduce some of the unpleasant
symptoms of menopause (such as hot flashes, skin itchiness and dryness, and brit-
tle bones). Progesterone-based medications are sometimes prescribed as treat-
ments for irregular menstruation; premenstrual syndrome; breast, uterine, or
kidney cancer; and weight loss related to cancer or AIDS. HRT may also be used
by trans women during the gender transition process.
A. J. Smuskiewicz
See also: Androgens; Estrogen; Hormone Replacement Therapy; Oxytocin; Progester-
one; Synthetic Hormones; Testosterone.
Further Reading
Baker, S. (2007). The sex hormone secrets. Psychology Today. Retrieved from https://
www.psychologytoday.com/gb/articles/200701/the-sex-hormone-secrets
Our Bodies Ourselves. (2019). Hormones that affect sexual desire. Retrieved from https://
www.ourbodiesourselves.org/book-excerpts/health-article/hormones-affecting
-sexual-desire/
ScienceDirect. (2019). Sex hormones. Retrieved from https://www.sciencedirect.com
/topics/neuroscience/sex-hormones
Sex Reassignment Surgery
“Sex reassignment surgery” (SRS), also called “genital reconstruction surgery” or
“gender affirmation surgery,” refers to surgical procedures in which the body is
either masculinized or feminized as desired or required. Some, but not all, trans-
gender people seek this type of surgical intervention as part of their gender transi-
tion process. Surgeries may include chest, genital, or facial reconstruction.
Most transgender people who choose to undergo SRS will have also used hor-
mone therapy and may have had other procedures, such as electrolysis to remove
facial hair. The types of interventions and procedures chosen will depend on the
individual, their identity and expression, as well as additional factors such as
financial access and access to appropriate medical care. SRS first became publicly
available in the United States in the 1950s.
SRS procedures will vary across people. During construction of a neovagina
(vaginoplasty), the testicles are removed, as is the interior muscle tissue of the
penis. The neovagina is then created from the inverted skin of the penis or from
skin grafts. A nerve-sensitive portion of the penis head is shaped into a clitoris to
preserve sexual stimulation—though some nerve tissue may be lost in the opera-
tion. Following the surgery, the neovagina must be regularly cleaned and lubri-
cated because sufficient natural lubrication is not produced. In addition, the
vaginal opening must be frequently dilated with a special device to maintain an
adequate width and depth to the vagina as the body has a natural tendency to try
to close the opening. For some, it may be possible to orgasm during sexual stimu-
lation of the neovagina, although this will vary among people.
Sex Tourism 617
Construction of a neophallus is more complicated than construction of a neo-
vagina and the results more varied. The first step is to remove the uterus, fallo-
pian tubes, ovaries, and vaginal tissues. Testicular implants are then inserted into
the vulvar tissue to create a scrotum. Next, in a procedure called phalloplasty, the
surgeon attempts to create a functioning, sufficiently sized penis from the nerve-
containing clitoral tissue, together with vascularized (blood vessel–containing)
tissue taken from other body areas, such as the abdomen, thigh, or forearm. To
enable the person to have an erection, the surgeon usually implants a penile pros-
thesis within the newly formed penile tissue. The prosthesis is either semirigid or
inflatable. In addition, the urethra must be lengthened using any available vascu-
larized genital skin. Given the difficulty of these procedures, there may be com-
plications and nerve damage resulting in loss of sexual pleasure and function. As
such, the benefits and risks of these procedures need to be carefully considered
by the individual in consultation with their health care providers.
Reliable statistics regarding SRS procedures and their outcomes are difficult to
obtain. Various sources place the approximate number of SRS procedures per-
formed in the United States each year at anywhere from one hundred to one thou-
sand or more—with feminization surgeries far more common than masculinization
surgeries. Hundreds to thousands more SRS procedures are performed every year
in other countries throughout the world, especially in Thailand, which has been
dubbed the “SRS capital” of the world. Although the precise number of these sur-
geries is uncertain, it is clear that the number of these operations has increased in
recent decades. While many people are satisfied with the results of their surger-
ies, others are not and later report regret at having completed the procedures.
A. J. Smuskiewicz
See also: Gender Diversity; Gender Transition; Transgender.
Further Reading
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman,
J., … Monstrey, S. (2012). Standards of care for the health of transsexual, trans-
gender, and gender-nonconforming people, version 7. International Journal of
Transgenderism, 13(4), 165–232.
The Gender Centre Inc. (2019). Female to male information kit. Retrieved from https://
gendercentre.org.au/resources/kits-fact-sheets/female-to-male
The Gender Centre Inc. (2019). Male to female information kit. Retrieved from https://
gendercentre.org.au/resources/kits-fact-sheets/male-to-female
Guss, C., Shumer, D., & Katz-Wise, S. L. (2015). Transgender and gender nonconforming
adolescent care: Psychosocial and medical considerations. Current Opinion in
Pediatrics, 26(4), 421–426.
Iantaffi, A., & Barker, M. J. (2017). How to understand your gender: A practical guide for
exploring who you are. London: Jessica Kingsley Publishers.
Sex Tourism
“Sex tourism” refers to traveling for the specific purpose of procuring sex, inti-
macy, exoticism, or unconstrained sexual experiences. Although sex tourism can
be found almost anywhere in the world, it tends to be most popular in regions
618 Sex Toys
where the cost of sex is lower (e.g., the Caribbean, Cambodia, Thailand, Philip-
pines, Bangladesh, Jamaica, and Dominican Republic). The high demand for sex
tourism in these areas is a significant source of income that many of these coun-
tries rely on for economic performance or contribution for gross domestic prod-
uct. From a tourist perspective, Eastern cultures are popular sex tourist destinations
because of the desire to have sexual experiences with others that are exotic or
non-Western. Traditionally, sex tourists were thought to be predominately hetero-
sexual men traveling to have sex with women. In recent decades, however, it has
been discovered that the dynamics and demographics of the sex tourism industry
are much more complex; women, men who have sex with men, and locals are now
known to also engage in the industry.
Though prostitution is legal in many popular sex tourism destinations, the sex
tourism industry contributes to one of the largest criminal industries in the
world—human trafficking. Given the demand for child sex tourism, children are
especially vulnerable to human trafficking; child sex tourism is currently a
multibillion-dollar industry that affects over 2 million children each year. Despite
most countries having laws to protect children against sex tourism, unenforced
laws make it feasible to avoid charges of sex crimes. The advancement of internet
and mobile technology, as well as an upsurge in global users, has provided an
increase in anonymity and hidden avenues to access child sex tourism. Such
advancements have also contributed to decreased risk of arrest and an increase of
sexual exploitation of children in the travel and tourism industry.
Nicole C. Doria and Matthew Numer
See also: Prostitution; Sex Work; Sex Workers, Male; Sexual Slavery.
Further Reading
Centers for Disease Control and Prevention (CDC). (2013). Sex tourism. Retrieved from
https://wwwnc.cdc.gov/travel/page/sex-tourism
Hawke, A., & Raphael, A. (2016). Offenders on the move: Global study on sexual exploi-
tation of children in travel and tourism. Retrieved from https://www.ecpat.org.uk/
offenders-on-the-move-global-study-on-sexual-exploitation-of-children-in-travel
-and-tourism-2016
Kosuri, M., & Jeglic, E. (2017). Child sex tourism: American perceptions of foreign vic-
tims. Journal of Sexual Aggression, 23(2), 207–221.
Richards, T., & Reid, J. (2015). Gender stereotyping and sex trafficking: Comparative
review of research on male and female sex tourism. Journal of Crime and Justice,
38(3), 1–20.
SexInfo. (2018). Sex tourism. Retrieved from http://www.soc.ucsb.edu/sexinfo/article/sex
-tourism
Sex Toys
The term “sex toy” can be used to describe a number of objects and accessories
that are used to increase sexual pleasure or support sexual activity, either solo or
partnered. Sex toys refer to items that are used by people of all gender identities,
sexual orientations, and types of relationships and can be used all over the body,
including on, around, and in genitalia. In the United States, items designated as
Sex Toys 619
sex toys can only be purchased by individuals eighteen years of age and older.
However, it is not illegal for young people to own sex toys, and other countries
have different laws, some more lenient and others more restrictive.
Archaeologists have discovered stone carvings from over 8,000 years ago
(between 4000 BCE and 6000 BCE) that resemble phalluses, indicating that
objects have been used to facilitate sexual pleasure throughout the history of
humanity and is not limited to current usages and technologies. Historically, mod-
ern sex accessories were only available in sex stores or porn shops, which later
expanded to include sex toy stores (designed specifically for the purpose of ped-
dling these items), and now, many sex toys are available in drugstores and on
major online retail sites. This demonstrates how sex toys have become more
accepted in the mainstream, and this is mirrored by the centering of sex toys in
certain TV shows like Sex and the City, movies, and in popular books, such as 50
Shades of Grey and the Marketplace Series.
A vibrator is any object used sexually that vibrates in some way. These items
can be used externally for clitoral, vulvar, penile, scrotal, or nipple stimulation, or
internally for vaginal or anal stimulation (items should only be used anally if they
have a base wider than the rest of the toy). One of the most frequently recognized
sex toys is the rabbit-style or dual stimulator vibrator, made popular on Sex and
the City, although vibrators come in all shapes, sizes, colors, and styles. Many use
batteries from AAA to D, some are rechargeable, and a few types still plug into
the wall for their power source.
Following vibrators, another popular sex toy are dildos, insertable toys for the
mouth, vagina, or anus. Some dildos may vibrate, while many do not; the names
can be interchangeable for vibrating dildos, often based on the primary function
of the toy. Dildos can be held in the hand or strapped onto the body via a harness.
Just as vibrators offer diverse options, dildos are offered in a plethora of lengths,
widths, colors, levels of realism, and styles. The most commonly used type of har-
ness for a dildo is worn around the waist, but harnesses are also manufactured that
can be worn on the forehead, chin, chest, palm, thigh, or foot, depending on the
preference of the wearer. People of all genders can penetrate others or be pene-
trated themselves by dildos, and people of all sexual orientations may engage in
strap-on sexual activity, using one or more dildos and harnesses.
There are a variety of different sex toys designed for use in the anus. These
include, but are not limited to, anal dildos, butt plugs, anal beads, and anal
probes. Dildos are meant to be used in motion, while butt plugs, anal beads, and
anal probes are meant to be used in a stationary manner inside the anus to pro-
vide a feeling of fullness and anal stimulation. It is important to note that any toy
used in the anus should have a flared based (wider than the rest of the toy) to
keep it from slipping inside the body and getting stuck in the anal canal, or even-
tually, in the intestines. Also, toys used anally should be designated for that
purpose, used with a condom, or made of a sterilizable material because anal
bacteria can cause oral and vaginal infections during cross-contamination even
in the same body. People of all genders and sexual orientations may enjoy using
anal toys, and the enjoyment of anal stimulation is not limited to any sexual
orientation.
620 Sex Toys
Penis rings, sometimes referred to as “cock rings,” are usually worn around the
testicles and penis in order to permit blood to flow into the penis but not back out
again. This can somewhat increase the length, width, and time of erection tempo-
rarily as well as provide a more intense orgasm for the wearer. It should be noted
that these objects should not be worn longer than fifteen to twenty minutes at a
time in order to prevent discomfort and potential medical problems. Some rings
also have a vibrating function. These may also be worn on nonvibrating dildos to
add a vibrating effect. Penis rings are frequently suggested as a first step to treat
erectile dysfunction, sometimes partnered with a penis pump in order to have an
erection.
Another group of sex toys can be considered more sexual health toys. These are
items that help to strengthen vaginal and pelvic floor muscles. Because having
strong pelvic floor muscles can help with bladder control (including during preg-
nancy and aging), easier recovery after vaginal birth, and stronger orgasms, toned
muscles can be supportive for a number of positive health outcomes. While Kegel
exercises can be done independently of toys, once inserted, these items can help
the body to do these exercises subconsciously when the wearer is moving. Typi-
cally, these are round balls specifically designed to be worn for hours at a time,
allowing the wearer to build stronger Kegel muscles by triggering the muscles to
subconsciously contract and then release during any movement.
Any sex toy that is made from a jelly material (some called sil-a-gel, gelee, Jel-
ee, etc.) is not guaranteed to be safe for use inside the body. These materials con-
tain something called phthalates, which are rubber softeners (like what they use
on shower curtains), and not only do they often smell bad, but they can leach into
the body during use, causing irritation, pain, and even potentially cancer, based on
research studies commissioned by Smitten Kitten and Tantus (The Coalition
Against Toxic Toys). As sex toys are not regulated by the FDA in the United States,
manufacturers are not restricted to body-safe materials. Sex toy materials that are
phthalate free and more safe for use on and in bodies include hard plastic, elasto-
mer, TPR, medical-grade silicone, glass or Pyrex, metal (aluminum or stainless
steel), ceramic, Corian, granite, polyurethane-coated wood, and marble. If a mate-
rial is unknown, using a condom over a toy is an effective method for barring
transfer of phthalates to the body. When a sex toy will be used by multiple part-
ners, it is considered best practice to either use a condom on the toy in order to
prevent the potential spread of bacteria and sexually transmitted infections or to
choose a sex toy material that can be sterilized, such as medical-grade silicone,
metal, ceramic, Corian, or glass. These materials can be sterilized by being wiped
down with 10 percent bleach solution or toy-specific sterilizer, being boiled for
three to five minutes, or being put through the dishwasher on the top shelf (the lat-
ter two options should only be used for nonvibrating toys).
There are a variety of other toys not specifically discussed here. Many of these
toys are specific to kink or BDSM play, such as floggers, paddles, nipple clamps,
wrist and ankle restraints, spreader bars, ball gags, whips, ropes, and others. In
addition, new sex toys are placed on the market on a regular basis, and while they
may fall into one of the categories discussed above, they often have unique quali-
ties, like a vibrator that can be worn as a glove, a dildo that can simulate
Sex Work 621
ejaculatory fluid, or a vibrating toy that can be controlled via the internet (referred
to as “teledildonics”).
Shanna K. Kattari
See also: Afterplay; Anal Intercourse; Arousal; Clitoris; Foreplay; Grafenberg Spot
(G-spot); Kegel Exercises; Masturbation; Oral Sex; Orgasm; Pelvic Floor Muscles; Sex
Education; Sexual Satisfaction.
Further Reading
BadVibes. (n.d.). Smitten Kitten. Retrieved from http://badvibes.org/the-smitten-kitten
Health Services Brown University. (2015). Sex toys. Retrieved from https://www.brown
.edu/campus-life/health/services/promotion/sexual-health-sex-101/sex-toys
Moskowitz, C. (2010, July). Stone age carving: Ancient dildo? Live Science. Retrieved
from http://www.livescience.com/9971-stone-age-carving-ancient-dildo.html
Scarleteen. (2019). Sex toys. Retrieved from http://www.scarleteen.com/tags/sex_toys
Teen Health Source. (n.d.). Sex toys. Retrieved from http://teenhealthsource.com/sex/sex
-toys/
Venning, R., & Cavanah, C. (2003). Sex toys 101: A playfully uninhibited guide. New
York: Simon & Schuster.
Sex Work
“Sex work” refers to sexual services or erotic entertainment provided for material
or monetary compensation. The use of the term “sex work” underscores the
employment and labor aspect of commercial sex while at the same time encom-
passing a variety of erotic services that do not involve direct sexual contact. A sex
worker includes any individual working in the adult entertainment or sex industry,
such as an exotic dancer or stripper, burlesque dancer, phone sex operator, domi-
natrix, fetish or role-play artist, erotic model, erotic masseur, peepshow performer,
porn actor or actress (including internet webcam performer and print model), and
prostitute (including brothel worker, street-based worker, bar prostitute, call girl,
gigolo or hustler, and escort).
The term “sex work,” coined by Carol Leigh circa 1979, was created to decrease
stigma and to raise awareness of the safety and rights of those who trade sexual
services as their work. The development of this perspective can be traced back to
the beginning of the prostitutes’ rights movement, which evolved into the sex
workers’ rights movement, as prostitutes began to reference their work as legiti-
mate labor. In the beginning, use of the term “sex work” had generally applied to
prostitutes. Rather than using the term “prostitution,” “sex work” was created as a
more inclusive term that identifies sex work as an occupation with multiple posi-
tions, including prostitution.
Many sex workers have faced challenges to have their work identified and
accepted as legitimate work from which one can maintain a sustainable living and
have employment protections. During the 1970s and 1980s, feminists frequently
debated about pornography and prostitution. While the dominant discourse was
on the negative effects and consequences, some feminists presented a more liber-
ated view of female sexuality and work options. Such feminists birthed a wave of
622 Sex Work
sex work activists who began to challenge the dominant discourse on prostitution
and pornography in defense of women’s sexual freedom, expression, and labor
choices.
Call Off Your Old Tired Ethics (COYOTE), the first prostitutes’ rights organi-
zation in the United States, spurred by Margo St. James and others, was formed in
1973. COYOTE, also later referred to as the North American Task Force on Pros-
titution, formed to address issues from the sex worker perspective via self-made
pamphlets, posters, and conference papers. Throughout the following decades,
more sex worker organizations developed, created publications, established plat-
forms for sex worker voices and concerns to be heard, and began raising aware-
ness about sex work and the conditions that some sex workers face, especially in
the wake of the HIV/AIDS epidemic.
Since some sex work requires sexual contact, sexual health is a primary con-
cern. In the early stages of the HIV/AIDS epidemic, prostitutes were accused of
being a conduit for the spread of the virus. Early information about HIV was writ-
ten in gay publications as well as sex-worker publications in order to debunk
myths and provide factual information. For example, in an article from the 1980s
publication Tucson Whores and Tricks, a writer provided research statistics and
current information, for that time, about the documented risks of HIV/AIDS to
prostitutes rather than the assumed risks that came from prostitutes: “There has
been an overemphasis on the danger of contracting AIDS from prostitutes, and an
underemphasis of the dangers to prostitutes. . . . Of the approximately 14,000
cases of AIDS, 1% have contracted through heterosexual sex. That amounts to
140 people. The media has not made it clear that 90% of these cases represent
women who have caught AIDS from men” (Unknown, 1985).
Considering the risk of sexually transmitted infections, including HIV, con-
doms are crucial for sex workers who have sexual contact with clients. However,
it is common practice to use carrying condoms as evidence against people who
are accused of prostitution, and this has been a practice in several countries for
decades. In recent years, some sex worker organizations and human rights organi-
zations have taken up this issue as an infringement of people’s rights to protect
themselves and as a public health issue.
Sex workers face particular scrutiny in society and in mainstream media. Using
sex work concepts to sell products, activities, and clothing has become increas-
ingly popular. More recent examples of sex work portrayed in the media depict
varied portrayals of sex work and the sex industry. Examples include pole dancing
classes (of which many are offered by former and current exotic dancers); stiletto-
style shoes that are marketed to the average working woman (similar to those
worn by many sex workers); exotic dancers appearing in music videos; phone sex
operators in movies such as Spike Lee’s Girl 6 and music videos like Hotline Bling
by Drake; TV shows depicting sex workers, such as the HBO series Cathouse,
featuring a legal brothel in Nevada; the Showtime series Secret Life of a Call Girl,
which focuses on the fictitious account of the life of a call girl in London; and the
realty TV show Kendra on Top, featuring a former Playboy model’s life after leav-
ing the sex industry.
Sex Workers, Male 623
Although prostitution is said to be the “world’s oldest profession,” it has yet to
be recognized as a profession. One researcher wrote, “Sex work, like other expres-
sions of sexuality that deviate from the norm, will be oppressed, and sex workers
discriminated against” (Hunter, 1991). This refers to policies and laws that con-
tinue to make sex work a crime, stigmatize sex workers, and tolerate violence
against sex workers. Though sex work in its various forms has increasingly
become part of the discourse in academia and mainstream media, issues of legal-
ization and decriminalization continue to be at the forefront of the current debates
for sex worker rights organizations.
Kevicha Echols
See also: Pornography; Prostitution; Sex Workers, Male; Sexual Rights; Sexually Trans-
mitted Infections (STIs); Sugar Daddies and Sugar Babies.
Further Reading
Centers for Disease Control and Prevention. (2019). HIV among women. Retrieved from
http://www.cdc.gov/hiv/group/gender/women/index.html
Francoeur, R., & Koch, P. B. (1998). Prostitution—sex workers. In R. Francoeur, P. B.
Koch, & D. Weis (Eds.), Sexuality in America (196–201). New York: Continuum.
Gall, G. (2007). Sex worker unionization: An exploratory study of emerging collective
organization. Industrial Relations Journal, 38(1), 70–88.
Hunter, A. (1991). The development of theoretical approaches to sex work in Australian
sex worker rights groups. In S. A. Gerull & B. Halstead (Eds.), Sex industry and
public policy conference (110). Canberra, Australia: Australian Institute of
Criminology.
Koken, J. A. (2010). The meaning of the “whore”: How feminist theories on prostitution
help research on female sex workers. In M. Ditmore, A. Levy, & A. Willman
(Eds.), Sex work matters: Power and intimacy in the global sex industry. London:
Zed Books.
McElroy, W. (1996). Sexual correctness: The gender-feminist attack on women. Jefferson,
NC: McFarland.
Unknown. (1985). Sex in the age of AIDS: Information for women in the sex industry.
Tucson Whores and Tricks: A Journal of Health and Politics for Sex Profession-
als, 6–9.
Sex Workers, Male
Male sex workers include men who exchange, barter, or trade sex and sex-related
services for money, goods, or other forms of capital. Male sex work can include,
but is not limited to, prostitution, escorting, modeling, pornographic acting, web-
cam sex performances, live sex shows, and other entertainment and commercial
endeavors. In some instances, male sex workers engage in “survival sex,” which is
an attempt to make money to support basic human needs such as food and hous-
ing. Clients or consumers of male sex workers can include women, men, transgen-
der persons, persons living with disabilities, as well as couples. Furthermore, male
sex workers may identify as gay, bisexual, queer, heterosexual, or “gay-for-pay.”
Male sex workers who sell sex to men may not necessarily be attracted to men;
624 Sexaholics Anonymous
and vice versa, male sex workers who sell sex to women may not necessarily be
attracted to women.
Male sex workers exist in many of today’s societies despite the fact that male
sex workers are less prevalent than female sex workers. Male sex workers are
diverse in terms of social demographics and motivations to work in the commer-
cial sex industry. Although many male sex workers engage in commercial sex
trade at massage parlors, brothels, and bars, male sex workers also utilize the
internet at high frequencies. Internet and mobile phone technology platforms
(e.g., geosocial mobile applications, social media applications) have increased the
global visibility of male sex workers. For instance, there are over sixty countries
worldwide that advertise male escorts through websites, and some of these web-
sites advertise sexual services. Legality of male sex work, in general, varies by
country and region.
Documented cases of male sex work date as far back as ancient Greece and
Rome, but scholars have taken more concerted efforts in recent years to research
male sex workers. Scholarship produced between the 1940s and 1970s focused on
sociopathy and social deviance of male sex workers, whereas scholarship from the
1980s and 1990s examined implications of male sex work on public health. When
compared to female sex workers and men in the general population across many
different countries, researchers have reported that HIV and sexually transmitted
infections were higher among men who engaged in sex work. Researchers are
continuing to track the social and public health implications of male sex work.
Franco Dispenza
See also: Pornography; Prostitution; Sex Work.
Further Reading
Baral, S. D., Friedman, M. R., Geibel, S., Rebe, K., Bozhinov, B., Diouf, D., … Caceres, C.
(2015). Male sex workers: Practices, contexts, and vulnerabilities for HIV acquisi-
tion and transmission. Lancet (London, England), 385(9964), 260–273.
Kumar, N., Minichiello, V., Scott, J., & Harrington, T. (2017). A global overview of male
escort websites. Journal of Homosexuality, 64(12), 1731–1744.
Minichiello, V., & Scott, J. (Eds.). (2014). Male sex work and society. New York: Har-
rington Park Press.
Minichiello, V., Scott, J., & Callander, D. (2013). New pleasures and old dangers: Rein-
venting male sex work. Journal of Sex Research, 50(3–4), 263–275.
Sexaholics Anonymous
Sexaholics Anonymous (SA) is an organization designed to help people recover
from sexual “addictions” or out-of-control sexual behavior, with the only mem-
bership requirement being “a desire to stop lusting and become sexually sober.”
The recovery program used by SA is based on the twelve steps developed by
Alcoholics Anonymous (AA). Members meet in local groups in which they share
their experiences to help one another solve their common problems. The organiza-
tion is financially supported through nonmandatory contributions from its mem-
bers. SA is headquartered in Brentwood, Tennessee.
Sexism 625
Unlike some other organizations designed to help sex addicts, SA does not
believe it is possible to control or limit, and still enjoy, sexual obsessions or com-
pulsions. Rather, it advocates completely stopping the problematic sexual
behaviors.
SA was founded in the 1970s by an individual known as “Roy K.” (Members
prefer to maintain their anonymity by using only the first letter of their last name.)
In 1979, Roy K obtained permission from AA to use its twelve steps as the core of
SA’s own recovery program. Roy K’s strict, conservative, evangelical religious
ideas are reflected not only in the adaptation of AA’s twelve steps but also in the
main guidebook used by SA, officially titled Sexaholics Anonymous but often
referred to as The White Book. The text of this book and of SA’s official website
elaborate on the group’s conservative ideas. The website, for example, describes
how people become “sexaholics” by becoming disconnected from family and
friends and tuning out “with fantasy and masturbation.”
As described by SA, the way to stop sexual compulsions lies in a combination
of physical, emotional, and spiritual healing. The “sexaholic” can achieve such
healing only by turning away from the “isolating obsession” and by turning to the
fellowship of SA group meetings, by turning to God, and by improving relations
with other people.
The uncompromisingly conservative messages of SA—which include opposi-
tion to same-sex couples, to sex with anyone other than a spouse, to masturbation,
and to other behaviors that are generally accepted, or at least tolerated, elsewhere
in society—are a source of much criticism among the group’s detractors. Further-
more, many psychologists argue that the group’s strict definition of sexual sobri-
ety is not useful or helpful for many people struggling with sexual compulsions.
Despite such criticism, many members of SA have testified to the ways in which
the organization has helped them conquer serious problems that had previously
been destroying their lives.
A. J. Smuskiewicz
See also: Compulsivity, Sexual; Hypersexuality; Out-of-Control Sexual Behavior; Por-
nography Addiction.
Further Reading
Sexaholics Anonymous. (2001). Sexaholics anonymous. Brentwood, TN: Sexaholics
Anonymous.
Sexaholics Anonymous. (2019). Home page. Retrieved from http://www.sa.org
Sexism
Sexism is discrimination and bias that devalues a person or group of people—
namely women and that which is considered feminine based on sex or gender. The
term “sexism” was introduced during the 1960s, but the beliefs and practices asso-
ciated with it pervade human history and have persistently lowered the quality of
women’s lives and devalued all things feminine.
The terms “sex” and “gender” are often seen as interchangeable, but scholars
make a clear distinction in that “sex” refers to one’s physical reality (secondary
626 Sexism
sex characteristics, genitalia, reproductive system), whereas “gender” is either the
socially constructed expectations (gender stereotypes, feminine, masculine), sex-
based social roles, or an aspect of one’s identity (a person with an assigned sex of
male may have a gender identity of female). Sexism is oppressive to both women
(sex) and feminine (gender) stereotypes, roles, and identity. It is important to note
that as much as these distinctions are useful in advancing scholarship, common
usage must be respected. These concepts are complex, amorphous, and often
overlapping. For example, a transgender person with an assigned sex of female
may indeed consider themselves to be a man, regardless of whether there have
been alterations to secondary sex characteristics or genitalia.
Can a woman be sexist toward men? No. A woman, or any person, may indeed
have prejudices and negative views of men and masculinity (misandry). But sex-
ism, like racism, must be understood within the larger edifice of hegemony that
results in structurally reinforced oppression of certain types of humans. The his-
tory of world cultures clearly shows that the vast majority have been and are today
patriarchal, both formally and implicitly. Sexism—biases and discrimination
against women and the feminine—is embedded in patriarchy. Men have not expe-
rienced systematic oppression and so are not the object of sexism. The fact that
this distinction has only recently been established is itself evidence of the capacity
of patriarchy. It is further support for the adage that “privilege is invisible to those
who have it.” It was once presumed that women (feminine) or men (masculine)
could be the object of sexism. Those in power, men, who benefited from patriar-
chy, were blind to the reality that social structures, language, and tacit norms
systematically oppress women.
Peter Glick and Susan Fiske developed a model of ambivalent sexism that dis-
tinguishes between hostile and benevolent sexism. The former refers to explicit,
negative, and harmful biases that contend women and femininity are inferior to
men and masculinity. It is explicit and, like racism, it is based on a general antipa-
thy toward a type of person. Benevolent sexism has a veneer of positivity, for it is
based on a perceived affection instead of antipathy. Further, it is often associated
with helping behaviors, such as offering to carry a woman’s package or picking up
a dinner bill. Despite this, it is constructed on damaging stereotypes of women
(incompetent, weak) and the superiority of men. It perpetuates the patronizing
attitude that women require men’s protection and help.
Others have compared old-fashioned and modern sexism. Old-fashioned sex-
ism is the essentialist belief that biological forces result in universal and clear sex
differences. This view is seen in many Western faith traditions and is often used
to justify societal gender roles that place men in positions of power (provider, pub-
lic or professional leader, head of house). Modern sexism is the false belief that the
unequal treatment of the sexes is a historical reality that no longer exists. Such a
view denies that women are still discriminated against and is hostile toward cur-
rent policies (workplace, governmental) designed to create equity between the
sexes.
Finally, internalized sexism occurs when a girl or woman incorporates the sex-
ist images, assumptions, and beliefs of society into her view of herself and of other
women. This results in a perception that women, including oneself, are mere
Sexology 627
objects of desire, are incompetent, and are powerless. Internalized sexism leads to
an invalidation and derogation of the feminine.
Sexism oppresses women and girls in that it provides the ideological underpin-
nings of patriarchy. Sexist discrimination of women and femininity is woven
throughout the entire fabric of a patriarchy. This includes, but is not limited to,
institutional structures, language, workplace practices, division of household
labor, placement into leadership positions, public policy, interpersonal relations,
sexual conduct, judicial procedures, and individual attitudes.
The history of world cultures demonstrates sex disparities in a number of life
quality markers. Women have disproportionally been the victims of sexual objec-
tification, intimate partner violence, employment discrimination, pay inequity,
and stress-related physical ailments (e.g., chronic pain, irritable bowel syndrome,
asthma). It is sexism that perpetuates these disparities.
Ed de St. Aubin and Alexandria Colburn
See also: Feminist Theory; Gender; Stereotypes, Gender; Stereotypes, Sexual.
Further Reading
Glick, P., & Fiske, S. T. (2012). An ambivalent alliance: Hostile and benevolent sexism as
complementary justifications for gender inequity. In J. Dixon & M. Levine (Eds.),
Beyond prejudice: Extending the social psychology of conflict, inequity and social
change (70–88). New York: Cambridge University Press.
Swim, J. K., & Hyers, L. L. (2009). Sexism. In T. D. Nelson (Ed.), Handbook of prejudice,
stereotyping, and discrimination (407–430). New York: Psychology Press.
Sexology
Rich in its history, sexology is the scientific study of human sexuality. Over
recent centuries, the area of expertise has legitimized itself as a scholarly disci-
pline composed of various branches from the field of biology (e.g., anatomy,
physiology, evolutionary theory) and the social sciences (e.g., psychology,
anthropology, history, philosophy). Periodically trivialized or regarded as
obscene, this serious field of study examines sexual diversity of the human con-
dition by means of rigorous scientific research. In search of how “natural” and
“healthy” sexuality manifests, sexologists have historically challenged the
assumptions and cultural boundaries surrounding sexual behavior and desire. In
an attempt to discover the scientific laws of sexuality, early sex research was
primarily focused on the construction of a medical model for professional refer-
ence regarding what was deemed sexual dysfunction (according to the time
period) (McGann, 2011; Roberts, 2011). Since that time, sexological ventures
have expanded on both physiological and behavioral research and have provided
an array of normalizing evidence used to advocate for the social justice of sexual
minorities and, in more recent decades, encourage informative pleasure-based
models of instruction.
Although many have sought to analyze the internal and external factors influ-
encing one’s sexual health as far back as Hippocrates and Aristotle, modern sex-
ology is an innovation of approximately the past 200 years. Fluctuating motives
628 Sexology
and parties involved have left a complex legacy across the development of sexol-
ogy as a professional field. Originally introduced by Elizabeth Osgood Goodrich
Willard in 1867, the term “sexology” is often attributed to the early German
pioneer Iwan Bloch and his innovative exploration of sexuality as a scientific
study. Bloch illustrated the concept of Sexualwissenschaft (sexology) in his work
Das Sexualleben unserer Zeit in seinen Beziehungen zur modernen Kultur (The
Sexual Life of Our Time in Its Relations to Modern Civilization, 1908); although
the earlier work Psychopathia Sexualis with Especial Reference to Contrary Sex-
ual Instinct: A Medical Study (1886) by German psychiatrist Richard Freiherr
von Krafft-Ebing is often considered the founding text substantiating sexology
as a scientific discipline. Krafft-Ebing’s examination of sexual behavior among
criminals founded his assertion of four major types of sexual abnormality: lack
of sex drive, excessive sex drive, poorly regulated sex drive, and perversions
“contrary to sexual instinct.” In addition, he coined the terms “sadism,” “mas-
ochism,” and “fetishism” in order to better describe the various activities he
deemed perverse.
The groundbreaking work in Europe of the late nineteenth and early twenti-
eth century was also heavily influenced by English physician Henry Havelock
Ellis and German physician Magnus Hirschfeld. Ellis’s book entitled Studies in
the Psychology of Sex (1896) popularized the significance of individual and cul-
tural relativity in relation to sexual behaviors and their assumed connotations.
This was revolutionary in an era where concepts such as masturbation and
homosexuality were severely pathologized. As for Hirschfeld, some of his sig-
nificant contributions to the field of sexology include the inception of transgen-
der advocacy; publishing the first journal dedicated to sexology,
Sexualwissenschaft (1908); founding the first society for sexology, Ärztliche
Gesellschaft für Sexualwissenschaft und Eugenik (Medical Society for Sexual
Science and Eugenics, 1913), alongside Bloch; and founding the first institute
dedicated to sexual research in Berlin, Institut für Sexualwissenschaft (Institute
for Sexual Research) (1919).
After the tyrannical Nazi pillaging of medical collections and scientific contri-
butions of Jewish scholars, Europe relinquished the lead in sexological develop-
ments of the early twentieth century to American scholars such as Alfred Kinsey.
While Hirschfeld’s notoriously extensive data collections supported many of Kin-
sey’s subsequent findings, it was Kinsey’s meticulously unprecedented research
that would ultimately set the standards for modern sexology. His books Sexual
Behavior of the Human Male (1948) and Sexual Behavior of the Human Female
(1953), known as “The Kinsey Reports,” took the world by storm as he exposed
myths regarding the frequency of premarital and extramarital sex, the presence of
same-sex behavior, and the publicly muted capacity of female arousal (Kinsey et
al., 1948, 1953). In addition, the introduction of Kinsey’s Continuum of Sexual
Orientation, aptly known as “The Kinsey Scale,” familiarized the public with a
more fluid space between homosexuality and heterosexuality, which was later
expanded on by Fritz Klein. Klein’s expansion measured seven separate compo-
nents of sexuality (attraction, behavior, fantasies, lifestyle, emotional preference,
social preference, and self-identification) as they relate to a person’s past, present,
Sexology 629
and ideal future for a more comprehensive representation of experiential varia-
tion. Klein also published The Bisexual Option: A Concept of One Hundred Per-
cent Intimacy (1978), based on his original research, and founded the Journal of
Bisexuality (1999).
Also similar to Kinsey’s studies was the work of Dr. William Masters and Vir-
ginia Johnson, who began conducting laboratory research in the late 1950s. With
the evolution of technology, Masters and Johnson were able to thoroughly explore
physiological response during sexual arousal and sexual intercourse. Their book
Human Sexual Response (1966) continued to dispel colloquial assumptions, much
like the work of Alfred Kinsey. Innovative equipment developed by Masters and
Johnson allowed the pair to measure a variety of physiological responses, the most
peculiar of which included a transparent phallic mechanism equipped with a small
camera in order to record vaginal contractions.
Decades after the work of Masters and Johnson, the scientific research of Helen
Singer Kaplan further explored sexual functioning with particular focus sur-
rounding dysfunction and desire. Kaplan’s three-phase model of sexual response
addressed desire as a significant component of the human sexual response cycle
and sexual functioning. Her books The New Sex Therapy (1974) and Disorders of
Sexual Desire (1979) afforded countless therapists scientific explanation and treat-
ment interventions for practical application. This movement toward pleasure-
based functioning, and away from behavioral pathology, continued with the
hands-on body work of Betty Dodson. Dodson’s work during and after the sexual
revolution included the formation of BodySex Workshops for guided exploration
and masturbation instruction for women (Hooper & Holford, 2004); subsequently,
male body workshops to address performance anxiety were later adapted (Hooper
& Holford, 2004). Some more well-known pleasure-based contributions to the
field include the work of John Perry and Beverly Whipple in their exploration of
Grafenberg spot (G-spot) functions; Dr. Ruth Westheimer’s promotion of sexual
literacy and better interpersonal communication within sexual relationships; and
Sue Johanson’s candid sex education and popularized endorsement of sexual
health aids such as sex toys.
The complexity of contemporary sexuality has far surpassed the limited notions
of conception, coital positions, and sexual orientation many might assume.
Although often faced with censorship, the greater purpose of sexology has not
been short-lived. Comprehensive biopsychosocial considerations have expanded
the field further than any intentions of early contributors, far beyond what many of
them may have even been able to anticipate. At this point, sexology has grown
from an attempt to adequately quantify and categorize the operations of reproduc-
tive body parts and human behavior into a theoretical exploration of sexuality as
its own social phenomena.
Ilyssa Boseski
See also: Desire, Models of; Dodson, Betty; Ellis, Henry Havelock; Hirschfeld, Magnus;
Johnson, Virginia; Kaplan, Helen Singer; Kaplan’s Triphasic Model; Kinsey, Alfred; Kin-
sey’s Continuum of Sexual Orientation; Krafft-Ebing, Richard von; Masters and Johnson
Four-Stage Model of Sexual Response; Sexual Behavior in the Human Male and Sexual
Behavior in the Human Female; Society for the Scientific Study of Sexuality (SSSS).
630 Sexting
Further Reading
Bullough, V. L. (1994). Science in the bedroom: A history of sex research. New York:
Basic Books.
Haeberle, E. J. (1983). The birth of sexology: A brief history in documents. (n.p.)
Hoenig, J. (1977). Dramatic personae: Selected biographical sketches of 19th century pio-
neers in sexology. In J. Money and H. Musaph (Eds.), Handbook of sexology
(21–43). Holland: Elsevier/North Holland Biomedical Press.
Hooper, A., & Holford, J. (2004). Anne Hooper’s Sexology 101: From Victorian transves-
tites to ‘70’s swingers and internet Viagra. Berkeley, CA: Ulysses Press.
Kinsey, A. C., Pomeroy, W. R., & Martin, C. E. (1948). Sexual behavior in the human
male. Bloomington: Indiana University Press.
Kinsey, A. C., Pomeroy, W. R., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in
the human female. Bloomington: Indiana University Press.
Kuefler, M. (2007). The history of sexuality sourcebook. Orchard Park, NY: Broadview
Press.
McGann, P. J. (2011). Healing (disorderly) desire: Medical-therapeutic regulation of sexu-
ality. In S. Siedman, N. Fischer, & C. Meeks (Eds.), Introducing the new sexuality
studies (427–437). New York: Routledge Taylor & Francis Group.
Oosterhuis, H. (2000). Stepchildren of nature: Krafft-Ebing, psychiatry, and the making
of sexual identity. Chicago: Chicago University Press.
Roberts, C. (2011). Medicine and the making of a sexual body. In S. Siedman, N. Fischer,
& C. Meeks (Eds.), Introducing the new sexuality studies (67–74). New York:
Routledge Taylor & Francis Group.
Siedman, S. (2011). Theoretical perspectives. In S. Siedman, N. Fischer, & C. Meeks
(Eds.), Introducing the new sexuality studies (3–12). New York: Routledge Taylor
& Francis Group.
Siedman, S., Fischer, N., & Meeks, C. (2011). Introducing the new sexuality studies (2nd
ed.). New York: Routledge Taylor & Francis Group.
Szuchman, L. T., & Muscarella, F. (Eds.). (2000). Psychological perspectives on human
sexuality. New York: John Wiley & Sons.
Yarber, W. L., Sayad, B. A., & Strong, B. (2010). Human sexuality: Diversity in contem-
porary America (7th ed.). New York: McGraw-Hill.
Sexting
Sexting is the “willing interactive exchange of sexual-oriented messages using a
digital mobile communications device” (Manning, 2013). As that definition sug-
gests, several elements must come together for sexting to occur. It must be consen-
sual, meaning that both the sender and receivers of sext messages want to participate.
A person sending a sext message to another person who does not want it would not
be considered sexting. Sexting must also be interactive. If a person were simply
making sexual messages for himself or herself to read, that would not be sexting.
The messages involved with sexting are sexually oriented, whether that is explicitly
sexual statements or images or even subtle hints about sex. Finally, sexting involves
mobile communications devices such as cell phones. Sexual interaction on a home
computer or laptop would be cybersex, as the device is not as portable.
Although most studies now demonstrate that a majority of adults sext, initial
studies about sexting were inconsistent in showing how many people were
Sexual Abuse 631
sexting. The accepted explanation for this is that many of these studies did not
offer a clear definition of sexting. Sexting is also considered to be a cultural prac-
tice, meaning that people in different areas and communities might be more likely
to sext than people from others.
Research reveals that people sext for many reasons. These include exploring
possibilities of what their partners enjoy sexually, using the sext messages for self-
pleasure, or simply to pass time.
Early studies about sexting mostly focused on adolescent sexting practices.
These studies examined the harms of sexting, such as the possibility for nude pho-
tos shared during sexting to be shared with others, causing hurt or humiliation.
These studies found that many young people were practicing sexting, and, as one
might expect, people tend to sext more as they approach adulthood. Some scholars
have critiqued these studies as alarmist because they only focused on the negative
aspects of sexting and might overstate the harms.
Legal scholars have also researched sexting, placing a focus on how sexting
would be interpreted under laws that were created before sexting existed. This
includes questions about age of consent, or when, legally, people are old enough to
sext. Legal scholars have also pointed out how sharing sext images of underage
adults could be considered as the illegal distribution of child pornography.
Because sexting is a relatively new practice, sexting research about both adults
and adolescents is still in its early stages. Although researchers have some good
ideas about how many people sext and why, they still have much to learn about
sexting. Given that adolescents do run into problems with sexting, most of the
research will probably investigate their sexting habits. Other researchers have
started examining how sexting can be beneficial for adults, especially when it
comes to exploring sexual needs and desires.
Jimmie Manning
See also: Adolescent Sexuality; Age of Consent; Online Dating; Online Sexual Activity.
Further Reading
Döring, N. (2014). Consensual sexting among adolescents: Risk prevention through absti-
nence education or safer sexting? Cyberpsychology: Journal of Psychosocial
Research on Cyberspace, 8(1), article 9.
Humbach, J. A. (2010). Sexting and the First Amendment. Hastings Constitutional Law
Quarterly, 37, 433–486.
Lounsbury, K., Mitchell, K. J., & Finkelhor, D. (2011). The true prevalence of “sexting.”
Retrieved from http://www.unh.edu/ccrc/pdf/Sexting%20Fact%20Sheet%204_29
_11.pdf
Manning, J. (2013). Interpretive theorizing in the seductive world of sexuality and inter-
personal communication: Getting guerilla with studies of sexting and purity rings.
International Journal of Communication, 7, 2507–2520.
Sexual Abuse
Sexual abuse is defined as any sexual act or game where the aggressor is at a more
advanced psychosexual stage in life than the intended victim or is in a position of
power over the intended victim. It is also sometimes referred to as molestation,
sexual violence, or sexual victimization. Sexual abuse can include acts where
632 Sexual Abuse
physical contact does not take place, such as harassment, taking photographs, or
showing unwanted sexual material. Research on sexual abuse has increased over
the past few decades. Often, “sexual abuse” is used as an umbrella term for all
types of sexual violence. However, sexual abuse can be looked at as a sexual
encounter that lacks consent, equality, respect, trust, and safety. Sexual abuse in
research is mainly studied as sexual violence that occurs between an adult and a
child (eighteen years old and below). Sexual assault can also be sexual violence
that takes place between adults. It is also important to know that not all sexual
abuse is traumatic or all reactions severe; each experience is different for the indi-
vidual and should be understood and treated as such.
The majority of sexual abuse victims do not report the assault, so it can be dif-
ficult to know or even estimate the prevalence. Some research has shown that
sexual abuse is reported by 28–30 percent of women. Research has also shown
that 12 percent of men and 17 percent of women were sexually abused before
adolescence.
Survivors of sexual abuse may show a number of negative symptoms through-
out their life, such as mental health problems, substance abuse, suicidal
thoughts/attempts, and sexual dysfunctions. One area that seems to be strongly
affected by sexual abuse is intimate partner relationships. Research shows that
in a relationship where one partner has suffered from childhood sexual abuse,
victims may have poor attachment boundaries, decreased levels of communica-
tion within the relationship, less understanding of each other, and a loss of con-
nection and cohesion over the trauma. Also, trauma transmission may is likely
to appear within these same relationships. Due to a lack of relationship and
sexual satisfaction among sexual abuse victims, they become more likely to be
in high-conflict relationships or to avoid sexual and intimate relationships all
together.
Sexual harassment includes unwelcomed sexual advances, sexual requests, and
other sexual conduct and is considered a type of sexual abuse when the abuser is
in a position of power over the victim. Sexual harassment can happen in the work-
place, between teachers and students, between doctors and patients, and in any
other setting where the abuser holds power over the victim prior to the onset of the
abuse. Studies have shown that 41 percent of women and 32 percent of men have
experienced sexual harassment in the workplace at least once.
Childhood sexual abuse is any form of sexual activity that takes place with a
minor and is a form of child abuse. This abuse can occur in a variety of ways and
does not have to involve physical contact. A child cannot give consent to engage in
sexual acts because of their age. Types of childhood sexual abuse can include but
are not limited to digital interactions (sexting or phone calls that are sexual in
nature); fondling or touching the child; exposing oneself to the child; masturbat-
ing in front of or forcing the child to masturbate; intercourse of any kind (oral,
vaginal, or anal); having, seeing, or sharing any type of images or videos of chil-
dren with sexual content; sex trafficking; or any other sexual misconduct that can
be harmful to a child. Any of these actions can lead to legal consequences, and
each state in the United States has its own varying legal definition of child sexual
abuse.
Sexual Abuse 633
Starting in 2002, development of a sexual abuse scandal in the Catholic Church
was detailed in the media. Many individuals came forward, stating that they had
been abused by their priests and clergymen when they were children. This type of
sexual abuse not only dealt with the abuser being in a position of power over their
victim but was also a form of childhood sexual abuse due to the victims being
below the age of consent.
Individuals who have developmental disabilities are more likely to be sexually
abused. The perpetrators are usually known to the victims and may be family
members, friends, service providers, psychiatrists, personal care staff, or residen-
tial care staff. It is important to note that oftentimes this abuse goes undiscovered
due to the lack of oversight of care and lack of sexual education and consent taught
to the victims.
Help from individual therapy and counseling has been shown to lessen the
symptoms of the trauma and can help victims become survivors. There have been
numerous studies on how individual therapy works with sexual abuse survivors.
Research has showed that using eye movement desensitization and reprocessing
individual therapy with survivors had long-lasting gains and improved the symp-
toms of sexual abuse trauma. Little research has been done on how couples ther-
apy could help relationship satisfaction for a couple where one partner is a survivor
of sexual abuse. One theoretical foundation that has been helpful for survivors of
sexual abuse, as well as couples, is narrative therapy.
Amanda Baker
See also: Child Sexual Abuse; Date Rape; Incest; Psychosexual Therapy; Rape; Rape
Trauma Syndrome; Roman Catholic Church Sexual Abuse Scandal; Sexual Assault; Sex-
ual Consent; Sexual Harassment.
Further Reading
Cobia, D., Sobansky, R., & Ingram, M. (2004). Female survivors of childhood sexual
abuse: Implications for couples’ therapists. The Family Journal, 12(3), 312–318.
Crooks, R., & Baur, K. (2005). Our sexuality. Belmont, CA: Thomson/Wadsworth.
Edmond, T., & Rubin, A. (2004). Assessing the long-term effects of EMDR: Results from
an 18-month follow-up study with adult female survivors of CSA. Journal of Child
Sexual Abuse, 13(1), 69–86.
Habigzang, L. F., & Koller, S. H. (2013). Evaluation of the therapeutic process in cases of
sexual abuse. Revista Latinoamericana de Psicologia, 45(2), 201–210.
Jeary, K. (2005). Sexual abuse and sexual offending against elderly people: A focus on
perpetrators and victims. Journal of Forensic Psychiatry & Psychology, 16(2),
328–343.
Kane, M. N. (2008). Investigating attitudes of Catholic priests toward the media and the
US Conference of Catholic Bishops response to the sexual abuse scandals of 2002.
Mental Health, Religion & Culture, 11(6), 579–595.
King, B. M. (2012). Human sexuality today (7th ed.). Upper Saddle River, NJ: Prentice
Hall.
Mahoney, A., & Poling, A. (2011). Sexual abuse prevention for people with severe devel-
opmental disabilities. Journal of Developmental & Physical Disabilities, 23(4),
369–376.
RAINN. (2019). Child sexual abuse. Retrieved from https://www.rainn.org/get-informa
tion/types-of-sexual-assault/child-sexual-abuse
634 Sexual Assault
Sexual Assault
Sexual assault is a coerced or forced sexual act between two people where one is
engaged in the activity against their will. This is a form of sexual violence and
sexual victimization and can happen in a number of ways. Sexual assault includes
rape (forced oral, vaginal, or anal penetration or by use of a date rape drug), sexual
activities with a minor, fondling, unwanted kissing, or any form of unwanted sex-
ual torture. Sexual assault is a crime, and each U.S. state has its own varying legal
definition. “Sexual assault” can also be used as an umbrella term for sexual abuse,
sexual violence, and sexual victimization. “Sexual assault” is the usual wording
for legal definitions. Research often differentiates between sexual assault and sex-
ual abuse by stating that sexual assault refers to sexual violence that takes place
between adults while sexual abuse is sexual victimization that takes place between
a victim and someone with power.
Rape is a form of sexual assault that can include oral, anal, or vaginal penetra-
tion through actual or threat of physical, emotional, or psychological harm and
coercion without consent from the victim. Rape can happen to anyone of any gen-
der, age, or sexual orientation. “Rape” is often used interchangeably with “sexual
assault.” Definitions of rape differ from state to state and between federal agen-
cies. The common theme of rape is the offender’s willingness to disrespect the
victim’s right to consent and to take advantage of a nonconsenting individual.
Date rape drugs are drugs or alcohol used to hinder a person’s ability to consent
to sexual activity. This is called drug-facilitated sexual assault. Any drug that can
affect a person’s judgment and behavior can be a date rape drug. There are many
different types of drugs that can be used, and drug-facilitated sexual assault takes
place not only on dates but also while out with friends at a bar and in many other
scenarios. Alcohol is the most common drug used. Other date rape drugs are
gamma hydroxybutyrate (GHB), Rohypnol (roofies), and ketamine (Special K). It
is important to know that regardless of the drug used or a person’s behavior, a
victim is not to be blamed for what happened.
Sexual assault is one of the biggest public health concerns on college campuses.
Anywhere from 20–25 percent of females are sexually assaulted in some way dur-
ing their undergraduate years. Sexual assault on college campuses has gained
national attention within the last few years and has gained a lot of research atten-
tion as well. Sexual assault on college campuses includes harassment, rape, date
rape, and other forms. Many universities have started to look at the use of violence
prevention education and modalities to help decrease the frequency of sexual
assaults on campuses.
Amanda Baker
See also: Child Sexual Abuse; Date Rape; Rape; Rape Trauma Syndrome; Sexual Abuse;
Sexual Consent; Sexual Harassment.
Further Reading
Crooks, R., & Baur, K. (2005). Our sexuality. Belmont, CA: Thomson/Wadsworth.
Exner, D., & Cummings, N. (2011). Implications for sexual assault prevention: College
students as prosocial bystanders. Journal of American College Health, 59(7),
655–657.
Sexual Avoidance 635
King, B. M. (2012). Human sexuality today (7th ed.). Upper Saddle River, NJ: Prentice
Hall.
RAINN. (2019). Drug-facilitated sexual assault. Retrieved from https://rainn.org/get
-information/types-of-sexual-assault/drug-facilitated-assault
Sexual Avoidance
“Sexual avoidance” refers to actively avoiding all sexual activity. Unlike a motiva-
tion to abstain from sexual activity for religious reasons or due to particular cir-
cumstances (e.g., to focus on other aspects of life or because the individual is not
in a relationship), the term “sexual avoidance” is typically used to describe the
avoidance of sexual activity motivated by feelings of anxiety, fear, or shame.
In some cases, sexual avoidance is a result of hypoactive sexual desire (desire
that is persistently deficient or absent); sexual activity is avoided because the per-
son has no interest in engaging in it. Men and women with other sexual dysfunc-
tions may engage in sexual avoidance in order to avoid an unsatisfactory sexual
encounter. For example, men with erectile disorder may take steps to ensure they
do not have sex with their partner, such as going to bed after the partner has gone
to sleep and not initiating sex or even nonsexual contact for fear that it may lead to
sex. At times, the partner of the person with the sexual dysfunction may also avoid
sexual activity as a means of avoiding rejection or a disappointing sexual
encounter.
Sexual aversion disorder is another possible cause of sexual avoidance. With
sexual aversion disorder, the avoidance of sexual activity goes beyond a lack of
interest or a desire to avoid an unsatisfactory sexual encounter. People with sexual
aversion disorder may be mistaken for having low desire, but aversion includes an
intense fear or revulsion of some or all sexual activities, a type of phobic response.
Some people use the term “sexual anorexia” as a synonym for sexual avoid-
ance. Used in this manner, sexual avoidance is seen as similar to sex addiction.
With sex addiction, individuals are seen as acting out sexually to avoid negative
feelings and intimacy. With sexual anorexia, individuals are seen as acting in by
cutting themselves off from sex and intimacy. Rather than a lack of desire or pho-
bic response preventing sexual activity, the individual avoids sex out of
compulsion.
Sexual avoidance is diagnosed through the use of a thorough sexual history.
Treatment for the condition typically consists of sex therapy, a specialized form of
psychotherapy or talk therapy. Therapy includes the attempt to determine the
cause of the avoidant behavior, and treatment is determined based on this cause.
In the case of sexual aversion, antianxiety medication combined with systematic
desensitization may be used. Systematic desensitization involves gradual expo-
sure to the situations that cause the phobic response while using relaxation tech-
niques to reduce anxiety.
Treatment for sexual dysfunctions such as low desire, erectile disorder, prema-
ture ejaculation, and pain disorders may include medical intervention and sex
therapy. Sexual avoidance may cause significant distress for the individual and for
636 Sexual Behavior in the Human Male
their partner if they are in a relationship. A component of the sex therapy treat-
ment may include couple therapy to address the impact of the avoidant behavior
and to improve any relational factors that may be contributing to or maintaining
the problem.
Adrienne M. Bairstow
See also: Abstinence; Desire Disorders; Erotophilia and Erotophobia; Psychosexual Ther-
apy; Sex Guilt; Sexual Dysfunction, Treatment of.
Further Reading
Encyclopedia of Mental Disorders. (2019). Sexual aversion disorder. Retrieved fromhttp://
www.minddisorders.com/Py-Z/Sexual-aversion-disorder.html
Hartney, E. (2018). What you should know about sexual anorexia. Retrieved from http://
addictions.about.com/od/sexaddiction/a/what_is_sexual_anorexia.htm
Katehakis, A. (2014). The devasting pain of “sexual anorexics.” Retrieved from https://
www.psychologytoday.com/blog/sex-lies-trauma/201408/sexual-anorexia-the
-shadow-addiction
Sexual Behavior in the Human Maleand Sexual Behavior in
the Human Female
Published in 1948, Sexual Behavior in the Human Male, and its companion pub-
lished in 1953, Sexual Behavior in the Human Female, are collectively known as
“The Kinsey Reports.” They were written by Alfred Kinsey and colleagues based
on his studies of human sexual behavior. The books were the first to bring the
study of human sexuality to the public and mainstream media and were associated
with a shift in public attitudes toward sex and sexuality.
In 1938, Alfred Kinsey was teaching a marriage course at Indiana University.
His students wanted to learn a wide range of topics surrounding marriage, and
they wanted the course to include both male and female students. To learn more
about his students, Kinsey required them to fill out a survey about their sexual
histories. Members of the Indiana University faculty disliked what Kinsey was
teaching, and the research he was doing along with it, so they petitioned the presi-
dent of the university to remove him from the course. The president gave Kinsey
a choice to keep his class or do research but not both. Kinsey chose the research.
Kinsey’s research team included Clyde Martin, who handled the statistical
analysis; Wardell Pomeroy, a psychologist; and Paul Gebhard, a trained anthro-
pologist. Providing almost all the data were 5,994 females and 5,300 males, with
the majority of participants being younger white adults with some college educa-
tion. Kinsey used in-depth, face-to-face interviews by highly trained interview-
ers. In each interview, a subject would be questioned about their history on up to
521 items, depending on their specific experience. Histories covered social and
economic data, physical and physiologic data, marital histories, sexual outlets,
heterosexual histories, and homosexual histories.
Sexual Behavior in the Human Male became a best seller, making Kinsey a
household name. Included in the male Kinsey Report was Kinsey’s heterosexual-
homosexual rating scale, better known simply as the Kinsey Scale. Kinsey
Sexual Consent 637
reported that people did not fit into neat and exclusive heterosexual and homo-
sexual categories but that sexual behavior, thoughts, and feeling are inconsistent
across time.
Other topics of the book included anal sex, bisexuality, coitus, erogenous zones,
extramarital sex, fantasy, foreplay, homosexuality, masturbation, nudity, oral sex,
orgasm, peak performance or maximum sexual activity, premarital sex, sadomas-
ochism, and sex with prostitutes. The controversial and shocking findings chal-
lenged conventional beliefs about sexuality and other taboo topics. While some
criticized Kinsey’s research as an unsuitable public topic, others criticized his
research methods. One critique was on his sampling method. Some believed his
sample was not a true representation of the U.S. population since he mostly inter-
viewed college students, prostitutes, and prison inmates.
The most important contribution of the female edition was the exploration of
basic male-female similarities and differences. Kinsey broke the myth that
women merely engaged in sex for procreation or to please their male partners.
While the female sexual behavior findings advocated for female sexuality, out-
rage again broke out over the findings, as it had over the male version. Critiques
again questioned his research methods, arguing that the statistics could not be
accurate because good women would not engage in the activities that are dis-
cussed in the book or, if they had, they would not have revealed their experiences
to Dr. Kinsey.
Lauren Ewaniuk
See also: Kinsey, Alfred; Kinsey’s Continuum of Sexual Orientation.
Further Reading
Kinsey, A. C., Pomeroy, W. R., & Martin, C. E. (1948). Sexual behavior in the human
male. Bloomington: Indiana University Press.
Kinsey, A. C., Pomeroy, W. R., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in
the human female. Bloomington: Indiana University Press.
Sexual Consent
Consent, the ability to make fully informed decisions, is a human right, essential
to our sexual rights of sexual autonomy and bodily integrity. According to the
World Association of Sexual Health, “Everyone has the right to control and decide
freely on matters related to their sexuality and their body. This includes the choice
of sexual behaviors, practices, partners and relationships with due regard to the
rights of others. Free and informed decision making requires free and informed
consent prior to any sexually-related testing, interventions, therapies, surgeries, or
research.” Informed consent and sexual consent describe the process of ensuring
our sexual right to freely choose to participate in sex-related interventions or
research and to pursue sexual activity, respectively.
Informed consent precedes participation in sexuality-related research or
sexuality-related testing and interventions. Informed consent has three dimen-
sions: ensuring individuals have the competence to provide consent, understand
the activities to which they consent, and are participating entirely voluntarily. In
638 Sexual Consent
research, for example, researchers inform the participant about the purpose of the
research project, the activities expected of participants, and the potential benefits
and risks. Researchers carry the responsibility to ensure that participants have
understood the procedures and are competent to make a qualified choice about
their participation. Participation is completely voluntary; participants have the
right to decline or withdraw from the study at any time. This informed consent
process mirrors sexual consent.
Sexual consent is a conscious, clear, voluntary agreement to pursue sexual
activity and other sex-related matters. Like informed consent, a person must have
a thorough understanding of the sexual activities that will be pursued as well as
the risks and benefits of engaging in such activities. At the time of consent, indi-
viduals must have the capacity to fully comprehend the meaning of the sexual
activity and its social, emotional, and physical consequences. Sexual consent
requires that individuals must be willing and freely agree to participate at the out-
set and throughout the duration of the activity. Crucially, individuals have the
right to decline or withdraw from sexual activities at any time, for any reason, and
without any aversive consequences.
This definition indicates that pursuing sexual activity with a person who lacks
the ability to provide consent is nonconsensual. Legally, individuals are unable to
provide consent when they are mentally incapacitated (e.g., severe cognitive dis-
abilities, intoxicated from substances or alcohol), physically helpless (e.g., uncon-
scious, sleeping), lack independence (e.g., children), or otherwise lack
comprehension of the significance of sexual activity. The requirement of clear,
voluntary agreement means that sexual consent can never be assumed based on
subtle cues or context. Legally, consent cannot be supposed from a person’s silence
or failure to resist sexual activity. When a partner says “stop,” “I’m not sure,” or
“maybe later,” or is silent, pulls away, or acts ambivalent in any way, they are
declining consent. Moreover, flirtation, sexy clothing, sexual settings (e.g., strip
club, sex party, sex work), and prior or existing sexual or romantic relationships do
not imply consent. Finally, if a person initially consents to sexual activity and
withdraws consent for any reason, at any point during sexual activity, continued
sexual activity is nonconsensual. Essentially, pursuing sexual activity without
clear consent is nonconsensual and constitutes sexual coercion and violence,
which violates both the sexual health principles and the law.
Importantly, sexual consent, which describes willingness and agreement to
engage in sexual activity, differs from sexual desire or “wanting” to engage in the
activity. Individuals may want to engage in sexual activity or experience physio-
logical arousal (e.g., erection, lubrication, increase in heart rate) without being
willing to participate in sexual activity. Ensuring a person’s willingness, in addi-
tion to pleasure, safeguards pleasurable, safe, consensual sexual experiences.
Most people effortlessly obtain sexual consent, although some believe sexual
consent is complicated. Researchers argue that gendered expectations and sexual
double standards contribute to this belief. In the United States, individuals receive
vastly different sociocultural messages about sexuality based on gender. Feminine
individuals receive messages around risk and immorality, while, paradoxically,
equating their worth with sexual prowess (e.g., look “hot” but not “slutty”; be
Sexual Consent 639
popular but not prudish). Feminine ideals to be “nice” and passive conflict with
pressure to firmly resist sexual activity. In contrast, masculine individuals face
pressure to be constantly interested in and ready for sexual activity, are taught to
persistently seek sexual activity, and gain social status through acquiring sexual
experiences. These gendered messages are associated with traditional sexual
scripts (heterosexual norms for negotiating sexual activity), which portray that the
person who initiates sexual activity (usually a masculine individual) assumes that
their partner (usually a feminine individual) consents, until the partner refuses the
initiator’s advances. Research has demonstrated that sexual consent occurs less
often when individuals more strongly adhere to gendered expectations and tradi-
tional sexual scripts. In addition, same-gender partners who lack social norms to
guide their sexual behavior are more likely to obtain sexual consent than those in
heterosexual relationships.
Sexual consent can become complicated when individuals feel uncertain or
lack effective communication to express their unwillingness (due to intoxication
or confusion, the behavior happening too quickly to refuse, etc.). Moreover, indi-
viduals may be concerned about the social consequences of refusing (e.g., hurting
the other’s feelings). Research has shown that while people believe a direct verbal
“no” is the most effective way to refuse, saying no can feel awkward and embar-
rassing. As a result, many people soften their refusals (“I’m not ready yet,” “I like
you, but . . . ,” or give excuses rather than state their unwillingness), which leads
to confusion. As such, individuals should assume nonconsent until clear, unam-
biguous sexual consent is granted.
A popular myth about consent is the erroneous belief that obtaining verbal con-
sent will “kill the mood.” Yet, the “mood” of sexual activity depends on the ability
to actively attend and respond to one’s partner’s verbal and nonverbal expressions
of sexual willingness and enjoyment. Sexual pleasure diminishes when individu-
als do not attend to or ignore the verbal and nonverbal expressions of their partner.
Moreover, research has demonstrated that the vast majority of people report con-
senting to their last sexual encounter both nonverbally and verbally. Nonverbal
indicators of consent include a combination of direct (undressing themselves or
their partner, touching their partner) and indirect nonverbal behaviors (not resist-
ing their partner’s attempts while also reciprocating their partner’s advances,
caressing, getting closer). When combined with verbal indicators of consent
(e.g., expressing desire and willingness), the sexual consent process can enhance
the “mood.”
The sexual consent process begins with obtaining a clear agreement to initiate
a specific sexual activity, agreeing to progress to more intimate activities, and
stopping sexual activity when consent becomes unclear or is withdrawn. As a
preliminary step, individuals need to understand their feelings, boundaries, and
degree of willingness to engage in specific sexual behaviors with their partner. To
initiate sexual activity, these feelings are expressed to the partner(s), verbally and
nonverbally. Consent is an ongoing process, involving continuously observing
one’s partner’s enjoyment and willingness and seeking additional agreement to
progress to more intimate behaviors. Suppose an individual obtained consent to
unbutton their partner’s shirt. As an ongoing process, they would observe their
640 Sexual Dimorphism
partner’s facial expressions and bodily movements as they move from one button
to the next, looking for evidence of pleasure versus discomfort, using nonverbal
and verbal cues. Sexual behavior proceeds when individuals and partners exhibit
clear willingness and pleasure, and it stops when the individual’s or their partner’s
pleasure and willingness become unclear or withdrawn (silence, pulling away,
looking away, saying no, slowing down, not actively participating, etc.). Inquiring
about the other’s feelings after stopping sexual activity facilitates clarity while
easing social awkwardness. This process affirms everyone’s right to freely choose
or withdraw from sexual activity, at any time, without negative consequences. The
key to mutually positive sexual interactions is to be sensitive to your partner’s
desires, needs, and willingness.
Sexual consent is a fundamental right. Each person has the responsibility to
ensure that they have the consent of others. Sexual consent safeguards everyone’s
bodily integrity and the right to have safe, consensual sexual interactions. Wanted,
pleasurable, consensual sex is abundantly more satisfying that nonconsensual sex.
By ensuring that all parties involved are willing and freely enjoying themselves,
sexual consent maximizes the capacity for sexual pleasure.
Janna A. Dickenson and Itor Finotelli Jr.
See also: Age of Consent; Communication, Sexual; Rape; Sexual Assault; Sexual Rights;
Sexual Script; Statutory Rape.
Further Reading
Archard, D. (1998). Sexual consent. Boulder, CO: Westview Press.
Kismödi, E., Corona, E., Maticka-Tyndale, E., Rubio-Aurioles, E., & Coleman, E. (2017).
Sexual rights as human rights: A guide for the WAS declaration of sexual rights.
International Journal of Sexual Health, 29(Sup1), 1–92. doi: 10.1080/19317611
.2017.1353865
Muehlenhard, C. L., Humphreys, T. P., Jozkowski, K. N., & Peterson, Z. D. (2016). The
complexities of sexual consent among college students: A conceptual and empiri-
cal review. The Journal of Sex Research, 53(4–5), 457–487.
Sexual Dimorphism
“Sexual dimorphism” refers to the anatomical differences between males and
females of the same species, excluding their sexual organs. Multitudes of animal
species are sexually dimorphic, including humans. The opposite of sexual dimor-
phism is sexual monomorphism, which is when males and females of the same
species appear identical except for their sexual organs. Sexual dimorphism is
manifested in a variety of different ways, including size, coloration, and second-
ary sex characteristics. Sexual dimorphism stems from evolution and is often a
result of sexual selection. While there are apparent physical differences between
human males and females, they are more physically similar to one another when
compared to the level of differentiation in many other species.
Sexual dimorphism is a result of evolution. In a sexually dimorphic species,
each sex has evolved to further traits that are advantageous and reduce traits that
are not. It is thought that sexual selection is an evolutionary mode of driving
Sexual Dimorphism 641
sexual dimorphism. Sexual selection is a form of natural selection; members of
one sex look for certain characteristics in the other sex when choosing mates. This
interaction results in differences between the sexes, because the favorable charac-
teristics in each sex are increasingly passed on genetically over time. For example,
the females of a species may prefer larger males because this is a visual sign of
their capability to fight and survive. Over time, larger males will have more off-
spring, and so the genes for larger size are passed on to future generations, and,
eventually, the males of the species evolve to be larger to compete for female
attraction. It is hypothesized that sexual selection may be the reason human
females have larger breasts filled with fatty tissue. Humans are the only mammals
in which females always have breasts—not only during lactation. Therefore, it is
thought that female humans evolved to have breasts as a signal of fertility to attract
mates.
Sexual dimorphism can be expressed in visually extreme ways or in subtle
ways. For example, male and female peafowl look dramatically different: the
males display ornate tail feathers, while the females have subdued feathers. As
another example, mandrills have different coloration on their faces and are
extremely different in size. In humans, the sexes are more similar to one another
when compared to many species with extremely different appearances. For exam-
ple, human males are typically larger than females, but the difference is not as
pronounced as it is in many primates, like the mandrills.
Nevertheless, there are apparent differences between human males and females.
As previously mentioned, males are generally larger than females. According to
the National Health Statistic Reports, males in the United States are 9 percent
taller than females on average. In development, females go through puberty at an
earlier age, and they are typically taller than males in early adolescence. In addi-
tion, males have a higher percentage of muscle mass than females. Females store
more fat on their bodies, partially due to having a lower average basal metabolic
rate than males.
Secondary sex characteristics are also examples of sexual dimorphism in
humans. These are characteristics that typically appear during puberty but are not
part of the reproductive system. For example, females have larger breasts, wider
hips, and a distribution of fat deposits around the buttocks, hips, and thighs. These
differences are due to females having a higher level of estrogen than males. Females
also tend to have rounder features, such as face shape, and softer, plumper skin. In
turn, males have broader shoulders and a lower body fat percentage than females.
Males grow facial hair, and they often have thicker body hair present on areas such
as the chest and back. Also, males have a larger larynx, commonly known as an
Adam’s apple. Males also have more testosterone, which aids in increasing muscle
mass and the length of vocal cords and growing facial and body hair.
Sexual dimorphism in the brains of human males and females is a controversial
subject. Overall, scientists have found greater similarities between male and
female brains than they have found differences. However, researchers have found
some significant differences as well. Male brains tend to be slightly larger in vol-
ume than female brains on average. Researchers have attempted to determine
which structures of either sex’s brain have more or less volume and tissue density,
642 Sexual Dimorphism
but it has proven to be difficult research. A study of 2,750 females and 2,466 males
found differences in the thickness of cortices—the researchers found that women
have thicker cortices on average than males. The same study found that volumes
of subcortical regions were higher in males than females; these subcortical regions
included the hippocampus and amygdala. Scientists have long attempted to deter-
mine if anatomical brain differences may be attributed to behavioral or intelli-
gence differences between males and females, but no conclusions can be drawn
with certainty.
Sexual dimorphism is widely variable among human males and females. The
different characteristics between males and females do not occur in the same pro-
portion for each individual. In addition, an estimated 1.7 percent of the population
is intersex—people born with sexual anatomy and characteristics that do not fit the
typical presentation for male or female. Furthermore, gender identity is a compli-
cated topic and is increasingly discussed in today’s society. Sex is assigned at birth,
but someone’s personal gender identity does not always correspond with the gender
typically assigned to one’s sex. Essentially, an individual’s anatomical presentation
is not always an indicator of their gender identity. Some transgender people may
choose to undergo a transition process. This sometimes includes hormone replace-
ment therapy and/or sex reassignment surgery. Both can result in an individual’s
sex characteristics and anatomy being altered to fit the desired presentation of their
gender identity. Therefore, characteristics differentiating male and female humans
are not always as clearly determined as they may be in nonhuman animals.
Sexual dimorphism is found across the spectrum of animal species and can
include extreme differences as well as less obvious ones. The range of differentia-
tion also varies widely among individuals, and there are people whose character-
istics do not align with the sexual binary. Ultimately, human males and females
are more similar than dissimilar.
Casey T. Tobin
See also: Biological Theories of Sexual Orientation; Breast, Female; Evolutionary Per-
spectives on Gender and Sexual Behavior; Female Sexuality; Gender Identity; Intersexu-
ality; Male Sexuality; Puberty; Sex Differentiation of the Brain and Sexual Orientation.
Further Reading
Leary, C. (2016). Nine of the most dramatic examples of sexual dimorphism. Retrieved
from https://www.mnn.com/earth-matters/animals/blogs/9-most-dramatic-exam
ples-sexual-dimorphism
McDowell, M. A., Fryar, C. D., Ogden, C. L., & Flegal, K. M. (2008). Anthropometric
reference data for children and adults: United Sates, 2003–2006. National Health
Statistics Reports, 10. Retrieved from https://cdc.gov/nchs/data/nhsr/nhsr010.pdf
Ritchie, S. J., Cox, S. R., Shen, X., Lombardo, M. V., Reus, L. M., Alloza, C., … Deary,
I. J. (2018). Sex differences in the adult human brain: Evidence from 5216 UK
Biobank participants. Cerebral Cortex, 28(8), 2959–2975.
Viloria, H. (2015). How common is intersex? An explanation of the stats. Retrieved from
https://intersexequality.com/how-common-is-intersex-in-humans/
Wolchover, N. (2011). Men vs. women: Our key physical differences explained. Retrieved
from https://livescience.com/33513-men-vs-women-our-physical-differences-ex
plained.html
Sexual Disorders, Female 643
Sexual Disorders, Female
Female sexual disorders are broadly referred to as female sexual dysfunctions.
A sexual dysfunction is any physical or psychological problem that affects sexual
health and well-being. Female sexual dysfunctions affect one or more aspects of a
woman’s sexual function and can be related to arousal, desire, orgasm, or pain. In
order for a sexual problem to be considered a disorder, it must be persistent, con-
sistent, and cause “clinically significant” distress to the individual. Sexual disor-
ders are defined slightly differently based on the professional setting (medical or
psychological, for instance). In the medical field, sexual disorders are classified
based on the International Classification of Diseases, Eleventh Revision (ICD-11).
Here, sexual dysfunctions are defined as syndromes that comprise the various
ways in which adult people may have difficulty experiencing personally satisfy-
ing, noncoercive sexual activities. Sexual response is a complex interaction of
psychological, interpersonal, social, cultural and physiological processes and one
or more of these factors may affect any stage of the sexual response. In order to be
considered a sexual dysfunction, the dysfunction must: 1) occur frequently,
although it may be absent on some occasions; 2) have been present for at least
several months; and 3) be associated with clinically significant distress (World
Health Organization, 2018).
In ICD-11, sexual dysfunction is broken down into hypoactive sexual desire
dysfunction, sexual arousal dysfunctions, orgasmic dysfunctions, and dysfunc-
tions related to pelvic organ prolapse.
In comparison, for mental health professionals, sexual dysfunctions are defined
in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5). Similarly, in the DSM, sexual disorders are defined as a “clinically sig-
nificant disturbance in a person’s ability to respond sexually or to experience sex-
ual pleasure. An individual may have several sexual dysfunctions at the same
time” (American Psychiatric Association, 2013). Female sexual dysfunctions in the
DSM-5 include female orgasmic disorder, female sexual interest/arousal disorder,
and genito-pelvic pain/penetration disorder. If a woman meets criteria for one of
these disorders, and her symptoms are not better explained by a psychological or
medical condition, her doctor may diagnose her with a sexual disorder and will
consider the time of onset (lifelong versus acquired; generalized versus situational)
and the severity of the dysfunction (mild, moderate, severe). For instance, if a
woman experiences pain with intercourse, a provider would want to understand
when this began—whether it has always been an issue (lifelong) or if it has occurred
more recently (acquired). The health care provider would also want to better under-
stand if the pain occurs during all kinds of penetration, both sexual and nonsexual
(e.g., using tampons or wearing tight clothing) (generalized) or if it is specific to a
particular partner or activity such as penetrative intercourse (situational).
There is no single cause of female sexual dysfunctions. When considering
treatment, many factors must be considered, including (1) partner factors
(e.g., does the partner have any sexual problems or health concerns); (2) relation-
ship factors (e.g., conflict, communication); (3) individual factors (e.g., poor body
image, history of abuse, lack of education about sexuality), psychiatric concerns
644 Sexual Disorders, Male
(e.g., anxiety, depression), or current stressors (e.g., job loss, pregnancy); (4) cul-
tural or religious factors (e.g., shame around sexual activity, negative attitudes
toward sexuality); and (5) medical factors relevant to prognosis, course, or
treatment.
Treatment of female sexual dysfunctions varies depending on the specific dys-
function but can include a thorough medical evaluation and medical interventions
such as medications, individual or couple’s sex therapy, and pelvic floor physical
therapy.
Abby Girard
See also: Anorgasmia; Arousal; Desire Disorders; Diagnostic and Statistical Manual of
Mental Disorders (DSM); Dyspareunia; Female Sexuality; International Classification of
Diseases, Eleventh Revision (ICD-11); Sexual Disorders, Male; Sexual Dysfunction,
Treatment of.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Mayo Clinic. (2016). Female sexual dysfunction. Retrieved from https://www.mayoclinic
.org/diseases-conditions/female-sexual-dysfunction/symptoms-causes/syc
-20372549
World Health Organization. (2018). International statistical classification of diseases and
related health problems (11th rev.). Retrieved from https://icd.who.int/browse11/
l-m/en
Sexual Disorders, Male
Male sexual disorders are broadly referred to as male sexual dysfunctions. A sex-
ual dysfunction is any physical or psychological problem that affects sexual health
and well-being. Male sexual dysfunctions can affect all men, but most are more
common in men as they age. Male sexual dysfunctions affect one or more aspects
of a man’s sexual function and can be related to desire, erection, or orgasm. In
order for a sexual issue to be considered a disorder, it must be persistent, consistent,
and cause “clinically significant” distress to the individual. Sexual disorders are
defined slightly differently based on the professional setting (medical or psycho-
logical, for instance). In the medical field, sexual disorders are classified based on
the International Classification of Diseases, Eleventh Revision (ICD-11). Here,
sexual dysfunctions are defined as syndromes that comprise the various ways in
which adult people may have difficulty experiencing personally satisfying, nonco-
ercive sexual activities. Sexual response is a complex interaction of psychological,
interpersonal, social, cultural and physiological processes and one or more of these
factors may affect any stage of the sexual response. In order to be considered a
sexual dysfunction, the dysfunction must: 1) occur frequently, although it may be
absent on some occasions; 2) have been present for at least several months; and 3)
be associated with clinically significant distress (World Health Organization, 2018).
In ICD-11, sexual dysfunction is broken down into hypoactive sexual desire
dysfunction, sexual arousal dysfunctions, orgasmic dysfunctions, and dysfunc-
tions related to pelvic organ prolapse.
Sexual Disorders, Male 645
In comparison, for mental health professionals, sexual dysfunctions are defined
in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5). Similarly, in the DSM sexual disorders are defined as a “clinically sig-
nificant disturbance in a person’s ability to respond sexually or to experience sex-
ual pleasure. An individual may have several sexual dysfunctions at the same
time” (American Psychiatric Association, 2013). Male sexual dysfunctions as
classified in DSM-5 include erectile disorder, delayed ejaculation, male hypoac-
tive sexual desire disorder, and premature (early) ejaculation. If a man meets crite-
ria for one of these disorders, and his symptoms are not better explained by a
psychological or medical condition, his doctor may diagnose him with a sexual
disorder and will consider the time of onset (lifelong versus acquired; generalized
versus situational) and the severity of the dysfunction (mild, moderate, severe).
For instance, if a man experiences difficulty with erection, a provider would want
to understand when this began—whether it has always been an issue (lifelong) or
whether it occurred more recently (acquired). The health care provider would also
want to know if the difficulty with erections occurs all the time (e.g., during mas-
turbation and partnered sexual acts, regardless of the partner or situation; general-
ized) or if the difficulty is specific to a particular partner or activity such as
penetrative intercourse only (situational).
There is no single cause of male sexual dysfunctions. When considering treat-
ment, many factors must be considered, including (1) partner factors (e.g., does the
partner have any sexual problems or health concerns); (2) relationship factors (e.g.,
conflict, communication); (3) individual factors (e.g., poor body image, perfor-
mance anxiety, lack of education about sexuality), psychiatric concerns (e.g., anxi-
ety, depression), or current stressors (e.g., job loss, work stress); (4) cultural or
religious factors (e.g., shame around sexual activity, negative attitudes toward
sexuality); and (5) medical factors relevant to prognosis, course, or treatment.
Treatment of male sexual dysfunctions varies depending on the specific dys-
function but can include a thorough medical evaluation and treatment with medi-
cation, individual or couple’s sex therapy, and pelvic floor physical therapy.
Abby Girard
See also: Arousal; Desire Disorders; Diagnostic and Statistical Manual of Mental Disor-
ders (DSM); Erectile Dysfunction; International Classification of Diseases, Eleventh
Revision (ICD-11); Male Sexuality; Orgasm; Performance Anxiety; Premature Ejacula-
tion; Sexual Disorders, Female; Sexual Dysfunction, Treatment of.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Cleveland Clinic. (2019). Sexual dysfunction in males. Retrieved from https://my
.clevelandclinic.org/health/diseases/9122-sexual-dysfunction-in-males
Mayo Clinic. (2018). Female sexual dysfunction. Retrieved from https://www.mayoclinic
.org/diseases-conditions/female-sexual-dysfunction/symptoms-causes/syc
-20372549
World Health Organization. (2018). International statistical classification of diseases and
related health problems (11th rev.). Geneva: World Health Organization. Retrieved
from https://icd.who.int/browse11/l-m/en
646 Sexual Dysfunction, Treatment of
Sexual Dysfunction, Treatment of
“Sexual dysfunction” refers to any of a number of problems that may impair a
person’s sexual ability or sexual satisfaction. Sexual dysfunctions are one cate-
gory included in the Diagnostic and Statistical Manual of Mental Disorders
(DSM), which includes the following diagnoses for men: delayed ejaculation
(ejaculation that takes an extended period of time), erectile disorder (the inability
to obtain or maintain an erection sufficient for penetration), male hypoactive sex-
ual desire disorder (lack of or reduced sexual interest), premature (early) ejacula-
tion disorder (ejaculation occurring soon after the start of sexual activity or within
one minute of penetration), substance or medication-induced sexual dysfunction,
and unspecified sexual dysfunction.
The DSM includes the following sexual dysfunction diagnoses for women:
female orgasmic disorder (the delay or absence of orgasm, or a reduction in
intensity of orgasmic sensations), female sexual interest/arousal disorder (lack of
or reduction in sexual interest or arousal), gentio-pelvic pain/penetration disor-
der (difficulty with vaginal penetration, or pain or fear of pain with penetration),
substance/medication-induced sexual dysfunction, and unspecified sexual
dysfunction.
Although sexual dysfunctions are included in the DSM, the term is more com-
monly used to refer to conditions that negatively affect an individual’s sexual
function, regardless of whether they are due to physical, psychological, or com-
bined factors. Even in the case of conditions with biological causes, there are often
psychological factors that contribute to or maintain the problem. For example,
heart disease may have the physical side effect of erectile disorder. However, once
a man experiences erectile disorder on one occasion, he may become anxious
about sex. This anxiety can itself lead to erectile disorder even once the physical
condition has been resolved. For this reason, sexual dysfunction should be assessed
for biological, psychological, and social factors, all of which should be treated for
optimal outcome.
Sexual dysfunction often includes impairment of function in one of the phases
of the sexual response cycle: excitement, plateau, orgasm, and resolution. It should
be noted, however, that sexual pain, while commonly considered a sexual dys-
function, may not impair any of the phases of the sexual response cycle. Sexual
dysfunction may also be categorized as lifelong (present from the first sexual
experience) or acquired (a condition that developed after a period of problem free
sexual activity) and as generalized (occurring with various situations, sexual
activities, and partners) or situational (occurring with only some types of situa-
tions, activities, and partners).
Treatment for sexual dysfunction begins with a thorough medical history and
exam to determine if there are any physical causes for the dysfunction. The pre-
scribed treatment is dependent on the specific sexual impairment. Treatment may
include medication (for example, for conditions including premature ejaculation
or sexual pain), pelvic physical therapy (for conditions such as sexual pain), and
sex therapy (a specialized form of psychotherapy or talk therapy). As mentioned
above, even in the cases of biology-based sexual dysfunction, psychological
Sexual Expression 647
factors may be involved in contributing to or maintaining the problem. As a result,
sex therapy can be useful in conjunction with other treatments.
Sex therapy includes a thorough sexual history of both partners. This is impor-
tant as in some cases both partners have a sexual dysfunction. Assessment will
also determine if there are any social factors that contribute to the problem (such
as a lack of sexual knowledge or negative views about sex) or relational factors
(such as conflict or communication difficulties). It is common for couples affected
by sexual dysfunction to engage in sexual avoidance, wherein one or both partners
avoids sexual activity in order to avoid being rejected or to avoid a disappointing
sexual experience. In some cases, couples begin to avoid even nonsexual touch for
fear that it will lead to sex.
A common component of sex therapy treatment for sexual dysfunction includes
the use of sensate focus exercises. Sensate focus exercises are a series of nonde-
mand pleasuring activities. Couples are given instructions for each activity and
make a commitment to complete the exercises in the privacy of their home at a
time when they will not be interrupted. The exercises start with touching activi-
ties that do not include the breasts or genitals so that the couple can become accus-
tomed again to intimate touch without the pressure of expectations around
erections or orgasms. The goal is merely to experience pleasurable touch. The
exercises progress to genital touch and eventually to penetrative sex if possible
and desired by the couple.
Adrienne M. Bairstow
See also: Desire Disorders; Diagnostic and Statistical Manual of Mental Disorders
(DSM); Psychosexual Therapy; Sensate Focus; Sexual Satisfaction.
Further Reading
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Cleveland Clinic. (2019). Sexual dysfunction. Retrieved from http://my.clevelandclinic
.org/health/diseases/9121-sexual-dysfunction
Pietrangelo, A. (2016). What is sexual dysfunction? Retrieved from http://www.healthline
.com/health-slideshow/what-sexual-dysfunction#1
U.S. National Library of Medicine. (2016). Sexual problems in men. Retrieved from http://
www.nlm.nih.gov/medlineplus/sexualproblemsinmen.html
U.S. National Library of Medicine. (2016). Sexual problems in women. Retrieved from
http://www.nlm.nih.gov/medlineplus/sexualproblemsinwomen.html
Sexual Expression
Sexual expression is the way individuals convey their sense of their sexual self,
which can include their gender, their sexual orientation, and their sensuality.
Gender expression is a form of sexual expression, as it affects someone’s male-
ness, femaleness, or other combination. How does the individual convey male or
female styles? In traditional sex-role stereotyped ways, with women in dresses,
primarily wearing pink, or men in suits or blazers with pants? Or with more flex-
ibility, with women wearing more androgynous clothing, pants, T-shirts, jeans,
648 Sexual Expression
and with men wearing more typically feminine clothing, including dresses,
makeup, and even high-heeled shoes? Women seem to have more flexibility
wearing men’s clothing than men do wearing women’s clothing. For example,
women who dress as men, in suits and even ties, are given a pass, whereas men
who wear women’s clothing are often ridiculed, mocked, and worse, beaten up or
murdered. They are seen as unmanly, feminine, or gay, which is seen as threaten-
ing to some men.
Sexual orientation, different from gender, is about how individuals resonate
with a partner or partners. Perhaps they are heterosexual or straight. Perhaps they
are gay or lesbian. Maybe they are bisexual, relating to both men and women.
They might be asexual, with no sexual feelings toward another person. Or pan-
sexual, where they are attracted to all genders, basing their choice on the individ-
ual rather than the gender. Sexual orientation is part of a person’s sexual self and
is not a choice.
Sexual expression also includes how individuals manage or convey their sexu-
ality. Are they monogamous or polyamorous? Are they sexual with intercourse or
without? Are they sexual with themselves and with others? Are they sensual? Do
they walk or carry themselves with an awareness of themselves as sexual beings?
Do they sparkle with personality? Do they make others feel good about them-
selves? Are their clothes sensual, with styles and soft fabrics such as velvet or
silk? Sexual expression also includes how often a person has sex by themselves
or with others. It can include what kind of sex they are having, whether oral, anal,
or vaginal sex, sex without intercourse, using toys such as vibrators, or if they
have sex with others, or in a group, or if they are into kink, which could include
sadism and masochism, S&M, which some refer to as sexuality and mutuality.
Even the way someone kisses, or does not like to kiss, is part of their sexual
expression. Are they physically affectionate? Are they huggers or not? Even
arousal to paraphilic objects is part of sexual expression, which can include cer-
tain pieces of clothing, high heels, rubber, costumes, leather, or tools, such as
boots and whips.
The important idea is to make sure all partners are consenting and that no one
is being forced to do something they do not want to do. Consent is essential in
sexual relationships. Otherwise the sexual acts or expressions of sexuality are
called sexual assault, sexual abuse, sexual coercion, sexual violence, sexual bat-
tery, molestation, or rape, with often traumatic consequences for the victim (or
survivor) and possible consequences for the perpetrator.
Sexual expression is a combination of gender, gender expression, sexual orien-
tation, and the ways someone has sex, including frequency, number of partners,
and sexual acts. Each person’s sexual expression is unique. The challenges and
opportunities are to learn more about the sexual expression of others as well as to
learn more about one’s own sexual expression and then to share that information
with a partner. This is what helps create true intimacy.
Judith Steinhart
See also: Gender Expression; Gender Identity; Paraphilias; Sexual Identity; Sexual Ori-
entation; Stereotypes, Gender; Stereotypes, Sexual.
Sexual Harassment 649
Further Reading
DeLamater, J. (2012). Sexual expression in later life: A review and synthesis. Journal of
Sex Research, 49(2–3), 125–141.
Sprecher, S., & Cate, R. M. (2005). Sexual satisfaction and sexual expression as predic-
tors of relationship satisfaction and stability. In J. H. Harvey, A. Wenzel, &
S. Sprecher (Eds.), The handbook of sexuality in close relationships (235–256),
New York: Routledge.
Sexual Harassment
Sexual harassment includes any sort of unwanted physical contact, such as hug-
ging, touching clothing, and patting or stroking hair or body parts; verbal and
written communications including suggestive comments, requests for sexual
favors, comments about someone’s body or clothing, rumor spreading, or threats
of sexual contact or assault; and nonverbal actions such as staring and making
suggestive gestures or expressions. Not all forms of sexual harassment are sexual
in nature in that sexual harassment can also occur based on a person’s sex, gender,
or sexual orientation. For example, if someone continually makes derogatory
comments about a particular sexual orientation, this could be considered sexual
harassment. When these actions or a combination of several of these actions cre-
ate an uncomfortable or hostile environment, particularly if it occurs in a work or
school setting, it is considered sexual harassment.
There are two general types of sexual harassment that may be experienced. The
first type, hostile environment, is the more common, but it is also difficult to
define. Typically, a hostile environment will involve another person making inap-
propriate and unwanted sexual comments or suggestively touching or acting sexu-
ally inappropriate with another person. The second type of sexual harassment is
the quid pro quo. This type of harassment involves someone, often an employer or
another person in a position of power, suggesting that someone perform a sexual
favor in return for a benefit, such as a job position, promotion, or better grade.
Sexual harassment offenders can be of any sex and any gender identity, although
significantly more females report being sexually harassed. This could either be
due to actual higher rates of perpetration against females or a lack of reporting
from male victims. In either case, it is important for victims of sexual harassment
to know their rights and what steps they should take to make sure that the harass-
ment ends. First, and foremost, victims need to voice their concerns and document
the events that are making them uncomfortable. This may include confronting the
perpetrator about their behavior. Sometimes that person does not realize their
actions could be deemed sexual in nature and that they are making someone feel
uncomfortable. If the victim is uncomfortable approaching the perpetrator, sup-
port may be available from a supervisor, a human resources representative, or any
other coworker or peer with whom they feel comfortable disclosing their story.
Although not all environments and companies have sexual harassment policies, it
is still strongly encouraged to take steps to prevent sexual harassment. Many com-
panies and organizations have preestablished policies and procedures in place so
that anyone that learns of sexual harassment, particularly in the workplace or at
650 Sexual Harassment
school, is able to contact the appropriate person or department to file a formal
complaint.
If policies are in place, once a formal complaint has been filed, an internal
investigation about the incident(s) will commence. This procedure varies from
environment to environment but often includes interviewing the victim and the
accused perpetrator. Victims should be aware that the person who has made them
feel uncomfortable will most likely continue to work or study alongside them
throughout the investigation and possibly after as well, depending on the outcome.
In a work setting, employers are required to remain impartial during the investiga-
tion and therefore are not able to terminate or demote the accused employee unless
the investigation determines that the accusations were valid. Incidents of sexual
harassment, isolated or continued, can cause poor workplace, educational, or other
environmental conditions for not only the victim of the harassment but also the
surrounding people.
If the sexual harassment occurred in a work or school environment, in the event
the internal investigation determines there was either insufficient evidence to
prove an incident of sexual harassment or that the event(s) that occurred were not
sexual in nature, the accused person may maintain their employment or position
with the organization. An investigation that ends in this manner can be very dis-
tressing for victims because they will continue to be in a situation that may be
uncomfortable. Since sexual harassment is considered a form of workplace dis-
crimination, employees are protected under Title VII of the Civil Rights Act of
1964; if it occurs in an educational environment, people are protected under Title
IX. With respect to sexual harassment in the workplace, Title VII is a U.S. federal
law that states that it is illegal for a company or employer to discriminate against
an individual based on their sex. Therefore, victims can contact the Equal Employ-
ment Opportunity Commission directly and file a formal complaint, and they will
then conduct their own investigation.
Whether the victim can get justice or not, sexual harassment can have lasting
effects on their physical and social well-being. These symptoms can include head-
aches, nausea, weight fluctuations, lowered self-esteem, sexual dysfunction, and
sleeping troubles. Experiencing these symptoms could also lead to more serious
disorders, such as depression, anxiety, or posttraumatic stress disorder. These
symptoms or disorders could eventually lead to the victim being unable to per-
form in their daily life activities, including at their job, and could result in job loss
or demotion, lack of educational opportunity, or lack of or impaired other daily
life activities.
Casey T. Tobin
See also: Rape; Sexual Abuse; Sexual Assault; Sexual Harassment in College; Sexual
Harassment in Education; Sexual Harassment in the Workplace.
Further Reading
Crouch, M. (2001). Thinking about sexual harassment: A guide for the perplexed. New
York: Oxford.
Grossman, J. (2016). Nine to five: How gender, sex, and sexuality continue to define the
American workplace. Cambridge: Cambridge University Press.
Sexual Harassment in College 651
Sexual Harassment in College
Fueled by a newfound independence, freedom, and possible substance experimen-
tation, sexual harassment on college campuses is quite prevalent, so prevalent that
it seems as if experiencing sexual harassment sometime over the course of a col-
lege education is inevitable. Sexual harassment encompasses a wide variety of
behaviors. From a physical standpoint, sexual harassment includes any unwanted
physical contact including, but not limited to, hugging, touching of clothes or hair,
touching body parts, sexual assault, and rape. It also includes any form of
unwanted verbal, written, or nonverbal communication, such as heckling, request-
ing sexual favors, sending pictures of naked body parts or sex-related content,
making suggestive gestures or expressions, and threats of sexual contact or assault.
Any nonsexual discrimination or aggression based on gender identity or sexual
orientation is also considered sexual harassment. For example, if an administrator,
professor, staff member, or student were to make comments about a particular
sexual orientation being less successful than the rest of the population, it would be
considered sexual discrimination and, therefore, also sexual harassment. Any of
these actions, singularly or in conjunction, that creates an uncomfortable, hostile,
or fear-inducing environment is considered sexual harassment.
People of all gender identities can be the victims and the perpetrators of sexual
harassment on college campuses. Sexual harassment is not limited to faculty-to-
student cases. Students, instructors, interns, professors, residence life staff,
administrators, and supporting staff can be victims or perpetrators of sexual
harassment. Females report the highest rates of experiencing harassment, with
males reported as the most frequent perpetrators. This could be an actual repre-
sentation of the incidence of sexual harassment; however, it is important to con-
sider that males may underreport being the victims of harassment. Many male
victims are reluctant to report sexual harassment for fear of the stigma of being
weak or vulnerable. In general, it is known that sexual harassment is underre-
ported across all demographics.
At federally funded educational institutions, students and faculty are protected
against sexual harassment and discrimination under Title IX of the Education
Amendments of 1972. This federal law requires all schools to make it publicly
known and posted that sexual harassment and discrimination is prohibited and
will not be tolerated under any circumstances. The college must provide a clear
grievance procedure for victims to make a formal complaint or start an investiga-
tion regarding sexual harassment. It is required that institutions investigate every
allegation and remedy the situation in a timely manner. Title IX also ensures both
the victim and the accused perpetrator are given the same rights during the inves-
tigation and hearings. If any institution fails to adhere to the regulations of Title
IX, it could possibly lose federal funding. However, since the law was established
in 1972, this has yet to occur. If the victim is unsatisfied with the outcome of the
school’s investigation and hearing, that individual may choose to file a lawsuit
against the institution for sexual discrimination.
Sexual harassment can lead to significant and potentially long-lasting psycho-
logical effects. Victims of all gender identities have reportedly experienced loss of
652 Sexual Harassment in Education
self-esteem, guilt, shame, inability to concentrate, sexual dysfunction, and self-
harm. As a student, these effects have a significant academic and social impact
that may result in a student missing many of the typical college experiences. Stu-
dents’ academic success may be impeded by the urge to drop classes, switch
schools, or withdraw from the university to avoid contact with the person harass-
ing them. The psychological effects paired with a decline in academic perfor-
mance could lead to more serious mental health disorders, including depression,
anxiety, eating disorder, posttraumatic stress disorder, and suicidal thoughts or
attempts.
If the accused perpetrator is found guilty of sexual harassment, they may face a
number of consequences depending on the severity of the harassment. These
repercussions can include a referral for counseling, probation, suspension, or
expulsion from the institution. If legal action was taken outside of the college,
perpetrators could face significant fines and possible incarceration.
Sexual harassment can have an impact on people beyond the harasser and the
harassed. The institution may suffer because students may lose their sense of a
safe learning environment. If sexual harassment is an issue on a campus, this
could have a significant impact on the reputation of the college, which in turn
could affect the likelihood of top-rated professors coming to their campus, num-
ber of applicants, and fund-raising efforts. In order to prevent sexual harassment
on college campuses, many institutions have adopted prevention programs that
include sexual harassment, discrimination, and sexual assault awareness. These
programs aim to educate students, faculty, staff, and administrators about the top-
ics of harassment and consent, knowing when to intervene, and when to report
suspected sexual harassment.
Casey T. Tobin
See also: Rape; Sexual Assault; Sexual Harassment; Sexual Harassment in Education;
Sexual Harassment in the Workplace.
Further Reading
Crouch, M. (2001). Thinking about sexual harassment: A guide for the perplexed. New
York: Oxford.
Kipnis, L. (2017). Unwanted advances: Sexual paranoia comes to campus. New York:
Harper.
Watts, M. (2015). Sexual violence on campus: Overview, issues and actions. Hauppauge,
NY: Nova Science Publishers.
Sexual Harassment in Education
In the United States, under Title IX of the Education Amendments of 1972, sex-
ual harassment in school is defined as any unwelcome conduct that is sexual in
nature and interferes with a student’s ability to participate in or benefit from edu-
cational programs. Specifically, Title IX states that sexual harassment is a form of
sex discrimination and requires all public and private educational institutions that
receive federal funds to decrease and eliminate sexual harassment in schools.
Sexual Harassment in Education 653
Nevertheless, according to recent reports, sexual harassment remains pervasive
in American schools.
Title IX is designed to protect students from sexual harassment perpetrated not
only by teachers and other school employees but also by fellow students and any-
one else involved with school activities (e.g., visiting speakers). Conduct that is
considered sexual harassment can be both verbal and physical and includes sexual
propositions, touching of a sexual nature, displaying or distributing sexually
explicit drawings and pictures, performing sexual gestures, telling dirty jokes,
and circulating or showing emails or websites of a sexual nature.
Unlawful sexual harassment is divided into two categories: quid pro quo
harassment and hostile environment harassment. Quid pro quo harassment
occurs when teachers or other school employees explicitly or implicitly ask stu-
dents to submit to unwelcome sexual advances as a condition for better grades,
better assignments on sport teams, or other rewards. All other types of sexual
harassment are considered hostile environment harassment and can be perpe-
trated by school employees, students, or others associated with school programs
and activities. To be recognized as unlawful, the hostile environment harassment
claim must show the actual impact on the victimized student in an academic
setting.
National surveys conducted among high school students in the United States
indicate that 40–50 percent experience at least one sexual harassment incident in
a given year, and the percentage increases to 80 percent at some point over their
high school career. Peer harassment (i.e., a student or a group of students harass-
ing another student) is the most common form of sexual harassment in school, and
female students are more likely to become the targets. Although students are sex-
ually harassed more frequently in person, online forms of sexual harassment such
as through texting, email, and social media are on the rise. Cases of harassment by
teachers and other authority figures are far less frequent, but they do occur, often
with serious consequences.
Recently, the rising incidences of bullying in schools have received consider-
able attention. It is important to note that many of these bullying incidents involve
sexual harassment, targeting vulnerable populations such as gay, lesbian, and
transgender students. As a first step toward eliminating these incidences, schools
should establish clear policies against sexual harassment and bullying and spell
out how they intend to implement these policies.
Yoko Crume
See also: Sexual Harassment; Sexual Harassment in College; Sexual Harassment in the
Workplace.
Further Reading
Hill, C. A, & Kearl, H. (2011). Crossing the line: Sexual harassment at school. Washing-
ton, DC: AAUW.
Hornor, G. (2012). Emotional maltreatment. Journal of Pediatric Health Care, 26(6),
436–442.
The U.S. Department of Education. (2008). Sexual harassment: It’s not academic. Wash-
ington, DC: U.S. Department of Education.
654 Sexual Harassment in the Workplace
Sexual Harassment in the Workplace
Sexual harassment is a form of sex discrimination that encompasses unwelcome
sexual advances, requests for sexual favors, and other verbal or physical harass-
ment of a sexual nature. Although many victims are reluctant to report their expe-
riences, surveys show that it affects more women than men. Prompt reporting
helps resolve issues quickly, and workplace training aids in preventing further
occurrences.
A federal law known as Title VII of the Civil Rights Act of 1964 prohibits many
forms of discrimination, such as sexual harassment. Title VII applies to private
employers with fifteen or more employees, including state and local governments.
It also applies to employment agencies, labor organizations, and the federal gov-
ernment regardless of the number of employees. To be unlawful, conduct must
explicitly or implicitly affect an individual’s employment; unreasonably interfere
with an individual’s work performance; or create an intimidating, hostile, or offen-
sive work environment. In the workplace, actions such as touching colleagues,
repeatedly requesting dates, making sexual comments, and using vulgar language
are all potentially problematic.
Because of low reporting rates, it is difficult to quantify the experience of sex-
ual harassment in the workplace. Low reporting rates are due to a variety of fac-
tors, such as fear of retaliation from employers, concern for the harasser, shame,
belief in the futility of the grievance process, or fear of being blamed for the
harassment. Reporting is also complicated by varying perceptions of what consti-
tutes sexual harassment. For example, the offensive conduct can take place
between members of the same sex. In addition, the harasser can be the victim’s
supervisor, an agent of the employer, a supervisor in another area, a colleague, or
an outside party. The victim does not have to be the person harassed but could be
anyone affected by the offensive conduct. Unlawful sexual harassment may also
occur without economic injury to or discharge of the victim. Despite the chal-
lenges in determining the prevalence of sexual harassment, studies show that it
affects women more than men, with at least one-third of women in the United
States experiencing some form of sexual harassment. One in ten men report expe-
riencing it as well, and a quarter of men say they worry about being falsely accused
of sexual harassment.
It is important to file a complaint with a supervisor or human resources depart-
ment promptly to increase the chance of a quick resolution. Once a harassment
complaint is filed, it cannot be retracted. An employer is obligated to investigate
all complaints, and supervisors are obligated to report any suspected or known
harassment. Employees who have filed complaints should continue to perform
their normal work duties and report any retaliation. The retaliation laws are broad
and may protect coworkers of the victim as well as witnesses in the investigation.
Prevention is the best tool to eliminate sexual harassment in the workplace.
Many employers take steps to prevent sexual harassment from occurring by com-
municating to employees that sexual harassment will not be tolerated. One com-
mon method for doing so is by providing a written antiharassment policy to
employees, outlining what harassment is, telling all employees that harassment
Sexual Health 655
will not be tolerated, and setting out how employees should respond to incidents
of harassment. Other methods of dealing with harassment include sexual harass-
ment training and establishing an effective complaint or grievance process offer-
ing immediate and appropriate action when an employee complains.
Linda Tancs
See also: Sexual Harassment; Sexual Harassment in College; Sexual Harassment in
Education.
Further Reading
Saguy, A. C. (2003). What is sexual harassment? From Capitol Hill to the Sorbonne (3rd
ed.) Oakland: University of California Press.
U.S. Equal Employment Opportunity Commission. (n.d.) Facts about sexual harassment.
Retrieved from http://www.eeoc.gov/eeoc/publications/fs-sex.cfm
Sexual Health
The World Health Organization defines sexual health as “a state of physical, emo-
tional, mental, and social well-being in relation to sexuality; it is not merely the
absence of disease, dysfunction, or infirmity. Sexual health requires a positive and
respectful approach to sexuality and sexual relationships, as well as the possibility
of having pleasurable and safe sexual experiences, free of coercion, discrimina-
tion, and violence. For sexual health to be attained and maintained, the sexual
rights of all persons must be respected, protected, and fulfilled” (WHO, 2006).
Based on this definition, the World Association for Sexual Health has devel-
oped a Declaration of Sexual Rights, which outlines the sexual rights that are
“essential for the achievement of the highest attainable sexual health” (WAS,
2014).
Based on these, someone who could be considered a sexually healthy person
would
• have accurate sexual knowledge so they can have happy relationships and
enjoyable sex
• know how to avoid infections and seek safe and effective treatment if they
have symptoms of a sexually transmitted infection
• know how to plan for a baby when they (and their partner[s]) want one, know
how to avoid unintended pregnancies, and know that safe methods of abortion
are available in the event of an unexpected pregnancy
• manage their sexual relationships so that their intimacy and pleasure needs
are satisfied without harming other people
Looking at this in another way, a sexually healthy person can be described as hav-
ing an ethical approach to their sex life. The fundamentals of human ethics are the
concepts of autonomy, nonmaleficence, and beneficence. Put simply, a sexually
healthy person has sex when there is consent (agreement) and an expected positive
outcome (enjoyment, pleasure, satisfaction) without harm for all participants. Of
course, sexual events are rarely perfect; sometimes orgasm does not happen,
656 Sexual Health
sometimes there is pain, sometimes a vagina stays dry or a penis stays flaccid or
an anus does not relax, or sometimes a throat gag reflex is overreactive. All these
things come and go, and there are ways, both through knowledge and actions, to
deal with these sexual challenges as they arise—the important thing is to practice
sexual loving kindness.
While some people choose to only have sex with someone they love, and others
find anonymous sex more to their preference, everyone can have sex in a loving
way, whether they are “in love” with the person or otherwise. This is not to say
that casual, or quick, or mutually consensual “rough” play is not healthy. On the
contrary, loving means respect for the other person(s) and a commitment to mutual
satisfaction and pleasure, however that is found.
Sexual knowledge, and access to this knowledge, is a sexual right that many in
the world are unable to exercise due to legal, religious, economic, and other struc-
tural barriers. While the fundamentals and mechanics of reproductive sex may
well be “instinctual,” there is much a person needs to learn about themselves and
their potential sexual partner(s) before they meet the criteria of a sexually healthy
person. Sexual knowledge is more than techniques or positions; a sexually healthy
person can develop an attitude that is open to pleasure, intimacy, connection,
excitement, consideration, and compassion for themselves and their partners.
Sexually transmitted infections (STIs) are only one component of the definition
of sexual health. Many people may consider “the absence of an STI” as a good
definition of sexual health; however, many people have chronic, sometimes life-
long, viral infections that are sexually transmitted (e.g., herpes, HPV, hepatitis,
HIV) and can still be sexually healthy. Everyone can respect and be honest with
their sexual partners by using condoms for intercourse and enjoying outercourse
or nonpenetrative sex. Sexually healthy people can have regular tests for STIs and
can take medications to manage any viral or bacterial STIs. A sexually healthy
person is also able to be honest and communicate with the people they have had
sex with and let them know if an STI appears or is found following an STI test.
Sexually healthy people who have sex with members of the other sex use effec-
tive contraception when they do not wish to reproduce, and if an unintended preg-
nancy occurs, they can seek out a safe termination of the pregnancy using
medications or a small operation. Unsafe abortions are a major cause of death and
disability in women in many parts of the world. Sexually healthy people think
about contraception as well as STI prevention, pleasure, and orgasm when having
sex with members of the other sex.
Sexually health people manage their sexual relationships so that their intimacy
and pleasure needs are satisfied without harming other people. It is self-evident
how someone who forces their needs for pleasure onto another, without regard for
the other’s desires or wishes, is sexually unhealthy. A sexually healthy individual
is able to listen and read their partner’s verbal and nonverbal body language and
respond to what their partner’s body or voice is saying. A sexually healthy person
can negotiate and communicate their needs for hugs, orgasm, and sex while
respecting the response of their partner. A sexually healthy person can also mas-
turbate to meet their immediate needs if they are aroused and their partner is not
in the mood for sex or there is currently no partner available.
Sexual Identity 657
In summary, a sexually healthy person is a good lover, both in and out of the
bedroom, and, as a consequence, a sexually healthy person creates happier and
healthier communities.
Kelwyn Browne
See also: Communication, Sexual; Intimacy, Sexual and Relational; Sex Education; Sex-
ual Rights; Sexually Transmitted Infections (STIs).
Further Reading
World Association for Sexual Health. (2014). Declaration of sexual rights. Retrieved from
http://www.worldsexology.org/wp-content/uploads/2013/08/declaration_of
_sexual_rights_sep03_2014.pdf
World Health Organization. (2006). Defining sexual health. Retrieved from https://www
.who.int/reproductivehealth/topics/sexual_health/sh_definitions/en/
Wylie, K. R. (Ed.). (2015). ABC of sexual health (3rd ed.). Chichester: Wiley-Blackwell.
Sexual Identity
“Sexual identity” refers to how individuals view and understand themselves as
sexual beings. “Sexual identity” is often incorrectly seen as synonymous with
“sexual orientation identity,” but the two are very different concepts. Individuals’
sexual orientation identity refers to their understanding of their sexual orientation,
or to whom they are emotionally, romantically, or sexually attracted, whereas sex-
ual identity is a much broader concept. Sexual identity encompasses all personal
and social aspects of individuals’ lives related to their sexual orientation identity,
sexual or romantic thoughts and desires, sexual or romantic beliefs, and sexual or
romantic activities.
The first well-known exploration of individuals’ sexual development was writ-
ten by Sigmund Freud in the early 1900s. Freud suggested that individuals are
sexual from birth and go through a series of stages during which they come to
understand, manipulate, and exercise their sexual impulses in socially appropriate
ways. In the mid-twentieth century, Erik Erikson (1950/1985) expanded on Freud’s
work by developing a theory of ego identity development that detailed the process
through which individuals come to understand themselves and establish how they
interact with others throughout their lives.
Building on Erikson’s work, researchers and theorists began to explore how
individuals incorporate aspects of their identities, such as their race or ethnicity,
culture, and sexuality into their global identity, or their sense of themselves as a
whole person. The term “sexual identity” began being used in social science lit-
erature extensively in the late 1970s. Two of the first researchers to focus on indi-
viduals’ understandings of themselves as sexual individuals were Vivienne Cass
and Richard Troiden, both of whom did research with gay men. Their models
came to be known as models of sexual identity development even though they
were actually models that sought to explain how individuals came to understand
themselves as a sexual minority, accept themselves as a sexual minority, reveal
their sexual minority identity to others, and then integrate their sexual minority
identity into their global identity. Cass’s (1984) and Troiden’s (1988) models were
658 Sexual Identity
later expanded on by other researchers and theorists, but the work generally con-
tinued to focus on sexual minorities.
The late 1990s and early 2000s saw a shift toward recognizing that all people
have sexual identities, not just those who identify as sexual minorities. This
required a reevaluation of how the term “sexual identity” was being used, as it
needed to be expanded to include aspects of sexuality in the lives of those who
identify as heterosexual as well. Within the academic literature, Eliason (1995)
was among the first to explore sexual identity development among individuals
who identified as heterosexual. Rather than exploring sexual identity as a tempo-
ral process, his work sought to classify individuals’ level of exploration or com-
mitment to their sexual identity. Eliason’s findings indicated that most individuals
who identify as heterosexual had not given much thought to their sexual identity
and had committed themselves to identifying as heterosexual without much
thought as to what being heterosexual meant or exploring any other possibilities.
Around this time, the term “sexual orientation identity” began to be used to
differentiate between individuals’ sexual orientation and their overall sexual iden-
tities, even though academic, professional, and popular literature often continues
to use “sexual identity” to refer to sexual orientation identity. Worthington and his
colleagues developed a theory of how individuals who identify as heterosexual
develop their sexual identity. This work sought to identify where individuals were
on four aspects of sexual identity development: commitment, which indicates an
individual has committed to a sexual identity without exploring the various com-
ponents of sexual identity; exploration, which represents the degree to which indi-
viduals are actively exploring aspects of their sexual identity; synthesis and
integration, which indicates an individual has gone through the process of explor-
ing their sexual identity, has come to a more advanced understanding of it, and has
integrated it into their global identity; and sexual orientation identity uncertainty,
which represents the degree of uncertainty individuals feel about their sexual ori-
entation identity.
Worthington and his colleagues found individuals who identify as sexual
minorities generally spend more time considering their overall sexual identity as
they are already required to examine their sexual orientation identity, and this
introspection spreads to other areas of sexual identity exploration. More advanced
sexual identity development has been linked with positive sexual health outcomes,
indicating it is an important process in individuals’ lives. Worthington’s model is
generally considered to represent the most comprehensive way of understanding
sexual identity among all individuals as it considers not just individuals’ sexual
orientation identities but all aspects of their lives that make up their sexual
identity.
Richard A. Brandon-Friedman
See also: Gender Identity; Gender Identity Development; Romantic Attraction and Orien-
tation; Sexual Orientation.
Further Reading
Argüello, T. M. (2018). Identity development. In M. P. Dentato (Ed.), Social work practice
with the LGBTQ community (71–96). New York: Oxford University Press.
Sexual Learning 659
Brandon-Friedman, R. A. (2018). The impact of sexual identity development on the sexual
health of youth formerly in the foster care system. Manuscript submitted for
publication.
Brandon-Friedman, R. A. (2018). Youth sexual identity development theories: A guide for
social workers. Manuscript submitted for publication.
Cass, V. C. (1984). Homosexual identity formation: Testing a theoretical model. Journal
of Sex Research, 20, 143–167.
Eliason, M. J. (1995). Accounts of sexual identity formation in heterosexual students. Sex
Roles, 32, 821–834.
Erikson, E. H. (1985). Childhood and society: 35th anniversary edition. New York: W. W.
Norton & Company. (Original work published 1950)
Freud, S. (2000). Three essays on the theory of sexuality (J. Strachey, Trans.). New York:
Basic Books. (Original work published 1915)
Troiden, R. R. (1988). Gay and lesbian identity: A sociological analysis. Dix Hills, NY:
General Hall.
Worthington, R. L., Navarro, R. L., Savoy, H. B., & Hampton, D. (2008). Development,
reliability, and validity of the Measure of Sexual Identity Exploration and Com-
mitment (MoSIEC). Developmental Psychology, 44(1), 22–33. doi: 10.1037/
0012-1649.44.1.22
Sexual Learning
Sexual learning is a lifelong normative experience socializing people into appro-
priate sexual behaviors and beliefs, including expectations of the appropriate gen-
der partner and an implied progression of intimate behaviors. Sexual learning
happens both through formal sex education and informally through peers, family,
and media.
Sex is taboo yet drenched in intrigue. Many parents feel schools should provide
sex education, so they do not have to. Formal sex education is affected by social
and political forces and can be abstinence or contraception based, yet it often
involves clinical reproductive biology disconnected from pleasure or relation-
ships. Dissatisfied with formal sex education, young people learn about sex from
peers and older siblings. This education is often reliant on stereotypes, myths, and
misinformation.
Many theories in sociology and psychology assert how people learn to be sex-
ual, such as social scripts and social learning theory, which posit a link between
behaviors and environmental cues.
Scripting theory is based on the assertion that behavior is shaped by the social
environment, so actors will engage in acts they believe to be socially preferable.
As social forces shift over time, so do attitudes about sex. Due to these changes
regarding sexuality, scripts instructing what is acceptable to do sexually, when,
and with whom are affected by age, cultural context, and social location (Gagnon
& Simon, 2005). The shared nature of these beliefs facilitates sexual learning.
Scripts operate on three interconnected levels: the cultural, the interpersonal,
and the intrapsychic. The cultural level encompasses media, political forces, and
large-scale ideologies. Put simply, cultural messages tell people what they are
660 Sexual Orientation
supposed to do, interpersonal scripts provide feedback from partners, and intra-
psychic scripts inform how people are supposed to feel. The best example of an
instructive sexual script is the baseball analogy, which instructs actors to start
with kissing (“first base”), as they progress through steps of intimacy. Regardless
of personal experience, actors know this appropriate progression.
Similar to sexual scripts, social learning theory asserts that people learn
behavioral cues from exposure in their social environment, yet this is mediated
by perceiving rewards and consequences so that rewarded actions are encour-
aged and punished actions discouraged. Social learning theory recognizes recip-
rocal determinism—or the effects of the combination of cognition, environment,
and behavior—and notes that behavioral reinforcement can be both direct or
vicarious.
Media expand the possibility for sexual learning, formal and informal. Internet
technology makes people aware of new research and ideological debates. Technol-
ogy expands informal knowledge by increasing exposure to different practices,
creating new narratives upon which people can draw in sexual decision making.
Due to this, media can supersede peers as a socialization agent and create endless
possibilities for sexual learning.
Rachel Kalish
See also: Media and Sexuality; Sex Education; Sexual Script; Social Learning Theory,
Gender and; Stereotypes, Gender; Stereotypes, Sexual.
Further Reading
Bandura, A. (1971). Social learning theory. New York: General Learning Press.
Gagnon, J. H., & Simon, W. (2005). Sexual conduct: The social sources of human sexual-
ity (2nd ed.). New Brunswick, NJ: Aldine Transaction.
Levine, J. (2003). Harmful to minors: The perils of protecting children from sex. New
York: Thunders Mouth Press.
Simon, W., & J. H. Gagnon. (1984). Sexual scripts. Society, 22, 53–60.
Sexual Orientation
Sexual orientation is the interaction between thoughts and feelings that produces
attraction, sexual desire, and feelings of love for other people. Some individuals
experience these thoughts and feelings toward members of the other sex—referred
to as a heterosexual (straight) orientation. Others’ thoughts and feelings are
directed to members of the same sex—referred to as a same-sex, or gay or lesbian,
orientation. Still others experience attraction and desire toward both sexes (bisex-
ual orientation) or toward neither sex (asexual orientation). As our understanding
of sexual orientation and gender grows, people are beginning to use new language
to describe their sexual orientation to a variety of genders, including pansexual
and skoliosexual.
Sexual orientation is sometimes, but not always, reflected in people’s behaviors
and choice of relationship partner or partners. Many people will engage in sexual
activity and have relationships with those to whom they are attracted. For exam-
ple, many heterosexual people will engage in sex with members of the other sex
Sexual Orientation 661
and will typically have other-sex partners. Likewise, many gay and lesbian people
will engage in sex with members of the same sex and often have relationships with
same-sex partners. However, this is not always the case, and some people, both
heterosexual and gay or lesbian, report having had sexual encounters with mem-
bers of both sexes. Similarly, if a person is not sexually active (e.g., they are a
virgin and/or they practice celibacy for personal, religious, or medical reasons),
this does not mean that they stop having a sexual orientation, only that they are
not currently engaging in some or all types of sexual behavior. This is especially
important to remember for individuals who identify as bisexual but are in a com-
mitted, monogamous relationship with one partner.
Sexual orientation is also distinct from sexual identity. Across all times and
cultures, some individuals experience heterosexual, gay or lesbian, bisexual, or
asexual orientations. However, how we label and understand these orientations
and subsequent behavior varies by culture and across time. For example, before
1869 there were no “homosexuals” because the word had not even been invented
yet; “heterosexuals” were not “invented” until 1892, more than twenty years later.
In the present time, culture influences how we understand same- and other-sex
orientations. Within each culture, different labels and words will be used to
describe this same basic phenomenon. For example, in Western culture, people
may use the words “straight,” “gay,” “bisexual,” “asexual,” “pansexual,” “queer,”
“kinky,” and so on. These terms reflect subjective sexual identities and are often
related to, but not necessarily the same as, one’s sexual orientation.
Sexual orientation is often considered to be binary—gay or lesbian versus
straight or heterosexual. The problem with this distinction is that it ignores the
great amount of variability that is seen among people. Another way of conceptual-
izing sexual orientation is as a spectrum. Most characteristics within the human
population fall somewhere on a spectrum. For example, think of height—some
people are very short, some people are very tall, and most people fall somewhere
in between. This idea has also been suggested as a way of describing sexual orien-
tation. Some people are exclusively gay or lesbian, some people are exclusively
heterosexual, and some fall somewhere in between. A third way of considering
sexual orientation was proposed by Michael Storms in 1980. Storms suggested
that instead of considering gay and straight as “opposites,” it might make more
sense to consider desire for men as distinct from desire for women. What this
means is that an individual can have high desire for men and low desire for women
(e.g., a gay male or a straight female), high desire for women and low desire for
men (e.g., a lesbian woman or a straight man), or high desire for both men and
women (e.g., bisexual men and women). The benefit of this model of sexual orien-
tation is that it can also be used to explain asexual orientation as a low (or no)
desire for both men and women, something that a gay or straight binary or gay or
straight spectrum is unable to do.
One of the most frequently asked questions about sexual orientation is about
prevalence. How many people are straight? How many are gay or bisexual? How
many asexual individuals are there? While this may seem like a straightforward
question, it is actually quite hard to measure, and what specifically is measured
can lead to different answers. In a recent U.S. national probability sample of
662 Sexual Orientation
almost 6,000 men and women ages fourteen to ninety-four, 92.2 percent of adult
men and 93.1 percent of adult women self-identified as heterosexual; 4.2 percent
of adult men and 0.9 percent of adult women identified as gay or lesbian; 2.6 per-
cent of men and 3.6 percent of women identified as bisexual; and 1.0 percent of
men and 2.3 percent of women identified as “other.” When considering same-sex
behavior in this same sample, 9.3 percent of men aged twenty to twenty-four had
received oral sex from a male partner, while 9.3 percent had given oral sex to a
male partner, and 10.8 percent had received anal sex; the numbers were higher for
women: 16.8 percent had received oral sex and 14 percent had given it to a female
partner. Some studies suggest that when asked about same-sex attraction, rates are
much higher with as many as two to three times more people reporting attraction
as compared to behavior or identity. Finally, while asexuality is a relatively new
area of scientific research, national probability samples from both the United
States and the United Kingdom indicate that roughly 1.0 percent of the population
identifies as asexual.
Another commonly asked question about sexual orientation is whether it is
something people are born with or whether it is a choice someone makes. The vast
majority of scientists and researchers believe there is sufficient evidence to indi-
cate that sexual orientation is something that people are born with and not some-
thing that is chosen or that can be changed. There is growing evidence that
genetics, birth order and handedness, and anatomical brain structures all contrib-
ute to one’s sexual orientation, suggesting that there is not one specific “cause” of
sexual orientation but rather many possible causes with biological origins. That
said, while nurture doesn’t “cause” one’s sexual orientation, the culture in which
someone is raised influences many aspects of their life, including how they express
themselves sexually and define their identities, roles, and behaviors. Consequently,
both nature and nurture need to be considered when discussing and understanding
sexual orientation.
Heather L. Armstrong
See also: Asexuality; Biological Theories of Sexual Orientation; Bisexuality; Demisexu-
ality; Heterosexuality; Homosexuality; Kinsey’s Continuum of Sexual Orientation; Pan-
sexuality; Romantic Attraction and Orientation; Sex Differentiation of the Brain and
Sexual Orientation; Sexual Identity; Storms’s Model of Sexual Orientation.
Further Reading
Alderson, K. (2014). Sexual/affectional orientations and diversity. In C. F. Pukall (Ed.),
Human sexuality: A contemporary introduction. Don Mills, ON: Oxford Univer-
sity Press.
Blanchard, R., Cantor, J. M., Bogaert, A. F., Breedlove, S. M., & Ellis, L. (2006). Interac-
tion of fraternal birth order and handedness in the development of male homo-
sexuality. Hormones and Behavior, 49, 405–414.
Bogaert, A. F. (2004). Asexuality: Its prevalence and associated factors in a national prob-
ability sample. The Journal of Sex Research, 41, 279–287.
Bullough, B. L., & Bullough, B. (1997). The history of the science of sexual orientation
1880–1980. Journal of Psychology & Human Sexuality, 9, 1–16.
Chandra, A., Mosher, W. D., & Copen, C. (2011, March). Sexual behavior, sexual attrac-
tion, and sexual identity in the United States: Data from the 2006–2008 National
Sexual Revolution 663
Survey of Family Growth. National Health Statistics Reports, No. 36. Washing-
ton, DC: U.S. Department of Health and Human Services.
Herbenick, D., Reece, M., Schick, V., Sanders, S. A., Dodge, B., & Fortenberry, J. D.
(2010). Sexual behavior in the United States: Results from a national probability
sample of men and women ages 14–94. Journal of Sexual Medicine, 7(Supp 5),
255–265.
Jannini, E. A., Blanchard, R., Camperio-Ciani, A., & Bancroft, J. (2010). Male homosexu-
ality: Nature or culture? Journal of Sexual Medicine, 7, 3245–3253.
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human
male. Philadelphia: W. B. Saunders Company.
Kirk, K. M., Bailey, J. M., & Martin, N. G. (2000). Etiology of male sexual orientation in
an Australian twin sample. Psychology, Evolution & Gender, 2, 301–311.
Poston, D. L., & Baumle, A. K. (2010). Patterns of asexuality in the United States. Demo-
graphic Research, 23(18), 509–530.
Savic, I., & Lindstrom, P. (2008). PET and MRI show differences in cerebral asymmetry
and functional connectivity between homo- and heterosexual subjects. Proceed-
ings of the National Academy of Sciences, 105, 9403–9408.
Savin-Williams, R. C. (2006). Who’s gay? Does it matter? Current Directions in Psycho-
logical Science, 15(1), 40–44.
Storms, M. D. (1980). Theories of sexual orientation. Journal of Personality and Social
Psychology, 38, 783–792.
Sexual Revolution
The sexual revolution was a period during the 1960s and 1970s when social atti-
tudes toward human sexuality became substantially more tolerant, liberal, and
broad-minded, especially in the United States and western Europe. As a result of
these liberalized attitudes, many women felt freer to engage in certain behaviors
that were previously socially frowned upon. These behaviors included having
casual sex outside of marriage, wearing sexually provocative clothing, and pursu-
ing careers that had been mostly restricted to men. Thus, the sexual revolution
was inextricably linked with the women’s liberation movement of the same period.
However, the sexual behaviors and social attitudes of men also became more lib-
eral and free during this period.
Many social scientists attribute the events of the sexual revolution primarily to
two developments in the United States: the development and legalization of birth
control pills and the legalization of abortion.
In 1960, the U.S. Food and Drug Administration approved the first oral contra-
ceptive (birth control pill) for general use by women. Within three years, more
than two million American women were using the Pill to prevent pregnancy. The
Pill allowed women the freedom to have sexual intercourse anytime and with any-
one they pleased without the risk of pregnancy. In addition to birth control pills,
other new forms of contraception became widely available for women during the
1960s, including intrauterine devices.
In 1973, the U.S. Supreme Court ruled in the Roe v. Wade case that abortion
was legal during the first trimester of pregnancy. Previous to this ruling, women
664 Sexual Revolution
who wanted an abortion had to resort to illegal procedures that were often danger-
ous. If caught getting an abortion, a woman could be charged with murder or
manslaughter. The legalization of abortion meant that women who did not intend
to become pregnant and did not wish to keep the pregnancy could get a profes-
sional and safe abortion.
Some social scientists argue that the sexual revolution should not be attributed
to these court rulings. Rather, they view the sexual revolution as part of the over-
all civil rights movement of the era, in which various socially marginalized
groups—such as African Americans, hippies and other young people, and antiwar
demonstrators—fought for greater influence, freedom of expression, or social
equality. Whatever the causes, following the contraceptive and abortion rulings,
there was a fairly rapid change in sexual behaviors. Studies revealed that between
1965 and 1975, the number of American women having sexual intercourse before
marriage dramatically increased.
Coinciding with the new ability of women to have sex without the fear of preg-
nancy, women began to assert their rights in other areas. These developments
were referred to as women’s liberation (women’s lib). Fashion trends throughout
the 1960s and early 1970s were dominated by the liberation of female sexuality in
the form of overtly sexual and revealing styles, including tight miniskirts, colorful
low-cut tops, and dancer-type go-go boots. Women began wearing their hair lon-
ger and started to use more provocative makeup styles.
In addition to the superficial trends of fashion, there were more substantially
positive results of the sexual revolution for women. One of these developments
was an increase in the number of women attending colleges and universities in the
United States—a number that by the 2000s exceeded the number of male stu-
dents. As a result, more women entered white-collar professional careers in busi-
ness, medicine, science, and other areas that were previously dominated by men.
Areas of popular culture that both reflected and promoted aspects of the sex-
ual revolution included magazines, television, movies, and music, which all
increased their sexual content during the 1960s and 1970s. Hardcore porno-
graphic magazines, such as Hustler (first published in 1974), became available
on magazine stands alongside the softcore Playboy (first published in 1953).
Love American Style, a TV comedy that aired from 1969 to 1974, was one of
many television programs that showed people in risqué sexual situations that
were new to that entertainment medium. Carnal Knowledge (1971) and Last
Tango in Paris (1972) were among the popular movies of the time that pushed
the boundaries of depicting sexual situations. Pop songs that did the same
included “Let’s Spend the Night Together” by the Rolling Stones (1967) and
“Lola” by the Kinks (1970).
As the social transformations of the sexual revolution were taking place, many
conservative, traditional people in the United States strongly objected to these
trends as immoral and socially harmful. They claimed that the liberalized sexual
attitudes were corrupting traditional values and leading to excessive promiscuity,
including among teenagers. The clashes that pitted social conservatives against
feminists and other social liberals marked the beginning of the United States’
“culture wars,” which continue to divide the population today.
Sexual Rights 665
The results of the sexual revolution have been mixed in terms of positive and
negative effects. Whether one views these results as good or bad often depends on
one’s political and cultural perspective. Conservative critics argue that the “free
love” attitudes of the 1960s and 1970s led to a culture in which casual sex and
hookups became common for both men and women. These critics link an increase
in the prevalence of sexually transmitted infections, as well as the emergence of
HIV/AIDS in the 1980s, to the sexual promiscuity of the sexual revolution. Other
social trends often associated with the sexual revolution are increases in the num-
bers of divorces, out-of-wedlock births, and single mothers.
Liberal defenders of the sexual revolution counter that such unfortunate trends
are outweighed in importance by the fact that women have made enormous strides
in many measures of freedom and success, including economic independence,
career achievement, and sexual liberation. Furthermore, the sexual liberation of
women that began in the 1960s and 1970s has continued to spread to other seg-
ments of the population, such as the LGBT (lesbian, gay, bisexual, transgender)
community.
A. J. Smuskiewicz
See also: Abortion Legislation; Estrogen-Progestin Birth Control Pills; Female Sexuality;
Gay Rights Movement; Male Sexuality; Roe v. Wade; Sexual Rights.
Further Reading
Allyn, D. (2000). Make love, not war: The sexual revolution: An unfettered history. Bos-
ton: Little, Brown and Company.
PBS. (n.d.). The pill and the sexual revolution. Retrieved from http://www.pbs.org/wgbh/
amex/pill/peopleevents/e_revolution.html
Thompson, K. M. J. (2013). A brief history of birth control in the U.S. Retrieved from
https://www.ourbodiesourselves.org/book-excerpts/health-article/a-brief-history
-of-birth-control/
Sexual Rights
Sexual rights, often referred to more inclusively as sexual and reproductive rights,
is the concept of human rights as they apply to sexuality and reproduction. Sexual
rights include a wide range of issues that often overlap and intersect in important
ways. For example, sexual rights issues may include sexuality education, improv-
ing access to health care services focused on sexuality and reproduction
(e.g., screenings for sexually transmitted infections, prenatal care), sexual plea-
sure, violence against women, sex work, and protection for those with diverse
sexual orientations and gender identities. Such sexual rights are embedded in a
larger concept of human rights, which typically includes the right to privacy, free-
dom from violence, freedom of thought, equality and freedom from discrimina-
tion, and the right to health and well-being.
Sexual and reproductive rights are most typically championed by nonprofit
and/or nongovernmental organizations (NGOs) working toward equality and
social justice at both regional levels and across the globe. Some of the most nota-
ble NGOs that fight for sexual rights include Amnesty International, the
666 Sexual Rights
International HIV/AIDS Alliance, the International Planned Parenthood Federa-
tion (IPPF), the World Association for Sexual Health (WAS), and the World Health
Organization (WHO).
Depending on the organization and its major areas of focus, the term “sexual
rights” has been defined in a number of ways. For example, some definitions
include reproductive justice, whereas others are more distinctly focused on goals
such as freedom of sexual expression and pleasure. Sexual rights have been
increasingly included in definitions of sexual health as well as overarching con-
ceptualizations of health and well-being. In a historic 2002 report, part of an effort
to create a clear description for use in policy development, aid work, and health
care, the WHO defined sexual rights in the following manner:
Sexual rights embrace human rights that are already recognized in national laws,
international human rights documents and other consensus statements. They
include the right of all persons, free of coercion, discrimination and violence, to:
• the highest attainable standard of sexual health, including access to
sexual and reproductive health care services;
• seek, receive and impart information related to sexuality;
• sexuality education;
• respect for bodily integrity;
• choose their partner;
• decide to be sexually active or not;
• consensual sexual relations;
• consensual marriage;
• decide whether or not, and when, to have children; and
• pursue a satisfying, safe and pleasurable sexual life.
The WHO further identified sexual rights as a fundamental component of sexual
health, and the organization has embraced the position that sexual health cannot be
maintained unless individuals’ sexual rights are protected and upheld (WHO, 2002).
Members of WAS, a worldwide, multidisciplinary umbrella organization for
scientific societies, professionals, and NGOs working in the field of human sexu-
ality, penned what is believed to be the first official documentation of sexual
rights. The Declaration of Sexual Rights was first proclaimed in 1997 at the Thir-
teenth World Congress of Sexology in Valencia, Spain. In 1999, at the Fourteenth
World Congress of Sexology in Hong Kong, the document was revised and for-
mally adopted by the WAS General Assembly. This revised version included
eleven sexual rights, though it has subsequently been expanded. The 2014 WAS
Declaration of Sexual Rights outlines and discusses the following sixteen sexual
rights:
• the right to equality and nondiscrimination
• the right to life, liberty, and security of the person
• the right to autonomy and bodily integrity
• the right to be free from torture and cruel, inhuman, or degrading treat-
ment or punishment
• the right to be free from all forms of violence and coercion
Sexual Rights 667
• the right to privacy
• the right to the highest attainable standard of health, including sexual
health, with the possibility of pleasurable, satisfying, and safe sexual
experiences
• the right to enjoy the benefits of scientific progress and its application
• the right to information
• the right to education and the right to comprehensive sexuality
education
• the right to enter, form, and dissolve marriage or other similar types of
relationships based on equality and full and free consent
• the right to decide whether to have children, the number and spacing of
children, and to have the information and the means to do so
• the right to the freedom of thought, opinion, and expression
• the right to freedom of association and peaceful assembly
• the right to participation in public and political life
• the right to access justice, remedies, and redress
The WAS Declaration of Sexual Rights further outlines the importance of attend-
ing to the interaction of “biological, psychological, social, economic, political, cul-
tural, legal, historical, religious, and spiritual factors” in considering sexual rights
and health (World Association for Sexual Health, 2013).
The IPPF, a global NGO committed to promoting sexual and reproductive
health, has also published a declaration of sexual rights. Sexual Rights: An IPPF
Declaration, published in 2008, has three main parts. First, a preamble intro-
duces the declaration as it is relevant to the mission and vision of the IPPF. The
document then addresses seven “guiding principles,” which introduce key con-
cepts related to human rights and explain how such universal human rights apply
to sexuality. The final section of the IPPF Declaration is titled “Sexual Rights
Are Human Rights Related to Sexuality” and outlines the following sexual
rights:
• Article 1: Right to equality, equal protection of the law and freedom from
all forms of discrimination based on sex, sexuality or gender
• Article 2: The right to participation for all persons, regardless of sex,
sexuality or gender
• Article 3: The rights to life, liberty, security of the person and bodily
integrity;
• Article 4: Right to privacy
• Article 5: Right to personal autonomy and recognition before the law
• Article 6: Right to freedom of thought, opinion and expression; right to
association
• Article 7: Right to health and to the benefits of scientific progress
• Article 8: Right to education and information
• Article 9: Right to choose whether or not to marry and to found and plan
a family, and to decide whether or not, how and when, to have children
• Article 10: Right to accountability and redress
Sexual Rights: An IPPF Declaration (International Planned Parenthood Federa-
tion, 2013) overlaps in many ways with other declarations of sexual rights;
668 Sexual Satisfaction
however, it is notable for including significantly greater detail about rights
surrounding family planning (Article 9), a major emphasis of the organization.
Jennifer A. Vencill
See also: Consent; Planned Parenthood; Reproductive Coercion; Safer Sex; Sex Educa-
tion; Sex Work; Sexual Assault; Sexual Health; Sexual Slavery; Sexually Transmitted
Infections (STIs).
Further Reading
Herdt, G. (Ed.). (2009). Moral panics, sex panics: Fear and the fight over sexual rights.
New York: NYU Press.
International Planned Parenthood Federation. (2013). Sexual rights: An IPPF declaration.
Retrieved http://www.ippf.org/resource/Sexual-Rights-IPPF-declaration
Lind, A. (2010). Development, sexual rights, and global governance. New York:
Routledge.
Sexual Rights Initiative. (2016). Intro to sexual rights. Retrieved from https://www
.sexualrightsinitiative.com/sexual-rights
World Association for Sexual Health. (2013). Declaration of sexual rights. Retrieved from
https://worldsexualhealth.net/resources/declaration-of-sexual-rights/
World Health Organization. (2002). Defining sexual health. Report of a technical consul-
tation on sexual health 28–31 January 2002, Geneva. Retrieved from http://www
.who.int/reproductivehealth/topics/gender_rights/defining_sexual_health/en/
Sexual Satisfaction
Sexual satisfaction is complicated and very subjective. What one person enjoys
will not necessarily be the same thing that someone else, maybe even their part-
ner, also likes. For the purposes of research, sexual satisfaction has been defined
as “an affective response arising from one’s subjective evaluation of the positive
and negative dimensions associated with one’s sexual relationship” (Lawrance &
Byers, 1995). In other words, sexual satisfaction (or dissatisfaction) is the way an
individual feels about their sexual relationship based on all the good and bad ele-
ments of that relationship.
E. S. Byers and colleagues have studied what leads to sexual satisfaction in a
relationship in depth over the last twenty years and have developed the interper-
sonal exchange model of sexual satisfaction (IEMSS) as a conceptual frame-
work to explain and predict sexual satisfaction. The IEMSS posits that within a
sexual relationship, there are costs and rewards. Sexual costs are things that
require effort, either mental or physical, or things that produce pain, embarrass-
ment, or anxiety. A general example could be engaging in a sexual activity that
your partner really enjoys but that is not particularly exciting for you. Con-
versely, sexual rewards are things that are pleasurable and gratifying; this could
be the feeling of connection you have with your partner after sex or the physical
pleasure of a really good orgasm. Within a relationship and over time, if an indi-
vidual’s sexual rewards are greater than their sexual costs, the individual will
Sexual Satisfaction 669
feel sexually satisfied. If the costs become higher than the rewards, and this
continues for a prolonged period of time, then the individual will likely feel
dissatisfied.
The IEMSS also accounts for an individual’s expectations about their relation-
ship (called their comparison level). If the costs and rewards of the relationship
are greater than or in line with the expectations of the individual, then satisfac-
tion occurs. If an individual feels as though their expectations are not being met,
even if the rewards outweigh the costs, they will likely feel dissatisfied. There is
one additional component to the model. Satisfaction will be greatest in a rela-
tionship when rewards and costs are seen as equal between partners. If one part-
ner is getting many rewards and one partner is experiencing many costs, then the
satisfaction of both partners will decrease. The IEMSS has been used to study
satisfaction in long-term and short-term relationships as well as in varying
cultures.
Sexual satisfaction has been studied extensively, and there are several things
that, in addition to the components of the IEMSS, are consistently linked with
sexual satisfaction. First, relationship satisfaction is highly intertwined with
sexual satisfaction; those who are happy in their relationships are generally sex-
ually satisfied and vice versa. Sexual function is also closely linked with sexual
satisfaction; when people experience sexual dysfunction, their satisfaction tends
to drops. Finally, many studies have examined gender differences in sexual sat-
isfaction, and, in general, both men and women report comparable levels of
satisfaction.
Heather L. Armstrong
See also: Communication, Sexual; Desire; Psychosexual Therapy; Sensate Focus; Sexual
Disorders, Female; Sexual Disorders, Male.
Further Reading
Armstrong, H. L., & Reissing, E. D. (2013). Women who have sex with women: A com-
prehensive review of the literature and conceptual model of sexual function. Sex-
ual and Relationship Therapy, 28, 364–399.
Byers, E. S., Demmons, S., & Lawrance, K.-A. (1998). Sexual satisfaction within dating
relationships: A test of the interpersonal exchange model of sexual satisfaction.
Journal of Social and Personal Relationships, 15, 257–267.
Byers, E. S., & MacNeil, S. (2006). Further validation of the interpersonal exchange
model of sexual satisfaction. Sex & Marital Therapy, 32, 53–69.
Lawrance, K.-A., & Byers, E. S. (1995). Sexual satisfaction in long-term heterosexual
relationships: The interpersonal exchange model of sexual satisfaction. Personal
Relationships, 2, 267–285.
Raisi, F., Yekta, Z. P., Ebadi, A., & Shahvari, Z. (2015). What are Iranian married wom-
en’s rewards? Using interpersonal exchange model of sexual satisfaction: A quali-
tative study. Sexual and Relationship Therapy, 30(4), 475–489.
Sánchez-Fuentes, M. D. M., & Santos-Iglesias, P. (2015). Sexual satisfaction in Spanish
heterosexual couples: Testing the interpersonal exchange model of sexual satisfac-
tion. Journal of Sex & Marital Therapy, 42(3), 223–242.
670 Sexual Script
Sánchez-Fuentes, M. D. M., Santos-Iglesias, P., & Sierra, J. C. (2014). A systematic review
of sexual satisfaction. International Journal of Clinical and Health Psychology,
14, 67–75.
Stephenson, K. R., & Meston, C. M. (2011). The association between sexual costs and
sexual satisfaction in women: An exploration of the interpersonal exchange model
of sexual satisfaction. The Canadian Journal of Human Sexuality, 20, 31–40.
Sexual Script
Gagnon and Simon (1973) developed sexual script theory in their influential book
Sexual Conduct. Their theory shifted the view in sexological studies from largely
biological and psychoanalytic to include cultural and social aspects as well. Since
its development, sexual script theory has been one of the most cited modern theo-
ries of understanding sexual behavior and has gone on to incorporate views of
learning, sociobiology, postmodern, and feminist perspectives.
A sexual script is a cognitive schema or a mental template that serves to signal
how one should understand or behave in a sexual situation. A script is typically
signaled by one event that sets in action the anticipation of the following sequence
that might unfold. Some of these events can be seen to increase the probability
that the next step in the chain will occur; others may be seen to decrease that
probability.
Sexual scripts have been broken down into three different levels: the cul-
tural, interpersonal, and intrapersonal. Cultural scripts are those that individu-
als learn from media and different social institutions, such as law, religion, and
school. Cultural scripts shape our understanding of what are appropriate and
inappropriate sexual choices within society or culture. Some sexual behavior is
considered taboo, illegal, or admonished, while others are encouraged, lauded,
and envied. Interpersonal scripts involve specific actors engaging within the
framework of cultural scripts and concretely enacting these abstract ideas.
Interpersonal scripts have two levels. On one level, they are the reinforcement
of cultural scripts in a more social or interactional manner. On another level,
interpersonal scripts are also a way of direct learning from others through the
response to the immediate cues and actions of others. In other words, they are a
way of acting out cultural scripts. When all the actors involved share similar
scripts, there is relative harmony. However, when there are differences, con-
flict, improvisation, and learning through assimilation and accommodation
may happen. Intrapsychic scripts are the unique ways in which a person inter-
nalizes the cultural and interpersonal scripts with their sexual interest, desires,
and preferences. Intrapsychic scripts develop an internal mental eroticism con-
taining fantasies, memories, and mental rehearsals. It also includes the process
of negotiating interpersonal scripts with others within the cultural script
context.
Sexual script theory has been applied to a broad array of research, including
gender roles in sexual initiation, casual sex, HIV/AIDS epidemic, rape, and use of
pornography, to name a few. Researchers using sexual script theory tend to use
two broad approaches to analysis: critical review and self-report. Critical review
Sexual Slavery 671
methods explore cultural-level scripts through the analysis of cultural artifacts,
such as mass media, or an already accrued body of research. Self-report methods
instead use participants who are asked to describe sexual scripts or validate the
existence of hypothetical scripts. In this paradigm, participants may be asked to
describe what happened in a specific sexual scenario or to respond to a hypotheti-
cal scenario.
Alexander Kovic
See also: Gender Roles, Socialization and; Sex Education; Stereotypes, Gender; Stereo-
types, Sexual.
Further Reading
Gagnon, J., & Simon, W. (1973). Sexual conduct: The social sources of human sexuality.
Piscataway, NJ: Aldine Transaction.
Krahé, B., & Tomaszewska-Jedrysiak, P. (2011). Sexual scripts and the acceptance of sex-
ual aggression in Polish adolescents. European Journal of Developmental Psy-
chology, 8(6), 697–712.
Masters, N. T., Casey, E., Wells, E. A., & Morrison, D. M. (2013). Sexual scripts among
young heterosexually active men and women: Continuity and change. Journal of
Sex Research, 50(5), 409–420.
McCormick, N. B. (2010). Preface to sexual scripts: Social and therapeutic implications.
Sexual and Relationship Therapy, 25(1), 91–95.
Morrison, D. M., Masters, N. T., Wells, E. A., Casey, E., Beadnell, B., & Hoppe, M. J.
(2015). “He enjoys giving her pleasure”: Diversity and complexity in young men’s
sexual scripts. Archives of Sexual Behavior, 44(3), 655–668.
Simon, W., & Gagnon, J. H. (2003). Sexual scripts: Origins, influences and changes.
Qualitative Sociology, 26(4), 491–497.
Wiederman, M. W. (2015). Sexual script theory: Past, present, and future. In J. DeLama-
ter & R. F. Plante (Eds.), Handbook of the sociology of sexualities (7–22). Cham,
Switzerland: Springer Press.
Sexual Slavery
Sexual slavery is a form of oppressive dominance over an individual or group of
people through the overt and comprehensive control of sex or sexuality. The term
“slavery” is generally used to differentiate individuals who are coerced into sex-
ual behavior from individuals who engage voluntarily in prostitution. Other rele-
vant terms often used by scholars include “forced sexual labor,” “trafficking in the
sex industry,” and “commercial sexual exploitation.”
Humanity unfortunately has witnessed several potent examples of sexual slav-
ery throughout history. For example, “comfort women” were kept by the Japanese
military during World War II, raped multiple times per day, endured immense
physical and psychological pain from sexually transmitted infections and forced
abortions, and were often threatened with death. Indeed, an estimated 75 percent
of them died during their capture. More recently, an estimated 20,000 women in
Yugoslavia were methodically raped as a strategy for “ethnic cleansing” during
conflict there in the 1990s, and many Yazidi women were sexually enslaved at the
hands of ISIS during the civil war in Syria and surrounding areas.
672 Sexual Slavery
Although we often only consider egregious examples, sexual slavery is undoubt-
edly present in day-to-day society and throughout the world. A 2017 report by the
International Labour Organization estimates that approximately 4.8 million indi-
viduals are exposed to forced sexual exploitation (i.e., “persons in forced labor and
services imposed by private actors for sexual exploitation”) every year. Moreover,
because of the hidden nature of sexual exploitation and the victims who are
involved, the few estimates that exist likely underestimate the magnitude of the
problem. The vast majority of victims are women and children (usually girls), and
in contrast to assumptions often made by policy makers and the general public,
they often remain within a single country as opposed to being trafficked across
international borders.
Sexual slavery is a multibillion-dollar industry and the third-largest profit
earner for international organized crime after drugs and weapons. The potential
for financial gain is a clear motivator for traffickers to engage in this behavior,
with the industry reaping approximately $44.3 billion. Some scholars suggest that
the glamorization of pimping in modern culture (i.e., through film and music) may
also play a role in motivating traffickers to engage in this behavior.
Perpetrators use many notable techniques to lure individuals into sexual slav-
ery to maximize their own personal gain and minimize their risk of being caught.
In particular, they often prey on vulnerable young women or others (e.g., those
facing homelessness or living in group homes; lesbian, gay, bisexual, or transgen-
der youth), sometimes targeting them at bus stations or shopping centers. Many
contextual and situational factors make an individual vulnerable to being forced
into sexual labor, such as experiences of poverty, childhood violence, family dys-
function, inadequate education, illicit substance dependency, and the presence of
prostitution markets. As highlighted by a few researchers, risk factors can be bro-
ken down into four categories: individual characteristics (e.g., history of substance
abuse, runaway, being a sexual minority), family dynamics (e.g., parental dys-
function, family violence), community (e.g., gang membership, transient male
population), and sociocultural and economic (e.g., high crime rates, poverty or
unemployment. Perpetrators may provide initial financial or emotional support
and may even engage in intimate relations with their victims before increasingly
using and abusing them. Others pose online as supportive peers or place job
advertisements on the internet promising a purportedly legitimate employment
opportunity within a country or across international borders. As victims become
ensnared in sexual slavery, victims who cross international borders can be classi-
fied as illegal immigrants by the country they have traveled to, leaving them with
little or no legal recourse against their attackers. Furthermore, because a victim
may form a complex attachment with the perpetrator, they may be unaware of
being exploited and remain resistant to outside intervention.
Most survivors of sexual slavery who manage to escape the horrific conditions
imposed on them experience severe posttraumatic stress. A meta-analysis evalu-
ating negative outcomes of sex trafficking highlights depression, anxiety, and
posttraumatic stress disorder as the most common mental health symptoms expe-
rienced by victims. A study evaluating the psychosocial outcomes of the “comfort
women” described above found that many of these women experienced learned
Sexual Slavery 673
helplessness throughout their capture, which kept them from actively seeking
shelter. Some reported experiencing extreme bouts of anger throughout their cap-
ture and suffered from sexually transmitted infections. Long-term symptoms of
the abuse included anxiety disorders and substance abuse, and almost all the sur-
vivors who were interviewed recounted that their social functioning had been
severely impaired by their experiences.
To deal with the problems of sexual slavery, U.S. governmental policies have
been implemented, albeit often with very limited scope or impact. For example, the
Mann Act of 1910 (aka the White Slave Traffic Act) prohibited the transportation of
any girl or woman for immoral purposes across borders. As an expansion, the
International Convention for the Suppression of the Traffic in Women and Children
notably changed the term “white slavery” to “trafficking.” In 2000, the U.S. gov-
ernment enacted the Trafficking Victims Protection Act, which only aids undocu-
mented immigrants exposed to severe trafficking unless they are under the age of
eighteen years old. To support survivors of sexual slavery and reduce the overall
prevalence, engaged governments recognize the necessity of ensuring the avail-
ability of appropriate housing, food and clothing, mental health counseling, legal
services, and other necessities to vulnerable populations. Some notable programs
in the United States to mitigate the harm caused by sex trafficking include the
Early Intervention Prostitution Program and the Commercial Sexual Exploitation
of Children Community Intervention Project Training Institute. A 2018 qualitative
study by Bruhns and colleagues noted that victims under eighteen years old were
typically forcefully prevented from leaving the sex trade by their exploiters,
emphasizing the need for intense and comprehensive resources including safe
houses and witness protection programs for these victims. In contrast, the study
suggests that older victims require logistical information to help them exit.
Overall, the most effective worldwide legal policies on sexual exploitation are
based on empirical evidence rather than on theoretical ideologies. A more wide-
spread understanding of forced sexual labor, and improved policy to combat it,
may help ease feelings of negative judgment and bias often experienced by
survivors.
Laura Kabbash and Scott T. Ronis
See also: Child Sexual Abuse; Prostitution; Rape; Rape Trauma Syndrome; Sex Tourism;
Sexual Abuse.
Further Reading
Bruhns, M. E., del Prado, A., Slezakova, J., Lapinski, A. J., Li, T., & Pizer, B. (2018). Sur-
vivors’ perspectives on recovery from commercial sexual exploitation beginning
in childhood. Counseling Psychologist, 46(4), 413–455.
Felner, J. K., & DuBois, D. L. (2017). Addressing the commercial sexual exploitation of
children and youth: A systematic review of program and policy evaluations. Jour-
nal of Child & Adolescent Trauma, 10(2), 187–201.
Hepburn, S., & Simon, R. J. (2010). Hidden in plain sight: Human trafficking in the United
States. Gender Issues, 27(1–2), 1–26.
Hoffman, Y., Grossman, E., Shrira, A., Kedar, M., Ben-Ezra, M., Dinnayi, M., … Zivot-
ofsky, A. (2018). Complex PTSD and its correlates amongst female Yazidi victims
of sexual slavery living in post-ISIS camps. World Psychiatry, 17(1), 110–112.
674 Sexuality across the Life Span
International Labor Organization. (2017). Global estimates of modern slavery: Forced
labour and forced marriage. Geneva, Switzerland. Retrieved from https://www
.ilo.org
Kotrla, K. (2010). Domestic minor sex trafficking in the United States. Social Work, 55(2),
181–187.
Lee, J., Kwak, Y.-S., Kim, Y.-J., Kim, E.-J., Park, E. J., Shin, Y., … Lee, S. I. (2018). Psy-
chiatric sequelae of former “comfort women,” survivors of the Japanese military
sexual slavery during World War II. Psychiatry Investigation, 15(4), 336.
Lerum, K., & Brents, B. G. (2016). Sociological perspectives on sex work and human traf-
ficking. Sociological Perspectives, 59(1), 17–26.
Miller-Perrin, C., & Wurtele, S. K. (2017). Sex trafficking and the commercial sexual
exploitation of children. Women & Therapy, 40(1–2), 123–151.
O’Brien, J. E., White, K., & Rizo, C. F. (2017). Domestic minor sex trafficking among
child welfare–involved youth: An exploratory study of correlates. Child Maltreat-
ment, 22(3), 265–274.
Oram, S., Stöckl, H., Busza, J., Howard, L. M., & Zimmerman, C. (2012). Prevalence and
risk of violence and the physical, mental, and sexual health problems associated
with human trafficking: Systematic review. PLoS Medicine, 9(5), 1–13.
Woolman, S., & Bishop, M. (2006). State as pimp: Sexual slavery in South Africa. Devel-
opment Southern Africa, 23(3), 385–400.
Sexuality across the Life Span
Sexuality develops and changes throughout a person’s life. While there are times,
like puberty, when changes are pronounced, sexuality continues to influence peo-
ple’s lives in many ways from birth (and even before) until death. Further, sexual
development is influenced by many things, including biological, social, and psy-
chological experiences. Knowing what to expect and how sexuality can affect
someone can help people have realistic expectations, manage changes success-
fully, and lead healthy sexual lives.
Sexual development begins before birth as the fetus grows and develops sexual
characteristics and organs. Infants and young children can experience pleasure
from physical contact, and it is common for them to self-stimulate, either manu-
ally or by rubbing their genitals on something such as a blanket or toy. It is impor-
tant to note that behaviors that may seem sexual to observing adults are motivated
by curiosity, pleasure, and self-soothing rather than by sexual desire as young
children do not yet have an understanding of sexuality. Likewise, as children age,
they become aware of their bodies and the bodies of others, and they begin to rec-
ognize physical differences between males and females. Curious children may
play games like “doctor” in which they compare their bodies with other children.
Again, this play is not sexually motivated and is done as a way for children to
learn and understand theirs and others’ bodies. Knowing these behaviors are nor-
mal and to be expected can help parents manage this behavior if they observe it
among their own children. Parents’ reactions to their children’s sexual behavior
can have an important effect on later sexual development. If parents react nega-
tively and punish their children, the child may learn to feel ashamed and guilty
about their sexuality. As such, it is preferable for parents to teach their children
Sexuality across the Life Span 675
appropriate ways in which to express their sexuality. Sex education is a lifelong
process, and parents play a key role in teaching their children to feel good about
their bodies, to be respectful of themselves and others, and to feel comfortable
asking their parents questions about sexuality.
In preadolescence and adolescence, children’s interest in sex increases, and
masturbation is common. While many activities and friendships occur primarily
with same-sex peers, interest in dating also increases. Social norms tend to be
strictly enforced, and many adolescents face peer pressure to behave in socially
accepted ways. Importantly, adolescents go through puberty and so experience
many physical, cognitive, and emotional changes that affect their sexual develop-
ment. During later adolescence, many people begin to form romantic relation-
ships and may begin to experiment with partnered sexual behaviors. Typical
sexual exploration follows the sexual script that begins with kissing and pro-
gresses to genital touching, oral sex, and finally sexual intercourse. Generally
speaking, the average age of first sexual intercourse is seventeen for both males
and females, and a positive first experience has been shown to be related to better
sexual adjustment later in life. As adolescents become sexually active, they need
to be aware of safer sex practices to protect themselves and their partners from
sexually transmitted infections and, if having sex with other-sex partners, unin-
tended pregnancy.
As adults, people are likely to have a variety of sexual experiences and relation-
ships. Most people will be single at some point, either intentionally or because
they have not yet found a long-term partner. During this time, some may be absti-
nent, while others may have casual sex with one or multiple partners. Most people
will also experience dating and getting to know a partner in a more intimate way.
Some people will live with partners, and most people marry at least once in their
lives. Some of these will experience divorce and infidelity. All these experiences
teach people about their own sexuality and the sexuality of their partners. Com-
munication is key between partners in order to have positive and healthy sexual
experiences.
As people age, their bodies change, and some aspects of sexual function, like
having an erection or experiencing vaginal lubrication, may become more chal-
lenging. However, there is much diversity among people. Some older adults expe-
rience less sexual activity, while others continue to have sex on a regular basis;
one study found that more than half of adults over seventy-five were engaging in
sexual activity three or more times per month. As the body changes, as in puberty,
it is important for people to know what to expect so that they can be prepared and
make adjustments as needed. Sexual expression in older adults may place more of
an emphasis on the emotional and intimate connection between partners and may
focus more on kissing and sexual touching rather than penetrative sex.
All life stages and relationship experiences provide the opportunity for people
to grow and develop sexually. Being aware of sexuality at all stages of life is
important for the sexual health of individuals and their partners. Once people
know what to expect, they can prepare, respond, and make informed decisions
about their sexual lives.
Heather L. Armstrong
676 Sexuality among Older Adults
See also: Adolescent Sexuality; Childhood Sexuality; Puberty; Sexual Health; Sexuality
among Older Adults; Sexuality among Younger Adults.
Further Reading
Haffner, D. (2008). From diapers to dating. New York: Newmarket Press.
O’Sullivan, L. F., Cheng, M. M., Harris, K. M., & Brooks-Gunn, J. (2007). I wanna hold
your hand: The progression of social, romantic and sexual events in adolescent
relationships. Perspectives on Sexual and Reproductive Health, 39(2), 100–107.
Reissing, E. D., Andruff (Armstrong), H. L., & Wentland, J. J. (2012). Looking back: The
experience of first sexual intercourse and current sexual adjustment in young het-
erosexual adults. The Journal of Sex Research, 49(1), 27–35.
Reissing, E. D., & Armstrong, H. L. (2020). Sexuality over the lifespan. In C. F. Pukall
(Ed.), Human sexuality (3rd ed.) (203–221). Don Mills, ON: Oxford University
Press.
Waite, L. J., Laumann, E. O., Das, A., & Schumm, L. P. (2009). Sexuality: Measures of
partnerships, practices, attitudes, and problems in the National Social Life,
Healthy, and Aging Study. The Journals of Gerontology. Series B, Psychological
Sciences and Social Sciences, 64B(Supp 1), i56–i66.
Sexuality among Older Adults
Sexuality involves a focus on sexual matters and involvement in sexual activity.
Sexual activity declines as people age, but interest and ability to engage in sex
remain in later life. Sexual satisfaction is a significant contributor to quality of life
with older adults, ranking close to religious commitments. Differences in sexual-
ity between older adult men and women exist.
Sexuality is a blend of biological, psychological, and cultural aspects of life. In
other words, it has physiological origins, but it also represents socially constructed
realities that shift. For example, biological constraints limit sexual behavior at
certain ages. This leads people to believe older adults do not have as much sex
because it is not physically possible. However, research shows higher levels of
sexual activity among older adults now compared to previous decades. Though
physical limitations exist, cultural acceptance of sexuality in old age is increasing
and leading to more sex. Keep in mind, medical advances related to erectile dys-
function, facilitating the production of vaginal lubrication, and certain hormone
therapies have contributed to this as well.
Statistics on populations up to the age of eighty-five years show over 50 percent
of older adults engage in sexual activity regularly. Numbers are as high as 73 per-
cent around the age of sixty but as low as 25 percent around the age of eighty. The
most common reason for giving up sex involves physical limitations. This includes
perceived health concerns related to heart disease and strokes, exhaustion and
pain related to respiratory disease and arthritis, and lowered self-confidence after
surgeries affecting appearance, such as mastectomies. Regardless, sexual activity
has the ability to increase health and well-being. Sex leads to a lower risk of heart
attack, less cancer, and more restful sleep. Another reason for reduced sexual
activity in old age is lack of an available partner. This is specifically problematic
for women. The likelihood of having a sexual partner decreases for women as they
Sexuality among Older Adults 677
age due to higher mortality rates for men. There is also a higher level of cultural
acceptance related to older men marrying younger women, which reduces the dat-
ing pool for females who lose significant others or go through divorces late in life.
Data show less than 1 percent of older women have multiple partners in any given
year, but even in situations involving lifelong partners, sexual activity decreases
due to an increase in familiarity and sexual boredom. Management of aging par-
ents and care provided for grandchildren also contribute.
Current estimates indicate that by 2030 up to six million people in the United
States will identify as lesbian, gay, or bisexual. People in older diverse populations
such as these report higher levels of life satisfaction than earlier in life. This is
primarily due to having already managed problems associated with a culturally
stigmatized identity. Stereotypes involving people with alternative sexual orienta-
tions have diminished significantly, such as the dissolving perception of older gay
men as lonely or predatory. However, problems related to sexuality persist with
institutional discrimination, victimization, and specific issues connected to health
care and human services access. Consider limitations for life partners related to
access to pensions and visitation barriers related to medical contexts. Over 60 per-
cent of older people in the LGBTQ community have younger sexual partners. This
creates unique challenges due to generational variation. Older men who have sex
with other men are at higher risk of HIV and other sexually transmitted infec-
tions. Compared to heterosexual populations, older lesbian and bisexual women
have more chronic health problems and alcohol abuse issues, which adversely
affects behavior patterns related to sex.
Sexual urges do not cease when older adults move into elder care facilities.
However, health care providers often have problems viewing older adults as sex-
ual beings. Sexual activity, especially masturbation, is viewed as problematic, not
enriching. With sexually active adults in elder care environments, including older
adult housing, males are more likely to seek out multiple partners. Females may
insulate themselves from risk by building a personal relationship first and engag-
ing in sex later. Both rarely use protection, including condoms. In some facilities,
such as nursing homes, policies restrict older adults from going to private places
to engage in intimacy. Facilities also place multiple residents in one room, which
lowers the availability of locations for those wanting privacy for sexual activities.
Furthermore, over half of nursing homes have policies requiring family approval
for sexual activity if a resident has any sign of cognitive impairment, with around
12 percent requiring approval regardless of mental state. Some even require writ-
ten physician orders allowing a resident to have sex.
Jason S. Ulsperger
See also: Sexual Health; Sexuality across the Life Span; Sexuality among Younger Adults.
Further Reading
Baumle A. (2013). International handbook on the demography of sexuality. Dordrecht,
Netherlands: Springer.
Fredriksen-Goldsen, K., Kim, H., Shui, C., & Bryan, A. (2017). Chronic health conditions
and key health indicators among lesbian, gay, and bisexual older US adults, 2013–
2014. American Journal of Public Health, 107(8), 1332–1338.
678 Sexuality among Younger Adults
Jen, S. (2017). Older women and sexuality: Narratives of gender, age, and living environ-
ment. Journal of Women & Aging, 29(1), 87–97.
Lester, P., Kohen, I., Stefanacci, R., & Feuerman, M. (2016). Sex in nursing homes: A
survey of nursing home policies governing resident sexual activity. Journal of the
American Medical Directors Association, 17(1), 71–74.
Ulsperger, J. S., & Knottnerus, J. D. (2015). Elder care catastrophe: Rituals of abuse in
nursing homes and what you can do about it. London: Routledge.
Sexuality among Younger Adults
Puberty ends at between eighteen and twenty-four years of age, and by the time
early adulthood is reached, physical and sexual development have reached mat-
uration for males and females. Height and weight may increase slightly around
this time, and physical abilities will peak in early adulthood. Adult females have
developed breasts, underarm and pubic hair, and widened hips. For most
females, menstruation is a monthly occurrence, and having children may be
considered. Males have reached their maximum height, gained a deeper voice,
attained broader shoulders, increased in muscle mass, and have underarm and
pubic hair.
Around middle adulthood, many changes begin to occur in adults. Changes
include an increased sensitivity to sound, having skin that is not as elastic and
results in wrinkles and dryness, vision variations, graying and thinning hair,
being more prone to illnesses than before, and a possible decrease in reproduction
capabilities. Many common illnesses and diseases have an impact on an adult’s
sexuality. These illnesses or complications include heart disease, diabetes, hyper-
tension, digestive problems, glaucoma, arthritis, and prostate issues.
Once males reach the age of twenty-five, testosterone levels begin to slowly
decline, which may influence sexual desire and activity. Over time, males may not
be able to have an erection as easily as they once had, or may not be able to sustain
an erection once they have one. The quantity of semen released decreases as a
man ages, as does the strength of his ejaculation. However, healthy males con-
tinue producing sperm until death, and so they are capable of fathering a child
later in life.
Of the many eggs a female begins with, only 400–500 will go through ovula-
tion. The number of eggs declines over time, and those that remain during adult-
hood may decline in quality. As adulthood progresses, females’ fertility gradually
declines as the individual begins to move into perimenopause (forty to forty-five
years old). During this time, individuals experience irregular periods and a decline
in estrogen levels, which may result in decreased vaginal lubrication, lack of sex-
ual desire, and possible mood changes.
Psychological and social development have different implications in adulthood
because the process is no longer defined by significant physical and cognitive
changes. Much of a person’s life span is in adulthood, significant psychosocial
gains are evident, and often adults report higher levels of satisfaction with their
sex life if they are in a committed relationship compared to their single peers. In
part, the emotional bond that forms between partners over time often leads to
Sexuality among Younger Adults 679
sexual intimacy. Sexual schemas, the perspective one has about their own sexual
aspects, are further developed in adulthood. As one moves through adulthood,
often they will have a wide variety of sexual techniques and experiences, allowing
for a more positive perspective of their own sexuality. As adults age, the process
and purpose of sexual experiences tend to move toward emotional connections
and intimacy rather than sexual orgasm.
Typically, pregnancies occur between ages twenty and forty, and childbirth can
influence an individual and their partner(s)’ sex life immensely. The frequency of
sexual activity may drop after pregnancy because of hormonal changes, stress,
self-esteem, changes in responsibilities, and involvement with children. Preg-
nancy within a relationship has an impact on all parties involved. Whether it is a
same-sex partnership, a mixed-sex partnership, or a polyamorous partnership,
pregnancy and the birth of a child will have an impact on intimacy, private time,
sexual encounters, financial responsibilities, and emotional reactions to one
another and to the child.
Sexual social development continues in adulthood with factors that include
sexual satisfaction, reproductive decisions, sexually transmitted infection preven-
tion, intimate relationships, relationship status, and lifestyle choices. Many people
reach adulthood with previous sexual experiences in adolescence. Younger adults
tend to have more sexual freedom and experiment more than middle-aged or older
adults, possibly because they are not in a committed relationship. As young adults
navigate the dating scene, many of them form a series of relatively short-term,
monogamous relationships. However, in Western cultures, the social expectation
is for adults to eventually settle down and commit to a partner for a long-term
relationship.
During early adulthood, sexual capabilities peak. It is not uncommon for peo-
ple to have multiple partners during this time, but this tendency does make this
age group more prone to acquiring sexually transmitted infections and unplanned
pregnancies than adults who are in monogamous relationships. Although long-
term, monogamous relationships are still valued by young adults, they tend to
occur later in life. In young adults, people tend to focus more on obtaining a col-
lege education, developing their career, and gaining financial stability before they
settle down with a lifelong partner. Many opt for cohabitation before getting mar-
ried for financial reasons and to learn more about each other before making the
commitment of marriage.
Casey T. Tobin
See also: Adolescent Sexuality; Marriage; Pregnancy; Sexuality across the Life Span;
Sexuality among Older Adults.
Further Reading
Cavanaugh, J., & Blanchard-Fields, F. (2015). Adult development and aging (7th ed.).
Stamford, CT: Cengage.
Darling, C., Cassidy, D., & Powell, L. (2014). Family life education: Working with families
across the lifespan (3rd ed.). Long Grove, IL: Waveland Press.
Edelman, C. L., Mandle, C. L., & Kudzma, E. C. (2013). Health promotion throughout the
life span. St. Louis, MO: Elsevier Health Sciences Mosby.
680 Sexualization
Sexualization
The American Psychological Association defines sexualization as “the inappro-
priate imposition of sexuality upon a person, whether through objectification,
overvaluing or emphasizing the person’s appearance or sexual behavior, or some
other means” (Grinnell, 2018). To sexualize something or someone can mean to
make them sexual when they are not being or feeling sexual. It can mean to think
about them in a sexual way when they are not thinking of themselves that way.
Many people are critical of the tactics that advertisers and the media use to
sexualize young people. That is, they are concerned about how ads, TV shows,
and movies attach adult sexual meanings to the way children and teenagers look,
feel, and behave. For a long time, women have objected to the ways in which they
have been sexualized as well. The concern is that sexualization suggests that the
worth of a woman is based on her sexual desirability rather than her abilities or
intelligence.
Dr. Dennis Dailey describes sexualization as the use of sexuality to influence,
manipulate, or control another person. His holistic model of sexuality has been
used in many textbooks and educational settings. His view is that sexualization
involves how we use our sexuality and may include manipulating or controlling
others. In this interpretation, the behaviors are personal between two people.
These can range from mild behaviors, like flirting, to more serious activities, like
seduction, withholding sex from an intimate partner to punish them or to get
something, sexual harassment, sexual abuse, incest, and rape.
Sexualization is sometimes considered the “darker” side of sexuality, as it
describes a range of behaviors from the relatively harmless to the violent, cruel, or
criminal. The reality is that no one has the right to exploit someone sexually. Some
of the behaviors, particularly “flirting” and “seduction,” can have a positive or
negative impact. It depends on the intent of the person engaging in such behavior
as well as the way in which it is interpreted by the person on the receiving end.
Flirting is a relatively harmless behavior, but it can be an attempt to manipulate
someone else, and it can cause the person who is manipulated to feel hurt or
shame. Flirting with a police officer to get out of a speeding ticket may not be
harmful, but flirting with the new girl in school on a dare may be hurtful and
embarrassing.
Seduction is the act of enticing someone to engage in sexual activity. This may
be mutually pleasurable for both parties, but it can be a negative experience if
someone is manipulated into doing something to which they have not fully
consented.
Sexual harassment is illegal. It means bothering someone with unwanted sex-
ual words or behaviors. It can be making the space where someone works, studies,
or lives feel sexually unsafe. It could mean unwanted touching, such as hugging
an underling or patting someone’s buttocks. It could mean a teacher, supervisor, or
other person in authority asking for sexual activity in exchange for grades, hiring,
raises, and so on. The laws provide protection against sexual harassment.
Rape is a crime in which someone forces genital contact with another. Force
can include using physical strength, threats, weapons, or implied threats that cause
Sexually Transmitted Infections (STIs) 681
fear in the person who is raped. It can also involve drugs or alcohol that reduces
the ability for someone to consent to have sex.
Incest is forced sexual contact of a minor who is related to the perpetrator by
birth or marriage. Incest is always illegal and betrays the trust that children and
youth give to their families. Like sexual harassment, rape, and sexual assault,
incest should be reported to the authorities.
On a social level, researchers have studied the impact of the media’s widespread
use of sexualization. They found that people who consume sexualized media are
more likely to consider themselves as sex objects. Current media puts an emphasis
on sexual appearance, physical beauty, and sexual appeal to others. Most people
do not have the idealized physical attributes of models or performers on television,
in movies, video games, and advertisements. Those who view themselves as sex
objects tend to pay chronic attention to their physical appearance and feel less
valuable or authentic than others. When a person’s value comes only from their
sexual appeal or behavior to the exclusion of other characteristics, they can have
low self-esteem, anxiety, and shame. In research on the effects of sexualization by
the media, the objectification effect was more pronounced for participants using
video games or online media. The effect of media use on self-objectification
equally affected men and women, older and younger participants, and participants
of several ethnic backgrounds.
Michael J. McGee
See also: Advertising, Sex in; Media and Sexuality; Sexual Consent; Sexual Harassment;
Sexual Health.
Further Reading
Advocates for Youth. (2007). Life planning education: A comprehensive sex education
curriculum. Washington, DC: Advocates for Youth.
Dailey, D. M. (1981). Sexual expression and aging. In F. J. Berghorn & D. E. Schafer
(Eds.), The dynamics of aging: Original essays on the process and experiences of
growing old (311–330). Boulder, CO: Westview Press.
Grinnell, R. (2018). Sexualization. Psych Central. Retrieved from https://psychcentral
.com/encyclopedia/sexualization/
Karsay, K., Knoll, J., & Matthes, J. (2018). Sexualizing media use and self-objectification:
A meta-analysis. Psychology of Women Quarterly, 42(1), 9–28.
Sexually Transmitted Infections (STIs)
Sexually transmitted infections (STIs) are infections that are passed from person
to person through intimate sexual contact, including oral, vaginal, and anal sex.
STIs affect people of all genders, sexual orientations, backgrounds, economic lev-
els, and cultures. In the United States, approximately 20 million new infections
occur each year, and half of these are among those ages fifteen to twenty-four. The
most common STIs generally fall into one of three categories: bacterial STIs con-
sisting of bacterial vaginosis (BV), gonorrhea, syphilis, and chlamydia; viral STIs
consisting of genital herpes, viral hepatitis, HIV, and human papillomavirus
(HPV); and parasitic STIs consisting of pubic lice (crabs) and trichomoniasis. STIs
682 Sexually Transmitted Infections (STIs)
such as those listed above can be transferred in a variety of ways during both
sexual and, in some cases, nonsexual contact. While some people experience
symptoms when they contract an STI, many do not. Therefore, regularly STI
screening is recommended for most sexually active people.
Bacterial STIs include bacterial vaginosis (BV), gonorrhea, syphilis, and
chlamydia. BV is an imbalance of the bacteria present in the vagina and can
sometimes occur after a sexual encounter with a new sex partner or with mul-
tiple sex partners. BV can also occur due to nonsexual things such as antibiotic
use; vaginal douching; or using perfumed soaps, shower gel, or bubble bath.
Semen may also trigger BV, so using a condom during sexual intercourse with
a male partner may be preventative. Gonorrhea infection can occur in the
vagina, uterus, cervix, urethra, anus, mouth, eyes, and throat. Gonorrhea can be
passed through oral, anal, and vaginal sex with a partner who has gonorrhea. In
addition, it can also be spread through contact by touching an infected area and
then touching another place on the body where the infection can enter, such as
the eyes or genitals. Syphilis is usually spread through direct contact with a
syphilis sore during vaginal, oral, and anal sex. As such, syphilis usually
appears on the penis, or around the vagina or anus, but it can occur elsewhere,
such as the mouth. Chlamydia is passed through condomless oral, anal, or vagi-
nal intercourse with a partner who has chlamydia. It is the most commonly
reported STI in the United States, and in 2017, 1,708,569 infections were
reported. Rates of chlamydia are increasing in the United States, especially
among women. This is worrisome as many women do not experience symp-
toms, and, left untreated, chlamydia can cause infertility, ectopic pregnancy,
and chronic pelvic pain.
Viral STIs include herpes, hepatitis, HIV, and HPV. In humans, two types of
herpes virus, HSV1 and HSV2, can be spread through genital-to-genital, oral-to-
genital, or oral-to-oral contact. Transmission is most likely to occur when herpes
blisters (also known as cold sores if located on the mouth or lips) are present;
however, transmission can occur when symptoms are not present. Hepatitis A is
typically transmitted by consuming food or drinking water that has been con-
taminated with human fecal matter containing the virus, although it can also be
transmitted through sexual contact with a person who has the virus. Hepatitis B
is spread from person to person through direct contact with blood, sexual fluids
such as semen, and needles from drug use. Hepatitis C is also spread through
contact with blood containing the virus, commonly through sharing needles or
other equipment used to inject drugs. HIV is spread through contact with blood,
semen, vaginal fluids, and other bodily fluids such as spinal fluid, breast milk,
and amniotic fluid. Advances in HIV treatment now mean that people living with
HIV who are virally suppressed through treatment are not able to transmit the
virus. HIV can enter the body through the mucous membranes, damaged tissues,
or through the bloodstream. It then proceeds to attack and destroy the immune
system’s infection-fighting cells, making copies of itself, and then killing the
healthy cells. HPV is a group of common viruses that includes more than one
hundred different types, some of which can be spread through oral, anal, or vagi-
nal sexual contact. HPV can cause genital warts but, importantly, also causes
Sexually Transmitted Infections (STIs) 683
cervical, vaginal, vulvar, penile, anal, and oral cancers, depending on the site of
infection.
STIs can also be caused by parasites. Pubic lice are usually spread through
sexual contact or by contact with clothing, bed linens, or towels that have been
used by a person with pubic lice. Also known as crabs, pubic lice are parasitic
insects that prefer to invade the pubic or genital region of human beings, though it
is not unusual to find them in other areas with coarse hair, such as armpits or
beards. Trichomoniasis (also known as trich) is caused by a tiny parasite called
Trichomonas vaginalis. This parasite typically infects the vagina and urethra,
although the head of the penis or prostate gland can also be infected. It is spread
through condomless vaginal or anal sex.
Symptoms may vary with each individual STI and with each individual person.
Often, people experience no symptoms at all. In general, symptoms may include
pelvic pain, smelly discharge, itching and burning, abdominal pain, fever, pain
during sex, pain with urination, and/or changes in menstrual cycle. If any of these
symptoms are experienced, it is important to speak with a health care professional
for testing and treatment.
Diagnosis of STIs may be through examination of the genitals or pelvic area by
a physician, or, in some cases, through fluid sampling, blood tests, or even biopsies
of the area. Attempted self-diagnosis, home treatments, or ignoring symptoms can
lead to more severe problems. Yearly check-ups with a physician that include hon-
est dialogue about sexual activities and genital checks are highly recommended
for most sexually active people, and more frequent testing is recommended for
individuals who have new or multiple partners. Early diagnosis and treatment is
important for the individual’s health and to prevent the onward spread of STIs.
Most STIs can usually be successfully treated and cured. Treatments vary
depending on the type and how long the infection has been present. HIV and her-
pes infection presently have no cure, although treatment is available for symptoms
and to reduce the presence of the viruses in the body. People living with HIV who
are virally suppressed through treatment are not able to transmit the virus to
others.
In order to reduce the likelihood of acquiring an STI, prevention strategies such
as using condoms and avoiding sexual contact during an active infection are rec-
ommended. Vaccines are also available for hepatitis and HPV. Clear and honest
communication between partners about past sexual history and previous STI
infection is important. Yearly exams by a qualified physician or sexual health pro-
fessional, as well as testing for STIs before having condomless sex or after a
potential exposure event, will help reduce the rate of STIs.
When engaging in any type of sexual contact, correctly used condoms provide
the best protection against STIs. There are two types of condoms. The most com-
mon is placed over a penis (insertive), while the other is placed within a vagina or
rectum (receptive). If a person has a latex allergy, polyurethane condoms should
be used instead. Dental dams also offer protection from STIs during oral sex when
used correctly. Importantly, other forms of birth control (e.g., the Pill, an IUD) do
not offer protection from STIs, so condoms or dental dams should still be used.
Linda D. Hinkle
684 Shepard, Matthew
See also: Bacterial Vaginosis; Chancroid; Chlamydia; Condoms, Female (Receptive);
Condoms, Male (Insertive); Dental Dam; Gonorrhea; Hepatitis, Herpes; Human Immu-
nodeficiency Virus (HIV); Human Papillomavirus (HPV); Molluscum Contagiosum;
Pubic Lice; Safer Sex; Scabies; Syphilis; Testing, STI; Trichomoniasis.
Further Reading
Brianti, P., De Flammineis, E., & Mercuri, S. R. (2017). Review of HPV-related diseases
and cancers. New Microbiology, 40(2), 80–85.
Centers for Disease Control and Prevention. (2017). Sexually transmitted diseases: Ado-
lescents and young adults. Retrieved from https://www.cdc.gov/std/life-stages
-populations/adolescents-youngadults.htm
Centers for Disease Control and Prevention. (2018). Sexually transmitted disease surveil-
lance, 2017: Chlamydia. Retrieved from https://www.cdc.gov/std/stats17/chlamydia
.htm
Drumright, L. N., Gorbach, P. M., & Holmes, K. K. (2004). Do people really know their
sex partners?: Concurrency, knowledge of partner behavior, and sexually trans-
mitted infections within partnerships. Sexually Transmitted Diseases, 31(7),
437–442.
Holmes, K. K., Levine, R., & Weaver, M. (2004). Effectiveness of condoms in preventing
sexually transmitted infections. Bulletin of the World Health Organization, 82(6),
454–461.
National Health Service. (2018). Trichomoniasis. Retrieved from https://www.nhs.uk/
conditions/trichomoniasis/#
Rodger, A. J., Cambiano, V., Bruun, T., Vernazza, P., Collins, S., van Lunzen, J., … Lun-
dgren, J. (2016). Sexual activity without condoms and risk of HIV transmission in
serodifferent couples when the HIV-positive partner is using suppressive antiret-
roviral therapy. JAMA, 316(1), 171–181.
Shepard, Matthew
Matthew Shepard (1976–1998) became a symbol for the LGBTQ+ rights move-
ment after he was the victim of a vicious hate crime in October 1998. Shepard was
a gay college student in Laramie, Wyoming, who was attacked after meeting two
men, Aaron McKinney and Russell Henderson, at a bar. Five days later, he died in
the hospital. His death provoked discussions about the violence and discrimina-
tion experienced by individuals of the LGBTQ+ community. Shepard’s story has
been documented in many books, movies, and plays, including The Laramie Proj-
ect and Matthew Shepard Is a Friend of Mine.
Matthew Shepard was born on December 1, 1976, to Judy and Dennis Shepard
in Casper, Wyoming. He had one younger brother. Shepard attended school in
Casper until his junior year, when his family moved to Saudi Arabia. He gradu-
ated high school from The American School in Switzerland. While living abroad,
he learned how to speak German and Italian. He was also very involved in com-
munity theater.
At age twenty-one, Shepard became a freshman at the University of Wyoming,
studying political science, foreign relations, and languages. He was chosen to be
the student representative for the Wyoming Environmental Council, and he also
became a member of a gay alliance club on campus. On the night of October 6,
Slut Shaming 685
1998, Shepard went to the Fireside Bar in Laramie alone after seeing some friends
at a local restaurant. He met McKinney and Henderson, who allegedly led Shepard
to believe they were gay.
Shepard left the bar with McKinney and Henderson, and they took him to a
remote location several miles east of Laramie. There, they robbed, beat, and pistol
whipped Shepard, and they tied him to a fence and left him to die in freezing tem-
peratures. Nearly eighteen hours later, Shepard was discovered by a cyclist, who
initially thought he was a scarecrow. He was taken to Ivinson Memorial Hospital
in Laramie, but due to his severe injuries, he needed to be transferred to a hospital
outside of Fort Collins, Colorado.
Shepard died from his injuries early on October 12, surrounded by his family.
McKinney and Henderson were convicted of felony murder and sentenced to two
consecutive life sentences. Despite the nature of the attack, the men could not be
charged with a hate crime because no such laws existed in Wyoming at the time.
Shepard’s murder elicited protests and an increased advocacy for federal legis-
lation for LGBTQ+ victims of violence. Shepard’s parents founded the Matthew
Shepard Foundation to honor their son’s memory and to advocate for acceptance
for LGBTQ+ individuals. His mother became a vocal activist for the LGBTQ+
community.
Over a decade after Shepard’s murder, President Barack Obama signed the
Matthew Shepard and James Byrd Jr. Hate Crimes Prevention Act (HCPA) in
2009. The HCPA is a federal law that added sexual orientation and gender identity
to the list of protected classes against biased crimes. This means that the U.S.
Department of Justice is able to investigate and prosecute bias-motivated crimes
of violence against individuals for either their gender identity or sexual
orientation.
Sarah Gannon
See also: Antigay Prejudice; Gay Rights Movement; LGBTQ+.
Further Reading
Anti-Defamation League. (n.d.). Matthew Shepard and James Byrd Jr. Hate Crimes Pre-
vention Act (HCPA): What you need to know. Retrieved from https://www.adl.org/
sites/default/files/documents/assets/pdf/combating-hate/What-you-need-to-know
-about-HCPA.pdf
Hassanein, R. (2019). Remembering and honoring Matthew Shepard. Retrieved from
https://www.hrc.org/blog/remembering-and-honoring-matthew-shepard
Hurst, J. C. (1999). The Matthew Shepard tragedy. About Campus, 4(3), 5.
Matthew Shepard Foundation. (2019). Frequently asked questions. Retrieved from http://
www.matthewshepard.org/faq/
Medium. (n.d.). Matthew’s Place. Retrieved from https://medium.com/matthews-place
Slut Shaming
Slut shaming, also known as slut bashing, is a form of stigma and bullying directed
at people (most often women and girls) who are perceived or believed to have vio-
lated some form of traditional expectations for sexual behaviors. It involves
686 Slut Shaming
attacking a person and making them feel guilty and ashamed for their sexual
behaviors—real or perceived—that deviate from societal norms. Such norms are
often gendered and stereotypical in nature—for example, the myth that “good
girls” do not or should not want sexual activity. Viewed through this lens, slut
shaming is often considered a method of sociocultural regulation of patriarchal
sexual values (e.g., that sex is the acquisition of pleasure from a woman, some-
thing one “takes” from a woman) as well as a major component of rape culture.
Slut shaming has garnered national attention in recent years due to its increasing
presence online as a form of cyberbullying and harassment, particularly of women
and girls.
Typical practices of slut shaming involve attacking a woman or girl for being
sexual (in any capacity), having one or more sexual partners, or expressing or act-
ing on their sexual feelings. Other circumstances in which women and girls have
been “slut shamed” include violating accepted dress codes by wearing attire that
is judged to be too sexually provocative, using or fighting for access to birth con-
trol, and after being sexually assaulted. In this latter example, slut shaming is akin
to victim blaming by contending that the crime of sexual violence was caused,
fully or in part, by the woman’s sexually provocative behaviors or clothing, thereby
absolving the perpetrator of any wrongdoing.
Though its exact definition varies by historical era, the term “slut” is typically
used in a derogatory fashion to describe a woman who is sexually promiscuous,
unclean, or disgusting. Slut shaming may, though does not necessarily, involve
use of the term “slut” or related insults (whore, tramp, etc.). At its core, the act of
slut shaming is less about the word “slut” and more significantly involves the
implication that if a woman is sexual in a way that traditional society disapproves
of, she is and should feel inferior. Thus, slut shaming might involve anything from
direct verbal abuse or spreading rumors and gossip about a person’s sexual behav-
iors to online harassment, sharing sexual photos or videos of a person without
their consent, or physical intimidation or assault.
Slut shaming appears to be increasing in the age of social media and technol-
ogy and has far-reaching negative consequences, again particularly for women
and young girls. Data reveal that two out of five girls in the United States have had
sexual rumors spread about them, three out of four have received unwanted sexual
comments or looks, and one in five has had negative sexual messages written
about her in a public area. Being publicly shamed and denigrated in this manner—
often for ongoing and lengthy periods of time—can be highly traumatic, resulting
in subsequent mental health concerns such as anxiety, depression, and, in some
cases, suicide. In addition, it has been noted that once a person has been slut
shamed and labeled a “slut” or “whore,” they are more likely to become a target of
sexual violence as they are now viewed as inferior or even deserving of the vio-
lence. As noted above, if the person actually is sexually assaulted or harassed, the
label of “slut” is often used to rationalize the behavior and protect the
perpetrator.
A major cultural response to slut shaming was the growth of the SlutWalk pro-
test march. SlutWalk, which has become a global movement, started in 2011 in
response to an incident in which a Toronto law enforcement officer told a group
Smegma 687
of students that “women should avoid dressing like sluts” in order to prevent
sexual assault. The protest most often takes the form of a march where some par-
ticipants dress in “slutty” attire, such as short skirts and high heels. Other Slut-
Walks have encouraged participants to wear any form of clothing in which they
have been slut shamed or sexually assaulted as a way of highlighting that sexual
violence can and does occur regardless of attire that is deemed sexually
provocative.
Jennifer A. Vencill
See also: Double Standards, Sexual; Female Sexuality; Madonna/Whore Dichotomy;
Sexual Assault; Sexual Harassment; Stereotypes, Sexual.
Further Reading
Friedman, J. (2011). What you really really want: The smart girl’s shame-free guide to sex
and safety. New York: Seal Press.
Tanenbaum, L. (2000). Slut! Growing up female with a bad reputation. New York: Harp-
erCollins Publishers.
Tanenbaum, L. (2015). I am not a slut: Slut-shaming in the age of the Internet. New York:
HarperCollins Publishers.
Smegma
Smegma is a combination of fats and oils, exfoliated skin cells, and moisture pro-
duced by human genitals. In males, it is produced by the foreskin of the penis and
can accumulate between the foreskin and the glans of the penis. In females, it is
produced generally by glands around the clitoris and accumulates around the cli-
toris and in the folds of the labia minora. It is believed that smegma evolved as a
natural lubricant for sexual intercourse. Problems with smegma are relatively
minor and can be solved with good hygiene.
Most discussion of smegma concentrates on what is produced by males.
Researchers have argued about the value of smegma and why it is produced by the
body. Tests show that it is composed of more than 25 percent fats and 13 percent
proteins. Much of this comes from skin cells that are shed by the penis and the
foreskin. When newly produced, smegma has a smooth, moist texture. It acts as a
lubricant to help the foreskin slide back to expose the glans during intercourse.
During childhood, little if any is produced. However, during adolescence, the
male begins to produce more and more, reaching peak production about the time
of sexual maturity. During middle age, production declines. By old age, men pro-
duce almost no smegma. Individual experiences may differ somewhat. The oppo-
nents and supporters of male circumcision often include a discussion of the
benefits and drawbacks of smegma, because a circumcised penis does not produce
smegma.
As smegma ages, it becomes greasy or hardens onto the penis. Because it con-
tains dead skin cells and bacteria, an unpleasant odor may also result. Dirt, sand,
and other particles may accumulate under the foreskin with the smegma. This can
result in irritation to the penis and even an infection. Early researchers believed
smegma could also increase the chances of cancer, but this has now been
688 Social Learning Theory, Gender and
discounted. Smegma can easily be removed with gentle daily washing with soap
and water. Excessive washing with soap can lead to dermatitis and should be
avoided.
Tim J. Watts
See also: Circumcision; Foreskin; Labia; Penis.
Further Reading
The Circumcision Decision. (2013). Smegma. Retrieved from http://thecircumcision
decision.com/smegma/
Lentz, M. (2017). Smegma removal: How to clean smegma in males and females. Health-
line. Retrieved from https://www.healthline.com/health/how-to-get-rid-of
-smegma
Social Learning Theory, Gender and
Social learning theory was developed by Albert Bandura through his laboratory
experiments focusing on modeling and behavior. A famous experiment of his, con-
ducted in 1965, involved three groups of four-year-old children and Bobo dolls. All
the children were shown a film where a model exhibited aggressive behavior toward
an inflated Bobo doll, but the three groups were shown three different consequences
for this behavior: the actor was punished for his actions, the actor was ignored for
his actions, or the actor was rewarded with treats for his actions. Based on the con-
sequences shown to the groups, the children’s behaviors, including their actions and
speech, imitated the observed model, showing that learning involves a cognitive
process whereas behaviors are modeled on the observed behavior of others and the
consequences of that behavior. From this experiment, Bandura used social learning
theory as a way to explain how behavioral responses of people are a function of a
cognitive process through attention, retention, motor reproduction, and incentive
and motivational processes. These four concepts can also be used to explain how
gender identity and expression is shaped by the various influences within society.
Gender identity, as conceptualized by behavioral psychologist John Money in
his book Man and Women, Boy and Girl (1972) and challenged later by the bio-
physical work of Milton Diamond and philosopher Judith Butler, is a person’s own
psychological awareness of their gender, whether it be male, female, transgender,
or another diverse identity. Gender identity can be the same or different from
one’s biological sex, how a person is labeled as male, female, or intersex based on
the specific combinations of their chromosomes, gonads, and hormone levels.
While biological sex is based on a person’s physical body, gender identity and
expression are shaped by society’s expectations of how the biological sex should
act, appear, and behave on a personal (hairstyle, clothing, voice), interpersonal
(how one performs their gender gives signals to another person on how to act or
treat someone), and institutional basis (masculinity characteristics are more val-
ued than feminine characteristics).
Being able to perform these attributes in a socially favorable manner produces
rewards or incentives. Through social learning theory’s concept of attention, the
Social Learning Theory, Gender and 689
person must pay attention to the social cues around them to learn and then imitate
the behavior. For example, if a young girl sees her mother always crossing her legs
while sitting in a chair (but never her father), she will believe that crossing her legs
is something that girls do. With the concept of retention, if the young girl watches
TV and further sees that women mostly cross their legs while sitting in order to be
“ladylike,” these constant examples will help her retain this information so that
she is more likely to perform this activity again. Having the ability to remember
the motor reproductive process of the expected activity (sit in chair, cross one leg
over the other, place hands on knees to keep legs closed), along with the observa-
tion (all women cross their legs when sitting), is also a sign of cognition influenc-
ing behavior. Finally, the incentive and motivational process for the young girl is
when she receives affirmative messages about crossing her legs when sitting (“She
is sitting like such a lady!”), but her behavior and thinking is also shaped by any
negative messaging that she receives (“Real women keep their legs closed!”).
Social learning theory recognizes that both positive and negative messages and
the increase or lack of incentives or punishments can shape how one expresses
their gender.
For people who identify as gender diverse, transgender, genderqueer, or who
are outside of the gender dichotomy of male and female, some of the social under-
standing of how to perform as a certain gender can be challenging, confusing, and
frustrating. The further away one is from the dichotomy of gender (masculine to
feminine), the more negative the consequences and the fewer incentives one may
receive. This dynamic between gender-diverse people and society does not always
provide a safe space for one to create, dress, live, or behave, which increases the
chance of discrimination when one does not express their gender in socially
accepted ways.
Shane’a Thomas
See also: Binary Gender System; Gender; Gender Diversity; Gender Expression; Gender
Identity; Gender Identity Development; Gender Roles, Socialization and; Genderqueer;
Intersexuality; Stereotypes, Gender; Transgender.
Further Reading
Fausto-Sterling, A. (2012). Sex/gender: Biology in the social world. New York:
Routledge.
Lehmiller, J. J. (2014). The psychology of human sexuality. Hoboken, NJ: Wiley-
Blackwell.
Longres, J. (2000). Human behavior in the social environment (3rd ed.). Belmont, CA:
Wadsworth/Thomson Learning.
Mazur, J. (1998). Learning and behavior (4th ed.). Upper Saddle River, NJ: Prentice-
Hall.
Seidman, S. (2012). Theoretical perspectives. In S. Seidman, N. Fisher, & C. Meeks
(Eds.), Introducing the new sexuality studies (2nd ed., 3–12). New York:
Routledge.
Tauches, K. (2012). Transgendering: Challenging the “normal.” In S. Seidman, N. Fisher,
& C. Meeks (Eds.), Introducing the new sexuality studies (2nd ed., 135–139). New
York: Routledge.
690 Society for the Scientific Study of Sexuality (SSSS)
Society for the Scientific Study of Sexuality (SSSS)
The Society for the Scientific Study of Sexuality (SSSS, pronounced “quad S”) is
an international nonprofit organization committed to sexuality research. Founded
in 1957, SSSS is the oldest professional organization for the study of sexuality in
the United States. Through various academic and professional endeavors, SSSS
maintains an interdisciplinary network of professionals who believe in the impor-
tance of the rigorous study of sexuality at the clinical, educational, and social
levels. Within this network lives a diverse grouping of professionals, including
therapists, anthropologists, medical practitioners, theologians, lawyers, sexolo-
gists, psychologists, educators, researchers, therapists, activists, and policy mak-
ers. The range of perspectives held by SSSS members has supported the growth of
sexual science as an academic and professional field of study.
Albert Ellis (1973–2007) was an American psychologist who was passionate
about human sexuality. Considered a key player in the American sexual revolu-
tion, Ellis worked alongside well-known sexologists, including Alfred Kinsey.
Amid publishing books and papers on sexual liberation, guilt-free sexuality, and
love, Ellis rallied support from other academics to create an organization where
sexuality could be the primary focus of research. This gathering of minds in the
realm of sexual science came to be known as the Society for the Scientific Study
of Sexuality.
There are more than 700 members in SSSS among seven categories of member-
ship: general members, fellows, chartered members, students, developing profes-
sionals, lifetime members, and honorary members. Membership benefits include
discounted attendance to society events, regional and national members meetings,
awards for professional excellence and public service, and connections to the
organization’s directory of professional resources. Both members and nonmem-
bers have access to the public events offered by the SSSS, such as conferences,
scholarly publications, and newsletters.
SSSS is committed to the future of sexual science. The SSSS student mentor-
ship program was instituted to connect people that would otherwise be stratified
by geographical location and work experience. All SSSS members are eligible to
be mentors or mentees. In this way, students and developing professionals can
learn from researchers and fellows, and those established in their careers can con-
tribute to the field of sexology in a new way.
Members of SSSS are strongly encouraged to be involved in the organization.
Members are seen as community leaders, and through an ambassador program,
young and old SSSS members are equally supported to plan futures in profes-
sional, community, or academic leadership.
SSSS has three primary publications in circulation. The most well-known pub-
lication is the Journal of Sex Research, which is a scientific quarterly reputed to
contain the latest in sexual science research. The Annual Review of Sex Research
is the yearly equivalent to the Journal of Sex Research. Its purpose is to synthesize
recent advances in theory and research. The least academic of the three publica-
tions is Sexual Science, an online newsletter sharing information on upcoming
trainings, conferences, job opportunities, and more.
Shadeen Francis
Sodomy Laws 691
See also: Ellis, Albert; Kinsey, Alfred; Sexology.
Further Reading
Society for the Scientific Study of Sexuality. (2019). Home page. Retrieved from http://
www.sexscience.org
Taylor and Francis Group. (2010). Annual review of sex research. Retrieved from http://
www.tandfonline.com/loi/hzsr20#.VxlvhIrJE4
Sodomy Laws
“Sodomy laws” refer to any laws against certain sexual acts deemed by society to
be immoral, unnatural, and harmful. The term “sodomy” is used for such acts.
Throughout history, the laws of many different societies and cultures have recog-
nized different definitions for sodomy. In a general historical sense, sodomy laws
were targeted against the typical sexual acts engaged in by men with other men,
especially anal and oral sex. However, depending on the culture, such laws might
also encompass certain other sexual acts, including anal and oral sex between
mixed-sex partners as well as sexual relations with animals (bestiality), dead bod-
ies (necrophilia), and children (pedophilia).
The word “sodomy” is derived from the biblical tale of Sodom and Gomorrah,
two cities used as examples of extreme sexual immorality. Despite the biblical
condemnation, sodomy—in the sense of relations between men and relations
between men and boys—was fairly common and acceptable in many societies
during ancient times.
During the late 1900s, sodomy laws began to be modified or eliminated in
many states within the United States as societal attitudes toward same-sex behav-
ior became more liberal and tolerant. Still, as of 2019, sixteen states maintain
some version of sodomy laws. Furthermore, such laws remain important aspects
of social order in numerous other nations, such as those controlled by strict Islamic
governments.
Until the 1960s, sodomy—including mutually consensual sex between same-
sex partners—was classified as a serious felony crime throughout the United
States, with standard punishments consisting of fines and imprisonment. In 1961,
Illinois became the first state to eliminate criminal punishment for mutually con-
sensual sodomy between adults. This move followed recommendations made in
1955 by a group of liberal lawyers and law professors called the American Law
Institute.
Many—but not all—other states either eliminated or reduced their criminal
penalties for sodomy or same-sex sexual behavior during the 1970s. Some states
kept their sodomy laws but did not enforce them. Penalties described in remaining
sodomy laws—whether or not they were enforced—ranged up to life in prison.
A 1986 ruling by the U.S. Supreme Court, in the case of Bowers v. Hardwick,
upheld a Georgia law criminalizing oral and anal sex in both mixed-sex and same-
sex sexual activity. That ruling was used by some lawyers as justification for sod-
omy laws in several states, though other lawyers believed that the issue remained
unsettled.
692 Sodomy Laws
In 2003, the Supreme Court, in the case of Lawrence v. Texas, ruled that an
existing sodomy law in Texas was unconstitutional because it violated the
Fourteenth-Amendment right of adults to engage in private, mutually consensual
sexual conduct. That ruling had the legal effect of constitutionally invalidating
most remaining sodomy laws in other states as well—seemingly resolving the
issue in the United States. Nevertheless, of the fourteen states that had sodomy
laws at the time of the ruling, only two—Montana and Virginia—moved to
repeal their laws. Not even Texas formally repealed its sodomy law, though the
state added a disclaimer to the law noting that the high court ruled it to be
unconstitutional.
Despite the 2003 Supreme Court decision, sixteen states maintain sodomy
laws within their criminal statutes as of 2019: Alabama, Florida, Georgia, Idaho,
Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, North
Carolina, Oklahoma, and South Carolina; laws in Kansas, Kentucky, and Texas
target only same-sex behavior. Most of these laws are vaguely worded as to what
constitutes criminal behavior, using such phrases as “any unnatural and lascivi-
ous act” or “abominable and detestable crime against nature.” Political pressure
from socially conservative communities within these states tends to prevent leg-
islators from repealing such sodomy laws. However, these laws are usually not
actively enforced. Although a small number of people, mainly gay men, continue
to be arrested by local police under these laws, prosecutors do not pursue these
cases, so the arrested individuals are soon released. If adults engaging in consen-
sual sex were to be prosecuted under sodomy laws, the criminal prosecutions
would likely be struck down by state courts, using the 2003 high court decision
as a basis.
As of 2019, mutually consensual sexual activities between same-sex adults—
constituting acts of “sodomy”—are illegal in seventy countries. Most of these
countries are in Africa and the Middle East. In some of these nations—including
Afghanistan, Brunei, Iran, Mauritania, Pakistan, Nigeria, Qatar, Saudi Arabia,
Somalia, Sudan, the United Arab Emirates, and Yemen—sexual acts between
men could be punishable by death. In several other nations in these regions, sod-
omy is punishable with life in prison.
A. J. Smuskiewicz
See also: Anal Sex; Dating, Cross-Cultural Comparison of; Gay Rights Movement;
Homosexuality; Oral Sex; Same-Sex Attraction and Behavior.
Further Reading
American Civil Liberties Union. (2019). Getting rid of sodomy laws: History and strategy
that led to the Lawrence decision. Retrieved from https://www.aclu.org/getting-rid
-sodomy-laws-history-and-strategy-led-lawrence-decision
Duncan, P. (2017, July). Gay relationships are still criminalised in 72 countries, report
finds. The Guardian. Retrieved from https://www.theguardian.com/world/2017/
jul/27/gay-relationships-still-criminalised-countries-report
Human Dignity Trust. (2019). Map of countries that criminalise LGBT people. Retrieved
from https://www.humandignitytrust.org/lgbt-the-law/map-of-criminalisation/
Somnus Orgasm 693
Somnus Orgasm
Somnus orgasm is the uniquely female (assigned female at birth) phenomenon of
experiencing orgasm during sleep. Most often, people born with a vulva/vagina
who have an orgasm during sleep will wake during the orgasm, but this is not
always the case. Some may sleep through the experience and recall it later upon
waking or might not remember it occurring at all. As many as 42.7 percent of
women will likely experience an orgasm during sleep by the age of seventy-eight,
and the number of women could potentially be higher as this is a vastly understud-
ied area of sexuality research.
Some research suggests that somnus orgasm prevalence and frequency may be
more common during certain periods or life events. For example, some women
report experiencing orgasm during sleep when going through long periods of sex-
ual abstinence, during pregnancy, or at certain times of their menstrual cycle.
Some experts suggest that there may also be a relationship between somnus
orgasm and lucid dreaming, level of education (or future level of education), sex-
ual liberalism, likelihood of experiencing other types of orgasm, and previous
knowledge of somnus orgasm, though more research needs to be conducted before
these possible relationships can be better supported. Many women also report that
their sleep orgasm experiences occur most often during sexual dreams, but this is
not always the case.
While somnus orgasms have some similarities with the male experience of
nocturnal emission, there are several significant differences. The most notable
distinction is that somnus orgasms do not only occur during puberty such as male
nocturnal emissions do. Girls and women who experience orgasm during sleep
may experience their first occurrence before the age of five years old or at any
other point in their lives. In addition, many girls and women who experience som-
nus orgasms continue to do so regularly throughout their entire life. In fact, Alfred
Kinsey’s monumental sexuality studies suggested that somnus orgasms may
potentially be more prevalent and frequent among older women, which is the
opposite of male nocturnal emission frequency, which diminishes or ceases alto-
gether following adolescence. Another major difference is that, as far as current
research has found, women who experience orgasm during sleep do not appear to
ejaculate during these events like males during nocturnal emissions. Though
female ejaculation itself is well documented, it has not yet been formally studied
in regard to somnus orgasms. This is why some women may not be aware of an
orgasm happening at all, as there is no obvious physical evidence.
Women and girls who have experienced orgasm during sleep have often been
pathologized, thought to be suffering from various diseases or ailments, believed
to be promiscuous, or even persecuted for witchcraft. The earliest records suggest
that girls and women who reported having an orgasm while asleep were assumed
to be having an affair with the devil and therefore practicing witchcraft. Later, it
was commonly believed that virginal girls could not experience orgasm during
sleep, so it was thought to be a sign of promiscuity or sexual deviancy. One super-
natural explanation that has been common throughout history, and still very much
believed today by some, is that an orgasm during sleep is the result of a demonic
694 Sperm
sexual assault from an incubus (a sex demon who is thought to attack women in
their sleep). Even today, as many people are still unaware that somnus orgasms are
a normal event, some women seeking information from their doctors or therapists
are misdiagnosed with epilepsy or schizophrenia. Research has also demonstrated
that while most women and girls view their sleep orgasm experiences as enjoyable
and pleasurable, many (especially those who were young during their first or early
somnus orgasm events) felt embarrassed, ashamed, guilty, or frightened. This
serves to illustrate the importance of accurate sexual health education both in
schools and at home.
Lyndsay Mercier
See also: Female Sexuality; Nocturnal Emissions; Orgasm.
Further Reading
King, F. (2012). Waking into “the big O.” North Charleston, SC: Createspace.
Kinsey, A., Pomeroy, W., Martin C., & Gebhard, P. (1953). Sexual behavior in the human
female. Philadelphia: W. B. Saunders Company.
Mercier, L. (2020). Things that go bump in the night: Prevalence, predictors, and experi-
ences of women who orgasm during sleep. Dissertation. Widener University.
Sperm
Sperm are the male sex cells produced by the testicles, or testes. As a result of
penile-vaginal intercourse or other enhanced fertility treatments, a sperm cell
may fertilize an egg cell to form a zygote (fertilized egg), which develops into an
embryo. The embryo, in turn, develops into a fetus. Sperm carry the male deoxy-
ribonucleic acid (DNA), making up half of the genetic material inherited by the
baby. The other half comes from the female egg. At the time of fertilization,
the twenty-three chromosomes (structures that carry genes) in the sperm join with
the twenty-three chromosomes in the egg to produce the baby’s complete genetic
makeup of forty-six chromosomes.
Sperm are produced in the seminiferous tubules that fill the interior of the tes-
tes. They then travel to a coiled tube at the rear of the testes called the epididymis,
where they complete their development. During sexual arousal, the sperm are
released outside the testes into long tubes called vas deferens. The sperm next
become mixed with nourishing fluids from the prostate, seminal vesicles, and bul-
bourethral glands before passing out of the body through the penis during ejacula-
tion in a sticky mixture called semen. An average, healthy ejaculation of semen
contains approximately one hundred million sperm cells.
To fertilize an egg—a process that usually occurs within one of the fallopian
tubes just outside the uterus—a sperm cell has to penetrate the surface of the egg.
Enzymes released by the head of the sperm break down the egg’s coating to allow
entry into the egg. Before that, however, the long tail, or flagellum, behind the
head of the sperm whips from side to side to propel the sperm cell forward as it
makes its journey through the female reproductive tract. Sperm may remain via-
ble inside the female body for approximately five days after sexual intercourse.
Spermicides 695
The health and viability of sperm decline with age, especially after age fifty. To
be successful in fertilization, sperm must meet three main qualifications: (1) they
must exist in large numbers in the ejaculate—typically more than 15 million to
20 million sperm cells per milliliter; (2) they must have normal shapes—with an
oval head and a long whip-like tail; and (3) they must be able to move through the
vagina, cervix, and uterus to reach the egg in the fallopian tube. It is common for
a certain percentage of sperm to have abnormal shapes or abnormal movements.
In a man who is fertile, at least 40 percent of his sperm typically have normal
structure and movement.
Some research suggests that the sperm of older men carry an increased risk of
producing offspring with certain conditions, including autism and schizophre-
nia. In addition, the risk of miscarriage may increase in pregnancies caused by
older men.
Several things can be done in order to maintain fertility and the health of sperm.
Practicing safer sex—that is, using condoms or other protections against sexually
transmitted infections—can help prevent problems with fertility and sperm. Eat-
ing a healthy, well-balanced diet; maintaining an appropriate weight; and limiting
cigarette smoking and drug and alcohol intake can also help preserve sperm
health. Regular physical exercise and the reduction of stress are two additional
factors that have been shown to be important in maintaining fertility.
A. J. Smuskiewicz
See also: Conception; Contraception; Ejaculation; Fertility; Ova; Semen; Seminiferous
Tubules; Sex Chromosomes; Testicles.
Further Reading
Cleveland Critics. (2017). 7 things you can do to keep your sperm healthy. Retrieved from
https://health.clevelandclinic.org/7-things-you-can-do-to-keep-your-sperm
-healthy/
Mayo Clinic. (2018). Healthy sperm: Improving your fertility. Retrieved from http://www
.mayoclinic.org/healthy-living/getting-pregnant/in-depth/fertility/art-20047584
NHS. (2019). Low sperm count. Retrieved from https://www.nhs.uk/conditions/low-sperm
-count/
Spermicides
Spermicides are a contraceptive method that can be used alone or with another con-
traceptive method in order to increase effectiveness. They are composed of a sper-
micidal agent in a carrier (cream, gel, foam, film, pessary, or suppository) that
allows dispersion and retention in the vagina. In order to prevent pregnancy, the
spermicide must be inserted into the vagina next to the cervix at least fifteen min-
utes (and not more than three hours) before intercourse. The active agent, non-
oxynol-9, forms a chemical barrier that destroys the membrane of sperm cells, either
killing them or slowing them down so that they fail to pass through the cervix and
reach the ovum. This method is not widely used, being one of the least effective of
all birth control methods, with effectiveness rates ranging from 71–82 percent.
696 Spermicides
Spermicides are more effective when combined with another barrier method
such as a condom, diaphragm, or cervical cap. Contrary to popular belief,
nonoxynol-9 does not protect against sexually transmitted infections. In fact,
research shows that spermicides actually increase the risk of contracting HIV.
This is because the chemicals they contain can damage the vaginal mucus, caus-
ing vaginal irritation and small lesions on the vaginal walls, which raises the risk
of HIV transmission. Consequently, spermicides are not recommended for indi-
viduals who are allergic to nonoxynol-9, are at greater risk for contracting HIV,
are living with HIV, are using antiretroviral therapy, or have a history of toxic
shock syndrome.
Before each instance of vaginal intercourse takes place, the spermicide must
be placed deep into the vagina using an applicator or else placed directly on a
condom. Generally, it should be applied within one hour before intercourse,
although some gels have longer effectiveness. Some spermicides are effective
immediately after insertion, while others, such as suppositories and films, take
ten to fifteen minutes to become effective. It is important to read the instruc-
tions carefully so that the spermicide is used correctly and inserted at the opti-
mal time.
Spermicides have certain advantages and disadvantages. Conveniently, a con-
sultation with a health care provider is not required. Spermicides have no hor-
monal side effects, and there is immediate return to fertility after use. They also
help lubricate the vagina. Furthermore, because they can be inserted ahead of
time, they do not interrupt the sexual activity. An added benefit is that they can be
inserted into the vagina without a partner’s collaboration, which gives the person
with a vagina control over the contraception strategy. On the downside, spermi-
cides are one of the least effective birth control methods, especially when used
alone. They can cause irritation or burning of the vagina or penis, and some indi-
viduals are allergic to the chemical content. They also have an unpleasant odor
and taste. Finally, spermicides provide no protection against sexually transmitted
infection and may actually increase susceptibility.
Sylvie Lévesque
See also: Barrier Contraceptive Methods; Contraception; Pregnancy; Sexually Transmit-
ted Infections (STIs); Sperm; Vaginitis.
Further Reading
Black, A., Guilbert, E., Costescu, D., Dunn, S., Fisher, W., Kives, S., … Todd, N. (2015).
Canadian contraception consensus (Part 2 of 4). Journal of Obstetrics and Gynae-
cology Canada, 37(11), 1036–1039.
Glasier, A., & Gebbie, A. E. (2008). Handbook of family planning and reproductive
healthcare. (5th ed.). London: Churchill Livingstone.
McVeigh, E., Guillebaud, J., & Homburg, R. (2013). Oxford handbook of reproductive
medicine and family planning. Oxford: Oxford University Press.
Society of Obstetricians and Gynaecologists of Canada. (2019). Retrieved from www
.sexandu.ca
World Health Organization. (2018). Family planning: A global handbook for providers.
Retrieved from https://www.who.int/reproductivehealth/publications/fp-global
-handbook/en/
Sponge, Contraceptive 697
Sponge, Contraceptive
The sponge—more precisely called the vaginal sponge or the contraceptive
sponge—is a device inserted deep into the vagina to prevent pregnancy. It is disc-
shaped, soft, about two inches (five centimeters) in diameter, and made of poly-
urethane foam.
The device works both by physically blocking the entry of sperm into the cer-
vix (neck of the uterus) and by releasing spermicide, a chemical compound
(nonoxynol-9) that kills sperm. Only one brand of sponge is approved for use in
the United States by the Food and Drug Administration; it became available in
1983. Additional brands are available in other countries.
The sponge is generally easy and convenient to use, inexpensive, and requires
no prescription. Before inserting the sponge, it must be moistened with water to
activate the spermicide. The device can be left in place for as long as thirty hours.
It remains effective for twenty-four hours, during which time the woman can
have sexual intercourse as often as she likes. It should be kept in place at least six
hours after intercourse to prevent pregnancy. Many people prefer the sponge as a
contraceptive because, unlike birth control pills, it does not disrupt their hormone
balance and, thus, does not have the side effects associated with hormonal
changes.
However, the sponge is less effective than birth control pills and many other
methods of contraception. It is most effective for people who have never given
birth, with about nine to twelve out of every hundred becoming pregnant when
using the sponge as directed. For those who have previously given birth and who
use the sponge as directed, about twenty to twenty-four out of every hundred will
become pregnant. The sponge’s effectiveness at preventing pregnancy is enhanced
if the partner uses a condom or if the penis is withdrawn before ejaculation. A con-
dom will also help protect against sexually transmitted infections (STIs), for which
the sponge offers no protection.
The sponge is safe to use for most people. However, those who have hypersen-
sitivities (allergies) to polyurethane or sulfa drugs should not use the device as it
may cause skin irritation and dryness, resulting in small open wounds that raise
the risk of STIs. The device may also be inappropriate for people who have had a
history of toxic shock syndrome (TSS) as the sponge raises the risk of TSS—
which is characterized by fever, rash, dizziness, confusion, and, in the worst cases,
multiple organ failure—if it is left in place longer than thirty hours; if it is used
during vaginal bleeding; or if it is used soon after childbirth, miscarriage, or abor-
tion. The sponge may also lead to problems for those who have had frequent yeast
or urinary tract infections, particularly by raising the risk of such infections if it is
left in place for too long.
Some people experience difficulties inserting or removing the sponge, but
most, with practice, can easily learn to use it. The device is most easily inserted
while in a squatting position, using one or two fingers to slide it up the vagina as
far as it will go. The device has a strap, which is pulled to remove it.
A. J. Smuskiewicz
See also: Barrier Contraceptive Methods; Cervix; Contraception; Spermicides.
698 Start-Stop Technique
Further Reading
Health Link BC. (2017). Contraceptive sponge for birth control. Retrieved from https://
www.healthlinkbc.ca/health-topics/tw9510
Mayo Clinic. (2019). Contraceptive sponge. Retrieved from https://www.mayoclinic.org/
tests-procedures/contraceptive-sponge/about/pac-20384547
Planned Parenthood. (2019). Birth control sponge. Retrieved from https://www.planned
parenthood.org/learn/birth-control/birth-control-sponge
Start-Stop Technique
The start-stop technique is used to aid in the treatment of early (premature) ejacu-
lation. A urologist, Dr. James Semans, first described the start-stop technique in
1955. However, the technique was not popular at the time and did not become
popularized until years later when Dr. Helen Kaplan wrote about it as a successful
technique to delay ejaculation. The start-stop technique is now a common inter-
vention that sex therapists teach their clients who are seeking treatment for prema-
ture or early ejaculation.
The start-stop technique works by allowing the person to learn how to better
control when they ejaculate. By stopping stimulation to the penis periodically, the
person is able to learn their body’s signals for when they are close to ejaculating.
When the person is able to take note of these signs, they may withhold stimulation
prior to the point of no return, or the point at which ejaculation is inevitable regard-
less of continued stimulation or not. Practicing stopping prior to the point of no
return allows the person to gain control over their ejaculation and reduce the
occurrence of early ejaculation.
It is best to begin practicing the start-stop technique independently during
masturbation. The person can stimulate their penis and increase arousal. When
they become highly excited, stimulation of the penis is stopped completely for
several seconds (or potentially a bit longer) with the intention of decreasing
arousal. An erection should still be maintained during this break. After this short
break, stimulation may begin again. This process should be repeated several
times before ejaculation is permitted. The start-stop technique takes practice. Sex
therapists recommend that practice during masturbation occur several times per
week for thirty to sixty minutes per session for several weeks. Improved ejacula-
tory control should be noticed after several weeks of this practice. As control
improves, stimulation may be decreased during practice instead of stopping it
completely.
When the individual has become comfortable using this technique by them-
selves, they may try using this with their partner. During sex, the individual may
stop moving, pull out, or take a short break by switching positions in order to
decrease excitement and delay ejaculation. As control improves with the partner,
they may also choose to change the intensity of the stimulation instead of stopping
completely. Sexual communication with a partner is important while trying the
start-stop technique. An individual may ask their partner to change the type of
stimulation or the intensity of it during this practice.
Statutory Rape 699
The aim of the start-stop technique is to allow the person to hold themselves in
the plateau phase of the sexual response cycle for their desired amount of time.
This phase of the sexual response cycle comes after arousal, when the penis is
erect, but prior to orgasm or ejaculation. Mastering the start-stop technique allows
the person to stay in this phase for as long as desired.
Amanda Manuel
See also: Arousal; Communication, Sexual; Ejaculation; Masturbation; Orgasm; Prema-
ture Ejaculation.
Further Reading
Herbenick, D. (2012). Sex made easy. Philadelphia: Running Press.
Yarber, W., Sayad, B., & Strong, B. (2010). Human sexuality: Diversity in contemporary
America (7th Ed.). New York: McGraw-Hill.
Statutory Rape
Statutory rape (SR) is consensual sex between two people, one of whom is under
the “age of consent,” the minimum age at which someone is legally capable of
understanding the consequences of sex. The federal age of consent is sixteen. It is
a crime in all states for anyone thirty years or older to have sex with someone fif-
teen years or younger. However, individual states vary with regard to sexual rela-
tions between persons close in age; some states might prosecute an eighteen-year-old
who had sex with a fifteen-year-old, but others would not. This highlights the ten-
sion between SR laws’ original impetus—protecting minors from predatory
adults—and allowing for sexual relations among peers. Around half of high school
students have had sex, one in three within the past three months.
Up until the mid-1990s, SR laws were sporadically enforced relative to how
frequently they occurred. For example, in California, between 1975 and 1978,
around 400 cases were prosecuted annually while over 50,000 underage teens
gave birth outside marriage, a trend that continued for decades. Finally, in 1996,
Congress instituted welfare reform laws that called for aggressive prosecution of
SR in an effort to reduce adolescent pregnancy rates. Subsequent analysis of over
7,500 SR cases reported between 1996 and 2000 across twenty-one states revealed
that 60 percent of victims were fourteen- or fifteen-year-old females, 55 percent of
perpetrators were males age twenty or younger, and 29 percent said they were
“boyfriend and girlfriend.”
The criminal characterization of SR depends on the state and ages of victim
and offender. It may be called “statutory rape,” “sexual abuse,” or “encouraging
delinquency,” with a range of punishments from one to twenty years in jail and
lifetime registration as a sex offender. In general, the older the age of the perpe-
trator, the more severe the penalty. A victim’s willingness to engage in sex is not
a defense against SR charges, nor is an offender being mistaken about the
minor’s age.
Enforcement of SR law has been undermined by race and sexual politics
throughout America’s history. White men accused of sexual involvement with
700 Stereotypes, Gender
black girls were typically never prosecuted, whereas black men were almost
always arrested, convicted, and severely punished up until the 1950s. Similarly,
women involved with young boys were rarely arrested until relatively recently as
these relations were considered “appropriate initiation.” But male-on-male SR
cases typically ended in conviction due to concerns for “inculcating a homosexual
lifestyle.”
Today, arrest and conviction rates for SR still depend on the age, race, and gen-
der of victim and offender as well as whether they report being in a romantic ver-
sus casual relationship. For example, among romantic SR pairings, there are
sixteen arrests of female-on-female cases for every one arrest of a male-on-female
case. And, compared to arrest rates for more common white-on-white SR cases,
black-on-black pairings have a 17 percent less likelihood of arrest.
In some states, SR is governed by mandatory reporting. Health care providers,
teachers, and others who work with adolescents must report known or suspected
SR cases to police or face criminal charges themselves. The concern is that this
may cause young people to cover up their relationship, and, if pregnant, avoid
essential prenatal care for fear of getting themselves or their partners in trouble.
Ultimately, adolescents are likely to be confused about SR laws because in
some states they are legally allowed to consent to sex-related medical care, such as
obtaining treatment for sexually transmitted infections, before they can legally
consent to sex.
David J. Reynolds
See also: Adolescent Sexuality; Age of Consent; Sexual Consent; Sugar Daddies and
Sugar Babies.
Further Reading
Chaffin, M., Chenoweth, S., & Letourneau, E. J. (2016). Same-sex and race-based dispari-
ties in statutory rape arrests. Journal of Interpersonal Violence, 31, 26–48.
Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Flint, K. H., Hawkins, J., … Wechsler, H.
(2012). Youth risk behavior surveillance—United States, 2011. Morbidity and
Mortality Weekly Report, 61, 1–162.
Troup-Leasure, K., & Snyder, H. N. (2005). Statutory rape known to law enforcement.
Juvenile Justice Bulletin No. NCJ 208803. Washington, DC: Office of Juvenile
Justice & Delinquency Prevention.
Stereotypes, Gender
Gender stereotypes are socially constructed expectations that boys and men ought
to be masculine and that girls and women should be feminine. They are two
related clusters of beliefs, images, and assumptions about what male and female
should be. These stereotypes may be positive or negative, but they are ultimately
oppressive, especially for women. Gender stereotypes influence nearly all spheres
of one’s psychosocial existence during every phase of the life span.
Feminine stereotypes submit that girls and women are fragile, overly emo-
tional, and passive (negative) as well as nurturing, empathic, pure, and gentle
(positive). Masculinity is defined as aggressive, crude, emotionally constrained,
Stereotypes, Gender 701
entitled (negative) and independent, assertive, competent, and courageous (posi-
tive). Note that whether certain adjectives are positive or negative varies by con-
text. There are cultures, for example, in which aggressiveness is highly valued.
This is true for passivity as well.
Whether or not aspects of these stereotypes are viewed as positive or negative,
they are all repressive: they limit one’s ability to freely express the full range of
human sentiments and modes. Research has consistently shown that those who do
not conform to gender stereotypes in U.S. society experience social rejection and
more negative mental and physical health outcomes. Transgender women, for
example, are at a high risk for being targets of violence. Further, the research on
gender stereotypes during childhood demonstrates that current norms are more
condemning of boys who exhibit feminine qualities when compared to the accep-
tance, in general, of girls who show masculine tendencies. A girl labeled a “tom
boy” in her first decade of life is applauded for her vigor and adventurousness,
whereas a boy with feminine interests is devalued. While this results in a more
constricted developmental path for boys, it further highlights the notion that gen-
der stereotypes present that which is feminine as inferior to the masculine. The
social scripts associated with childhood gender valuations are slowly shifting.
As stereotypes, these differences between masculine and feminine are not
aligned with actual differences between the sexes (male, female, intersex), bio-
logical or otherwise. There are indeed distinctions between women and men: gen-
italia, secondary sex characteristics, hormone levels, reproductive functions, and
so on, However, even assumed biological differences—that were thought to be
based on divergent survival modes during our species’s evolutionary past—have
been challenged as recent research finds that survival demands were quite similar
for men and women. Further, the latest science demonstrates that the brains of
men and women do not differ in volume or neuro-connectivity. Turning to more
widely held stereotypes about sex differences in behaviors and abilities (e.g., math,
leadership), a literature review highlights that there is more variation within
groups of women or of men than there are between men and women. That is to
say, men and women, as groups, are more similar than they are different.
While gender stereotypes are potentially damaging to the lives of men, women,
and genderqueer or nonconforming individuals, this damage is far from equal.
Globally pervasive structural dynamics, those perpetuated by tacit and explicit
rules of society and its institutions (laws, health care, employment) favor men and
masculinity while devaluing women and femininity. Such hegemony within gen-
der stereotypes is associated with a host of beliefs and practices that severely
reduce the quality of life for women. For example, the stereotype that women are
only competent at household tasks and overly emotional directly aligns with poli-
cies of several societies that bar women from higher education or driving. The
stereotype of male entitlement maintains ideas held in many parts of the world
that women are the property of men, and therefore, a husband can rape and abuse
his wife without legal consequence. These stereotypes are also at work in U.S.
society in both more obvious (e.g., division of household labor, pay disparities,
sexual assault policy) and subtle ways (e.g., expected dating behaviors, assessment
of a political candidate, “acceptable” extracurricular activities).
702 Stereotypes, Sexual
The impact of gender stereotypes must be understood from an intersectional
lens. This highlights the way that overlapping structures of oppression (e.g., sex-
ism, racism, heterosexism, ageism, classism) intersect to shape lives and experi-
ences. For example, the gender stereotypes that are connected to being a black
man are different in important ways than those associated with being a white man.
Two men representing these different demographics will experience quite distinct
encounters with socially constructed expectations of their race and gender
together, which is also likely influenced by their sexual orientation, age, social
class, and so on.
Another dangerous consequence of gender stereotypes is that they reinforce
false binaries (female or male; feminine or masculine) and fail to account for
widely accepted variations in both sex and gender. There are not just two sexes,
nor are ways of being a human simplistically organized into two discrete
categories.
In sum, gender stereotypes impose limiting expectations on individuals that
stifle the full expression of human experiences. These clusters of beliefs, images,
and assumptions regarding how people of different genders are supposed to think,
behave, and relate are based on a false essentialism that wrongly posits biological
underpinnings. Further, gender stereotypes reinforce an incorrect binary perspec-
tive on sex and gender that carries important implications for the well-being and
safety of those who live outside these false binaries.
Ed de St. Aubin and Lauren B. Yadlosky
See also: Binary Gender System; Childhood Gender Nonconformity; Evolutionary Per-
spectives on Gender and Sexual Behavior; Female Sexuality; Femininity; Gender; Gen-
der Roles, Socialization and; Male Sexuality; Masculinity; Sexism; Stereotypes, Sexual.
Further Reading
Dyble, M., Salali, G. D., Chaudhary, N., Page, A., Smith, D., Thompson, J., … Migliano,
A. B. (2015). Sex equality can explain the unique social structure of hunter-
gatherer bands. Science, 348, 796–798.
Ellemers, N. (2018). Gender stereotypes. Annual Review of Psychology, 69, 275–298.
Hyde, J. (2014). Gender similarities and differences. Annual Review of Psychology, 85,
616–626.
Joel, D., Berman, Z., Tavor, I., Wexler, N., Gaber, O., Stein, Y., … Liem, F. (2015). Sex
beyond the genitalia: The human brain mosaic. Proceedings of the National Acad-
emy of Science, 112, 15468–15473.
Stereotypes, Sexual
Sexual stereotypes are culturally ingrained ideas about biological sex, gender, and
sexuality that shape a person’s understanding of their own identity as it relates to
their interpersonal and intimate relationships. Because people use stereotypes to
inform how they see the world, stereotypes can have a powerful influence on how
people behave, how they present to others, and what they believe to be attractive.
Oftentimes, people accept stereotypes as truths without realizing the effect they
have. Individuals might accept that men are more “aggressive, powerful, and
Stereotypes, Sexual 703
adventurous,” while women are “mild-mannered, emotionally expressive, and
passive.” Although most people understand that these generalizations cannot pos-
sibly be true for everyone, socialization may make them difficult to refute. With-
out a critical lens, stereotypes can promote systemic gender and sexual imbalances.
Cognitively, the main function of stereotyping is to allow people to quickly and
efficiently make judgments about someone’s behavior. However, by saying, for
instance, that “men don’t cry” or women “cry too often,” a dangerous dichotomy
is created so that neither sex can express their feelings without being perceived
negatively. These sorts of stereotypes also negate the experiences of transgender,
nonbinary, and queer individuals, who may not be recognized or included within
a sexual or gender binary.
Sexual stereotypes are informed by a number of factors beyond gender, includ-
ing race, sexuality, and class. Many stereotypes are deeply rooted in colonialism
and harken back to the time when two cultures initially collided. For instance, the
Jezebel stereotype, which refers to an overtly sexual woman with “uncontrollable
urges,” is a contemporary stereotype about black women from the Book of Kings
that has been perpetuated through EuroAmerican literature and society since the
nineteenth century. This attribution was originally formed after Europeans colo-
nized, assaulted, and enslaved African woman, sometimes showcasing them due
to their “extraordinary” bodies, which were seen as “objectively” more sexual
than white bodies. In more recent research on the effects of sexual stereotypes for
gay men, participants reported feeling that black gay men were most likely to be
“dominant” sexually, while Latinx gay men were thought to be more “passionate
and hot” overall. The study found that these assumptions affected the way partici-
pants chose their partners, the way they performed during sexual encounters, and
their level of sexual risk. These sorts of studies make it clear that sexual stereo-
types are formed by more than sexuality alone.
There are a number of potential explanations for why these stereotypes exist,
ranging from sociocultural influences to evolutionary biology. Sociocultural fac-
tors like television, music, and internet use have a large potential to affect the
development of sexual stereotypes. Television continues to play a large role in the
content and exposure children receive while they are developing their perceptions
of gender and sex. Certain genres of music, pornographic material, and internet
content can also contribute to higher endorsement of stereotypes about gender and
sex. Peers and communities also influence how individuals see sex, gender, and
stereotypes; people are more likely to adopt the perspectives of those around them
and ascribe to the sexual stereotypes of their peer group, despite actual sexual
behavior.
Sexual stereotypes may also be based on hardwired behavior adapted through
evolution. Stereotypes act as mental shortcuts in order to make decisions, assess
others’ intent, and perceive possible threats. When it comes to sexual stereotypes,
women’s intent is often seen as “warm and trustworthy,” while they are perceived
as nonthreatening and low in competence. For men, it is the opposite. From propa-
ganda to neurological imaging, certain groups are repeatedly dehumanized and
vilified through stereotypes that reinforce an “us” versus “them” or in-group or
out-group mentality. Interestingly, evolutionary psychology also suggests that
704 Stereotypes, Sexual
stereotypes help connect people with potential mates. There are reasons that
women are assumed to prioritize partnership and monogamy, while men are
assumed to prioritize many sexual partners and are more sexually assertive. Those
reasons are based on the ways in which human ancestors were able to procreate
and ensure family survival. Since female ancestors were anchored by child care, it
was important to be discerning about which mate would come back with food.
Hence, sexual stereotypes are not just social constructs; they are part of the human
biological legacy.
While biological perspectives have empirical support, people, thankfully, are
not doomed to behave according to patterns dictated hundreds or thousands of
years ago by cave-dwellers or colonial invaders. Newer research has begun to
challenge the evolutionary rationale for sexual stereotypes. For example, the sense
of power, not gender, could be responsible for the typically male stereotyped expe-
rience of sexual assertiveness and satisfaction, challenging the previously believed
evolutionary view of male sexual behavior. In addition, when women gain more
occupational and financial power, “passive” stereotypical behavior decreases.
Some social movements also show that stereotyping can be neutralized. For exam-
ple, the different waves of the feminist movement have been able to fight sexual
stereotypes such that women now outnumber men in all levels of higher educa-
tion, despite stereotypes of women having less intellect. Younger generations
endorse traditional sexual stereotypes and roles less over time, thanks to feminist
movements, same-sex rights, and social justice, telling people that stereotypes can
change as culture does too.
The impact of sexual stereotypes is pervasive and can affect several areas
related to personal well-being. Research shows that “stereotype threat,” the idea
that an individual conforms to stereotypes about them when they are made aware
of the stereotype, can increase someone’s potential for mental and physical health
problems. Sexual stereotypes can also increase sexual risk taking. For instance,
studies have shown that race-related sexual stereotypes (e.g., believing that some
groups of people are more likely to be living with HIV than others) can greatly
affect contraceptive use and sexual risk taking. And while some people may like
the stereotypes associated with their race or ethnicity, research suggests that,
overall, many people of color, and especially queer people of color, feel sexually
objectified and are more likely to experience adverse health consequences. This
becomes amplified when things like discrimination and prejudice factor into how
someone sees their sexual and gender identities.
Fortunately, there are proven strategies for fighting the stereotypes many peo-
ple unconsciously believe. For one, people can watch media that encourages a
range of behaviors, roles, and appearances for different genders. While completely
eliminating stereotypical content might not be realistic, challenging the images
and themes within this content can help people balance their potential impact. For
instance, the more aware someone is of stereotype threat, the more the harm of
that stereotype might be neutralized. Simply understanding and purposefully
negating stereotypes helps to lessen their influence.
Providing information and education can also help to decrease the influence of
stereotypes. Since stereotypes are mental shortcuts to help fill voids of
Sterilization 705
information, if people are provided with factual information, they are more likely
to hold accurate opinions and make more accurate judgments. When people know
specific personal information about friends, coworkers, or colleagues, they are
less apt to use stereotypes to fill in the blanks. Allowing people to get to know
each other as individuals, and not from a distance, might decrease the use of ste-
reotypes. Social psychological research has also shown that when people reject
prejudice as a community, stereotypes can change. When given tasks that require
teamwork, people are able to look beyond the stereotypes they know and connect
as individuals.
Alex M. Rivera and Marissa C. Floro
See also: Evolutionary Perspectives on Gender and Sexual Behavior; Female Sexuality;
Gender; Male Sexuality; Sexual Identity; Sexual Script; Stereotypes, Gender.
Further Reading
Calabrese, S. K., Earnshaw, V. A., Magnus, M., Hansen, N. B., Krakower, D. S., Under-
hill, K., & Dovidio, J. F. (2018). Sexual stereotypes ascribed to black men who
have sex with men: An intersectional analysis. Archives of Sexual Behavior, 47(1),
143–156.
Davis, S., & Tucker-Brown, A. (2013). Effects of black sexual stereotypes on sexual deci-
sion making among African American women. Journal of Pan African Studies,
5(9), 111–128.
Lammers, J., & Stoker, J. I. (2019). Power affects sexual assertiveness and sexual esteem
equally in women and men. Archives of Sexual Behavior, 48(2), 645–652.
Newcomb, M. E., Ryan, D. T., Garofalo, R., & Mustanski, B. (2015). Race-based sexual
stereotypes and their effects on sexual risk behavior in racially diverse young men
who have sex with men. Archives of Sexual Behavior, 44(7), 1959–1968.
Siegel, K., & Meunier, É. (2019). Traditional sex and gender stereotypes in the relation-
ships of non-disclosing behaviorally bisexual men. Archives of Sexual Behavior,
48(1), 333–345.
Ward, L. M., Merriwether, A., & Caruthers, A. (2006). Breasts are for men: Media, mas-
culinity ideologies, and men’s beliefs about women’s bodies. Sex Roles, 55,
703–714.
Wesche, R., Espinosa-Hernández, G., & Lefkowitz, E. (2016). Gender’s role in misper-
ceptions of peers’ sexual motives. Sexuality & Culture, 20(4), 1003–1019.
Sterilization
“Sterilization” refers to any procedure that permanently ends an individual’s
physical capacity to reproduce. It is used as a method of voluntary birth control by
persons who either wish to never reproduce or feel they have already produced the
maximum number of children they wish to have. Sterilization has also been used
as an involuntary control on the fertility of persons deemed “undesirable” by vari-
ous governments. Forced sterilization policies have touched most of the world
over the past two centuries, have their roots in racism and eugenics, and are closely
associated with genocide and “ethnic cleansing.”
Sterilization techniques involve permanently blocking the tubes that transport
gametes. A vasectomy refers to cutting and closing the vas deferens, which
706 Sterilization
transport sperm from the testicles, where it is produced, to the prostate, where it is
mixed with other fluids before leaving the body through the urethra. In most cases,
a vasectomy is performed through a small surgical incision in the scrotum as an
outpatient procedure. Tubal ligation refers to a number of techniques that cut or
block the fallopian tubes. The fallopian tubes allow sperm to travel to mature ova
and fertilized eggs to travel into the uterus. Transluminal tubal ligation uses an
intravaginal catheter to place expanding fiber inserts, springs, or coils that occlude,
or block, the tubes. Tablets of the pharmaceutical quinacrine are also sometimes
used off-label for tubal occlusion. Surgical tubal ligation is performed through
either a small incision (laparoscopy) or large incision (laparotomy) in the abdomi-
nal wall. It may be performed under local or general anesthesia and is sometimes
performed during cesarean birth or other abdominal surgery. Other surgical pro-
cedures such as ovariectomy (removal of the ovaries), hysterectomy (removal of
the uterus), and castration (removal of the testicles), also result in permanent ste-
rility but are no longer primarily used for this purpose.
There is currently no such thing as pharmaceutical sterilization, though public
outcry has followed reports of fictitious drugs circulated in internet hoaxes and
conspiracy theory campaigns. One urban legend involving a fictitious, sterility-
inducing “date rape drug” called Progestrex periodically surfaces. More troubling,
public health campaigns in developing nations—including Kenya, Nicaragua,
Tanzania, Mexico, and the Philippines—have been targeted with the claim that
their vaccines contain sterility drugs. The vaccine most frequently targeted is a
tetanus shot given to women aged fifteen to forty-five to prevent newborn
tetanus—a fatal condition spread through unsanitary birthing conditions and
unhygienic umbilical cord care, which kills around 60,000 newborn babies annu-
ally. The conspiracy theory states that the tetanus vaccine contains an antibody to
the pregnancy hormone human chorionic gonadotropin and will cause a woman’s
immune system to attack all future fertilized eggs. It is important to note that
while such an antibody has featured in research involving contraceptive vaccines,
such vaccinations have to be repeated at least every twelve weeks to be effective
and cannot render women permanently sterile.
However, history provides justification for fears of forced sterilization. Forced
sterilization is performed either without a person’s consent or knowledge, under
coercion, or as a requirement for receiving lifesaving benefits or health care.
Between 1907 and 1979, over thirty U.S. states and territories passed laws requir-
ing or allowing the forced sterilization of certain people. Enforcement was over-
seen by state eugenics boards, which employed physicians and social workers to
target individuals for forced sterilization. Physicians who performed such steril-
izations were granted immunity from malpractice suits. Targeted persons were
overwhelmingly female, and most were black, Latina, or Native American. Steril-
ization was by hysterectomy or tubal ligation and was frequently performed with-
out parental or patient consent on children undergoing other medical procedures
ranging from appendectomy to routine vaccination. Criteria for legal forced ster-
ilization included “feeblemindedness,” “idiocy,” “imbecility,” institutionalization,
incarceration, epilepsy, mental illness, alcoholism, suspected hereditary illness,
blindness, deafness, “deformity,” homosexuality, and transgender expression
(including women who wore “male clothing”); “moral delinquency,” including
Sternberg’s Triangular Theory of Love 707
unwed motherhood, prostitution, being a victim of rape or incest, and showing
evidence of “unbridled sexual desire,” such as by having many children; and
“dependency,” including receiving public welfare funds or public health services,
homelessness, poverty, and being an orphan or foster child. Over 60,000 people
were forcibly sterilized in the continental United States, outside of Indian reserva-
tions, through 1979. In Puerto Rico, over one-third of women of childbearing age
had been forcibly sterilized by 1968. On reservations, half of Native American
women had been forcibly sterilized by 1976. Though most U.S. forced steriliza-
tion laws were overturned by 1980, reports continue to surface, such as a 2013
case revealing the forced sterilization of at least 148 female inmates in California
prisons between 2006 and 2010.
Angela Libal
See also: Essure Coil; Fertility; Tubal Ligation; Vasectomy.
Further Reading
Carmon, I. (2014, June). For eugenic sterilization victims, belated justice. Retrieved from
http://www.msnbc.com/all/eugenic-sterilization-victims-belated-justice
Krase, K. (2014). History of forced sterilization and current U.S. abuses. Retrieved from
https://www.ourbodiesourselves.org/book-excerpts/health-article/forced-sterili
zation/
Lombardo, P. (n.d.). Eugenic sterilization laws. Retrieved from http://www.eugenicsarchive
.org/html/eugenics/essay8text.html
Planned Parenthood. (2019). Sterilization. Retrieved from https://www.plannedparenthood
.org/learn/birth-control/sterilization
Rutecki, G. W. (2010). Forced sterilization of Native Americans: Late twentieth century
physician cooperation with national eugenic policies. Retrieved from https://cbhd
.org/content/forced-sterilization-native-americans-late-twentieth-century-physician
-cooperation-national-
Walden, R. (2013). CIR prison investigation opens another chapter on sterilization of
women in U.S. Retrieved from http://www.ourbodiesourselves.org/2013/07/cir
-prison-investigation-opens-another-chapter-on-sterilization-of-women-in-u-s/
Sternberg’s Triangular Theory of Love
Psychologist and educator Robert Sternberg developed Sternberg’s triangular the-
ory of love in 1986. This theory outlines different types of love relationships and
the dynamics of these types of love. Sternberg argues that love is comprised of
three elements, marking the points of the triangle. These three elements are inti-
macy, passion, and commitment. These three elements may be combined into
seven different types of love. Over the course of a relationship, each quality may
be present in different amounts, and these amounts can fluctuate and change over
time. The fluctuation of these elements may affect the quality of the relationship.
The three elements are components that are present in relationships. The vari-
ety in the intensity and presence of these elements reflects how one feels toward
the other in a relationship. Intimacy involves mutual feelings of trust; there is a
sense of connectedness and openness where people share feelings and experi-
ences. Passion refers to physical attraction and sexual desire toward a person.
Commitment is linked to a decision to make a relationship long term.
708 Stonewall Riots
Isolating or combining these three elements may create seven love styles. “Lik-
ing” is a love style that occurs when only intimacy is present. This may be experi-
enced as a friendship. “Infatuation” occurs when passion is the only present
element. Some may think of this love style as lust. “Empty love” is connected only
to commitment. An example of this love style is when a couple remains married
even though their sexual and emotional connection has dissolved.
“Romantic love” is characterized by the combination of passion and intimacy.
This may occur in a new dating relationship. When passion and commitment are
shared, “fatuous love” results. This may be best described as a sudden marriage
after love at first sight. “Companionate love” is the result of blending intimacy and
commitment. Many long-term relationships may experience this type of love as
sexual attraction may wane at times during the course of a relationship.
The joining of all three elements—intimacy, passion, and commitment—
produces “consummate love.” According to the theory, this is the most desirable
love type for a romantic relationship. The marked absence of all three elements
results in an eighth love style called “nonlove.” This may occur after a relationship
has ended.
This theory utilizes language laced with strong connotations. For example,
“empty love” has a negative connotation that some may view as ethnocentric as
this type of love has been used to describe arranged marriages. This theory also
assumes people want relationships that include elements of intimacy, passion, and
commitment, as “consummate love” is celebrated as the highest form of love,
which may be invalidating to some with other relationship styles with which they
are very satisfied.
Research has shown that the three components of love become more pro-
nounced as individuals age from adolescence to young adulthood. Commitment
becomes most prominent in adult relationships and is highly regarded in adults’
understanding of love. Research has noted that there are only very modest differ-
ences between genders in regard to the three elements of love.
Amanda Manuel
See also: Attachment Theory of Love; Companionate Love; Consummate Love; Desire;
Intimacy, Sexual and Relational; Lee’s Theory of Love Styles; Love.
Further Reading
Sternberg, R. J. (1986). A triangular theory of love. Psychological Review, 93, 119–135.
Sumter, S. R., Valkenburg, P. M., & Peter, J. (2013). Perceptions of love across the lifes-
pan: Differences in passion, intimacy, and commitment. International Journal of
Behavioral Development, 37(5), 417–427.
Yarber, W., Sayad, B., & Strong, B. (2010). Human sexuality diversity in contemporary
America (7th Ed.). New York: McGraw-Hill.
Stonewall Riots
The Stonewall Inn, located in the Greenwich Village neighborhood of New York
City, is the birthplace of the modern LGBTQ+ movement. On June 28, 1969, the
patrons of the Stonewall Inn fought back against a police raid. For the first time,
Stonewall Riots 709
gay people refused to accept the status quo of oppression and stood up for them-
selves against regular city-sanctioned harassment. The Stonewall riots paved the
way for future LGBTQ+ people to be treated fairly and as equal to other members
of society.
In 1969, police raids on gay bars occurred regularly as it was illegal to serve gay
people alcohol or for gay people to dance with one another. During a typical raid,
the customers would be lined up to have their identification checked. Those with-
out identification or those dressed in drag were arrested. Women were required to
wear feminine clothing and would be arrested if their clothing was deemed too
masculine. Employees and management of the bars were also typically arrested.
On June 28, 1969, at 1:20 a.m., eight police officers arrived at the Stonewall Inn
for a planned raid, but the 200 patrons refused to cooperate. Standard procedure
was to line up the patrons, check identification, and have female officers take cus-
tomers dressed as women to the bathroom to verify their sex, upon which any men
dressed as women would be arrested. Those dressed as women that night refused
to go with the officers. Men in line began to refuse to produce their identification.
The police decided to take everyone present to the station, but the patrol wagons
had not arrived, leaving the arrested patrons to wait. Those not arrested were
allowed to leave, but instead of leaving, they stayed outside of the bar to see what
was unfolding. Within minutes over a hundred people congregated outside.
While waiting for the patrol wagons, a scuffle broke out when a woman in
handcuffs complained that her handcuffs were too tight. She was hit in the head
with a baton for complaining. She tried to escape repeatedly, but eventually an
officer was able to pick her up and heave her into the back of the wagon, which
was the last straw for the angry crowd.
The crowd continued to grow, and the police were greatly outnumbered. Some
police officers barricaded themselves inside the Stonewall Inn for their own safety.
The crowd had overturned a police wagon, and bottles, rocks, and bricks were
being thrown at the wagon and at the police inside the inn. The tactical police
force arrived to free the trapped police and arrest anyone they could. By 4:00 a.m.,
the streets had been cleared of the crowd. Thirteen people were arrested, four
police officers were injured, and much of the crowd was hospitalized.
News of the riot spread, and the next night thousands of people gathered in
front of the Stonewall Inn. Rioting, fires, and violence broke out again. More than
a hundred police officers arrived, but the riot continued until 4:00 a.m. On the
third night, around 1000 protestors gathered again. Another riot took place, with
injuries to both demonstrators and police, looting in local shops, and arrests of
five people.
The riots produced from a bar raid became a literal example of gays and lesbi-
ans fighting back and a symbol for many people. Many were moved by the rebel-
lion and sensed an opportunity to act. As a result of the Stonewall riots, gay rights
groups were established in every major American city. Before the riots at the
Stonewall Inn, homosexuals were harassed, oppressed, and despised. The events
of June 28, 1968, were one of the first instances of LGBTQ+ people fighting back
and demanding equal rights.
Lauren Ewaniuk
710 Storms’s Model of Sexual Orientation
See also: Drag; Gay Rights Movement; LGBTQ+.
Further Reading
Carter, D. (2004). Stonewall: The riots that sparked the gay revolution. New York:
St. Martin’s Press.
Duberman, M. (1994). Stonewall. New York: Plume.
Editors, C. R. (2015). The Stonewall riots: The history and legacy of the protests that
helped spark the modern gay rights movement. Scotts Valley, CA: CreateSpace.
Storms’s Model of Sexual Orientation
Storms’s model of sexual orientation was proposed by Michael Storms in 1980.
Storms expanded on the model of sexual orientation described by Alfred Kinsey
and suggested that rather than one spectrum of sexual orientation from exclu-
sively gay to exclusively straight, there were two spectrums of sexual attraction or
fantasy, one indicating level of attraction or fantasy to same-sex/gender people
and the other indicating level of attraction or fantasy to other-sex/gender people.
There are many ways to conceptualize sexual orientation, some of which are
more accurate than others. Some people think of sexual orientation as being made
up of discreet categories: people are either gay, straight, or bisexual. Because the
categories are discreet, people have to be in one category or another. This model
of sexual orientation was predominant until Alfred Kinsey began studying sexu-
ality in a more scientific manner. Based on his interviews with people about their
sexual behaviors, Kinsey proposed that there is a spectrum or a continuum of
sexual orientation. Kinsey believed that while some people were exclusively gay
or lesbian and some people were exclusively heterosexual, most people fell some-
where in between. As such, he developed a scale in order to measure sexual orien-
tation, which ranges from zero (exclusively straight or heterosexual) to six
(exclusively gay or homosexual); people with scores of one to five on this scale fall
somewhere in between exclusively straight and exclusively gay and may be con-
sidered as some degree of bisexual.
Expanding on Kinsey’s model, Storms proposed a new model of sexual orienta-
tion based on people’s fantasies and attractions to members of the same sex/gender
and members of the other sex/gender. He proposed that rather than one continuum
(gay to straight), there were actually two continuums. Storms’s continuums or
dimensions of sexual orientation were attraction/fantasy to people of the same
sex/gender (homoeroticism) and attraction or fantasy to people of the other sex/
gender (heteroeroticism). If someone indicated that they were high in heteroeroti-
cism and had no homoeroticism, then they would have a straight or heterosexual
sexual orientation. Similarly, if someone indicated that they were high in homo-
eroticism and had no heteroeroticism, then they would have a gay or lesbian sex-
ual orientation. If someone indicated that they experienced both high
heteroeroticism and high homoeroticism, meaning that they experienced sexual
attraction and fantasy to both people of the same and other sex/gender, then they
would have a bisexual sexual orientation.
Sugar Daddies and Sugar Babies 711
Storms’s model is conceptually important because it allows for a range of
attractions to same- and other-sex/gender people. For example, the model allows
for someone to report high heteroeroticism and moderate homoeroticism. It is also
important because it allows for and can theoretically explain asexuality. Accord-
ing to Storms’s model, if someone reports no heteroeroticism and no homoeroti-
cism, they would then have an asexual sexual orientation. This is a significant
development and improvement over the original Kinsey scale, which could not
account for an asexual sexual orientation.
Heather L. Armstrong
See also: Asexuality; Bisexuality; Kinsey’s Continuum of Sexual Orientation; Sexual
Identity; Sexual Orientation.
Further Reading
Storms, M. D. (1980). Theories of sexual orientation. Journal of Personality and Social
Psychology, 38(5), 783.
Swan, D. J. (2018). Models and measures of sexual orientation. In D. J. Swan & S. Habibi
(Eds.), Bisexuality: Theories, research, and recommendations for the invisible
sexuality (19–36). Cham, Switzerland: Springer.
Sugar Daddies and Sugar Babies
Sugar daddies are usually older, wealthier men who have emotional or sexual rela-
tionships with younger women or men (sugar babies) in exchange for money, mate-
rial goods, housing, or other luxury items. This mutually beneficial relationship is
known as sugar dating and has become more prevalent in dating culture since the
launch of the website Seeking Arrangement in 2006 (the largest sugar dating site).
Today, Seeking Arrangement has an active community of ten million members
across more than 139 countries with translations in ten languages. The community
includes eight million sugar babies and two million sugar daddies and mommies.
This is one of many platforms that are now available to facilitate sugar dating. The
increase in sugar dating can be attributed to the increased desire for a superficial
and affluent lifestyle and the internet’s ability to accommodate these desires
through sugar dating websites. Sugar dating, however, as a means of income (spe-
cifically to finance a higher education), is also a recent trend in North America.
Sugar dating has been criticized for being a new form of prostitution, and it has
been argued that it should be illegal. Others believe that this claim is inaccurate
because it does not take into consideration the different types of arrangements that
occur within sugar dating: exchange of sex for money without companionship,
exchange of sex for money with little companionship, or high level of companion-
ship where sex and money accompany the relationship as they do in traditional
dating. Given that prostitution excludes engagement in sexual activity as a result
of social companionship, sugar dating often does not fall within the realm of pros-
titution. Further, prostitution charges are rarely made as a result of sugar dating or
engagement with sugar dating websites.
Nicole C. Doria and Matthew Numer
712 Surrogate, Sexual
See also: Online Dating; Prostitution; Sex Work.
Further Reading
Brouard, P., & Crewe, M. (2012). Sweetening the deal? Sugar daddies, sugar mummies,
sugar babies and HIV in contemporary South Africa. Agenda, 26(4), 48–56.
Miller, A. (2012). Sugar dating: A new take on an old issue. Buffalo Journal of Gender,
Law and Social Policy, 20, 33.
Motyl, J. (2013). Trading sex for college tuition: How sugar daddy “dating” sites may be
sugar coating prostitution. Penn State Law Review, 117(3), 927–957.
Reed, L., Sharpe, C., Coker, K., & Harrington, E. (2015). Sugar babies, sugar daddies,
and the perceptions of sugar dating. ProQuest Dissertations and Theses.
Seeking Arrangement. (2019). About us. Retrieved from https://www.seeking.com/
about-us
Surrogate, Sexual
A sexual surrogate (also known as a “surrogate partner”) is a specially trained
intimacy skill professional. Surrogates work alongside supervising sex therapists
to better cultivate client sexual and relational intimacy skills by guiding sensual-
ity, sexual arousal and touching, relaxation techniques, and effective forms of
communication. This triangulated intervention helps clients develop the social
skills necessary to engage in satisfying sexual relationships as sexually healthy
persons when dating in their own lives. Surrogate services support a variety of
client challenges, including severe anxieties, trauma recovery, specific sexual dys-
function, physical disability, and the sexual rehabilitation of those sustaining vari-
ous injuries. As sexual difficulties can often be psychological rather than (or in
addition to) physical, these challenges can cause relationship problems, negative
body image issues, sexual avoidance, and an array of other significant life
obstacles.
According to the International Professional Surrogate Association (IPSA), the
leading authority on sexual surrogacy, gradual progress through diagnostic, skill-
building, and healing exercises offer the shared physical intimacies that “facilitate
development of healthy self-concepts and improve sexual functioning” (IPSA,
n.d.). It is important to note that surrogate relationships do not always include
sexual intercourse or any particular form of sexual contact. Surrogate partner
relationships are initiated under the premise of a finite and structured treatment
plan. While clients may voluntarily terminate support at any time, the sex therapy
team (client, surrogate partner, and therapist) is normally expected to collaborate
on the point of closure. Typically, clients attend weekly one- to two-hour sessions
with surrogate partners in addition to meetings held with supervising therapists,
for a total of at least thirty hours; more intensive therapy treatments are structured
over shorter periods of time to best serve clients with limited access to local sur-
rogate partner therapy.
Due to the sensitive nature of this type of therapy, comprehensive training pro-
grams and strict ethical codes are put in place for certified surrogate partners. In
addition to various bodywork techniques, surrogate interns are educated in psy-
chological, physical, and emotional human needs. Such training allows these
Surrogate Mothers 713
professionals to provide qualified referrals for operating therapists and appropri-
ate client-focused services. By initiating a therapeutic client relationship, sexual
surrogates agree to, above all else, recognize the client’s welfare as “the chief
focus and primary ethical responsibility” (IPSA, 1973). Surrogate partners are
also expected to uphold confidentiality; conduct themselves as professionals rep-
resentative of all surrogate partners and their respective organizations; ensure
they themselves, as well as their clients, are properly safeguarded against sexually
transmitted infections and conception; respect the boundaries of expertise as
applied strictly from the position of a surrogate (if other topical degrees or certifi-
cations are present); and recognize and address any personal limitations of com-
petency. These regulations maintain the integrity of the practice by reducing the
potential for client exploitation or services otherwise inadequate or harmful to
client development.
Ilyssa Boseski
See also: Communication, Sexual; Disabilities, Sexual Function and; Intimacy, Sexual
and Relational; Sex Education; Sexual Avoidance; Sexual Health.
Further Reading
International Professional Surrogates Association. (1973). Code of Ethics of the Interna-
tional Professional Surrogates Association. Retrieved from https://www
.surrogatetherapy.org/ipsa-mission/code-of-ethics/
International Professional Surrogates Association. (n.d.). Surrogate partner therapy.
Retrieved from http://www.surrogatetherapy.org/what-is-surrogate-partner-therapy/
Surrogate Mothers
Surrogate mothers are women who carry and bear children for other women, typi-
cally women who are infertile or who are otherwise unable to bear children. In
some countries, surrogates may receive payment for their childbearing services,
though they may also offer their services out of a desire to help people. In other
countries, this type of payment is illegal, although health care costs and other
costs related to the pregnancy may be covered by the adoptive parents. There are
two types of surrogate mothers: traditional and gestational surrogates.
A traditional, or partial, surrogate is inseminated with the male’s sperm through
the process of artificial insemination. Because the sperm fertilizes an egg of the
surrogate, the surrogate is technically the fetus’s biological mother. After carrying
the fetus to term and delivering it, the surrogate gives the baby up to the parents.
Typically, the surrogate will never see the baby again. However, some people
using surrogate services agree to let the surrogate mother visit the child from time
to time. In a mixed-sex couple or same-sex male couple, the male partner, or one
of the male partners, may donate his own sperm. However, if he is unable to pro-
duce viable sperm, of in the case of a same-sex female couple, the surrogate could
be inseminated with sperm from an anonymous donor.
Traditional surrogacy is the original form of surrogacy, and it has been used for
thousands of years, if one considers surrogate sexual intercourse. Modern-type
surrogacy involving artificial insemination, paid surrogates, and legal contracts
714 Surrogate Mothers
dates to about 1980. Reliable statistics on the numbers of traditional surrogate
births are unavailable because many cases go unreported.
A gestational, or full, surrogate is implanted with an embryo that was produced
in the laboratory through in vitro fertilization (IVF), usually using the egg of the
intended mother and the sperm of the intended father, if carrying for a mixed-sex
couple. Thus, the gestational surrogate—unlike the traditional surrogate—is not
the fetus’s biological mother. She simply carries the fetus in her womb until birth,
which makes her the child’s “birth mother.” She then gives the child over to the
parents who will raise it. In some cases, such as for same-sex couples, or if a
mixed-sex couple is experiencing infertility, eggs or sperm from donors will be
used in the IVF process.
Gestational surrogacy was first used in 1985. The number of gestational surro-
gate births in the United States has been increasing steadily throughout the 2000s,
from at least 740 in 2004 to at least 1,600 in 2011, according to the Society for
Assisted Reproductive Technology (SART). SART notes that the actual numbers
of these births are probably higher than suggested by these statistics because many
clinics do not report their surrogate procedures.
There are many reasons that people may choose to use a surrogate. Mixed-sex
couples may wish to have a child but may experience infertility problems. Often
these couples will have previously tried other assisted-reproduction techniques
such as IVF. Also, some women may choose to use a surrogate because of their
own health concerns, such as problems with their uterus (uterine cancer, fibroids,
polyps) that would make pregnancy risky or impossible. In addition, conditions in
other parts of the body, such as severe cardiovascular disease, could also raise the
health risks of pregnancy and childbirth and as such doctors may recommend con-
sidering surrogacy. Older women may also choose to use a surrogate to avoid age-
related complications with pregnancy. Same-sex couples, especially same-sex
male couples, may also wish to use surrogate mothers to have children, as might
single men who wish to become fathers. Although such individuals could choose
to adopt children, they might prefer using surrogacy because it produces a genetic
connection to the child or because they feel it offers some other personal connec-
tion that adoption may not provide.
Some surrogates are friends or relatives of the people for whom they perform
the service. Using such surrogates is generally less expensive than paying a sur-
rogate agency, which is the option used by most people in the United States. In
some countries, including the United States, an agency, for a substantial charge,
helps an individual or couple find a suitable surrogate and handles arrangements
involving legal documentation and fees paid by the individual or couple to the
surrogate.
Most surrogate agencies follow certain guidelines for the women they select as
surrogates. Agencies generally prefer to use women who are between the ages of
twenty-one and forty, who have previously given birth to at least one healthy baby
without complications, who have passed a professional psychological screening,
and who can provide personal references. The surrogate must also sign a legal
contract detailing her responsibilities, including providing proper prenatal care for
the fetus and giving the baby to the parents after birth. Finally, surrogates must
Swinging 715
pass thorough medical examinations, including tests for infectious diseases and
for the health of the uterus.
In the United States, the cost of using agency-based surrogacy services is often
at least $100,000 (and much more in some cases). The surrogate herself typically
receives anywhere from about $15,000 to $35,000 for a single pregnancy—in
addition to medical, legal, and travel costs.
The growing practice of surrogacy has raised a number of complicated legal
issues, mostly in regard to the parental legal rights of the child’s biological mother
or the woman who delivers the child versus the woman who raises the child. In
some cases, the surrogate mother may refuse to give the child to the partners or
may later desire to see the child she gave birth to. She may also seek to take pos-
session of the child away from the couple that has been raising it. When such cases
arise, they must go through court procedures according to the relevant state laws.
There are no federal laws that specifically address or restrict surrogacy.
Because gestational surrogates are not biologically related to the children they
give birth to, they rarely have firm legal grounding for later wanting to see the
child. Since this fact makes legal matters less potentially complicated for couples
wishing to use the services of surrogate mothers, gestational surrogacy is believed
to be more common than traditional surrogacy.
Laws in some states require individuals using surrogacy services to formally
adopt the child after birth or to obtain a formal “declaration of parentage” for the
child. In other states, a legal contract between the surrogacy users and the surro-
gate mother is all that is needed. In any case, an experienced attorney should be
used by anyone involved in this process to ensure that the responsibilities of all
parties are properly carried out.
A. J. Smuskiewicz
See also: Artificial Insemination; Assisted Reproductive Technology; Infertility; Ova
Donation; Pregnancy.
Further Reading
Cohen, D. L. (2013, March). Surrogate pregnancies on rise despite cost hurdles. Retrieved
from http://www.reuters.com/article/2013/03/18/us-parent-surrogate-idUSBRE92
H11Q20130318#8JgIWZ7wPEpE5sLo.97
Fenton-Glynn, C. (2019, April). Surrogacy: Why the world needs rules for “selling”
babies. The Guardian. Retrieved from https://www.bbc.co.uk/news/health
-47826356
Propst, A. (2017). Gestational carriers (surrogacy). Retrieved from http://www.babycenter
.com/surrogacy
Swinging
The act of swinging, often referred to as “the lifestyle,” is the engagement of sex-
ual relationships with people outside of the traditional couple arrangement. Swing-
ing can involve two or more couples or a couple and a single person. Swinging can
be done in public at places like sex clubs, or it can be practiced in private. Motiva-
tions for swinging vary and can range from a couple wanting to diversify their
716 Synthetic Hormones
sexual routine to being a way to allow a bisexual partner to fulfill their same-sex
attraction and sexual needs. Swinging is an activity that requires healthy and
competent sexual communication between all parties involved.
Monogamy, or being in a sexually exclusive two-person relationship, is a cul-
tural norm within Western societies. Laws, civil partnerships, and religious cere-
monies reinforce this arrangement of relationships via legal rights and religious
vows said during the processes of marriage. Monogamy is so dominant in Western
society that people or couples who deviate away from the norm and who choose to
engage sexually and consensually with other people or other couples are often
considered to be deviant or immoral and may be seen as threatening to society and
the traditional family structure.
The terms “swinging” and “swingers” emerged in the 1970s to replace the label
of wife-swapping, a term used by the media in the 1950s. Shortly after World War
II on air force bases, Gay Talese (1980) noted that couples engaged in the swap-
ping of spouses as a random exercise whereby car keys were placed in a hat and
husbands would pick a key by chance to determine who they would have sexual
engagements with that evening. It would be reasonable to suggest that swinging is
generally more organized now with some areas having formalized swinging clubs
that offer a wide array of sexual activities.
Research on swinging is limited. However, one study found that married cou-
ples who identified as swingers had higher rates of happiness within their mar-
riages than nonswinging married couples. This research suggests that “emotional
monogamy” was seen as integral to maintaining a successful coupling rather than
focusing on sexual monogamy within a relationship.
Lesley-Ann Smith
See also: Communication, Sexual; Extramarital Sex; Marriage; Monogamy; Open Mar-
riage; Polyamory.
Further Reading
Barker, M. (2013). Rewriting the rules: An integrative guide to love, sex and relation-
ships. East Sussex: Routledge.
Bergstrand, C., & Williams, J. B. (2000). Today’s alternative marriage styles: The case of
swingers. Electronic Journal of Human Sexuality, 3(10). Retrieved from http://
www.ejhs.org/volume3/swing/body.htm
Fernandes, E. M. (2009). The swinging paradigm: An evaluation of the marital and sexual
satisfaction of swingers. Electronic Journal of Human Sexuality, 12. Retrieved
from http://www.ejhs.org/Volume12/Swinging2.htm
Gould, T. (1999). The lifestyle: A look at the erotic rites of swingers. Buffalo, NY:
Firefly.
Talese, G. (1980). Thy neighbour’s wife. New York: Dell Publishing.
Synthetic Hormones
Synthetic hormones are compounds synthesized in a laboratory to mimic mole-
cules made by organs in the human body. Also known as hormone replacements,
they are best known to the general public for their use in hormonal birth control
Synthetic Hormones 717
options and in hormone replacement therapy (HRT) for women going through
menopause. However, synthetic hormones are widely used to replace or supple-
ment many of the human body’s naturally occurring hormone molecules in the
treatment of thyroid disorders, diabetes, joint pain, and a number of other
conditions.
Scientists first began to isolate and study hormones produced by the human
body in the 1930s. Among the first hormones to be widely studied—and later
synthesized—were estrogen and progesterone. After the discovery of these hor-
mones’ roles in pregnancy and fertility, early family planning activists such as
Margaret Sanger began to advocate for the production of an oral contraceptive
pill. As a result of Sanger’s activism and research conducted by American biolo-
gist Gregory Pincus, the world’s first oral contraceptive, Enovid, was approved by
the Food and Drug Administration in 1960. Estrogen and progesterone have come
to be the world’s most widely used artificial hormones.
A good deal of controversy exists over the differences among synthetic hor-
mones and so-called natural or bioidentical hormones. While hormone sources
and production methods vary widely, any hormone introduced into the human
body that is not made by the human body has gone through some process of arti-
ficial manufacture or synthesis in a laboratory.
In general, synthetic hormones are created chemically, without the aid of living
organisms. So-called natural hormones are derived at least in part from living
organisms and are typically produced by converting plant or animal compounds
into molecules that either resemble or are identical to hormone molecules made in
the human body.
Examples of “natural” hormones include estrogen and progesterone replace-
ments whose initial building blocks come from soybeans and wild yams (although
many of these hormones now are made chemically as well). Another example is
insulin hormone replacement for diabetics. In the past, artificial human insulin
was made by purifying insulin taken from cattle and pig pancreases; today insulin
is more commonly produced through the use of genetically modified yeasts and
bacteria. Both of these processes would fall under the broad umbrella of “natural”
hormone production.
Greater confusion exists around the term “bioidentical.” The Endocrine Soci-
ety, a scientific organization dedicated to endocrinology and hormone research,
defines bioidentical hormones as “compounds that have exactly the same chemical
and molecular structure as hormones that are produced in the human body.” In
comparison, nonbioidentical hormones have structures that imitate hormones pro-
duced in the human body and can act as a substitute, but they are not identical to
human hormones.
There is no standard agreement on approved sources or manufacturing meth-
ods for bioidentical hormones. As a result, bioidentical hormones may be purely
synthetic (manufactured chemically in a lab), or they may be derived from plants
or other organisms and then altered to have the exact structure of the human hor-
mones they replace. The lack of clarity on definitions of “synthetic,” “natural,”
and “bioidentical” has led some doctors to argue that, in the end, any hormone
introduced to a human body is in fact a synthetic hormone.
718 Synthetic Hormones
Whatever their sources or production methods, synthetic hormones are used to
treat a large and growing array of human health issues that are caused by either a
complete absence or a shortage of specific human-produced hormones. As men-
tioned above, the most common uses of synthetic hormones are hormonal birth
control methods and HRT. Synthetic estrogen, progesterone, or testosterone may
also be used as part of fertility treatments and by transgender individuals to
change their bodies to better reflect their gender identity.
Synthetic thyroid hormones are given to replace those that the thyroid is no
longer producing (as in the case of hypothyroidism) or to suppress the growth of
thyroid tissue in patients with thyroid cancer. The most common thyroid replace-
ment hormone is thyroxine, which is chemically produced. Dried animal thyroid
tissue, taken mainly from pigs, also is available and in the past was the standard
treatment for hypothyroidism. However, the American Thyroid Association cau-
tions that human and pig thyroids do not produce the same proportions of indi-
vidual active thyroid hormones.
Beginning in the 1960s, human growth hormone (HGH) was given to children
whose pituitary glands were not producing enough of the substance. Originally,
the only source of HGH was the pituitaries of human cadavers. However, it was
discovered that some of this “natural” HGH had come from a cadaver infected
with Creutzfeldt-Jakob disease, leading to a public health crisis and a ban on HGH
by 1985. Six months later, a synthetic version of HGH, known as recombinant
HGH, was created and marketed as Protropin and later as Kigtropin. Today the
illegal use of synthetic HGH by professional athletes and bodybuilders has raised
concerns about dangerous side effects.
Other synthetic hormone–related controversies include the use of certain artifi-
cial growth hormones to increase growth or milk production in livestock. The best
known of these is recombinant bovine growth hormone. Among ecologists and
environmental advocates, there is growing concern over the increasing presence
of a number of synthetic hormones—most notably those used in birth control
pills—in water supplies worldwide. Because not all synthetic hormones are
absorbed by the body, many are excreted through urine and end up in septic sys-
tems and sewage treatment plants. There is currently no effective method for
removing these artificially created molecules from the water, and many are begin-
ning to accumulate in watersheds, creating problems for fish and other wildlife
and, potentially, humans.
Terri Nichols
See also: Estrogen; Estrogen-Progestin Birth Control Pills; Gender Transition; Hormone
Replacement Therapy; Intrauterine Device (IUD); Menopause; Progesterone; Progestin-
Only Birth Control Pills; Sex Hormones.
Further Reading
Files, J. A., Ko, M. G., & Pruthi, S. (2011). Bioidentical hormone therapy. Mayo Clinic
Proceedings, 86(7), 673–680.
Holtorf, K. (2009). The bioidentical hormone debate: Are bioidentical hormones (estra-
diol, estriol, and progesterone) safer or more efficacious than commonly used
Syphilis 719
synthetic versions in hormone replacement therapy? Postgraduate Medicine,
121(1), 73–85.
PBS. (2019). The development of synthetic hormones. Retrieved from http://www.pbs.org/
wgbh/amex/pill/peopleevents/e_hormones.html
Syphilis
Syphilis is one of the sexually transmitted infections (STIs) that can cause genital
ulcer disease (GUD) as well as other bodily complications, depending on how
long an individual has the infection before being treated. Included in the GUD
group are granuloma inguinale, lymphogranuloma venereum, and the herpes sim-
plex virus. And, just like other STIs, syphilis can be present in a person without
causing signs or symptoms of disease. Similar to the other bacterial causes of
GUD, there are tests available to diagnose, antibiotics that currently work to treat,
and, happily, syphilis can be effectively prevented by the use of condoms for sex-
ual intercourse.
Syphilis seems to have been around in humans for a long time, and it may have
evolved to infect humans after “jumping” from other species, such as llamas or
primates. The first recorded cases of syphilis in the Western world were during the
epidemic in 1495, during a war in France, and following the return of Christopher
Columbus and his sailors from their travels to America. Mobile populations have
long been known to transmit new pathogens from one population to another. Sol-
diers and sailors were early travelers who engaged in population mixing (sexual
and casual contact) with new groups of people, and subsequently infections were
transmitted both to and from host and visitor. Some infections were not a big prob-
lem; others became epidemics. This new STI (syphilis) quickly spread across
Europe and had a devastating impact, including death. Just as now, different groups
blamed each other for transmission instead of talking practically about prevention.
The World Health Organization estimates there are close to 1 million new cases
of treatable STIs every day in the world, with 5.6 million new cases of syphilis
every year, or 15,342 cases every day. Globally, syphilis is on the increase again.
While anyone who has sex without a condom can theoretically catch syphilis, it is
more common in populations who have more sexual activity with more people,
compared to the general population. For example, sex workers and men who have
sex with men usually have more sexual events with more numbers of people than
other populations and so are at increased risk of exposure to and acquisition of
syphilis. These populations are also stigmatized, socially marginalized, and are
illegal in many countries of the world, making it more difficult to test and treat
them to prevent further transmission as well as prevent complications.
Syphilis is a bacteria known as Treponema pallidum, subspecies pallidum,
which under the microscope is shaped like a spiral (spirochete) and uses a
corkscrew-like mechanism to gain entry into the body. Despite syphilis being
around since before antibiotics were discovered, unlike most other STIs, Trepo-
nema pallidum remains sensitive to penicillin, so the infection is easily treated
with an injection of benzathine penicillin.
720 Syphilis
Transmission can happen when having sexual activity with someone who has
the bacteria and a lesion. The bacteria often causes a lesion (sore) at the site of
entry into the body, for example on the lip, tongue, anus, vulva, or penis. The
lesion may be hidden inside the anus, mouth, vagina, or under the foreskin in the
penis, and if it is painless, which it often is, the person may not know they have it.
If a condom is used, then the risk of transmission is much reduced. However, a
condom may not protect if the lesion is on a part of the anatomy not covered by the
condom, for example, on the scrotum or labia. Fortunately, this is not as common.
If an individual is having sex with someone and notices a lesion on their genitals
or mouth, it is best to politely encourage the partner to see a doctor for testing and
treatment and to put sex on hold until the lesion has healed.
Syphilis has four recognized disease phases. Primary syphilis is described
above, as a lesion occurring approximately three to six weeks after having sex
with a person who has syphilis. The lesion may be painful but most often is pain-
less. Without treatment, the lesion goes away by itself, but the bacteria remain in
the person’s body and then cause secondary syphilis a few months after primary.
In secondary syphilis, a skin rash occurs most commonly, and then the lesions
come back and there may be more than one. The lesions may also be present in
other parts of the body, including under the arms, on the anus, and on the face.
The person may also experience body aches and fever. Without treatment, syphilis
then goes into a latent stage where signs of infection are not visible but a blood test
can still detect the infection.
Primary, secondary, and early latent syphilis are also known as early syphilis
because these symptoms of infection happen in the first two years and are still
easily treatable with benzathine penicillin. Tertiary syphilis is much more danger-
ous and can happen twenty years or more after the initial exposure if the person
did not receive effective treatment in the early stages. Tertiary syphilis can cause
damage in several body organ systems, including the brain and heart. While it is
harder to treat, it is still treatable, but any damage done may be permanent and can
even be fatal. Thankfully, tertiary syphilis is rare now due to the wide availability
of early testing and effective treatment.
If a pregnant person has untreated syphilis, the fetus can be become infected
while in the uterus. Luckily, effective treatment of the pregnant person in the early
stages of pregnancy ensures the fetus is also effectively treated. Without treat-
ment, many pregnancies end in stillbirth or the baby is born with congenital syph-
ilis and may have developmental problems. As such, all pregnant people in many
countries are encouraged to have a syphilis test during pregnancy.
A simple blood test can determine if syphilis is present and if treatment is
needed. Having regular sexual health checkups is one way to maintain sexual
health. Some people have a yearly check, while others who have more sexual
activity with more people may need a checkup every three months or more often.
Using condoms for intercourse and having a good look for lesions before oral sex
is also a good idea to reduce risk. Syphilis remains a problem STI globally but is
easily tested and easily, cheaply, and effectively treated with a penicillin
injection.
Kelwyn Browne
Syphilis 721
See also: Condoms, Female (Receptive); Condoms, Male (Insertive); Sexually Transmit-
ted Infections (STIs); Testing, STI; Tuskegee Syphilis Study.
Further Reading
Australian Sexual Health Alliance. (2018). Australian STI management guidelines for use
in primary health care: Syphilis. Retrieved from http://www.sti.guidelines.org.au/
sexually-transmissible-infections/syphilis
Centres for Disease Control and Prevention. (2019). STD surveillance report, 2018.
Retrieved from http://www.cdc.gov/std/
STD Prevention Online. (2019). Home page. Retrieved from http://www.stdpreven
tiononline.org
World Health Organization. (2016). Global health sector strategy on sexually transmitted
infections, 2016–2021. Retrieved from http://www.who.int/reproductivehealth/
publications/rtis/ghss-stis/en/
Wylie, K. R. (Ed.). (2015). ABCs of sexual health (3rd ed.). Chichester: Wiley
Blackwell UK.
T
Tantric Intercourse
Tantric intercourse is a sexual practice that originated in India and has roots in
East Asian religions such as Hinduism, Buddhism, and Taoism; it is based on
spiritual practices and philosophies, including yoga and meditation. Tantric sex
emphasizes the importance of consciousness and enlightenment, which can be
achieved through sexual experience. Energy also plays an important role in Tant-
ric sex. Sexual energy within the body is believed to flow through the individual
and to connect the individual with their partner and with the larger natural and
spiritual world. This energetic connection is often described as being cosmic and
transcendental.
Although Tantra has been practiced for thousands of years, it is a relative new-
comer to Western society, and while interest is increasing, it is still seen as falling
into the category of “new age” practices. In general, Western cultures tend to
emphasize orgasm as the objective of sexual encounters, and orgasm is generally
considered as a biological and functional experience. While some foreplay may
occur, sexual intercourse is seen as the “main event,” and the sexual experience
typically ends when one or both partners experiences an orgasm—a process that
lasts on average about six minutes. Tantric sex, on the other hand, is generally a
prolonged experience between partners. Rather than a focus on orgasm, the focus
becomes a spiritual and energetic connection, which can lead to increased sexual
pleasure. Key components include extended foreplay, deep breathing, slow sexual
intercourse, and delayed ejaculation. Male practitioners of Tantric sex may learn
to control their orgasm so that it occurs without ejaculation, thus allowing them to
have multiple orgasms without a refractory period. Orgasms themselves are seen
as energetically charged, expansive events that enhance physical, cognitive, affec-
tive, and psychic experiences. Further, orgasms are considered to have individual,
partnered, and spiritual or transcendental qualities.
Some of the basic practices of Tantric sex may be useful in the treatment of
physical and sexual difficulties. For instance, the emphasis on extended foreplay
may help to promote orgasm in individuals (often women) who are unable to
orgasm during a typical sexual experience. Similarly, focusing on pleasure and
connection with the partner as well as extended breath work and slow sexual
intercourse may help prolong the length of time it takes for a man to orgasm, one
of the most common male sexual concerns. The emphasis on energy and connec-
tion with the partner may also help to improve and develop intimacy within the
relationship. Finally, because Tantric orgasm focuses on an energetic and spiritual
experience, individuals with severe physical difficulties that affect their sexual
functioning (e.g., severe neck or back injuries, paralysis) report being able to
724 Teen Pregnancy
experience orgasms that are described as being sexual, physical, and mental.
Thus, Tantra may be a hopeful option for individuals who wish to remain sexual
after a physically limiting injury or other disability that affects or prevents typical
sexual activity. Although scientific research in this field is presently limited, future
research may help expand our understanding of Tantra and its use in treating sex-
ual dysfunction.
Heather L. Armstrong
See also: Anorgasmia; Foreplay; Kama Sutra; Orgasm; Religion, Diversity of Human
Sexuality and; Sexual Dysfunction, Treatment of.
Further Reading
Lousada, M., & Angel, E. (2011). Tantric orgasm: Beyond Masters and Johnson. Sexual
and Relationship Therapy, 26, 389–402. doi: 10.1080/14681994.2011.647903
Rei, K. (2008). Tantric sex: The path to sexual bliss. New York: Dorling Kindersley.
Richardson, D. (2003). The heart of Tantric sex. Alresford: O Books.
Voigt, H. (1991). Enriching the sexual experience of couples: The Asian traditions and
sexual counseling. Journal of Sex & Marital Therapy, 17, 214–219.
Waldinger, M. D., McIntosh, J., & Schweitzer, D. H. (2009). A five-nation survey to assess
the distribution of the intravaginal ejaculatory latency time among the general
population. The Journal of Sexual Medicine, 6, 2888–2895. doi: 10.1111/j
.1743-6109.2009.01392.x
Teen Pregnancy
“Teen pregnancy” refers to any pregnancy that occurs to any female under twenty
years old, regardless of intention or relationship status. Teen pregnancy is both a
highly personal issue and an important societal concern. The young pregnant per-
son may or may not have intended to become pregnant, and they may or may not
be in a position to take care of and support a baby. They also may or may not have
a willing partner, husband, or parents to help. If not, and the individual chooses to
have and keep the baby, taxpayer-funded social services may be required to sup-
port the baby. Alternatively, abortion or adoption may be considered. Whatever
the case may be, there are likely to be many considerations for the individual, their
family, and society at large.
According to statistics compiled by the Centers for Disease Control and Pre-
vention (CDC), a total of 194,377 babies were born to women between the ages of
fifteen and nineteen in 2017—making for a birth rate of 18.8 per 1,000 teen women.
This birth rate represented a decrease of 7 percent compared with 2016. The birth
rates from 2016 to 2017 decreased for all ethnic groups—though birth rates for
African American, Hispanic, and indigenous teens remained more than twice as
high as rates for white teens. In addition, teen birth rates were significantly higher
in southern states and rural areas than in northern states and urban areas.
While reasons for the declining birth rate are not entirely clear, the CDC sug-
gests that more teens may be abstaining from sex, and those who are sexually
active may be more likely to use some form of birth control. The CDC also notes
that with respect to the ethnic and regional disparities in birth rate, higher birth
Teen Pregnancy 725
rates are associated with lower education and income, fewer community opportu-
nities for youth activities or employment, and participation in child welfare, foster
care, or juvenile justice systems.
The CDC further notes that addressing these issues of disparity could lead to
additional drops in teen pregnancy and birth rates—which, despite the decreases,
continue to be substantially higher in the United States than in most other Western
industrialized nations. To try to meet this objective, the CDC and other govern-
ment health institutions fund and participate in programs involving training, edu-
cation, counseling, community outreach, clinical care, and research focusing on
teen pregnancy.
Surveys of teen mothers conducted by the CDC from 2006 through 2010
revealed that 23 percent of the moms had intended for the pregnancy to occur,
while 77 percent had not intended it to happen. About 58 percent of the mothers
said that although they would have liked to eventually become pregnant, their
pregnancy happened too soon. Teen births accounted for 5 percent of all births in
the United States in 2017.
The CDC notes that teen pregnancy is a leading reason that girls drop out of
high school. Only about 50 percent of teenage mothers receive a high school
diploma by the time they are twenty-two, compared to about 90 percent of girls
who do not give birth as teenagers. Teen pregnancy is associated with poverty and
with receiving public benefits in order to support the family. Some reports indi-
cate that relatively few teen mothers receive child support payments from the
father.
Children born to teen mothers are more likely than other children to drop out of
high school themselves, more likely to have health problems, more likely to com-
mit criminal acts and be incarcerated, more likely to be unemployed as adults,
and, if female, more likely to also give birth while still a teen.
Considering these factors, the CDC reported that teen pregnancy and childbirth
accounted for an estimated $9.5 billion in costs to U.S. taxpayers in 2010. Those
costs included health care, foster care, eventual incarceration of the children of
teen mothers, and lost tax revenue resulting from lower education and income
among teen mothers. While this number has declined in recent years, teenage
pregnancy continues to have a massive social and economic impact in the United
States.
The prevention of teen pregnancy is considered a major public health priority
because of the potentially adverse consequences of pregnancy at a young age. In
this regard, the CDC recommends that young women be educated about the fol-
lowing points:
• knowledge of sexual issues, including sexually transmitted infections and
methods of preventing pregnancy
• the benefits of abstinence and limiting the number of partners
• the usefulness of condoms and remembering to use condoms
• dealing with perceptions of peer norms regarding sexual behavior
• understanding an individual’s ability and right to refuse sex
• avoiding places and situations that might lead to sex
726 Teena, Brandon
• communication with parents or other adults about sex, pregnancy, and
contraception
• access to youth-friendly clinical services
• understanding the role of public health agencies in reducing teen pregnancy
Open and honest communication between parents and their teenaged children
about these and other points can be very helpful in preventing unintended preg-
nancies. Parents have a responsibility to discuss these matters with their sons as
well as their daughters. Research suggests that conversations between parents and
their children about sex, relationships, birth control, and pregnancy tend to have
several positive effects on teen behavior, such as delaying sexual intercourse to a
later age. If teens do have sex, they tend to have it less often than other teens, and
they are more likely to use condoms and other birth control methods.
Family planning clinics play an important role in teen pregnancy prevention by
providing teens with counseling and information about sex, contraception, preg-
nancy, and sexually transmitted infections, as well as basic care. Clinics can also
offer guidance to parents about these issues. A reproductive health clinic is legally
obligated to ensure the confidentiality of the care they provide to teens—meaning
that the clinics generally cannot share teens’ health information with parents or
anyone else without the written permission of the teens. There are certain excep-
tions to this confidentiality rule, such as when the clinic is concerned that the teen
might harm themselves. The CDC reported in 2014 that almost 60 percent of sex-
ually active teens aged seventeen or younger visited a family planning clinic for
contraception services during the previous year.
According to the CDC, an estimated 90 percent of teens aged fifteen to seven-
teen used some form of contraception the last time they had sex, most commonly
condoms or birth control pills. Only about 1 percent of teens in that age group use
long-acting reversible contraception (LARC) methods, such as intrauterine
devices or hormonal implants. If more teens used LARC methods, unintended
pregnancies would likely decrease because those methods are highly effective and
easy to use as they do not require taking a pill every day or being prepared in
advance of a sexual encounter.
A. J. Smuskiewicz
See also: Abortion, Elective; Adolescent Sexuality; Contraception; Family Planning Clin-
ics; Pregnancy; Premarital Sex.
Further Reading
U.S. Centers for Disease Control and Prevention. (2019). Reproductive health: Teen preg-
nancy. Retrieved from https://www.cdc.gov/teenpregnancy/index.htm
U.S. Centers for Disease Control and Prevention. (2019). Teen births. Retrieved from
http://www.cdc.gov/nchs/fastats/teen-births.htm
Teena, Brandon
Brandon Teena (1972–1993) was a transgender man murdered on New Year’s Eve
in 1993 in Nebraska. Approximately one week prior, Jon Lotter and Marvin
Teena, Brandon 727
Nissen attacked and raped Teena, reportedly because they discovered Teena’s bio-
logical sex was different from his gender identity. At this time, few images of
transgender individuals were portrayed in the media. This crime was recounted in
the documentary The Brandon Teena Story and the major motion picture Boys
Don’t Cry.
Brandon Teena was born as Teena Marie Brandon on December 12, 1972, in
Lincoln, Nebraska. Teena was assigned as a female at birth. His mother was a
sixteen-year-old widow who had another daughter three years older than Teena.
Teena’s father was killed in a car accident before Teena’s birth.
Teena attended Catholic school until his expulsion senior year. When he
attended counseling, he disclosed that he was sexually abused by his uncle for
four years as a child. It is reported that around the time Teena experienced puberty,
he began dressing and presenting as male and started dating women.
Throughout Teena’s life, he had a handful of arrests and criminal charges,
many related to forgery. In 1993, a warrant was issued for Teena’s arrest after he
violated probation. It was around this time he began fully living as Brandon Teena.
He developed a friendship and moved in with a young mother, Lisa Lambert, who
resided in a farmhouse in Humboldt, Nebraska. Through Lambert, Brandon met
Lotter and Nissen. He also developed a close friendship speculated to be romantic
with Lana Tisdel.
Teena seemed to be accepted by Lotter and Nissen, until his arrest in December
1993. He was placed in jail when he could not make bail, and staff discovered
Teena was a biological female. He was placed in the women’s section of the jail
until Tisdel posted bail. Teena’s arrest and biological sex were printed in the local
newspaper.
On Christmas Eve, Teena attended a party where Lotter and Nissen pulled his
pants down, wanting to see his genitals. Once they discovered Teena’s biological
sex, they spent the day assaulting and raping him, later locking him in Nissen’s
bathroom. Teena escaped to Tisdel’s house, where they notified authorities. Teena
was taken to a hospital, where a rape kit was conducted and later lost.
Despite Teena reporting the attack, having a rape kit conducted, and having
witnesses to corroborate his account of the events, Sheriff Charles Laux did not
make an arrest. It was reported that Teena was mistreated by Sheriff Laux, even
referring to him as “it.” Laux brought Lotter and Nissen in for questioning, and
even with a partial confession, he made no arrests.
On December 31, 1993, Lotter and Nissen drove to Lambert’s farmhouse,
where Teena was staying. They shot and stabbed Teena, Lambert, and a third per-
son to death. After being charged, Lotter was sentenced to death, while Nissen
received life imprisonment in exchange for testifying against Lotter.
Teena’s treatment by law enforcement and tragic murder helped bring aware-
ness to the transgender community. It also showcased the violence and discrimi-
nation experienced by transgender individuals. This and other instances of
violence experienced by the LGBTQ+ community prompted individuals to begin
lobbying for more hate crime laws regarding gender identity and sexual orienta-
tion in the United States.
Sarah Gannon
728 Testicles
See also: Rape; Transgender; Transphobia.
Further Reading
Bass, A. (2011). Telling Brandon Teena’s story accurately. GLAAD. Retrieved from http://
www.glaad.org/2011/05/05/telling-brandon-teenas-story-accurately
Buist, C., & Stone, C. (2014). Transgender victims and offenders: Failures of the United
States criminal justice system and the necessity of queer criminology. Critical
Criminology, 22(1), 35–47.
Friedman, H. J. (2006). Brandon: An American tragedy. Retrieved from web.archive.org/
web/20071010043900/http://www.friedmanlaw.com/news-teena-brandon.php
Sloop, J. M. (2000). Disciplining the transgendered: Brandon Teena, public representa-
tion, and normativity. Western Journal of Communication, 64(2), 165.
Woods, C. S., Ewalt, J. P., & Baker, S. J. (2013). A matter of regionalism: Remembering
Brandon Teena and Willa Cather at the Nebraska History Museum. Quarterly
Journal of Speech, 99(3), 341–363.
Testicles
Testes, also called testicles, are two oval glands of the male reproductive system.
They are located in a fleshy sac called the scrotum, which is located behind the
penis. Testes produce the male sex cells, known as sperm, as well as the male sex
hormones, mainly testosterone.
Each testicle is the size of a large olive, measuring about 1.5 inches (4 centime-
ters) by 1.25 inches (3 centimeters). They are filled with dense masses of fibrous
tissue and small twisting tubes between the tissue. These tubes, known as semi-
niferous tubules, are the sites of sperm production and development. All the semi-
niferous tubules join to form twelve to fifteen larger tubes called efferent ducts,
which carry the sperm to a coiled tube at the rear of the testicle called the epididy-
mis. There, the sperm complete their development.
During sexual arousal, the sperm are released outside the testes into long tubes
called the vas deferens. The sperm then become mixed with nourishing fluids
from the prostate, seminal vesicles, and bulbourethral glands before passing out of
the body during ejaculation in a sticky mixture known as semen. The semen
passes through the penis via the urethra.
Testosterone is produced by cells in the testes called Leydig cells. The produc-
tion of this hormone reaches high levels at puberty, which typically starts between
the ages of twelve and fourteen. High levels of testosterone lead to the develop-
ment of male secondary sex characteristics, such as beard growth, a deeper voice,
increased muscle mass, and an enlarged penis and scrotum.
Disorders of the testes include cancer, infections, hormone abnormalities, and
injuries. Testicular cancer, the most common type of cancer in men younger than
age thirty-five, is characterized by a painless lump or hard area in one testicle.
Individuals may also feel aches in the groin or lower abdomen. Physicians recom-
mend that young men routinely examine their testicles for abnormalities so that
this type of cancer can be detected early, before it spreads to other tissues or lymph
glands. A diagnosis of testicular cancer can be confirmed with a blood test mea-
suring levels of certain chemicals and a biopsy. Treatment usually consists of
Testicular Cancer 729
removal of the affected testicle. Even if an individual has only one testicle, they
may still retain their fertility.
The removal of one or both testicles is known as an orchiectomy. Besides tes-
ticular cancer, orchiectomies may also be performed for other reasons, including
treatment for prostate cancer and during gender transition for trans women.
In hypogonadism, the testes produce abnormally low levels of testosterone. In
some cases, this condition is congenital (present at birth) and may be associated
with other congenital conditions, such as undescended testicles (in which the tes-
tes fail to move down into the scrotum) or Klinefelter syndrome (in which the
individual has an extra X chromosome). In other cases, hypogonadism may occur
later in life as a result of trauma, adverse effects of certain medications, disorders
of the pituitary gland, or aging. Hormone-based therapies are often used to treat
patients with hypogonadism.
Testicles can be injured in sports activities by being hit, kicked, or crushed. The
wearing of an athletic cup helps to prevent such traumatic injuries. Another sports-
related injury happens when the vas deferens and surrounding tissue become
twisted, cutting off the blood supply to a testicle. Such testicular torsion requires
emergency surgery.
A. J. Smuskiewicz
See also: Hypogonadism; Orchiectomy; Scrotum; Seminiferous Tubules; Sperm; Testicu-
lar Cancer; Testosterone; Vas Deferens.
Further Reading
National Cancer Institute. (2011). 21st century adult cancer sourcebook: Testicular can-
cer. Los Gatos, CA: Progressive Management/Smashwords.
National Institutes of Health. (2015). Male reproductive system. Retrieved from http://
www.nlm.nih.gov/medlineplus/malereproductivesystem.html
Testicular Cancer
Testicular cancer is cancer of the testicles (also called testes), the two oval glands
of the male reproductive system, located in the scrotum. Testicular cancer is the
most common type of cancer in men younger than age thirty-five, though it can
occur at any age. The average age at diagnosis is thirty-three. Each year, accord-
ing to the American Cancer Society, approximately 8,800 new cases of testicular
cancer are diagnosed, and about 380 men die of the disease, in the United States.
More than 90 percent of testicular cancers begin in cells known as germ cells,
where sperm is produced. The cancer gradually spreads to adjoining tissues and,
if left untreated, to other parts of the body. Cancerous cells called seminomas,
which are more common in older men, spread more slowly than nonseminomas,
which are more common in teenagers and younger men. Some types of testicular
cancers begin in stroma, the tissue where testosterone is produced.
The precise causes of testicular cancer are unknown. Unlike breast cancer, no
specific genes have been identified that increase an individual’s risk of testicular
cancer. Scientists have found, however, that many individuals with testicular can-
cer have extra copies of a section of chromosome 12 called isochromosome 12p.
730 Testicular Cancer
The role of genetics in testicular cancer is further suggested by the fact that white
men are four to five times more likely to be diagnosed with testicular cancer than
black men. Scientists have also found that individuals with certain other condi-
tions, including an undescended testicle or HIV infection, are also more likely to
develop testicular cancer.
The most common early symptom of testicular cancer is a painless lump, swell-
ing, or hard area in one testicle, though both testicles are sometimes affected.
Individuals may also feel aches in the groin or lower abdomen. Additional symp-
toms, in rare cases, may include soreness or growth of the breasts. This breast
growth is caused by a hormone that is secreted by some testicular tumors.
Advanced cases of testicular cancer often include pain in the lower back—an
indication that the cancer has spread to the abdominal lymph nodes or to the liver.
Cancer that has spread to the lungs typically causes coughing and breathing
difficulties.
Physicians recommend that people with testicles—especially young
individuals—routinely examine their testicles for abnormalities so that cancer can
be detected early, before it spreads to other tissues or lymph glands. To properly
examine the testicles, the individual should move the penis out of the way, gently
roll each testicle between the thumbs and fingers with both hands, and feel and
look for any lumps or changes in size or shape. Any suspicious findings should
prompt a visit to a physician.
A physician makes a diagnosis of testicular cancer with a physical examination
and certain tests. The first test is usually an ultrasound examination to create images
that aid in distinguishing cancerous tumors from benign (noncancerous) growths.
Next, a blood test may be performed to evaluate the levels of certain protein mark-
ers that are indicative of cancer, such as alpha-fetoprotein, human chorionic gonad-
otropin, and lactate dehydrogenase. Finally, the cancer diagnosis may be confirmed
with a biopsy, in which a small piece of the tumor is surgically removed and exam-
ined under a microscope. However, the physician may choose not to conduct a
biopsy to avoid the risk of spreading the cancerous cells during the procedure.
If cancer if diagnosed, additional imaging techniques may be used to deter-
mine the stage of the cancerous growth. Such techniques usually include com-
puted tomography or magnetic resonance imaging.
Treatment for patients with testicular cancer depends on the stage of cancer and
other aspects of the patient’s case. A team of doctors collaborates to determine the
wisest course of treatment, typically including a urologist (who specializes in the
urinary and reproductive systems), a radiation oncologist (who specializes in radi-
ation therapy), and a medical oncologist (who specializes in chemotherapy).
Most cases of testicular cancer will require a combination of treatments. In
many cases, the affected testicle (or testicles) will need to be removed in a proce-
dure called an orchiectomy. If the cancer has spread beyond the testicles, further
surgical interventions will likely be required. After surgery, the patient will prob-
ably require follow-up treatment with radiation therapy or chemotherapy (drug
therapy).
Treatment success is directly related to the patient’s stage of cancer—whether it
was localized in only the testicle(s), whether it had spread regionally (to nearby
Testing, STI 731
lymph nodes or other tissues), or whether it had spread to distant locations (such as
the lungs or brain). The five-year survival rate for treated patients with localized
testicular cancer is 99 percent; for treated patients with regional testicular cancer,
96 percent; and for treated patients with testicular cancer that has spread to distant
parts of the body, 74 percent.
Many famous people have had testicular cancer and have survived to be diag-
nosed as cancer-free. These people include cyclist Lance Armstrong, figure skater
Scott Hamilton, hockey player Brandon Davidson, and jockey Bob Champion.
A. J. Smuskiewicz
See also: Orchiectomy; Penile Cancer; Prostate Cancer; Testicles.
Further Reading
American Cancer Society. (2019). Testicular cancer. Retrieved from http://www.cancer
.org/cancer/testicularcancer/index
National Cancer Institute. (n.d.). Testicular cancer. Retrieved from http://www.cancer.gov/
cancertopics/types/testicular
Testing, STI
In terms of screening guidelines for sexually transmitted infections (STIs), most
health care providers in the United States follow the recommendations of the
United States Centers for Disease Control and Prevention (CDC) and the United
States Preventative Services Task Force. The purpose of screening is to target at-
risk populations, limit the spread of disease, and provide treatment to responsive
diseases. Complications associated with STIs include infertility, chronic pelvic
pain, infections of the upper genital tract, cervical cancer, and chronic hepatitis.
For chlamydia and gonorrhea, infections may be asymptomatic or present with
mild symptoms. However, if they go without treatment, serious complications can
occur in women, such as pelvic inflammatory disease, infertility, chronic pelvic
pain, and issues with pregnancy. For men who have sex with men (MSM), there is
a higher risk of exposure to STIs. As a result, they may benefit more from frequent
screening. Additional guidelines exist for transgender individuals, pregnant peo-
ple, and MSM for specific STIs. The CDC 2015 guidelines recommend screening
both men and women under twenty-four years of age annually for gonorrhea and
chlamydia. For MSM, screening every six to twelve months is recommended. For
all screening efforts, it is recommended that all of the sites of sexual contact be
sampled (vaginal, penile, oral, and rectal). Sampling can be performed by swab-
bing the sites or collecting a urine sample to perform a nucleic acid amplification
test, which will detect the organism. For those who complete recommended treat-
ments, a test of cure is not recommended.
All individuals who seek screening and treatment for STIs should also be
offered testing for HIV (recommended for ages thirteen to sixty-four by the CDC).
MSM should be screened at least annually if their status is negative, unknown, if
they have new partners, or if their partners have had at least one new partner.
For syphilis, screening is recommended for those who are at high risk, such as
MSM, people who are living with HIV, and pregnant people. This is performed by
732 Testosterone
using a screening assay such as rapid plasma reagin or a treponemal test such as
enzyme-linked immunosorbent assay on a blood sample. Further evaluation can
be performed with additional tests.
Screening for oncogenic forms of human papilloma virus (HPV) takes place
through cervical cancer screening via Pap smears in women over twenty-one
years old. Otherwise, it is not recommended in younger women or male partners
of women with HPV. While it is recommended that Pap smears start at age twenty-
one, specific HPV testing is not performed until age thirty. Hepatitis B screening
is recommended for MSM and others at high risk, and hepatitis C screening is
recommended for men and women who are at high risk or were born between
1945 and 1965. MSM at high risk, born between 1945 and 1965, or who are living
with HIV should also be screened for hepatitis C. Of note, vaccines are available
for HPV, hepatitis A, and hepatitis B. Screening is currently not recommended for
bacterial vaginosis, trichomoniasis, Mycoplasma genitalium, vulvovaginal candi-
diasis, or diseases that cause genital, anal, or perianal ulcers (herpes simplex virus
or chancroid) in asymptomatic individuals who have not been in contact with an
infected partner.
Rachel Snedecor
See also: Chlamydia; Gonorrhea; Hepatitis; Herpes; Human Immunodeficiency Virus
(HIV); Human Papillomavirus (HPV); Sexually Transmitted Infections (STIs); Syphilis;
Trichomoniasis.
Further Reading
Ghanem, K. G., & Tuddenham, S. (2019). Screening for sexually transmitted infections.
Retrieved from https://www.uptodate.com/contents/screening-for-sexually -tran
smitted-infections
Kohl, K. S., Markowitz, L. E., & Koumans, E. H. (2003). Developments in the screening
for Chlamydia trachomatis: A review. Obstetrics and Gynecology Clinics of North
America, 30(4), 637–658.
LeFevre, M. L. (2014). Screening for chlamydia and gonorrhea: U.S. Preventive Services
Task Force recommendation statement. Annals of Internal Medicine, 161(12),
902–910.
U.S. Preventive Services Task Force. (2016). Final recommendation statement: Syphilis
infection in nonpregnant adults and adolescents: Screening. Retrieved from http://
www.uspreventiveservicestaskforce.org/Page/Document/ Recommendation
StatementFinal/syphilis-infection-in-nonpregnant-adults-and-adolescents
Workowski, K. A., & Bolan, G. A. (2015). Sexually transmitted diseases treatment guide-
lines, 2015. MMWR, 64(3), 2–110.
Testosterone
Testosterone is the main male sex hormone. It and other male sex hormones, col-
lectively known as androgens, are secreted primarily by the testes, or testicles.
Small amounts of these hormones are also secreted by the adrenal glands and by
the ovaries.
Testosterone levels increase when a male reaches puberty, typically starting
between the ages of twelve and fourteen. At puberty, the pituitary gland releases a
Testosterone 733
hormone that stimulates the testes to boost their testosterone production. The tes-
tosterone is released into the bloodstream and flows throughout the body, prompt-
ing the development of male secondary sex characteristics. These characteristics
include the growth of hair on the face and body, the buildup of muscle mass, the
growth and maturing of the penis and testicles, and the deepening of the voice.
The changes of puberty occur over a period ranging from two to five years.
The small amount of testosterone produced in the female body is necessary for
normal female sexual development. The chemical activity of this “male” hormone
helps the ovaries produce estrogens, which are the main hormones responsible for
the development and maintenance of female secondary sex characteristics.
Besides its role in physical development, testosterone also influences behaviors,
including sexual arousal and general aggressiveness. Levels of testosterone spike
during sexual arousal and interest. Links have been found between testosterone
and sexual aggression, including rape, in some men. In some criminals who
repeatedly engage in such behaviors, orchiectomy (surgical removal of the testes,
also called castration) has successfully reduced their aggressive tendencies.
Healthy forms of aggressiveness, such as a competitive drive to succeed and high
levels of motivation and energy, have also been linked to testosterone. Further-
more, studies suggest that testosterone helps promote cognitive functions, such as
thinking ability, memory, concentration and focus, and spatial awareness.
Testosterone levels peak during early adulthood, at approximately age twenty.
Levels begin to decline at roughly age thirty at a normal rate of about 1 percent
per year. As their testosterone levels decline, some middle-aged men may experi-
ence reduced sexual desire, difficulty with erection, insomnia, lack of energy, and
depression. Having such symptoms is commonly referred to as “low T.”
Testosterone-based medications in the form of injections, pills, patches, gels, or
implantable pellets are available to relieve these symptoms. However, these drugs
carry a number of health risks, including heart attack, blood clots, an enlarged
prostate, testicle shrinkage, and enlarged breasts, as well as drastic mood swings.
Careful, medically supervised use of testosterone drugs can minimize their risks.
Testosterone levels can be boosted in alternative ways not involving the use of
drugs. These ways include high-intensity exercise, such as weight lifting, com-
bined with a diet low in fructose (fruit sugar) and high in saturated fats.
People concerned about their testosterone levels can have them measured in
blood, urine, or saliva tests. Blood tests are the most common way to evaluate
testosterone levels. One or two repeat measurements are usually made, preferably
in the morning, because testosterone levels fluctuate throughout the day. Normal
male testosterone levels range from about 300–1000 nanograms per deciliter
(ng/dL). Normal female levels range from about 15–17 ng/dL.
It is normal for testosterone levels to decline with age. However, one abnormal
cause for testosterone decline is a condition called hypogonadism, in which the
testes do not secrete enough of the hormone because of various congenital (pres-
ent at birth) problems, a malfunctioning pituitary gland, traumatic injury, or other
factors. Testosterone-containing drugs are used to treat hypogonadism.
Abnormally low levels of testosterone may also be caused by excessive amounts
of iron in the blood, kidney or liver disease, inflammation of the lungs, obesity,
734 Testosterone Replacement Therapy
and adverse reactions to radiation treatment or chemotherapy for cancer. In addi-
tion, people under a great deal of stress and those who drink alcohol excessively
tend to have reduced levels of testosterone.
Anabolic steroids are synthetic versions of testosterone that can be used to treat
some of the previously mentioned low-testosterone conditions. However, these
drugs are best known for being used by athletes in attempts to increase their
strength and enhance their performance. Such uses are neither legal nor safe. The
risks carried by all testosterone-based drugs are magnified when they are used in
unapproved, unsupervised ways. Because anabolic steroids disrupt the normal
hormonal balance in the body, they can lead to development of female sex charac-
teristics in males and male sex characteristics in females.
Abnormally high levels of testosterone are much less common than abnormally
low levels. Limited evidence suggests that excessive amounts of testosterone—
that is, levels outside the normal range—may be associated with increased likeli-
hood to become an alcoholic, to smoke cigarettes, and to engage in high-risk
sports and sexual activities. Such outcomes would logically lead, in turn, to
greater likelihood for cirrhosis of the liver, lung cancer, sexually transmitted
infections, and injuries. However, most physicians doubt these associations and do
not consider high testosterone to be a clinically meaningful condition. Rare cases
of excess testosterone could be related to hyperthyroidism (an overactive thyroid
gland) or tumors in the testicles or adrenal glands. The most common causes of
abnormally high testosterone levels are hormone therapy for low testosterone lev-
els and abuse of anabolic steroids.
Finally, testosterone therapy may also be used by trans men as part of their
gender transition process.
A. J. Smuskiewicz
See also: Androgen Insensitivity Syndrome; Androgens; Andropause; Gender Transition;
Hypogonadism; Male Sexuality; Puberty; Sex Hormones; Testicles; Testosterone Replace-
ment Therapy.
Further Reading
Brizendine, L. (2011). The male brain. New York: Harmony Books/Crown Publishing
Group.
Mayo Clinic. (2018). Testosterone therapy: Potential benefits and risks as you age.
Retrieved from https://www.mayoclinic.org/healthy-lifestyle/sexual-health/in
-depth/art-20045728
Testosterone Replacement Therapy
Testosterone replacement therapy (TRT), also known as androgen replacement
therapy, is a common prescription treatment for cisgender men whose testosterone
levels are abnormally low. Testosterone is also typically prescribed to treat inter-
sex conditions as well as masculine-identified transgender and nonbinary indi-
viduals suffering from gender dysphoria.
In cisgender men, testosterone naturally declines with age but can become low
any time for a variety of reasons. This condition is known as hypogonadism.
Treatment is generally only prescribed when symptoms are present. Symptoms of
Testosterone Replacement Therapy 735
low testosterone may include low libido, erectile dysfunction, fatigue and poor
energy level, decreased muscle mass, body and facial hair loss, difficulty concen-
trating, depression, irritability, or low sense of well-being.
Testosterone is highly effective in the treatment of gender dysphoria for indi-
viduals who were assigned female at birth but who identify as male or nonbinary,
or for intersex individuals who want to masculinize their appearance. In ovary-
based bodies, TRT causes changes to secondary sex characteristics such as redistri-
bution of body fat, increased muscular mass, growth of facial hair, deepening of the
voice by thickening of vocal cords, increased libido, clitoral enlargement, cessation
of menses, increased risk of male pattern baldness, and thickening of skin. Hered-
ity limits response to hormones. Cross-sex hormone treatment appears acceptably
safe over the short to medium term, though long-term data is lacking. The goal is to
improve the patient’s quality of life by facilitating their transition to a physical state
that more closely represents their sense of themselves. Weekly or biweekly injec-
tion is the traditional treatment method and tends to bring on changes most rapidly.
Changes are reported to have a more rapid onset after hysterectomy or menopause.
Once started, treatment is usually lifelong, unless fully masculinized effects are
not desired. Though it has been prescribed off-label for this purpose since the mid-
twentieth century, use of the cross-hormone replacement therapy for transgender
people has not been approved by the Food and Drug Administration.
The World Professional Association for Transgender Health (2011) recommends
the following guidelines for prescribing hormone therapy for a transgender
individual:
• persistent, well-documented gender dysphoria
• capacity to make an informed decision and consent
• legal age of majority (eighteen years or older in the United States)
• other medical and mental health issues under control
• one recommendation letter by mental health provider
Small doses of testosterone are occasionally considered as an option for treating
cisgender women with low libido. A number of studies have shown, however, that
the unwanted masculinizing side effects and other health risks usually outweigh
the marginal effectiveness.
Risks of TRT include acne, elevated cholesterol and decreased high-density
lipoprotein, increased triglycerides, potential liver toxicity, potential polycythe-
mia, and potential insulin resistance. Total mortality was not higher than in the
general population.
Testosterone may be administered as an injection, via a gel or cream applica-
tion, skin or oral patch, buccal lozenges, or slow-release implant. Pills are not
recommended due to the extra strain placed on the liver by oral testosterone. Dos-
age may change with age or surgery.
Testosterone is considered a controlled substance; as such, patients may have
trouble using mail-order pharmacy services or getting prescriptions filled for more
than a thirty-day supply.
C. Michael Woodward
736 Touching, Sexual Arousal and
See also: Androgen Insensitivity Syndrome; Androgens; Andropause; 5-Alpha-Reductase
Deficiency; Gender Dysphoria; Gender Transition; Hormone Replacement Therapy;
Hypogonadism; Sex Hormones; Testosterone.
Further Reading
Gooren, L. J., Giltay, E. J., & Bunck, M. C. (2008). Long term treatment of transsexuals
with cross-sex hormones: Extensive personal experience. The Journal of Clinical
Endocrinology & Metabolism, 93, 19–25.
Khatri, M. (2016, October 20). Is testosterone replacement therapy right for you? Retrieved
from https://www.webmd.com/men/guide/testosterone-replacement-therapy-is-it
-right-for-you#1
Maxey, K., & Woodward, C. M. (2014). Caring for transgender people. Tucson: Univer-
sity of Arizona College of Medicine.
Urology Times. (2016, November 17). Testosterone therapy in women: Is there a benefit?
Retrieved from http://www.urologytimes.com/modern-medicine-feature-articles/
testosterone-therapy-women-there-benefit
World Professional Association for Transgender Health. (2011). Standards of care for the
health of transsexual, transgender, and gender nonconforming people, 7th Ver-
sion. Retrieved from http://www.wpath.org
Touching, Sexual Arousal and
Touch is a necessary and natural human experience. Scholars of touch discuss
how important it is for infants to be touched as well as for people throughout their
life span. Often called the “Freud of touch,” Ashley Montagu (1971) discussed the
utmost importance of touch during human development in his book Touching:
The Human Significance of the Skin. Touching can release important hormones in
the body that enhance the immune system as well as promote bonding between
people.
People have differing levels of desire for touch. Dennis Dailey, a sexuality edu-
cator, calls this need for touch skin hunger. He uses this term to discuss how peo-
ple differ in their need to give and receive touch. Some people like to be touched,
hugged, or cuddled a lot. Others feel comfortable not touching much at all—a high
five may be enough physical contact for them. People with varying degrees of skin
hunger can enjoy touch in both sexual and nonsexual ways.
Sexual arousal from touch is a common experience. A person can become sex-
ually aroused from touch (called responsive desire—responding to a touch stim-
uli). When a person is in a sexually aroused state, touch can increase this arousal.
Touching erogenous zones (or sexually sensitive areas) may bring so much plea-
sure to a person they may achieve orgasm. Sexual arousal can make touches that
would otherwise be uncomfortable (such as tickling or scratching) very
pleasurable.
In addition to feeling pleasurable, touch also has many other physical and emo-
tional benefits. Moderate massage can lead to decreased depression and enhanced
immune functioning. Frequent hugging between romantic partners has been
shown to lower blood pressure and increase oxytocin, or “the love hormone,”
Touching, Sexual Arousal and 737
which enhances emotional bonding between partners. Skin-to-skin contact also
helps people to maintain a sense of normalcy as things are changing due to aging
or illness. With all its many benefits, touch and sexual arousal can come from
many different sources.
A person may want to touch themselves in a sexual way. Masturbation or self-
stimulation of the genitals is the most obvious form of sexually arousing self-
touch. Touching oneself in various places in a sensual manner may heighten
sexual arousal when engaged in sexual behaviors with another person. Self-touch
can also be healing in nonsexual ways and can help people calm down when they
are stressed.
Consensually giving and receiving touch can enhance intimacy with others in
both sexual and nonsexual ways. Holding hands, hugging, and cuddling with
friends and family can enhance closeness and feelings of safety and trust, thereby
strengthening the relationship. Engaging in more sensual touch with a romantic or
sexual partner can enhance feelings of both physical and emotional intimacy,
thereby enhancing the romantic or sexual bond.
There are also instances in which individuals engage in nonconsensual touch-
ing. Sometimes, bodies respond to touch in a sexual way even when an individual
is not consenting. Emily Nagoski (2015) discussed this in her book Come as You
Are. The things that bodies do during sexual arousal—erections, vaginal lubrica-
tion, and so on—can often feel good when experienced in a situation where that
touch is wanted. During times of unwanted touch, like rape or sexual molestation,
bodies may also respond sexually whether the victim is sexually aroused or not. It
is important to know that touch is a way to express and explore sexuality, but on
its own, when a body responds sexually, it does not mean that it was a wanted or
consensual experience.
Consensual touch can have many physical and emotional benefits. Touch can
promote physical health in the short and long term and can also help people to feel
better about themselves. Mutually consensual touch also helps people to feel more
connected to friends, family, and romantic and sexual partners. The need for touch
or skin hunger varies widely, and we must engage in ongoing conversations with
those we touch to make sure that we are meeting their skin hunger needs in con-
sensual and pleasurable ways.
Mark A. Levand and Stephanie C. Chando
See also: Arousal; Erogenous Zones; Intimacy, Sexual and Relational; Masturbation;
Oxytocin; Public Displays of Affection.
Further Reading
Advocates for Youth. (2007). Life planning education: A comprehensive sex education
curriculum. Washington, DC: Author.
Field, T. (2014). Touch (2nd ed.). Cambridge, MA: A Bradford Book.
Leonard, K. E., & Kalman, M. A. (2015). The meaning of touch to patients undergoing
chemotherapy. Oncology Nursing Forum, 42(5), 517–526.
Montagu, A. (1971). Touching: The human significance of the skin. New York: Columbia
University Press.
738 Transexual Menace
Nagoski, E. (2015). Come as you are: The surprising new science that will transform your
sex life. Delran, NJ: Simon & Schuster.
Redelman, M. J. (2008). Is there a place for sexuality in the holistic care of patients in the
palliative care phase of life? American Journal of Hospice & Palliative Medicine,
25(5), 366–371.
Transexual Menace
Transexual Menace was an advocacy organization founded in 1994 in New York
City by Riki Wilchins and Denise Norris. “The Menace” was the first known
direct-action political group specifically focused on transgender inclusion. Like
the HIV/AIDS advocacy group ACT UP! of the same era, they took their advo-
cacy to the streets in the form of protests and awareness activities.
The Menace organizers were trailblazers in the early days of the visible trans-
gender civil rights movement, defining themselves, demanding their legal rights,
and fighting for medical care and against job discrimination (Wilchins, 2017). The
group’s first gathering was held in response to the exclusion of transgender people
from gay pride events, a regular occurrence before the more-inclusive LGBTQ+
movement took hold. The name Transexual Menace was inspired by feminist
activist Betty Friedan, founder of the National Organization for Women, who
referred to lesbians involved in the feminist movement as the “lavender menace”
because she felt they detracted from the “real” women’s movement. Cofounder
Wilchins preferred the British spelling of “transexual” with one S rather than the
more common American spelling, “transsexual.”
At a time when transgender people were generally expected to blend in with
mainstream society in order to avoid harassment, Transexual Menace sought to be
visible. The Menace may, in fact, be best known for its logo, which featured a pair
of large red lips and the name “Transexual Menace” in blood-dripping letters
against a stark black background, closely resembling the instantly recognizable
logo of the cult classic The Rocky Horror Show film and stage production.
Hoping to bring more media attention to antitransgender hate crimes, Menace
members showed up en masse in public in their dramatic black and red T-shirts.
Among other activities, The Menace organized vigils during the trials of those
accused of crimes against transgender people, such as Tom Nissen and John Lot-
ter, two of the alleged killers of Nebraska trans man Brandon Teena.
Although Transexual Menace was never a legally established organization, it
grew to as many as forty loosely affiliated chapters, both across the United States
and abroad. Wilchins once mused that one simply needed to express interest in
starting a chapter to consider it done. A surprisingly high number of chapters were
in conservative areas of the United States, such as Indiana, Texas, and Arizona.
Transexual Menace’s story caught the attention of filmmaker Rosa von
Praunheim, who developed a feature-length documentary about the group in 1996.
The film, Transexual Menace, was originally developed for television but was also
screened at a number of film festivals around the country in subsequent years.
Among the Menace’s most impactful work was on behalf of transgender ath-
letes competing in the 1994 Gay Games. The Menace descended on a board
Transgender 739
meeting of the games’ organizers to protest the overly vigorous and invasive pro-
cess transgender women were forced to endure in order to compete. The Menace
convinced board members to change the regulations to be more equitable for the
1994 games; unfortunately, those regulations were reinstated for the 1998 games,
and transgender athletes were not fully embraced until the 2002 games in Sydney,
Australia.
Wilchins later went on to form GenderPAC (GPAC) in 1995, a national coali-
tion of trans rights groups specifically dedicated to transgender rights and public
policy, again in response to the lack of trans inclusion in the work being done by
national gay and lesbian organizations; GPAC later evolved into TrueChild, which
works to bring a “gender transformative” approach to policies and programs that
affect the healthy development of children and youth.
C. Michael Woodward
See also: GenderPAC; Teena, Brandon; Transgender; Transsexual.
Further Reading
TrueChild. (2017). Home page. Retrieved from https://www.truechild.org
Wilchins, R. (2017). TRANS/gressive: How transgender activists took on gay rights, femi-
nism, the media & congress…and won! New York: Riverdale Avenue Books.
Transgender
The term “transgender,” which gained popularity in Western societies in the
1990s, refers to individuals who do not identify as their gender or sex assigned at
birth. “Trans,” as a prefix, means “across”; thus, in relation to gender, “transgen-
der” refers to someone who does not identify with their sex or gender label
assigned as birth or who has moved across gender categories. Furthermore,
“trans,” as a shorthand, is often used as an umbrella term when discussing trans-
gender and gender-diverse people contemporarily. Transgender is a gender iden-
tity, not a sexual orientation. Gender identity refers to one’s inner sense of gender,
regardless of gender or sex assignment at birth. Being transgender is also not the
same as being a drag performer, though some drag performers do identify as
transgender.
To date, there are few studies with good estimates on the prevalence of trans-
gender identities in society. Estimates include numbers from the Diagnostic Sta-
tistical Manual, Dutch studies, and estimates collected by transgender people
themselves. Currently, the best prevalence numbers come from data analyzed and
summarized by the Williams Institute at UCLA, which estimates that approxi-
mately 0.3 percent of individuals living in the United States identify as transgen-
der, or about 700,000 individuals. Worldwide, the estimate is that there are around
15 million transgender people.
There are two known early sources for the word “transgender,” though debate
on the origin continues. The most frequently cited source of the term is an early
trans activist and trans person named Virginia Prince (1912–2009). Prince, in
1969, identified herself as a “transgenderal,” or, according to her definition, some-
one who wanted to change their gender but not necessarily their sex. The second,
740 Transgender
and less widely known, source of the term originated in a 1965 medical text writ-
ten by psychiatrist John F. Olivan. The specific term used by Olivan was “trans-
genderism,” indicating an individual who wished to change their gender or sex
(both “gender” and “sex” were used in this definition, highlighting the historical
confusion over the separation of these two distinct concepts).
The category of transgender, due to its wide definition and cultural or historical
shifts, has taken many different connotations. Caution should be taken when
applying this term to other time periods and other cultures. There are also cultural
variations of transgender terminology in specific communities, notably racial and
ethnic differences.
When discussing transgender people, there are many subcategories of identity.
Common identities under the trans umbrella include, but are not limited to, trans
woman (or male-to female transgender), trans man (or female-to-male transgen-
der), genderqueer, bigender, gender nonconforming, nonbinary, agender, and so
on. Trans women are individuals assigned male at birth but who identify and live
as women, commonly using the pronouns she, her, or hers, and who may employ
medical intervention to feminize their bodies. Trans men are individuals assigned
female at birth but who identify and live as men, commonly using the pronouns
he, him, or his, and who may employ medical intervention to masculinize their
bodies. Genderqueer, gender nonconforming, and nonbinary individuals embody
gender in many different ways, often blurring the boundaries between masculine
and feminine in specific and purposeful ways.
There is no one way to be transgender. Trans people often undergo a series of
steps to transition from their gender or sex assignment at birth to a different gen-
der identity and gender expression (that is, the outward signs of gender such as
clothing, hair, etc.). Transition for a trans person is a highly individualized pro-
cess, and no blueprint exists. Common steps include coming out to one’s self,
friends, family, coworkers, and employers; seeking mental health care to discuss
the desired outcome of transition and referral letters for medical care; hormone
transition including the administration of various hormone treatments from a
medical provider; and gender-affirming surgeries. There are many different hor-
monal and surgical options available, and, notably, not all trans people want hor-
mone intervention or surgical interventions.
Jay A. Irwin
See also: Agender; Bigender; Biological Sex; Cisgender; Drag; Gender Diversity; Gender
Identity; Gender Transition; Genderqueer; Nonbinary Gender Identities; Pronoun Usage;
Transexual Menace; Transphobia; Transsexual.
Further Reading
Erickson-Schroth, L. (Ed.). (2014). Trans bodies, trans selves: A resource for the trans-
gender community. New York: Oxford University Press.
Gates, G. J. (2011). How many people are lesbian, gay, bisexual, and transgender? Los
Angeles: The Williams Institute, UCLA School of Law. Retrieved from http://
williamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT
-Apr-2011.pdf
Stryker, S. (2008). Transgender history. Berkeley, CA: Seal Press.
Transphobia 741
Transphobia
“Transphobia” refers to attitudes and beliefs about transgender people that stigma-
tize and antagonize people within the transgender community. The word “trans-
gender” (or “trans”) is often used as an umbrella term to refer to any
gender-nonconforming person, behavior, expression, or identity, including people
who cross-dress, are transsexual, are genderqueer, are drag queens and kings, as
well as a host of other terms that people use to categorize their gender.
Transphobia, like other forms of stigma and discrimination, is manifested
across three main levels: structural, interpersonal, and internalized transphobia.
Structural forms of transphobia include laws and policies that discriminate against
trans individuals and include health care access barriers. The fact that transgender
individuals can be currently fired in thirty-two states because of their noncon-
forming gender identity is an example of structural transphobia. Interpersonal
forms of transphobia include sexual violence, hate crimes, workplace discrimina-
tion, and family rejection of trans people. For example, at least 50 percent of trans
people experience sexual assault or rape at least once in their life due to their
gender identity or expression. Lastly, internalized transphobia is a set of negative
beliefs and attitudes toward trans or gender nonconforming features in oneself
and in others.
Transphobia across its three levels negatively affects the mental and physical
well-being of transgender individuals. According to the transgender minority
stress model, trans people experience chronic stress due to the stigma attached to
their gender identities or expressions, which in turn leads to poor mental and
physical health. For example, transgender individuals often experience depres-
sion, substance abuse, high blood pressure, HIV infection, and low self-esteem
due to stigma and discrimination. Furthermore, many doctors refuse to provide
service to trans patients because of transphobic views, and as a result, trans people
often do not receive adequate health care and are therefore unable to develop posi-
tive well-being. High incidence of suicide due to experiencing stigma also affects
trans people; in one study, 41 percent of transgender people reported having
attempted suicide.
Members of the trans community who possess multiple stigmatized identities
may experience more severe and chronic forms of transphobia. Due to societal
pressures that favor masculinity over femininity, trans women often experience
more frequent and severe sexual harassment and violence. Furthermore, trans
women of color experience disproportionate levels of harassment and violence,
which leads to many deleterious health outcomes.
Research provides evidence on reducing transphobia. Both family acceptance
and social support, for example, help mitigate the negative consequences of inter-
personal transphobia experienced by trans individuals. Useful interventions to
counteract one’s internalized transphobia include reducing shame around one’s
transgender identity. Similarly, acceptance and sensing pride of one’s transgender
identity also protect against the negative effects of experiencing transphobia
among trans people.
Caitlin Monahan and Nadav Antebi-Gruszka
742 Transsexual
See also: Antigay Prejudice; Homophobia; Transgender.
Further Reading
Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E.
(2013). Stigma, mental health, and resilience in an online sample of the US trans-
gender population. American Journal of Public Health, 103(5), 943–951.
Bradford, J., Reisner, S. L., Honnold, J. A., & Xavier, J. (2013). Experiences of
transgender-related discrimination and implications for health: Results from The
Virginia Transgender Health Initiative Study. American Journal of Public Health,
103(10), 1820–1829.
Clements-Nolle, K., Marx, R., Guzman, R., & Katz, M. (2001). HIV prevalence, risk
behaviors, health care use, and mental health status of transgender persons: Impli-
cations for public health intervention. American Journal of Public Health, 91(6),
915–921.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., Decuypere, G., Feldman, J., ...
Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and
gender-nonconforming people, version 7. International Journal of Transgender-
ism, 13(4), 165–232.
Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., Harrison, J., & Keisling, M. (2010).
National transgender discrimination survey report on health and health care.
Washington, DC: National Center for Transgender Equality and the National Gay
and Lesbian Task Force.
Hill, D. B., & Willoughby, B. L. (2005). The development and validation of the genderism
and transphobia scale. Sex Roles, 53(7–8), 531–544.
Hughto, J. M., Reisner, S. L., & Pachankis, J. E. (2015). Transgender stigma and health:
A critical review of stigma determinants, mechanisms, and interventions. Social
Science & Medicine, 147, 222–231.
Macnish, M., & Gold-Peifer, M. (2014). Families in transition: Supporting families of
transgender youth. In T. Nelson & H. Winawer (Eds.), Critical topics in family
therapy (119–129). New York: Springer International Publishing.
Sevelius, J. M. (2012). Gender affirmation: A framework for conceptualizing risk behav-
ior among transgender women of color. Sex Roles, 68(11–12), 675–689.
Stotzer, R. L. (2009). Violence against transgender people: A review of United States
data. Aggression and Violent Behavior, 14(3), 170–179.
Transsexual
The term “transsexual” has meant different things in different time periods. The
contemporary usage of the term typically refers to a person who desires to or who
has modified their body to transition from one gender or sex to another through
the use of medical technologies such as hormones or surgeries. Previous defini-
tions operated as a catch-all term for people with different genders than their sex
assigned at birth. Occasionally, an alternate spelling of the word is used—
“transexual” instead of “transsexual.” It is important to note that, currently, there
is debate over the term “transsexual” within the transgender community. Some
individuals find the term antiquated or pejorative, while others use the term to
self-describe themselves. Currently, “transgender” or “trans” is the larger umbrella
term to refer to individuals who do not identify as the sex they were assigned at
Transsexual 743
birth. Transsexual, while still used by some individuals, should be used with cau-
tion as it is not adopted uniformly.
The term “transsexual” is often traced back to Magnus Hirschfeld, the German
sexologist and physician who advocated for the acceptance of sexual minorities
during the late 1800s and early 1900s. The term gained popularity in medical
communities largely due to the work of Harry Benjamin in the 1950s and 1960s
(e.g., the popular work The Transsexual Phenomenon of 1966). The term “trans-
sexual” became more known in a widespread audience when Christine Jorgensen’s
transition from male to female became a worldwide headline in 1952. The term
was designed to show a difference between individuals wishing to physically alter
their bodies (transsexuals) and individuals who only wished to wear differently
gendered clothing (transvestite).
Social movement groups associated with transgender rights have also adopted
the term “transsexual” in various time periods. The most well-known group using
the term is The Transexual Menace, an early direct-action group that advocated
for transgender acceptance and rights that was formed by advocate Riki Wilchins
in the 1990s.
The most widespread usage of the term “transsexual” is currently in the medi-
cal community to refer to individuals utilizing various medical transition steps.
Transition can look many different ways depending on the individual’s goals and
the steps needed to maximize a person’s comfort within their own body and sense
of self. Within the medical community, many guidelines exist to assist physicians
working with transsexual patients through their transition process. The most
holistic guideline is produced by the World Professional Association for Transgen-
der Health and is called the Standards of Care.
A chief complaint against the term “transsexual” within the trans community
is the overly medicalized and pathologized nature of the term. Historically, indi-
viduals who identified as transsexual were often diagnosed as having gender iden-
tity disorder, the psychological category that is now referred to as gender dysphoria
or gender dysphoric disorder. Diagnosis with one of these clinical terms was his-
torically required before a trans person could begin their medical transition.
Requiring individuals to be diagnosed with a mental illness before medical transi-
tion has been loosened in the most recent Standards of Care, but the inclusion of
such a category in the Diagnostic Statistical Manual of Mental Disorders can be
seen as stigmatizing.
Two major transsexual categories exist—trans women and trans men. Trans
women, or male-to-female transsexual people, are assigned male at birth and
undergo various medical interventions to alter their bodies to achieve a more typi-
cal female look. Trans men, or female-to-male transsexual people, are assigned
female at birth and undergo various medical interventions to alter their bodies to
achieve a more typical male look. Increasingly diverse ways of identifying, modi-
fying, and presenting gendered characteristics are acknowledged within trans
communities. Typically for transsexual-identified individuals, a more binary
expression of gender is endorsed. In other words, individuals who adopt a trans-
sexual self-identity often prefer more gender-typical gender expression. Trans
women who identify as transsexual may endorse more stereotypically female
744 Transvestite
gender expressions and attitudes, and trans men who identify as transsexual may
endorse more stereotypically male gender expression and attitudes.
Jay A. Irwin
See also: Benjamin, Harry; Gender Dysphoria; Gender Transition; Genderqueer;
Hirschfeld, Magnus; Jorgenson, Christine; Transexual Menace; Transgender; Transpho-
bia; World Professional Association for Transgender Health (WPATH).
Further Reading
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., …
Zucker, K. (2012). Standards of care for the health of transsexual, transgender, and
gender-nonconforming people, version 7. International Journal of Transgenderism,
13(4), 165–232.
Erickson-Schroth, L. (Ed.). (2104). Trans bodies, trans selves: A resource for the trans-
gender community. New York: Oxford University Press.
World Professional Association Transgender Health. (2019). Home page. Retrieved from
https://www.wpath.org
Transvestite
A transvestite is an individual who dresses in clothes characteristic of another
gender. The term typically refers to a man who dresses in women’s clothing such
as a dress, pantyhose, and high heels. Society generally considers this behavior to
be unusual. By contrast, it is generally more socially acceptable for a woman to
wear men’s clothing, such as a suit or tuxedo. Whatever the views of society, most
psychologists view transvestism as a healthy form of self-expression for most of
the individuals who engage in the behavior.
The term “transvestite” is commonly used interchangeably with “cross-
dresser.” Some people distinguish one term from the other based on the motiva-
tions of the dresser or other criteria, and some people find one term or the other
offensive. However, there is a range of views regarding this terminology within
the LGBT (lesbian, gay, bisexual, transgender) community, and the use of “trans-
vestite” or “cross-dresser” comes down to a matter of personal preference.
There is a fairly clear distinction between a transvestite and someone who is
transgender or transsexual. For example, a male transvestite enjoys dressing in
women’s clothing, but he generally self-identifies as male most of the time. By
contrast, a genetic male who is transgender always self-identifies as female, with
many such individuals eventually transforming their bodies through female hor-
mones and sex reassignment surgery. In some cases, some people who identify as
a transvestite may experience change in their gender identity over time and later
identify as transgender. Transvestism is not a reflection of sexual orientation, and
a transvestite may be straight, gay, bisexual, or another sexual orientation.
The reasons that a transvestite dresses in other-gender clothes vary among
individuals—and may even vary from one time to another in the same individ-
ual. Some male transvestites find a sense of peace and a relief from stress while
wearing soft, feminine clothes. While they pretend to be a woman, they may
also find escape from the demands and expectations that society places on them
Trichomoniasis 745
as a man. Many transvestites become sexually aroused by the way they feel and
look in women’s clothes. Some transvestites dress to entertain others. If male,
these individuals are often called female impersonators, gender illusionists, or
drag queens. Some women dress as men to “pass” as male in order to get cer-
tain jobs.
Some transvestites dress only in the privacy of their homes, but others enjoy
going out in public while dressed as the other gender. Going out in public is a huge
step that many transvestites are afraid to take, but those who do often discover a
sense of personal liberation that they do not otherwise know. They may find that
they enjoy living in public as a woman, even if only for a few hours at a time.
Some transvestites can successfully “pass” as a woman in public. Others cannot
pass but find that they are still accepted by others in social situations. Unfortu-
nately, some transvestites experience intolerance and violence from certain
people.
The prevalence of transvestism is unknown, as are the causes. It is known,
however, that most transvestites appear to be born with a tendency for the behav-
ior, which is often first manifested in childhood, and the behavior appears to last a
lifetime for most. Some transvestites feel guilty about their dressing and repeat-
edly try to stop the behavior with “purges” of their female wardrobe, but they
typically eventually restock the wardrobe. Many transvestites are happy and well
adjusted with their behavior. But for those who feel confused or disturbed by their
behavior, professional therapy can help them to accept themselves.
Transvestism has been known throughout history in all cultures, with varying
degrees of social acceptance. Some famous female transvestites have been Joan of
Arc, a French soldier in the 1400s; Isabelle Eberhardt, a Swiss explorer in the late
1800s and early 1900s; and Dorothy Lawrence, an English writer and soldier in
the 1900s. Some famous male transvestites have been Elagabus, a Roman emperor
in the third century; Francois Timoleon de Choisy, a French writer from the mid-
1600s to early 1700s; Ed Wood, an American movie director in the mid-1900s;
and the modern-day performers Eddie Izzard and RuPaul.
A. J. Smuskiewicz
See also: Drag; Gender Expression; Gender Roles, Socialization and; Transgender.
Further Reading
Coleman, V. (2014). Men in bras, panties, and dresses: The secret truths about transves-
tites. Seattle, WA: Amazon Digital Services.
Novic, R. (2005). Alice in Genderland: A crossdresser comes of age. Bloomington, IN:
iUniverse.
Tri Ess: The Society for the Second Self. (2019). Home page. Retrieved from http://www
.tri-ess.org
Trichomoniasis
Trichomoniasis is the most common nonviral sexually transmitted infection (STI).
The single-celled parasite causes more than 7 million infections per year in the
United States, which is almost twice the number of gonorrhea and chlamydia
746 Trichomoniasis
cases combined. Worldwide, there are more than 180 million cases annually.
Given the impressive number of people infected, it is surprising that most people
have never heard of this infection. The good news is that trichomoniasis is easily
treated with antibiotics, so perhaps part of the reason that it is not well known is
the fact that this infection can be completely cured. The bad news is that tricho-
moniasis is often difficult to diagnose.
Trichomoniasis is the infection caused by a single-celled parasite, Trichomonas
vaginalis. Viewed under the microscope, trichomonas (called “trich” for short) is
roughly the same size and shape as a white blood cell, appearing somewhat pear
shaped. Trich has five tails, called flagella, that whip around to propel the organ-
ism. If a clinician looks at a freshly prepared slide under the microscope, the trich
parasites will be easy to identify as they tumble and move across the viewing
field. However, if the slide sits out on the microscope for more than a minute, the
slide dries out and the trichomonas quickly stop moving, making them much more
difficult to identify as they sit side by side with the numerous white blood cells
that typically accompany trichomonal infections.
Trichomonal infections can be passed from partner to partner by direct genital
contact. Trich infections are the only STI that is passed through neither oral nor
anal sex. Transmission is, therefore, most often from genital intercourse between
a male and female or through sharing sex toys between two or more females.
Latex condoms greatly decrease the transmission of trichomonas, though not
when there is failure of the condom via breakage or improper use. Trichomonas
cannot be passed by kissing, hugging, or other casual contact, nor is it transmitted
in public restrooms, hot tubs, swimming pools, or bed linens. While trichomonas
can remain viable in moist areas such as damp towels or underwear, transmission
resulting in infection has never been documented.
Trich can infect any person, but 90 percent of male infections are completely
asymptomatic; the men are totally unaware of any symptoms. For the 10 percent
of men who do notice a problem, the most common complaints are a discharge
from their urethra and pain with urination or ejaculation. In females, the symp-
toms often come and go over weeks, months, or even years. Burning or discom-
fort while urinating, a light yellow or green frothy vaginal discharge, or a bad
odor (from the discharge) can signal the presence of trich. Another common
female symptom may be simply the new onset of pain or discomfort during sex,
with or without any of the other complaints.
Because the symptoms can wax and wane, or even disappear without treat-
ment, trichomonal infections can and often do persist for a long time. Women with
trich infections that show up as a vaginal discharge may assume they have a vagi-
nal yeast infection. After using an over-the-counter product for several days, the
discharge and irritation seem to resolve, which further confirms to that individual
that they did, indeed, have a yeast infection, which is now treated and gone. How-
ever, all that has really happened is that, following the natural history of trich
infections, a discharge, discomfort, and odor may be noticed for several days to a
week, and then the symptoms fade, but the infection persists. Weeks later, the
symptoms recur, but people may not connect the dots to realize it is the same
infection.
Trichomoniasis 747
Trichomoniasis can also present with burning and irritation with urination, and
in this case, the same scenario often replays via a presumed bladder infection.
This time, the individual may call or go in to see a clinician and may be prescribed
an antibiotic for a urinary tract infection. When the medical provider performs the
routine dipstick test on the urine, they will detect white blood cells, which are a
sign of inflammation and infection. The same will be seen with a quick glance
under the microscope (as mentioned earlier). These white blood cells are exactly
what the clinician is expecting, and many will base their treatment on the patient’s
symptoms—burning and discomfort with peeing—and these simple tests. This
diagnosis does not routinely call for a pelvic exam in this setting, so the physical
exam is likely to be normal. The doctor may then write a prescription for an anti-
biotic to treat the bladder infection, but the common medications that are used to
treat bladder infections will not affect the trichomonas. So, the symptoms go away
because of the natural course of the infection, but the infection remains and can
cause problems again down the road.
However, if the doctor sends the urine off for a culture (to confirm suspicion of
a bladder infection as well as to see which bacteria is causing it), but the real cause
of the symptoms is a trichomonal infection, the culture will come back as nega-
tive, which means no bacteria were present. In this situation, the patient is typi-
cally notified that they can stop their antibiotic and to follow up if the symptoms
recur. The take-home message here is not that every presumed bladder infection
should have a confirmatory culture but that if a patient has recurrent infections or
a single classic infection with a negative culture, then further exams and tests are
indicated to look for other masquerading infections such as trichomoniasis.
Fortunately, trichomonas does not cause permanent damage to the reproductive
or genitourinary tracts in the manner that other infections such as gonorrhea and
chlamydia do. However, there are some serious concerns with trichomonal infec-
tions. Perhaps the most important issue with trich is that the presence of a trich
infection, along with the irritation and inflammation that it causes, greatly
increases that person’s risk of contracting another STI—particularly the viral
infections. Trich infection at least triples the risk of contracting HIV from a part-
ner with HIV, with studies showing between three to five times increased risk.
Trichomonas is also linked with an increased risk of pelvic inflammatory disease
and infertility.
Another very significant issue with trichomonal infections is the increased inci-
dence of low-birthweight and even premature infants when a pregnant person con-
tracts trichomoniasis.
Trichomonal infections can be diagnosed by urine or vaginal or urethral dis-
charge samples. Clinicians can immediately examine these specimens under
microscopy, and as mentioned earlier, if the parasites are still swimming around,
it is a very obvious diagnosis. However, current studies show the sensitivity (the
ability to detect the organism if it is present) of these wet preps as roughly
60–70 percent. The accuracy of this test, though, known as the specificity (if the
test is positive, it really is trichomonas), is 98 percent. When these unicellular
organisms are bouncing along in their characteristic manner, it is very obvious.
Culturing the sample yields fairly accurate information, with 95 percent
748 Trichomoniasis
sensitivity, but can take up to a week to get results. Newer tests include ELISAs
and direct fluorescent antibody tests. Their 80–90 percent sensitivity rate is much
better than the wet preps, with results typically available in a couple of days.
Newly developed rapid diagnostic tests use polymerase chain reaction DNA
probes and boast excellent sensitivity (97%) and specificity (98%). This new tech-
nology comes at a price, of course—up to $200 per test for patients choosing to
test directly from an outpatient lab.
Pap smears are another source of detection for trichomonal infections, though
they should not be thought of as a good screening tool for this purpose. Pap smears
are designed to detect precancerous or cancerous changes of the cervix. However,
because of the high volume of Pap tests, even though they have a low sensitivity of
detecting trichomonas, many people are indeed diagnosed with trichomonal infec-
tions from their Pap test. (Note that a normal Pap test does not mean that the indi-
vidual definitely does not have trichomonas, nor any other STI.) Pap tests have
been shown to have anywhere from 25 percent to 60 percent sensitivity in detect-
ing trichomonas. This low number should come as no surprise for two reasons:
(1) obviously the trich are immobile by the time a pathologist receives the slide, so
they appear very similar to white blood cells, and (2) remember the pathologist is
focused on looking for precancerous changes in the cervical cells, not necessarily
zooming in on the neighboring ever-present white blood cells (which may, in fact,
be a trichomonas parasite).
There are also some clues on the physical exam that could lead the clinician to
look for trichomonas. People with vaginal infections may have a characteristic
frothy, light green discharge, along with a foul odor. This discharge may be noticed
only on speculum exam, although often the patient will be aware of it on their
underwear. In addition, the cervix or vaginal wall may have several small bright
red spots, called petechiae. Roughly one in ten vaginal trichomonal infections will
produce a classic strawberry cervix that is covered with these red spots, and this
presentation is virtually diagnostic of trichomonas.
There are only two antibiotics that can cure trichomoniasis: metronidazole and
tinidazole. The preferred choice is metronidazole. Unfortunately, this antibiotic
has a relatively high rate of side effects. Nausea (10 %), gastrointestinal discom-
fort or cramps (7%), metallic taste (9%), and headaches (18%) are the most com-
mon complaints. Also, the patient must abstain from all alcohol while taking
metronidazole and for at least twenty-four hours after completing the course of
antibiotic. Metronidazole can be given in a single dose of two grams or in twice-
a-day dosing of five hundred milligrams for a week. To minimize side effects and
maximize patient compliance, the single dose is typically recommended. How-
ever, if that single dose fails to clear the infection, then a full week of metronida-
zole is used. This drug should not be used in the first trimester of pregnancy.
A second-line antibiotic is tinidazole. This medication is given as a single two-
gram dose, and alcohol should be avoided for at least three days after the treat-
ment dose. Tinidazole, too, has side effects of bitter taste (6%) and nausea (5%),
though slightly less than metronidazole. It should not be given during the first tri-
mester of pregnancy or when breastfeeding.
Tubal Ligation 749
Both the person diagnosed with the trichomonal infection and their current
partner need to be treated with antibiotics at the same time (while abstaining from
intercourse during treatment) to avoid being reinfected. Due to the difficulty of
detecting trichomonas, physicians typically treat any potentially exposed partners
without actually testing them to confirm that they are infected as well. Depending
on where the patient lives, their physician may or may not be allowed to write
prescriptions for the appropriate antibiotic for the person to give to their partner(s).
This is called expedited partner therapy, and legal restrictions vary from state to
state in the United States.
Alternative therapies such as herbs, vinegar, or douching do not cure trichomo-
nal infections. In fact, douching is associated with adverse side effects and could
potentially push infections upward in the genital tract or create microtrauma in
the vaginal mucosa, which breaks down the lining enough to increase susceptibil-
ity to other STIs.
Trichomonas is passed from person to person only during vaginal intercourse
or through shared sex toys, so abstaining from sex will certainly prevent tricho-
moniasis, and consistent use of condoms will also greatly reduce risk. Risk factors
for contracting trichomoniasis are similar to those for most STIs, and the more
partners and individual has, the higher the risk.
The question of developing a preventative trichomonas vaccine has been raised.
A vaccine could potentially reduce societal costs from trich-related pregnancy
complications, increased incidence of HIV disease, and other medical costs due to
this difficult to detect, yet very common, disease.
Jill A. Grimes
See also: Sexually Transmitted Infections (STIs); Testing, STI; Vaginal Secretions; Vagi-
nitis; Yeast Infection (Candidiasis).
Further Reading
Grimes, J. A., Smith, L. A., & Fagerberg, K. (2013). Sexually transmitted disease: An
encyclopedia of diseases, prevention, treatment, and issues. Santa Barbara, CA:
Greenwood.
McAnulty, R. D., & Burnette, M. M. (Eds.). (2006). Sex and sexuality. Santa Barbara, CA:
Praeger.
Newton, D. E. (2009). Sexual health: A reference handbook. Santa Barbara, CA:
ABC-CLIO.
Tubal Ligation
A tubal ligation—commonly called “getting your tubes tied”—is a surgical pro-
cedure for permanent contraception. In this relatively simple procedure, the sur-
geon cuts, ties, or blocks the fallopian tubes, the tubes that carry eggs from the
ovaries to the uterus. Sperm normally fertilizes the egg in one of the two fallopian
tubes prior to the fertilized egg implanting itself in the uterine wall. Thus, a tubal
ligation is designed to prevent the sperm and egg from meeting, making fertiliza-
tion (and, by extension, pregnancy) impossible.
750 Tubal Ligation
Tubal ligation is a common surgical sterilization procedure. After a tubal liga-
tion, there is no need to use birth control pills or other forms of contraception. The
procedure has the added possible benefit of decreasing the risk of ovarian cancer.
A tubal ligation can be performed with various techniques. The fallopian tubes
can be cut and sealed with a cauterization (burning) tool. The tubes can be closed
by tying, clipping, or banding them, such as with plastic rings or clips. Another
option is to insert small metal coiled devices, called tubal implants, into the tubes.
These implants seal off the tubes and require no cutting or tying.
In most cases, tubal ligation is a minimally invasive surgical procedure per-
formed through one or two small abdominal incisions with laparoscopes—thin,
tubelike devices with surgical tools or cameras at the ends. Tubal ligation may be
performed as either an outpatient or inpatient surgical procedure with the use of
either regional anesthesia (known as an epidural) or short-acting general anesthe-
sia. The insertion of tubal implants is typically a ten-minute nonsurgical proce-
dure in which the physician inserts the implants up through the vagina and uterus
and into the fallopian tubes.
Many people choose to have a tubal ligation while they are having other abdom-
inal operations, such as a cesarean section (C-section). Many others choose to get
“postpartum” tubal ligations within twenty-four to thirty-six hours after vaginal
childbirth, when the fallopian tubes are higher in the abdomen and easier for the
surgeon to access.
Most people can go home several hours after an outpatient tubal ligation. When
performed in conjunction with childbirth, a tubal ligation does not usually add to
the hospital stay. Following the procedure, it is normal to experience minor dis-
comfort and pain at the site of the laparoscopic incision for a few days as well as
slight vaginal bleeding and bloating (caused by the gas used to lift the skin and
muscles away from the abdominal organs during the ligation procedure). The indi-
vidual may also feel some fatigue and dizziness.
Tubal ligation carries some risks and may not be suitable for everyone. For
example, the procedure is associated with complications in people who have
histories of previous pelvic or abdominal surgery, pelvic inflammatory disease,
type 2 diabetes, or obesity. Those conditions may cause complications because
they sometimes leave scarring or adhesions (sticking together) of tissues in the
abdomen—creating difficulties for the surgeon performing the tubal ligation. In
other cases, tubal ligation can result in complications by causing damage to the
bowel, bladder, or blood vessels; by producing a wound that does not heal or
that becomes infected; or by causing prolonged pelvic or abdominal pain.
A medical appointment one or two weeks after a tubal ligation is typically rec-
ommended to check the status of the patient’s healing and to look for any signs
of complications.
In approximately one out of every hundred women, tubal ligation is ineffective,
and the woman may become pregnant. Ineffective tubal ligations are most com-
mon in young women. Pregnancy can occur if a new open passage forms within
blocked tubes or if cut tubes grow back together. A pregnancy that occurs after a
tubal ligation has a relatively high chance of being ectopic—that is, the fertilized
egg becomes implanted in a location outside the uterus, usually in a fallopian
Turner Syndrome 751
tube. Ectopic pregnancies can occur several years after a tubal ligation. These are
emergency, life-threatening situations that require immediate medical attention.
Some tubal ligations can be reversed, should pregnancy be desired at a later
date. However, a reversal is a complex type of operation—and it is often not
successful.
A. J. Smuskiewicz
See also: Contraception; Essure Coil; Fallopian Tubes; Sterilization; Vasectomy.
Further Reading
Johns Hopkins Medicine. (2019). Tubal ligation. Retrieved from https://www
.hopkinsmedicine.org/health/treatment-tests-and-therapies/tubal-ligation
Mayo Clinic. (2018). Tubal ligation. Retrieved from https://www.mayoclinic.org/tests
-procedures/tubal-ligation/about/pac-20388360
National Health Service. (2018). Female sterilization. Retrieved from https://www.nhs.uk/
conditions/contraception/female-sterilisation/
Turner Syndrome
Turner syndrome is a chromosomal atypicality associated with the X chromo-
some. Individuals with Turner syndrome have one normal X chromosome and
either a partially missing or completely missing second X chromosome. If an indi-
vidual is completely missing their second X chromosome, they have the chromo-
some structure XO. Most pregnancies with Turner syndrome fail to progress, and
so it is relatively rare; it occurs in about 1 in every 2,500 newborn females world-
wide. The missing or absent structure of the second X chromosome affects devel-
opment before and after birth. Most people with Turner syndrome identify as
female or intersex.
Among humans, the typical sex chromosomal structure is either two XX chro-
mosomes in females or one X and one Y chromosome in males. Because individu-
als with Turner syndrome do not have a Y chromosome, they develop in utero as
female and have female reproductive organs, including a uterus and ovaries,
although ovarian function is usually significantly reduced or they may completely
stop functioning in early life.
Signs and symptoms of Turner syndrome vary among people. The most com-
mon characteristic is short stature, which can be noticeable during infancy or
childhood. Other characteristics of Turner syndrome include a broad chest, low-
set ears, variations with arm and leg structure, variations with hand and foot
structure, and underdeveloped female sex characteristics, such as breasts. About a
third of people with Turner syndrome have extra folds of skin on the neck, a low
hairline, skeletal abnormalities, swelling of the hands and feet, or kidney prob-
lems. Up to half of individuals may also experience heart abnormalities that can
be life-threatening.
Some individuals may be diagnosed before birth during prenatal screening or
via ultrasound, which may show heart or kidney abnormalities. Some individuals
with Turner syndrome may be diagnosed at birth or as children if physical symp-
toms are present. If no symptoms are noticed, diagnosis may not occur until the
752 Tuskegee Syphilis Study
individual is a teenager or young adult, and this may be as the result of slowed
growth and an absence of puberty, which does not begin as expected.
Many people with Turner syndrome require growth hormone therapy during
childhood, and many also require hormone replacement therapy to begin puberty.
Some individuals may also require hormone replacement therapy throughout their
life. Because of problems with ovarian development and function, and subsequent
hormonal effects, many people with Turner syndrome are infertile.
Turner syndrome is considered to be a random chromosome abnormality. There
does not appear to be a genetic or family history influence.
Heather L. Armstrong
See also: Chromosomal Sex; Intersexuality; Sex Chromosomes; X Chromosome.
Further Reading
Bondy, C. A. (2007). Care of girls and women with Turner syndrome: A guideline of the
Turner Syndrome Study Group. The Journal of Clinical Endocrinology & Metab-
olism, 92(1), 10–25.
Chivers, M. (2017). Gender. In C. F. Pukall (Ed.), Human sexuality: A contemporary
introduction (2nd ed.). Don Mills, ON: Oxford University Press.
Hjerrild, B. E., Mortensen, K. H., & Gravholt, C. H. (2008). Turner syndrome and clinical
treatment. British Medical Bulletin, 86, 77–93.
Mayo Clinic. (2019). Turner syndrome. Retrieved from https://www.mayoclinic.org/dis
eases-conditions/turner-syndrome/symptoms-causes/syc-20360782
National Institutes of Health. (2019). Turner syndrome. Retrieved from https://ghr.nlm
.nih.gov/condition/turner-syndrome#sourcesforpage
Tuskegee Syphilis Study
The Tuskegee Syphilis Study of Untreated Syphilis in the Negro Male was an
unethical study conducted by the United States Public Health Service (USPHS)
between 1932 and October 1972. This study was the longest nontherapeutic study
in medical history. The USPHS began the study, working with the Tuskegee Insti-
tution, to gain access to the African American community and nearby medical
facilities. The USPHS also invited other African American doctors and nurses to
be part of the experiment. The study enrolled 600 predominately poor and unedu-
cated African American men; 399 of the men had previously contracted syphilis,
while 201 men did not have syphilis and acted as controls. The men with syphilis
were not told they had this infection; rather they were told they had “bad blood.”
The purpose of the study was to see exactly what the disease would do to a human
being if left untreated. By 1947, it was known that penicillin could cure syphilis;
however, doctors in the study knowingly failed to treat participants in the study.
They also failed to tell the participants about penicillin, and they prevented them
from accessing available treatment from other sources. By the end of the study in
1972, twenty-eight men had died of syphilis, one hundred died from complica-
tions of syphilis, forty of their wives were infected, and nineteen of their children
were born with congenital syphilis.
Tuskegee Syphilis Study 753
Syphilis is a sexually transmitted infection that can cause long-term complica-
tions if not treated correctly. According to the Centers for Disease Control and
Prevention (CDC), syphilis is divided into four stages: the primary stage, second-
ary stage, latent stage, and the late or tertiary syphilis stage. Syphilis is spread
through direct contact with syphilis sores and is transmitted vaginally, anally,
orally, or through birth if the mother has syphilis infection.
During the first stage of syphilis, a person may notice a single, painless sore, or
chancre, in the infected area that will go away on its own in three to six weeks. If
the sore is not noticed, possibly because it is located inside the anus, vagina, or
cervix, or if the person ignores it and does not seek treatment, the syphilis infec-
tion will progress into stage two. During the second stage of syphilis, approxi-
mately one to three months after the primary infection, a person will develop a
skin rash most commonly on their abdomen, back, arms, and legs, including the
palms and soles of the feet. The rash can look red, rough, and reddish-pink and
may be formed of many flat, whitish lesions. Other possible symptoms are fever,
sore throat, headache, weight loss, fatigue, muscle ache, patchy hair loss, and
swollen lymph glands.
Even if the rash of secondary syphilis is not treated, it will eventually clear on
its own. If continually left untreated, the latent stage of syphilis occurs. During
this stage, which can last for years, the body does not experience any signs or
symptoms. The final stage, or tertiary syphilis, can occur approximately three to
fifteen years or longer after primary infection, although some people with syphilis
infection will never develop tertiary syphilis. However, when it does happen the
symptoms are very serious. During the last stage of syphilis, the bacteria attack
the neurological and cardiovascular systems of the body, ultimately damaging the
heart, brain, spinal cord, skin, bones, and other organs.
Prior to the Tuskegee Syphilis Study, in 1929, the USPHS conducted the “Was-
serman Survey.” The survey was held in six counties, including Macon County,
Alabama, which had the highest rate of untreated syphilis, to determine the preva-
lence of syphilis among African Americans in the South. In 1932, the Rosenwald
Fund withdrew their support of the Wassermen Survey and decided to focus the
study on African Americans exclusively in Macon County, Alabama.
Residents of Macon County were under the impression that doctors were com-
ing to begin a new health program. During recruitment for the Tuskegee Syphilis
Study, individuals were screened by doctors who were determined to find a good
study group of African American males, twenty-five years of age or older, who
had been living with syphilis for more than five years.
The subjects of the experiment were under the impression that they were
patients of a joint federal and local medical and nursing program at the Tuskegee
Institute. As a way to encourage the men to participate in the study, they received
free medical exams, free meals, and free burial insurance. The study was origi-
nally projected to be a six-month experiment but subsequently lasted forty years.
The men were under the impression that they would be examined and treated but
were misled because they were not given all the facts required to give consent.
Subsequently the men never received adequate treatment for the disease, were
754 Two-Spirit
never offered treatment, and were even prevented from accessing treatment from
other sources. In 1972, the Tuskegee Syphilis Study ended. The experiment was
the cover story of the New York Times, condemning the unethical, unjustified
forty-year experiment.
In 1972, Charlie Pollard, a Macon farmer, went into the office of civil rights
attorney Fred Gray and gave detailed information regarding his involvement in the
Tuskegee Syphilis Study; on that day Gray agreed to represent Pollard. In 1973, a
$1.8 billion class action lawsuit was filed on behalf of the participants and their
families. In 1974, an approximate $10 million out-of-court settlement was awarded
to the participants and their families. As a result of the lawsuit, the living partici-
pants were awarded lifetime medical benefits and burial services through the Tuske-
gee Health Benefit Program (THBP). In 1975, the wives, widows, and offspring of
the experiment participants were also afforded the opportunity to benefit from the
program. The CDC stated in 1995 that the program was expanded from medical
benefits to also including health benefits. According to the CDC, in 2004, the last
study participant died, and the last widow to receive THBP died in 2009. There are
twelve children of the participants that still receive medical and health benefits.
On May 16, 1997, former president of the United States Bill Clinton formally
and publicly apologized on behalf of the nation for the Tuskegee Syphilis Study.
The apology was used as an attempt to restore the trust of the African American
community as a result of the Tuskegee Syphilis Study.
Reginald Barker
See also: Sexually Transmitted Infections (STIs); Syphilis.
Further Reading
Carmack, H. J., Bates, B. R., & Harter, L. M. (2008). Narrative constructions of health
care issues and policies: The case of President Clinton’s apology-by-proxy for the
Tuskegee syphilis experiment. Journal of Medical Humanities, 29(2), 89–109.
Centers for Disease Control and Prevention. (2015). U.S. Public Health Service Syphilis
Study at Tuskegee. Retrieved from https://www.cdc.gov/tuskegee/index.html
Centers for Disease Control and Prevention. (2019). Syphilis: Basic fact sheet. Retrieved
from http://www.cdc.gov/std/syphilis/stdfact-syphilis.htm
Freimuth, V. S., Quinn, S. C., Thomas, S. B., Cole, G., Zook, E., & Duncan, T. (2001).
African Americans’ views on research and the Tuskegee Syphilis Study. Social
Science & Medicine, 52(5), 797–808.
Gray, F. D. (1998). The Tuskegee Syphilis Study: The real story and beyond. Montgomery,
AL: New South Books.
Presidential Commission for the Study of Bioethical Issues. (2012). A study guide to “eth-
ically impossible” STD research in Guatemala from 1946 to 1948. Retrieved from
https://bioethicsarchive.georgetown.edu/pcsbi/sites/default/files/StudyGuide_Ethi
callyImpossible_508_Nov26.pdf
Two-Spirit
“Two-spirit” is a term used to refer to cross-gender-identified, gender-diverse, and
gender-fluid individuals who are indigenous to North America and are part of
Native American or other indigenous tribes. This term was originated in 1990 at a
Two-Spirit 755
conference of indigenous people who were upset at the use of a colonized term
that settlers had been using to refer to gender-variant indigenous people. This
offensive term was defined as a male prostitute, or the passive male partner in anal
sex. By creating and popularizing the term “two-spirit,” a term coined by indige-
nous people but in English, the language of the colonizers, the hope was to offer a
replacement term that was less offensive. “Two-spirit” is a term that refers to gen-
der expression and not to sexual orientation.
Originally, two-spirit was used solely to describe someone who was assigned
male and embodied feminine spirit, or who was assigned female and embodied
masculine spirit. However, the term is now often used as an umbrella term to refer
to indigenous people who are gender diverse or gender nonconforming in a vari-
ety of ways. More than 155 North American tribes have historical accounts or
retellings of the acceptance and sometimes celebration of gender-diverse individ-
uals, including from before Europeans came to colonize the Americas. With colo-
nization came the perpetuation of homophobia and transphobia, which infiltrated
many indigenous cultures and led, in some instances, to certain tribes changing
their views toward their two-spirit members. It is important to note that while
many tribes acknowledge and even revere two-spirit individuals, not all tribes
have the same beliefs, and different tribes may have different words naming, atti-
tudes toward, and reactions to gender-diverse people.
In some indigenous cultures, such as the Dine (Navajo), there are four recog-
nized genders and a term for those whose gender expression does not match the
sex they were assigned at birth, nádleeh. The Tewa use the term kwido for all
gender-variant people, and the Lemhi tribe use tubasa for both those assigned
male and female at birth, while many other tribes have separate words to indicate
gender-diverse people who were assigned female at birth and those who were
assigned male at birth.
The roles of two-spirit individuals are different depending on the tribe. In some
tribes, they are simply accepted as part of the tribe. In other tribes, two-spirit indi-
viduals are given the roles of medicine people, name givers, matchmakers, holy
people, interpreters of dreams, warriors, healers, singers, or meditators. Historically,
some tribes had ceremonies or other rituals for two-spirit individuals to undergo as
children to assess whether their identities were truly two-spirit or whether they were
only interested in masculine or feminine things. Once it was determined that they
were two-spirit, they were given work traditionally assigned to their authentic gen-
der (rather than the sex they had been assigned) and were allowed to or encouraged
to wear the clothing of the gender with which they identified. In some tribes, two-
spirit individuals were regarded very highly and held elevated ranks.
Shanna K. Kattari
See also: Bigender; Gender Diversity; Gender Identity; Nonbinary Gender Identities;
Transgender.
Further Reading
Ansbacher, H. (Producer), Martin, R. (Producer), & Nibley, L. (Producer, Director).
(2009). Two spirits [Motion picture]. Say Yes Quickly Productions. Retrieved
from http://twospirits.org
756 Two-Spirit
Laframboise, S., & Anhorn, M. (2008). The way of the two spirited people: Native Ameri-
can concepts of gender and sexual orientation. Retrieved from http://www
.dancingtoeaglespiritsociety.org/twospirit.php
Naswood, E., & Jim, M. (2011). Mending the rainbow: Working with LGBT/two spirit
community. Presented at 12th National Indian Nations Conference, Palm Springs,
CA. Retrieved from http://www.tribal-institute.org/2010/A3-EltonNaswoodPP.pdf
U
Ulrichs, Karl
Karl Heinrich Ulrichs (1825–1895) was a German poet and political activist who
in the 1860s developed the first scientific theory about homosexuality and is seen
today as a pioneer of the modern gay rights movement.
Ulrichs was born on August 28, 1825, in Aurich, which was part of the King-
dom of Hanover. Ulrich’s childhood makes it clear where many of his ideas came
from. As a young child, he wore girls’ clothing and preferred playing with girls.
This gravitation would later inform how he discussed queerness and how it existed
in men. In 1839, at age fourteen, he had his first sexual experience when his male
riding instructor sexually abused him. This experience could be a factor in his
desire to separate queerness from pedophilia.
In 1846, Ulrichs graduated in law and theology from Göttingen University.
From 1846 to 1848, he studied history at Berlin University, and from 1849 to 1857,
he worked as an official legal adviser for the district court of Hildesheim in the
Kingdom of Hanover until he was dismissed when his homosexuality became
public knowledge. After his dismissal, Ulrich became more comfortable with his
identity and became more vocal, opening up to his family and friends. He
described himself as an “Urning,” a term he created to describe men who were
attracted to other men, who represented a third sex. Urnings were born that way,
and their sexuality was not the result of immorality or pathology. Ulrichs believed
that Urnings had a feminine quality about them to distinguish them from men
who were attracted to women.
Ulrichs wrote a series of essays published under the pseudonym “Numa
Numantius.” Later, Ulrichs published under his real name and wrote statements
of legal and moral support for men arrested for homosexual offences. In 1867,
Ulrichs became the first gay man to speak publicly in defense of homosexuality
and queerness when he pleaded at the Congress of German Jurists in Munich for
a resolution urging the repeal of antihomosexual laws (Kennedy, 1997).
Throughout the 1860s, Ulrichs’s writings got him in trouble with the law. His
books were banned in Saxony, Berlin, and throughout Prussia. In 1879, Ulrichs
published his twelfth and final book, Research on the Riddle of Man-Manly
Love, where he argues that homosexuality is not a disease or a sin but perfectly
natural and that the strict line of differentiation between men and women has
been overemphasized.
Lauren Ewaniuk
See also: Gay Rights Movement; Homosexuality; Queer.
758 Unconsummated Marriage
Further Reading
Kennedy, H. (1988). The life and works of Karl Heinrich Ulrichs: Pioneer of the modern
gay movement. Boston: Alyson.
Kennedy, H. (1997). Karl Heinrich Ulrichs, first theorist of homosexuality. In V. A. Rosa-
rio (Ed.), Science and homosexualities (pp. 26–45). New York: Routledge.
Yarber, W. L., Sayad, B. W., & Strong, B. (2010). Human sexuality: Diversity in contem-
porary America. New York: McGraw-Hill.
Unconsummated Marriage
“Unconsummated marriage” refers to a marriage between a man and woman in
which the couple has never had sexual intercourse since marrying. In most cases,
the couple has also not had intercourse previous to the marriage. Historically,
nonconsummation could be grounds for marriage annulment, an official decree
by the church that the marriage was not valid and that the formal relationship
was over.
There is limited research about unconsummated marriages, particularly in
North America, perhaps because premarital sex is more accepted. As such, most
of the existing research focuses on countries where premarital sex is uncommon.
Common causes of unconsummated marriages are vaginismus (a condition
where the vaginal muscles contract, causing penetration to be painful or impossi-
ble) and erectile disorder (a condition where the penis is unable to experience or
sustain an erection firm enough for sexual intercourse). Other causes of uncon-
summated marriage include premature or early ejaculation (where the man ejacu-
lates quickly, in this case before vaginal penetration), a thick hymen (a rare
condition where a woman has an unusually thick hymen that impedes penetra-
tion), a lack of sex education, sexual aversion (where an individual experiences
fear, panic, or revulsion at the thought of sex), and anxiety. In some cases, the
woman may have vaginismus and after repeated unsuccessful attempts at inter-
course the man develops erectile dysfunction. In other cases, one or both condi-
tions exist from the start of the sexual relationship.
In the case of arranged marriages, the partners may face pressure to engage in
sexual intercourse with someone who is almost a stranger, as they may have spent
little or no time becoming acquainted before marriage. In some cultures, relatives
may be nearby during the time of the expected first sexual intercourse or may
require proof that consummation has occurred (such as a sheet or handkerchief
stained with blood that is assumed will be produced when a virgin woman has
intercourse for the first time; however, this does not always happen). This
pressure-filled situation can result in anxiety leading to erectile dysfunction, caus-
ing intercourse to be impossible.
In North America, many unconsummated couples do not talk about their con-
cerns with anyone else. The couples may have a good relationship outside of sex
and may have a fulfilling sex life that simply excludes intercourse. Couples who
seek treatment are often motivated by a desire to become pregnant.
Treatment of unconsummated marriage involves a detailed history of both
partners to determine the factors associated with the inability to have sexual
Urethra 759
intercourse. Treatment is dependent on the factors identified as contributing to the
problem and may include sex education, suggestions for self and partner explora-
tion of the genitals, medical treatment for erectile dysfunction, pelvic floor physi-
cal therapy, surgical treatment for imperforate hymen, medication for severe
premature ejaculation, and dilator use for vaginismus (the use of graduated devices
to stretch the vagina and allow the woman to become accustomed to penetration).
Sex therapy, a specialized type of psychotherapy or talk therapy, may be useful for
all causes of unconsummated marriage. Sex therapy can provide needed sexual
health information and address the psychological impact of the concern as well as
any relational or psychological factors that may contribute to or maintain the
problem.
Adrienne M. Bairstow
See also: Hymen; Intercourse; Marriage; Premarital Sex; Premature Ejaculation; Sexual
Disorders, Female; Sexual Disorders, Male; Sexual Dysfunction, Treatment of; Vaginis-
mus; Virginity.
Further Reading
Promodu, K. (2011). Unconsummated marriage. Retrieved from http://www.drpromodus
institute.in/unconsummated-marriage.html
Rosenbaum, T. Y. (2015). Part 1: Couples in unconsummated marriages. Retrieved from
http://www.tallirosenbaum.com/en/node/47
Urethra
The urethra is a tube that carries urine from the bladder for removal from the
body. Because of anatomical differences, the urethra is very different in males and
females. In males, the urethra also serves in the reproductive act by carrying
semen. In females, it is used only for urination. The urethra is the site of relatively
common bacterial infections, particularly in women. Other medical concerns
related to the urethra include unusual development in males, cancer, and the pas-
sage of kidney stones.
The average female urethra is approximately two inches long. It runs from the
bladder and exits the body between the clitoris and the vagina. The urethral
sphincter muscle controls the flow of urine from the urethra. Control over the flow
is made possible by the pudendal nerve. The female urethra is used only to void
urine from the body.
The average male urethra is approximately eight inches long, because it runs
the length of the penis. After it exits the bladder, it passes through the prostate
gland. Several openings into the urethra are found here that play an important role
during intercourse. The ejaculatory duct allows the entry of sperm from the vas
deferens and ejaculate fluid from the seminal vesicles. Additional fluid from the
prostate gland also enters at this point. The urethra then passes through the exter-
nal urethral sphincter, which controls the flow of urine. The longest part of the
male urethra is known as the spongy urethra and runs along the underside of the
penis. When the urethra carries urine, the physiology at this point causes a spiral
stream of urine. This has the effect of cleaning the inside of the urethra, reducing
760 Uterine Cancer
the likelihood of infections. The female urethra lacks a similar feature, which
helps explain why urinary tract infections are more common in females.
Abnormal development of the urethra in males sometimes occurs, including the
opening of the urethra being located other than at the tip of the penis. In addition,
bacterial infection of the urethra, known as urethritis or a urinary tract infection,
sometimes occurs. The most common symptom is a burning pain when urinating.
Urethritis is usually treated with antibiotics. The passage of kidney stones down
the urethra causes a great deal of pain. Cancer of the urethra may occur. It can be
diagnosed by a physical examination or through testing of the urine.
Tim J. Watts
See also: Bulbourethral Glands; Penis; Prostate; Semen.
Further Reading
Mayo Clinic. (2019). Urethral structure. Retrieved from https://www.mayoclinic.org/
diseases-conditions/urethral-stricture/symptoms-causes/syc-20362330
National Institutes of Health. (2019). Urethral disorders. Retrieved from https://medline
plus.gov/urethraldisorders.html
Seladi-Schulman, J. (2018). Female urethra overview. Retrieved from https://www.health
line.com/human-body-maps/female-urethra
Uterine Cancer
Uterine cancer is the abnormal, malignant (cancerous) growth of cells of the
uterus, specifically the endometrium, the mucous lining of the interior walls of the
uterus. Uterine cancer is also called endometrial cancer.
Uterine cancer most commonly occurs after menopause, when menstrual peri-
ods stop. The condition is most frequently diagnosed in women between the ages
of fifty-five and sixty-four (making up about 34% of all cases). However, the can-
cer develops in some women before menopause. About 7 percent of cases are
diagnosed in women between the ages of twenty and forty-four. Approximately
3 percent of women will be diagnosed as having uterine cancer at some point in
their lives.
Symptoms of uterine cancer may include abnormal bleeding or other discharge
from the vagina. Other symptoms are pelvic pain during urination or sexual inter-
course or other unexplained pain in the pelvic region.
The causes of uterine cancer are not fully understood, but genetic factors are
known to play a role in the disease. People with a family history of uterine cancer
or colorectal cancer are at increased risk of uterine cancer. People are also at
greater risk of uterine cancer if they have had hyperplasia, abnormally rapid cell
growth in the endometrium. Even if this cell growth is benign (noncancerous), it
could be an early indication of cancer development. Uterine fibroids and polyps
are benign growths in uterine tissue that need to be monitored for signs of becom-
ing malignant. Obesity further increases the risk of uterine cancer, as does
estrogen-only hormone replacement therapy, use of tamoxifen to treat previous
breast cancer, diabetes, high blood pressure, never having children, having men-
strual periods before age twelve, and experiencing menopause after age fifty-five.
Uterine Cancer 761
Uterine cancer is usually diagnosed with a gynecological pelvic examination
(the physical inspection of the uterus, vagina, and adjacent tissues), ultrasonogra-
phy examination (the use of sound waves to create images of the uterus and adja-
cent tissues), and biopsy (a microscopic tissue evaluation to verify the benign or
malignant nature of cellular growth). Diagnosis will determine the stage of cancer
development in the patient. Uterine cancer is classified in four stages—I to IV. In
stage I, the cancer is confined to the endometrial and muscle layers of the uterus.
In stage II, the cancer has spread to the tissue of the cervix (the neck of the uterus).
Stage I and II cancers make up about 68 percent of all diagnoses. In stage III,
making up 20 percent of all diagnoses, the cancer has spread beyond the uterus, to
the fallopian tubes, ovaries, vagina, and regional lymph nodes. In stage IV, mak-
ing up 8 percent of all diagnoses, the cancer has metastasized (spread to other
parts of the body) beyond the pelvic region. The lungs are the main region to
which uterine cancer spreads.
Treatment depends on the patient’s specific diagnosis, including the stage of the
abnormal tissue growth. Noncancerous fibroids and polyps might be treated with
pain-relieving medications and surgical removal of the growths. If cancer is diag-
nosed in its early stages, chemotherapy (the use of medications to kill cancer cells)
and/or radiation therapy could be successful treatments. Radiation to kill cancer
cells can be administered externally, with a machine directing the rays at the pel-
vic area, or internally, with a radiation-emitting cylinder inserted inside the vagina.
Even if diagnosis indicates that the patient’s condition is currently noncancer-
ous or in the early stages of cancer, doctors may recommend a hysterectomy (sur-
gical removal of the uterus). This surgery is the most comprehensive way to ensure
removal of any dangerous or potentially dangerous tissues.
If uterine cancer is diagnosed in its later stages—when the cancer has spread to
tissues beyond the uterus—treatment will most likely include surgical removal
not only of the uterus but also removal of the ovaries, fallopian tubes, part of the
vagina, and adjacent lymph nodes. It is important to remove the lymph nodes
because once cancer cells invade the lymphatic system, they can quickly metasta-
size. Progesterone hormone therapy (the use of progesterone to alter the hormone
balance that cancer cells use to grow) is performed for some women with advanced
uterine cancer, especially women who wish to keep their uterus so that they can
still become pregnant.
Chemotherapy or radiation therapy may be required after hysterectomy for
patients in whom all cancerous tissue could not be surgically removed. Such
follow-up treatment may also be performed to better prevent a recurrence of can-
cer. Additional types of follow-up treatment may be required after hysterectomy
to address adverse effects, such as bleeding from the vagina, bladder, or rectum;
abdominal pain or bloating; leg swelling; shortness of breath; and loss of appetite
or weight. Doctors can address such postsurgery symptoms in regular checkups
with the patient.
More than 80 percent of women diagnosed with uterine cancer survive at least
five years after treatment. The earlier the cancer stage at diagnosis, the greater the
survival rate.
A. J. Smuskiewicz
762 Uterus
See also: Breast Cancer; Cervical Cancer; Endometrium; Hysterectomy; Ovarian Cancer;
Uterus.
Further Reading
Morice, P., Leary, A., Creutzberg, C., Abu-Rustum, N., & Darai, E. (2016). Endometrial
cancer. The Lancet, 387(10023), 1094–1108.
National Cancer Institute. (2019). Endometrial cancer treatment. Retrieved from https://
www.cancer.gov/types/uterine/patient/endometrial-treatment-pdq
National Cancer Institute. (n.d.). Uterine cancer—patient version. Retrieved from https://
www.cancer.gov/types/uterine
Uterus
The uterus, commonly called the womb, is a hollow female reproductive organ in
which pregnancy occur and the fetus develops. It is located near the base of the
abdomen and is usually about the size of a fist and the shape of an inverted pear.
The lower part of the uterus is a neck-like structure called the cervix, which leads
to the vagina. Sperm must make it through the cervix if fertilization is to occur.
Fertilization usually occurs in a fallopian tube, one of the two tubes that leads
from the ovaries, where eggs are stored and released, into the uterus. The fertil-
ized egg implants itself in the wall of the uterus, resulting in pregnancy.
During a woman’s reproductive years—which, in most women, extend from
her early teens into her late forties or early fifties—the walls of the uterus prepare
themselves roughly once a month to receive a fertilized egg by building up an
extra lining. During this preparation, the number and extent of blood vessels,
cells, and glands increase in this uterine lining. The extra lining is discharged
through the vagina in menstrual bleeding (commonly called periods) if fertiliza-
tion and pregnancy do not occur.
If fertilization and pregnancy do occur, the egg develops into an embryo in the
uterine wall. Tissues from the embryo and the uterus grow into a placenta, a disc-
shaped structure filled with blood vessels connecting the pregnant person’s circu-
latory system to that of the fetus. The placenta provides oxygen and nutrients to
the developing fetus while also carrying away wastes. A normal pregnancy lasts
for nine months, during which the uterus expands to twenty-four times its usual
size, as the organ’s cells grow larger. During birth, the muscles of the uterus and
abdomen repeatedly contract, causing the fetus to pass through the cervix and out
of the vagina. Additional contractions then force out the placenta.
A number of disorders can affect the uterus, some of which can interfere with a
normal pregnancy. Certain disorders cause the uterus to expel the embryo or fetus
before it is able to survive on the outside. Such early ends to pregnancy are called
miscarriages, or spontaneous abortions.
In endometriosis, tissue that normally lines the interior of the uterus grows in
other areas, such as on the outside of the uterus, on the ovaries, or on the bladder.
In adenomyosis, the tissue of the uterine lining grows within the muscular wall of
the uterus. Each of these conditions may require treatment with pain medications
and hormone-based therapies. Severe cases of adenomyosis may require surgery
to remove the uterus, a procedure known as hysterectomy.
Uterus 763
In a condition called hyperplasia, abnormally rapid cell growth occurs in the
uterus. It may be an early indication of cancer. Uterine cancer occurs most often
in those who have experienced menopause. Studies suggest that obesity and hor-
mone replacement therapy increase the risk of uterine cancer. Treatment usually
involves a hysterectomy.
Uterine fibroids, also called leiomyomas, are abnormal but noncancerous
growths in the tissue of the uterus. A number of treatment options are available,
ranging from “watchful waiting” (doing nothing unless symptoms become trou-
blesome) to various pain-relieving drugs to hysterectomy. Uterine, or endometrial,
polyps are abnormal growths that have the potential to spread to other parts of the
body and become cancerous. Treatment may involve drugs, surgical removal of
only the polyps, or hysterectomy.
A. J. Smuskiewicz
See also: Cervix; Endometriosis; Endometrium; Hysterectomy; Menstruation; Preg-
nancy; Uterine Cancer.
Further Reading
National Cancer Institute. (n.d.). Uterine cancer—patient version. Retrieved from https://
www.cancer.gov/types/uterine
National Institutes of Health. (2019). Uterine diseases. Retrieved from https://medlineplus
.gov/uterinediseases.html
Wolf, M. (2012). Everyone has a tipped uterus: 69 things your gynecologist wishes you
knew. Indianapolis: Dog Ear Publishing.
V
Vagina
Although medically inaccurate, the term “vagina” is popularly used to refer to the
external sexual organ of females, which is actually called the vulva. It is also some-
times used, also inaccurately, in reference to the vulva and the vagina combined.
The vagina is an internal muscular and tubular organ, extending from the
introitus (the opening to the vagina, situated between the urethral opening and the
anus) to the cervix (the bottom portion of the uterus). The structure of the vagina
expands in size and changes in shape during sexual intercourse and childbirth.
The vagina is also self-lubricating, with its interior lining being formed of a
mucous membrane (vaginal mucosa), and this is secreted often during sexual
arousal. This helps ease sexual intercourse; however, there are some women who
produce less of this than others, which can lead to discomfort or even pain when
engaging in sexual activity (artificial lubrication is a simple solution to this prob-
lem). The mucosa is surrounded by layers of fibrous tissue and muscle, which
assist in expansion and contraction of the vagina. The vagina also channels men-
strual flow as part of the menstrual cycle.
When most females are born, the introitus is partly covered by a thin piece of
tissue called the hymen. This may remain intact until first sexual intercourse;
however, other nonsexual activities, such as using tampons, may also cause the
hymen to rupture or tear. When this occurs, some women may experience slight
bleeding and pain, but this is seldom reported to be a traumatic experience.
Unlike males, females have two external openings in their genitals. These are
the urethral opening (urological tract, for urination) and the vaginal opening for
the genital tract. In males, the urethral opening typically serves as the opening for
both the urinary and reproductive tracts. In females, the vaginal opening is much
larger than the urethral opening, with both being protected by the labia, the “lips”
or folds of skin that comprise the major external parts of the vulva.
The vagina is a significant part of female sexual pleasure and sexuality. Most of
the nerve endings in the vagina are situated around the introitus. In addition,
located an inch or two inside the vagina on the anterior wall (toward the belly but-
ton) is the Grafenberg spot (G-spot), which may be a significant source of sexual
stimulation and pleasure for some women. On either side of the introitus are the
vestibular bulbs, which are made up of spongy, erectile tissue that expands in size
during sexual arousal and causes the vulva to extend outward. These bulbs form
the internal structure of the clitoris. During arousal and sexual stimulation, mus-
cles in the vagina often begin to contract. However, there are fewer nerves in the
top two-thirds of the vagina than in the bottom third near the introitus; as a result,
766 Vaginal Lubrication
penis length and width does not necessarily provide a heterosexual woman with
increased pleasurable stimulation. However, since sexual stimulation and pleasur-
able feelings vary from person to person, different females may experience differ-
ent pleasurable sensations from various forms of stimulation to their vagina
(combining individual psychology and physiology).
Callum E. Cooper
See also: Grafenberg Spot (G-Spot); Hymen; Labia; Vaginal Lubrication; Vaginal Secre-
tions; Vaginismus; Vulva.
Further Reading
Dalton, M. (2014). Forensic gynecology. Cambridge: Cambridge University Press.
Dutta, D. C. (2014). Textbook of gynecology. London: JP Medical.
Pomeroy, W. B. (1986). Girls and sex. Middlesex: Penguin.
Vaginal Lubrication
The vagina is the inner tube or canal leading from a female’s uterus to her exter-
nal genitalia. The interior of the vagina is lined with a mucosal membrane, which
contributes to vaginal secretions and lubrication. Some vaginal secretions indicate
a place in the menstrual cycle, while others are for cleansing purposes. Most of
these secretions come from other reproductive organs such as the cervix and
uterus. Some secretions have implications in sexual arousal. While some lubrica-
tion is always present, when the body is aroused the amount and process changes.
During sexual arousal, the amount of lubrication in the vagina increases to facili-
tate penetration. This is important because if there is not sufficient lubrication,
there will be too much friction in the vaginal cavity. This can cause sex to be pain-
ful and can also cause physical damage.
The vagina becomes lubricated through a process called transudation. Transu-
dation is when fluid passes through a barrier. In sexual arousal, this process is a
little different than in other instances in the body. When a person begins to feel
aroused, blood rushes to their genitals. This contributes to what is described as a
“full” feeling and is called vasocongestion. This is where the process of transuda-
tion becomes important. The blood in the genitals contains fluid that passes
through the vaginal tissue to lubricate the cavity. This is why, after consuming
alcohol, it can be difficult for a person to feel properly lubricated for penetration.
Drinking alcohol dehydrates the body, and if there is little fluid in the blood, then
an adequate amount cannot pass through the tissue.
Dehydration is not the only thing that can affect vaginal lubrication. Estrogen
also has implications for a person’s ability to produce vaginal lubrication. If a per-
son has higher estrogen levels, which younger females tend to have, then their
body will have an easier time completing this process. It is important to note that
estrogen levels also fluctuate during the menstrual cycle. That means that at times
in a person’s cycle when their estrogen levels are lower, they might not become as
wet as they might at different times in their cycle. During and after menopause,
when estrogen levels are lower, people may also have difficulty with lubrication
Vaginal Ring 767
during arousal. In all cases of vaginal dryness during arousal, a person can sup-
plement with store-bought lubricants. However, for older women, just adding
lubricant may not be enough. Because hormones like estrogen also have implica-
tions in the elasticity of vaginal tissues, it might be necessary to get a prescription
for a lubricant with estrogens that can keep tissues from tearing.
Rebecca Polly
See also: Arousal; Estrogen; Lubricants; Menopause; Menstruation; Vagina; Vaginal
Secretions.
Further Reading
Herbenick, D. (2009). Because it feels good: A woman’s guide to sexual pleasure and
satisfaction. Emmaus, PA: Rodale Books.
Herbenick, D. (2011). Read my lips: A complete guide to the vagina and vulva. Lanham,
MD: Rowman & Littlefield.
Vaginal Ring
In 2001, the Food and Drug Administration approved the use of the vaginal ring.
It is a small, bendable ring, approximately two inches in diameter, which is placed
in the vagina and releases hormones into the bloodstream to prevent pregnancy.
The vaginal ring is placed into a person’s vagina, where it remains for three
weeks. It releases synthetic estrogen (ethinyl estradiol) and progesterone (etono-
gestrel), which moves across the vaginal epithelium and enters the bloodstream.
These hormones work to prevent pregnancy primarily by preventing ovulation.
The hormones also thicken the cervical mucus, preventing sperm from meeting an
egg. After the vaginal ring has been in the vagina for three weeks, it should be
removed on the same day of the week it was inserted. The person goes without the
ring for one week, and then a new one is inserted into the vagina.
In order to get a vaginal ring, a person needs to consult with a health care pro-
vider and receive a prescription. Once they have obtained the ring from a drug-
store or pharmacy, a person uses their fingers to bend the sides of the ring together
and pushes it inside of their vagina. It is generally placed high in the vaginal canal,
back toward the cervix. At the end of three weeks, the vaginal ring is removed by
hooking a finger under the rim of the ring and pulling it out of the vagina. Once
removed it should be wrapped and thrown away. The person then goes without the
vaginal ring for the fourth week, and this is typically when menstruation occurs.
The vaginal ring can be removed during sexual intercourse for up to three hours
without losing effectiveness, but it is not necessary to remove it.
The vaginal ring is known to have both positive and negative side effects. A
common side effect often reported by users is lighter and shorter periods. The
vaginal ring may also prevent acne and improve menstrual cramping. Some nega-
tive side effects include bleeding between periods, nausea, vomiting, and swollen
or tender breasts. Typically, these side effects will cease after the first few months
of use. Longer-lasting side effects might include increased vaginal discharge, vag-
inal irritation, or a change in sexual desire.
768 Vaginal Secretions
The vaginal ring is very effective in preventing pregnancy. It is about 99 per-
cent effective with perfect use, meaning a ring that is kept in place for three weeks,
taken out for one week, and replaced with a new one after the fourth week. This
ensures the appropriate levels of hormones are circulating in a person’s body. With
inconsistent use, the vaginal ring is approximately 91 percent effective in prevent-
ing pregnancy. When someone chooses to stop using the vaginal ring, the ability
to become pregnant returns quickly.
The vaginal ring is a relatively safe method of birth control. However, hor-
mones affect different bodies in different ways. In some cases, and in certain bod-
ies, using the vaginal ring may come with more severe risks. These risks are rare
and can include liver tumors, gallstones, high blood pressure, or jaundice.
Sarah Gannon
See also: Cervix; Contraception; Pregnancy; Sex Hormones; Synthetic Hormones;
Vagina.
Further Reading
Bedsider. (2016). The ring. Retrieved from https://www.bedsider.org/methods/the_ring
#details
Jones, R. E., & Lopez, K. H. (2014). Human reproductive biology (4th ed.). San Diego,
CA: Academic Press.
Planned Parenthood. (2019). Birth control ring. Retrieved from https://www.planned
parenthood.org/learn/birth-control/birth-control-vaginal-ring-nuvaring
Roumen, F. J. M. E., & Mishell, D. R. (2012). The contraceptive vaginal ring, NuvaR-
ing®, a decade after its introduction. European Journal of Contraception &
Reproductive Health Care, 17(6), 415–427.
Vaginal Secretions
Vaginal secretions are discharges of fluid from the vagina. Vaginal secretions are
one way in which the body cleanses itself, maintains pH balance, and keeps skin
moisturized. Vaginal discharge is a natural defense against bacteria and any
potentially harmful infections.
Vaginal discharge occurs when fluid from glands inside the vagina and cervix
carry away dead cells, making room for new cells to grow. Discharge comes from
multiple sources, such as the vaginal wall, cervical mucous, and sweat and oil
within the vulva. Vaginal discharge is a regularly occurring thing that all people
with a vagina experience, and it can happen throughout the menstrual cycle. For
example, discharge can appear before and after the menstrual cycle, during ovula-
tion, and when sexually aroused. Discharge can also vary in color and texture,
amount, and odor. Discharge can be clear or white and range from smooth and
slippery to chunky and thick. Most healthy discharge is odorless, though smell
can vary if a person is pregnant, has been exercising, or needs to take care of per-
sonal hygiene.
Clear and watery discharge can happen any time and can be especially heavy
after exercising. Clear and mucous-like discharge happens during ovulation.
Brown or bloody discharge is also a common occurrence, which is usually part of
Vaginismus 769
the menstrual cycle. Discharge before or after the menstrual cycle can be brown in
color. Brown or red discharge in between periods can be the result of unprotected
sexual intercourse and possibly a sign of pregnancy. Brown discharge can also be
a sign of cervical cancer, but yearly pelvic exams and Pap smears can rule out
cancer.
Because the vagina is self-cleaning, douches, scented menstrual products, and
vaginal sprays are not necessary for maintaining a clean and healthy vagina. Some
of these products can in fact lead to abnormal discharge. Overcleaning the vagina
is unhealthy and can reduce naturally occurring bacteria that protect the vagina
from infection. Because discharge keeps skin moisturized, constant cleaning and
attempting to remove secretions can dry the vagina and lead to discomfort and
itching.
Changes in odor, consistency, and color can be indications of medical condi-
tions, especially if accompanied by vaginal itching, burning, or pain. Several fac-
tors can lead to abnormal discharge. Yeast infection is one of the most common
examples of infection that can be detected through changes in secretions. Vaginal
secretions during a yeast infection are most often odorless with a thick, white, cot-
tage cheese–like consistency. Itching or burning sensations around the vagina
also accompany yeast infections, and if the individual is sexually active, inter-
course can be painful during a yeast infection. A number of things can cause yeast
infections, including antibiotics, birth control pills, and stress. Although over-the-
counter medication is available for treating yeast infections, it is best to see a
doctor.
Unprotected sex can lead to sexually transmitted infections (STIs), which can
cause vaginal irritation and abnormal discharge. Gonorrhea and chlamydia are
two STIs that commonly include abnormal vaginal secretions. In both cases the
secretions can be cloudy or yellow and sometimes gray, accompanied by a fishy
odor. Both gonorrhea and chlamydia can have other symptoms as well, such as
painful urination and vaginal swelling, but abnormal discharge can be one of
the first signs of infection. Like yeast infections, STIs should be medically
treated.
Aman Agah
See also: Bacterial Vaginosis; Cervical Mucus Method; Douching; Menstruation; Sexu-
ally Transmitted Infections (STIs); Vagina; Yeast Infection (Candidiasis).
Further Reading
Boston Women’s Health Book Collective. (2011). Our bodies, ourselves. New York:
Simon & Schuster.
Rankin, L. (2010). What’s up down there? Questions you’d only ask your gynecologist if
she was your best friend. New York: St. Martin’s Press.
Vaginismus
“Vaginismus” refers to a condition wherein a woman experiences involuntary
contractions of the muscles in the outer third of the vagina, causing penetration to
be painful or impossible. Women with vaginismus often report that it feels like
770 Vaginismus
their partner is hitting a wall when they attempt penetration or that it feels like
their vagina is too small.
The classification of this condition has changed over the years. In the past,
vaginismus was included as a sexual pain disorder in the Diagnostic and Statisti-
cal Manual of Mental Disorders (DSM). This diagnosis required involuntary con-
tractions of the vaginal muscles upon penetration distress or interpersonal
difficulty as a result of the condition, and the condition could not be caused exclu-
sively by a physical medical condition. Vaginismus was distinguished from
another sexual pain disorder, dyspareunia (pain during intercourse without mus-
cle spasm).
With the fifth edition of the DSM, the DSM-5 (2013), the diagnoses of vaginis-
mus and dyspareunia have been removed and replaced by genito-pelvic pain/pen-
etration disorder. This diagnosis requires recurring difficulty with one of the
following: (1) vaginal penetration during intercourse, (2) pain during vaginal
intercourse or penetration attempts, (3) fear or anxiety about pain with penetra-
tion, or (4) tightening of the pelvic floor muscles during penetration attempts.
The decision to remove vaginismus from the DSM was prompted in part by
research that demonstrated that doctors do not reliably diagnose vaginismus; if
multiple doctors examine a woman with vaginismus, some will detect vaginal
spasms while others will not. The change in terminology also reflects the fact that
some women have a phobic response to penetration such that they are unable to
attempt intercourse. Finally, there is an overlap between vaginismus and dyspa-
reunia, in that women who have dyspareunia may then develop muscle spasms
characteristic of vaginismus. Although “vaginismus” is no longer in the DSM, the
term will likely continue to be used due to the long history of its use.
Vaginismus has also been referred to as pelvic floor dysfunction, a condition
wherein the muscles supporting the reproductive organs are too loose or too tight,
causing symptoms including pain during vaginal penetration. This name reflects
the latest research on the biological factors involved in vaginismus, notably the
tightening and spasm of the vaginal muscles.
Vaginismus interferes with sexual intercourse as well as with nonsexual activi-
ties such as gynecological exams and tampon use. Accordingly, some have argued
that vaginismus and other female pelvic pain disorders such as vulvodynia (pain
in the external genitals) should be considered pain disorders rather than sexual
disorders.
Vaginismus may also be classified according to onset of symptoms, as either
primary or secondary. “Primary vaginismus” refers to the experience of symp-
toms with the first attempt at intercourse or penetration. “Secondary vaginismus”
refers to symptoms that arise after a period of pain-free intercourse.
The exact prevalence of vaginismus is unknown, in part due to the inconsis-
tency of diagnosis and also to the fact that research studies use varying definitions
and terminology. The American Psychiatric Association states that approximately
15 percent of North American women report recurrent pain with intercourse.
Vaginismus may have a significant impact on a woman’s sex life and relation-
ships. Women with vaginismus often experience fear and anxiety about penetra-
tion or pain with penetration. They may avoid penetrative activities such as
Vaginitis 771
tampon use, gynecological exams, and vaginal intercourse. Some women avoid
all sexual activity out of fear that it may lead to penetrative sex. This avoidance
can lead to frustration for both partners.
A commonly recommended treatment for vaginismus is the use of Kegel exer-
cises, the contraction and release of the pelvic floor muscles. However, Kegel exer-
cises may actually worsen vaginismus. Women with vaginismus may have
underlying pelvic floor dysfunction with pelvic floor muscles that are too tight.
Kegel exercises may encourage a woman to hold the muscles even tighter, thus
worsening muscle tightness and spasm. It is important that a woman who is deal-
ing with vaginismus discuss an appropriate treatment plan with her doctors, pel-
vic floor physiotherapist, or other health care providers.
Additional treatments include the use of dilators alone or in conjunction with
pelvic floor physical therapy. Dilators are tapered devices in graduated sizes that
stretch the vaginal walls and allow a woman to become used to accommodating
something in the vagina. Pelvic physical therapy is a specialized type of physical
therapy that involves assessment and treatment of pelvic floor dysfunction. Physi-
cal therapy may include manual stretching and trigger point release, techniques to
relax the muscles, and biofeedback.
Sex therapy may also be helpful in treating vaginismus, particularly in con-
junction with physical therapy. Sex therapy is a form of psychotherapy or talk
therapy. Sex therapy can provide a woman with vaginismus and her partner with
education about sexual response, address any negative thoughts that may contrib-
ute to the problem (such as thoughts that a woman will never be able to achieve
penetration), and address any relationship dynamics that may be worsening the
situation (such as conflict within the relationship).
Adrienne M. Bairstow
See also: Diagnostic and Statistical Manual of Mental Disorders (DSM); Dyspareunia;
Kegel Exercises; Pelvic Floor Muscles; Psychosexual Therapy; Sexual Avoidance; Sexual
Dysfunction, Treatment of; Unconsummated Marriage; Vagina; Vulvodynia.
Further Reading
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental
disorders (4th ed., Text Rev.). Washington, DC: Author.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: Author.
Pelvic Health Solutions. (2019). Pelvic floor muscle tightness. Retrieved from http://www.
pelvichealthsolutions.ca/for-the-patient/pelvic-floor-muscle-tightness/
Pelvic Health Solutions. (2019). What is pelvic floor physiotherapy? Retrieved from http://
pelvichealthsolutions.ca/for-the-patient/what-is-pelvic-floor-physiotherapy/
Vaginitis
“Vaginitis” is the medical term for any inflammation of the vagina, whether the
inflammation is from a sexually transmitted infection (STI) or a noninfectious
cause such as an allergic reaction to semen or overgrowth of fungi or bacteria.
The most likely causes of vaginitis include candidiasis, bacterial vaginosis (BV),
772 Vaginitis
and trichomonas vaginalis. Each has its own presentation, reasons why it devel-
ops, and associated treatments.
Vaginal candidiasis is an overgrowth in the vagina by the fungus Candida.
Candidiasis is not an STI, yet many women inappropriately self-treat for yeast
infections for any vaginal discharge or discomfort, leading to untreated STIs that
can subsequently cause more serious complications. Candida albicans is respon-
sible for 80–92 percent of vaginal candidiasis, with the remaining percentage due
to other Candida species like Candida glabrata and Candida parapsilosis. This
infection is commonly known as a yeast infection although it is truly just an over-
growth of a normal yeast within the vagina.
Vulvovaginal candidiasis occurs in approximately 20 percent of women annu-
ally. After age 17, the frequency of first vaginal candidiasis infection increases so
rapidly that by the time they are 25 years, 54.7 percent of women have already
experienced their first episode. There are many risk factors for vaginal candidia-
sis. One such risk factor is being immunocompromised. Having a decreased
immune system (e.g., having HIV, being on steroids, or having uncontrolled dia-
betes) leaves the immune system unable to fight against this fungal infection so
that the candidal fungus begins to grow more rapidly. Antibiotic use is another
risk factor. Since the natural bacteria in the vagina are removed after an antibiotic
is used, this destruction of the natural bacteria gives space for the Candida to
grow, leading to a new fungal infection. Candida has also been found to be associ-
ated with initiation of sexual activity, oral contraceptive use, spermicide use, and
previous diagnosis of vulvovaginal candidiasis in the previous year. Although it is
not considered an STI since it occurs in people who do not have sex, sexual activ-
ity can still increase its spread. Other risk factors include use of vaginal sponges,
intrauterine devices, and diaphragms. Overgrowth can also occur due to high
estrogen levels—that is, in pregnancy, before menstruation, or if using birth con-
trol pills.
The symptoms of vaginal candidiasis include vaginal itching, swelling, and
associated thick, chunky, white cottage cheese–like vaginal discharge; these
symptoms can develop suddenly or progressively. Patients can also occasionally
complain of burning with urination (dysuria) or seeing scaly white lesions on the
labia, so a urinary tract infection and STI also need to be ruled out by a physician
when these symptoms develop. During the physical examination, a pelvic exam
will be performed using a speculum. This will allow the physician to view the
inside of the vagina and take samples of the vaginal discharge. Physical exam can
reveal redness and swelling of the vulva with associated redness of the vagina as
well. The thick white discharge is usually seen on physical exam, but in some
cases of non-albicans Candida, only mild redness of the vagina may be present.
Diagnosis of vulvovaginal candidiasis is based on history and physical and lab-
oratory findings. The sample of vaginal discharge will be looked at under a micro-
scope for evidence of hyphae—that is, the threadlike filaments associated with
fungus formation, using a potassium hydroxide (KOH) solution, which destroys
the cells and allows visualization of budding yeast. This is known as a KOH prep.
The presence of these hyphae on a KOH prep underneath the microscope, along
with symptoms, confirms the diagnosis and necessitates treatment. If the KOH
Vaginitis 773
prep is negative, as in half of cases of women with vulvovaginal candidiasis, a
culture should be performed prior to treatment to avoid giving antifungals to
patients who do not have the disease. Since diagnosis is based on the patient’s his-
tory, plus physical exam and laboratory findings, no further imaging studies need
to be performed. Self-diagnosis is not recommended given the fact that it is usu-
ally inaccurate. In a study of ninety-five women who self-treated for possible vul-
vovaginal infection, 33.7 percent had vulvovaginal candidiasis, 18.9 percent had
BV, 21.1 percent had mixed vaginitis, 13.7 percent had normal discharge, 10.5 per-
cent had other diagnoses, and 2.1 percent had trichomonas vaginitis. So, again,
self-diagnosis is inaccurate. Going to the physician for verification of the diagno-
sis will ensure that the true diagnosis is revealed and treated appropriately.
Treatment of vulvovaginal candidiasis includes vaginal or oral antifungal med-
ications that work to kill the fungus. Medications that are placed inside the vagina
are available for treatment anywhere from three to fourteen days depending on the
type of medication prescribed. Oral medications are available for treatment too, as
a single dose or a double dosing seventy-two hours apart based on complicated or
uncomplicated diagnosis. Longer therapy is required if it is a complicated infec-
tion. Complicated infections are described as those that are more frequent (more
than four times per year), have higher severity of disease on physical exams or
with symptoms, have uncontrolled diabetes or immunosuppression, are pregnant,
or have an infection with a Candida species other than Candida albicans.
T. vaginalis is a protozoan, a single-celled organism that can move. Trichomo-
nal infection is an STI that is spread between sexual partners, leading to the colo-
nization of the vagina, urethra, and paraurethral glands of infected individuals.
This infection is known as trichomoniasis. Trichomoniasis is prevalent in 3.1 per-
cent of the population and has been found to account for 3–5 million cases of vagi-
nitis per year in the United States.
Trichomonas is obtained by having sexual intercourse with an infected partner
and is associated with having other STIs as well. The presence of trichomoniasis
can increase the risk of acquiring HIV, worsening preterm labor, and causing a
pregnant person’s water to break early (preterm labor and delivery).
The classic symptoms of trichomoniasis can include large amounts of thin
yellow-green frothy vaginal discharge with foul-smelling fishy odor, cramping of
the uterus, painful urination, or painful sexual intercourse; bleeding after sexual
intercourse can also occur. When symptoms like these begin, it is important to
seek the evaluation of a physician to rule out a possible infection, especially since
other infections may be present in combination with the trichomoniasis. Treat-
ment of the T. vaginalis infection is with oral medications in a single-dose or
multiple-dose therapy, which kill the organism; some vaginal medications are
available as an alternative therapy. Treatment can range from one to seven days
depending on the type of medication.
BV is an infection of the vagina by any of multiple bacteria: Gardnerella vagi-
nalis, Prevotella species, Porphyromonas, Bacteroides, Peptostreptococcus spe-
cies, Mobiluncus species, Mycoplasma hominis, and Ureaplasma urealyticum.
After the normal bacteria in the vagina are altered in some way, these organisms
can infect the vagina and begin to multiply. Risk factors that can lead to this
774 Vas Deferens
alteration in normal bacteria include douching in the past six months, multiple or
new sexual partners, and cigarette smoking. The most common symptom is a
foul-smelling, thin, light gray vaginal discharge. After a pelvic exam is performed
and a sample of fluid is placed under a microscope for analysis, the diagnosis is
verified. Treatment is with either oral or vaginal medications prescribed by a doc-
tor with 3–7 day treatment plans depending on the type of medication. BV can
also resolve on its own in 13–36 percent of patients after 2–10 weeks of monitor-
ing; however, treatment with medication is recommended if the patient is
symptomatic.
Although the above three causes are responsible for most cases of vaginitis,
other possible sources of inflammation exist. Allergic reaction to irritants like
lotions, soaps, lubricants, and spermicides can cause inflammation, itching, and
discharge. Symptoms usually occur after use of the offending product and go
away after the product has been removed. Foreign bodies like retained tampons
can cause the body to react by producing inflammation and vaginal discharge.
STIs such as gonorrhea and chlamydia can also cause vaginitis.
Elizabeth Rodnez
See also: Bacterial Vaginosis; Sexually Transmitted Infections (STIs); Vagina; Vaginal
Secretions; Yeast Infection (Candidiasis).
Further Reading
Grimes, J. A., Smith, L. A., & Fagerberg, K. (2013). Sexually transmitted disease: An
encyclopedia of diseases, prevention, treatment, and issues. Santa Barbara, CA:
Greenwood.
McAnulty, R. D., & Burnette, M. M. (Eds.). (2006). Sex and sexuality. Santa Barbara, CA:
Praeger.
Newton, D. E. (2009). Sexual health: A reference handbook. Santa Barbara, CA:
ABC-CLIO.
Vas Deferens
The vas deferens, from the Latin for “carrying-away vessel,” is a duct or tube that
carries sperm away from the epididymis to the ejaculatory ducts in the urethra. It
stores sperm for up to several months in anticipation of ejaculation. The sperm are
provided with nutrients in the vas deferens, and dead or damaged sperm are reab-
sorbed by the lining to be recycled by the body. The vas deferens is a convenient
location for a contraceptive procedure known as a vasectomy.
The two vas deferens originate in the scrotum, at the lower end of the epididy-
mis. Sperm created by the testicles moves into the epididymis and is transferred to
the vas deferens. Each epididymis has a separate vas deferens. The vas deferens is
about a fourth of an inch wide but nearly a foot in length. It travels up from the
scrotum and into the pelvis. It then travels over the bladder and down the back
side. Connective tissue holds the vas deferens in place. The lining of the vas def-
erens has three layers, including a thick middle layer of smooth muscle that con-
tracts rhythmically to move the sperm along their way. The lower end of the vas
deferens widens into a chamber known as the ampullae. The ampullae act as
Vasectomy 775
storage chambers for the sperm. The lining of the ampullae secretes several sub-
stances that join the sperm to make semen. These substances include ergothione-
ine, which reduces chemical compounds, and fructose, a sugar used by the sperm
as a nutrient. The ampullae can hold sperm for up to several months. The ampul-
lae join with the ducts of the seminal vesicles to form the ejaculatory ducts that
allow semen to enter the urethra at the prostate.
A condition known as congenital absence of vas deferens refers to the obstruc-
tion or absence of vas deferens. This condition has been associated with cystic
fibrosis. Infections can also cause obstructions of the vas deferens. The location
and function of the vas deferens has also resulted in the development of medical
procedures to prevent conception. The vas deferens can be cut or obstructed in a
vasectomy to prevent sperm from being ejaculated. In some cases, this procedure
can be reversed if the patient changes their mind.
Tim J. Watts
See also: Ejaculation; Epididymis; Semen; Sperm; Urethra; Vasectomy.
Further Reading
Barclay, T. (2017). Ductus deferens. Retrieved from http://www.innerbody.com/image
_repmov/repo26-new2.html
National Institutes of Health. (2019). Congenital bilateral absence of the vas deferens.
Retrieved from https://ghr.nlm.nih.gov/condition/congenital-bilateral-absence
-of-the-vas-deferens
Science Direct. (2019). Vas deferens. Retrieved from https://www.sciencedirect.com/
topics/agricultural-and-biological-sciences/vas-deferens
Vasectomy
Also known as male sterilization surgery, a vasectomy is a surgical procedure to
prevent the release of sperm. Although there is possibility for reversal, the proce-
dure is complicated and not guaranteed, which is why a vasectomy is viewed as a
permanent form of male sterilization and birth control. It is a common procedure
around the globe, and some 500,000 men undergo the procedure each year in the
United States alone. Vasectomies are considered highly effective—only about 11
out of every 1,000 procedures will fail within the first two years of surgery.
Vasectomy works by cutting the vas deferens, which are the tubes that carry
sperm from the testes to the urethra. Once a vasectomy has been performed, the
sperm are blocked from leaving the testicle. There are two methods of performing
a vasectomy, conventionally or with a “no scalpel” procedure. In a conventional
procedure, a surgeon will make two small scalpel incisions in the upper part of the
scrotum, which is the pouch containing the testicles. A small section of the vas
deferens is removed through each of these incisions, leaving a small gap in the
tube, and the remaining ends may be sealed with heat or stitches. Then, the small
openings in the skin will be stitched or closed with surgical glue. In the “no scal-
pel” method, a surgeon will feel for the vas deferens and then hold it in place with
a clamp on the outside of the skin. One small puncture will be made in the clamped
skin with a sharp instrument and the vas deferens will be gently lifted out, cut and
776 Vasectomy
tied, and returned to the body. This method involves no interior stitches and no
usage of a scalpel. Both procedures take about thirty minutes or less and are usu-
ally performed as outpatient surgery by a urologist using local anesthesia. In most
cases, patients leave the surgical office within an hour or two, and full recovery
takes between seven and ten days.
After a vasectomy, individuals typically experience minor bruising and dis-
comfort, symptoms that should dissipate within two weeks of the procedure.
Immediate risks following a vasectomy include the possibility of bleeding into the
scrotum or infection. These issues are usually indicated with redness, swelling, or
tenderness in the scrotal region. Mild abdominal pain is normal; however, more
severe pain may indicate complications. Another possible complication from the
surgery is the development of a small mass in the scrotum. This can occur if
sperm has leaked from the cut end of the vas deferens. Although the growth is
typically benign, it may be sensitive to touch. In about 10 percent of cases, a
vasectomy patient will experience a chronic condition called post-vasectomy pain
syndrome, in which a person experiences persistent pain in the testes for no
explainable reason. In this scenario, it is generally recommended to undergo a
reverse vasectomy in order to help alleviate the pain. While there has historically
been some concern that having a vasectomy increases the risk of prostate cancer,
most modern research shows otherwise.
A vasectomy should not affect the ability to have an erection, nor does it pre-
vent ejaculation or sexually transmitted infections. It also does not create immedi-
ate sterilization, as the sperm count will slowly decrease with each ejaculation
following a vasectomy. Studies show that after three months or twenty ejacula-
tions, one out of five patients will still have sperm in their ejaculatory fluids.
Because of this, patients are advised to continue using other forms of birth control
for at least several months or until a semen analysis shows that there are no sperm
in the ejaculatory fluid.
English surgeon Sir Astley Cooper is thought to have been among the first doc-
tors to experiment with various vasectomy techniques in the late 1700s and early
1800s, performing the first vasectomy on a dog in 1823, but it was not until the
twentieth century that male sterilization procedures became safely practiced and
widely available. Then, in 1974, Dr. Shunqiang Li developed the “no scalpel” tech-
nique in China. The vasectomy reversal was invented and performed a year later.
Nowadays, in about 10 percent of cases, those who have undergone a vasectomy
will choose to reverse the procedure. While the process is similar (in reverse) to
the vasectomy, the surgery is more complicated and takes more time, although
many patients still return home the same day. Statistics show that if a reversal
procedure is performed within three years of the original vasectomy, around
97 percent of men will have sperm in their ejaculatory fluids, and the potential
pregnancy rate is about 75 percent. If the procedure is performed between three
and eight years after the vasectomy, pregnancy rates drop to about 50 percent.
Finally, if the procedure is performed fifteen years or more after the original sur-
gery, the pregnancy rate falls to approximately 30 percent.
Tamar Burris
Victorian Era 777
See also: Sterilization; Tubal Ligation; Vas Deferens.
Further Reading
Bullough, V. L. (2001). Encyclopedia of birth control. Santa Barbara, CA: ABC-CLIO.
NHS. (2018). Vasectomy (male sterilization). Retrieved from https://www.nhs.uk/
conditions/contraception/vasectomy-male-sterilisation/
Urology Care Foundation. (2019). What is a vasectomy? Retrieved from https://www
.urologyhealth.org/urologic-conditions/vasectomy
Zorea, A. W. (2012). Birth control. Westport, CT: Greenwood.
Victorian Era
During the Victorian era (named after the British monarch Queen Victoria, who
ruled from 1837 to 1904), sexual behaviors were viewed though the idealized
codes of conduct for being “English” or being an “Englishman.” Although the
common perception of these codes was described as hypocritical, narrow-minded,
prudish, and stuffy, they generally only applied to the middle-class society. These
idealized codes also extended to the United States.
The Victorian era was characterized by the notion that a person’s gender and
sexuality were the basic core of self-identity, potential, social and political stand-
ing, and personal freedom. There were different codes of conduct for the genders
and different stereotypes. It was commonly thought that females were not troubled
with sexual feelings, but it was acceptable for males to yield to their “baser
natures” (sexual desires). For females, fidelity in marriage was the supreme virtue,
and an act of adultery made them a social outcast. One factor affecting women’s
sexual behavior was the lack of reliable birth control, which also limited their
opportunity for becoming economically independent of their husband or family if
they had children. Sex was considered a woman’s contractual duty to her husband.
For males, sexual desire and behavior were to be diverted into disciplined aggres-
sion, such as sports, or with other alliances, such as mistresses, sex with domestic
help, or prostitutes (with discretion). Not all men had sexual contact outside of
their marriage, but it was a common behavior among Victorian men.
Women who did work were predominately in domestic service or factory and
white-collar work; however, approximately 2–5 percent of females supported
themselves with prostitution, which typically led to crime involvement, drug
abuse, and sexually transmitted infections. Some women formed liaisons inde-
pendently as mistresses, which generally led to social rejection, if discovered,
except for those with well-placed men in society who discretely managed the
alliance.
As for children and adolescents, sexual behavior, such as masturbation, was
highly criticized, and a number of efforts were made to control childhood sexual-
ity. The underlying belief was that the person who masturbated turned sexuality
inward.
However, by 1895, Sigmund Freud advocated sexual expression and orgasm for
both sexes among his bourgeois Victorian peers and patients but argued that
778 Virginity
female sexual satisfaction depended on the male’s behavior. He claimed that if
incomplete coitus or sources of sexual frustration occurred, the female might
develop hysteria or nervous exhaustion. Freud argued that it became a matter of
public interest for men to act with full sexual potency. Thus, sexuality became a
private and a public matter. As such, sexuality also became the basis for separat-
ing the Victorian wealthy middle class from the aristocracy, peasants, and work-
ing classes in British society, and the United States’ upper class, middle class,
working class, and lower class.
During the middle to the end of the twentieth century, the Victorian ideals and
morals gradually changed and were eventually largely discarded. However,
although it may appear that American society is currently a sexually liberated
culture, sexual behavior and sexual orientation are still controversial and often
taboo subjects.
Joan H. Hageman
See also: Freud, Sigmund; Masturbation; Sexual Revolution; Stereotypes, Gender; Ste-
reotypes, Sexual.
Further Reading
Acton, W. (1862). The functions and disorders of the reproductive organs in childhood,
youth, adult age, and advanced life, considered in their physiological, social, and
moral relations (3rd Ed.). London: Churchill.
Baines, B. J. (1998). Effacing rape in early modern representation. ELH, 65(1), 69–98.
Buckner, P. A. (2005). Rediscovering the British world. Calgary, Canada: Calgary Uni-
versity Press.
Davis, D. A. (1994). A theory for the 90s: Traumatic seduction in historical context. Psy-
choanalytic Review, 81(4), 627–640.
Freud, S. (1898). Sexuality in the etiology of the neuroses. Smith Ely, 3, 261–283.
Hager, K. (2010). Dickens and the rise of divorce: The failed-marriage plot and the novel
tradition. Aldershot, England: Ashgate.
Houghton, W. (1963). The Victorian frame of mind, 1830–1870. New Haven, CT: Yale
University Press.
Isis Creations. (n.d.). Sexuality & modernity: Victorian sexuality. Retrieved from http://
www.isis.aust.com/stephan/writings/sexuality/vict.htm
Masson, J. M. (1984). The assault on truth: Freud’s suppression of the seduction theory.
New York: Farrar, Strauss, and Giroux.
Murfin, R. C., & Ray, S. M. (2003). The Bedford glossary of critical and literary terms
(2nd ed.). Boston: Bedford/St. Martin’s.
Virginity
Virginity is typically defined as the state of a person who has not experienced
sexual intercourse. In many parts of the world, virginity has significant cultural
and religious importance, particularly for women, because it is a means of control-
ling reproduction, property, and family caste systems. In North America today, it
is still viewed as a major life event, important to identity formation as individuals
transition from adolescence to adulthood.
Virginity 779
Although there is almost unanimous agreement that penis-in-vagina inter-
course defines the transition between being a virgin and a nonvirgin, other sexual
behaviors are less clear. For example, 83.5 percent of participants in one study
believed that a person could engage in genital touching and remain a virgin, while
70.6 percent believed a person could have oral sex and remain a virgin. Given the
primacy of penile-vaginal intercourse as the transition between virgin and nonvir-
gin, as well as it being the behavior almost unanimously agreed on as constituting
having “had sex,” the term “technical virgin” has also emerged in the culture to
define someone who is maintaining their virginity status by engaging in oral sex
or anal sex but not engaging in penile-vaginal sex. Personal definitions of what
constitutes virginity loss are often motivated by whether or not the individual
thinks they would be viewed positively by the transition.
Sexual double standards still exist in North America where men’s sexual agency
is accepted and applauded whereas women’s sexual agency is restricted and
shamed. As a result, understandings of virginity and virginity loss are often dif-
ferent for women and men, and, consequently, sexual behaviors are influenced by
these belief systems. That being said, the average age at which most North Ameri-
can youth have their first sexual intercourse experience is seventeen. There is no
gender difference with respect to age at first intercourse. The most common rela-
tionship context in which virginity loss occurs is a romantic relationship. Condom
use tends to be at its highest prevalence at first intercourse.
There are three dominant scripts with respect to how North American society
understands virginity and virginity loss, including gift, stigma, and process. Some
individuals see their virginity as a “gift” that they value and of which they are
proud. Individuals who ascribe to a gift script want to find someone special for
their first intercourse experience, someone who understands the importance of the
gift and might also be able to reciprocate their virginity or an equally important
relationship variable like love or commitment. Individuals who view their virgin-
ity as a “stigma,” something they hide and are ashamed of, want to rid themselves
of their virgin status as soon as possible. As such, the intercourse partner may not
be as important as ridding oneself of the personal stigma. Individuals who are out
of sync with their peers, and lose their virginity later, tend to see their virginity
status as more stigmatizing and are often perceived to be less desirable as relation-
ship partners. Finally, some individuals view their virginity as a “process” akin to
a rite of passage or milestone that everyone goes through, in which people learn
about themselves, their partners, and about sexuality more generally. It is viewed
as a natural part of transitioning into adulthood.
When asked which of these three virginity scripts best describes their experi-
ence, 38 percent of respondents at a Canadian university viewed their virginity as
a gift, 8 percent chose stigma, and 54 percent identified with the process script.
However, these percentages are highly gendered. More women (40 percent) than
men (23 percent) identified with the gift script, while more men (32 percent) than
women (4 percent) chose the stigma script. Roughly equal numbers of men and
women described themselves using the process script. This finding highlights the
presence of a sexual double standard that still exists in attitudes toward virginity.
780 Virginity
Interestingly, there are connections between how people think about their vir-
ginity and how those thoughts translate into behavior the first time someone
engages in sexual intercourse. Using survey research, gift- or process-oriented
individuals are more likely to report that their first partner was a romantic partner,
while stigma-oriented individuals are equally likely to say romantic, friend, or
stranger. In addition, gift-oriented individuals predominantly feel love toward
their first intercourse partner, process-oriented individuals feel love and like
equally, and stigma-oriented individuals feel like or indifference toward their first
partner (Humphreys, 2013). Gift-oriented individuals also spend more time in a
relationship with their first partners before and after their first intercourse experi-
ence than do process- and stigma-oriented individuals. Emotional outcomes con-
nected to the experience of first intercourse also differ by virginity scripts,
including gift-oriented individuals feeling more “romance” and “pleasure” than
the other two groups and stigma-oriented individuals feeling more “relieved.”
After the first sexual intercourse, these three groups tend to engage in different
sexual trajectories as well, with stigma-oriented individuals having the greatest
number of lifetime sexual partners, followed by process- and then gift-oriented
individuals having the fewest.
While the above discussion has focused on norms in heterosexual youth, there
has been little research focused on the understanding, experience, or significance
of virginity (loss) among individuals identifying as LGBTQ+. While the idea that
penetration is necessary for virginity loss remains a common interpretation, qual-
itative research exploring LGBTQ+ definitions of virginity suggest that LGBTQ+
individuals may embrace broader definitions of virginity. Some gay men and les-
bians describe the possibility of multiple virginities for different sexual behaviors.
Some research has shown that more nonheterosexual individuals than heterosexu-
als believed that an individual could lose their virginity with a same-sex partner.
Furthermore, some nonheterosexual participants indicated that, in retrospect, they
considered their first same-sex sexual experience as the experience denoting their
personal virginity loss, suggesting that these individuals may redefine their per-
sonal definition of virginity to make the concept more applicable to their own
identity, context, and experiences. Many participants in one 2014 study spoke of
the difficulty of defining virginity, particularly within the LGBTQ+ community.
Due to the heterocentric nature of virginity (loss), these individuals did not feel
virginity, as a concept, applied to them and their experiences.
Terry Humphreys
See also: Abstinence; Adolescent Sexuality; Anal Intercourse; Double Standards, Sexual;
Intercourse; Oral Sex; Purity Pledges; Sexual Script; Sexuality across the Life Span.
Further Reading
Averett, P., Moore, A., & Price, L. (2014). Virginity meanings and definitions among the
LGBT community. Journal of Gay and Lesbian Social Services, 26, 259–278.
Bersamin, M. M., Fisher, D. A., Walker, S., Hill, D. L., & Grube, J. W. (2007). Defining
virginity and abstinence: Adolescents’ interpretations of sexual behaviors. Jour-
nal of Adolescent Health, 41(2), 182–188.
Brückner, H., & Bearman, P. (2005). After the promise: The STD consequences of ado-
lescent virginity pledges. Journal of Adolescent Health, 36(4), 271–278.
Voyeurism 781
Carpenter, L. (2005). Virginity lost: An intimate portrait of first sexual experiences. New
York: New York University Press.
Carpenter, L. M. (2001). The ambiguity of “having sex”: The subjective experience of
virginity loss in the United States. The Journal of Sex Research, 38, 127–139.
Gesselman, A. N., Webster, G. D., & Garcia, J. R. (2017). Has virginity lost its virtue?
Relationship stigma associated with being a sexually inexperienced adult. The
Journal of Sex Research, 54, 202–213.
Humphreys, T. P. (2013). Cognitive frameworks of virginity and first intercourse. Journal
of Sex Research, 50, 664–675.
Maticka-Tyndale, E., Barrett, M., & McKay, A. (2000). Adolescent sexual and reproduc-
tive health in Canada: A review of national data sources and their limitations. The
Canadian Journal of Human Sexuality, 9, 41–66.
Ott, M. A., & Pfeiffer, E. J. (2009). “That’s nasty” to curiosity: Early adolescent cogni-
tions about sexual abstinence. Journal of Adolescent Health, 44(6), 575–581.
Peterson, Z. D., & Muehlenhard, C. L. (2007). What is sex and why does it matter? A
motivational approach to exploring individuals’ definitions of sex. Journal of Sex
Research, 44(3), 256–268.
Reissing, E. D., Andruff (Armstrong), H. L., & Wentland, J. J. (2012). Looking back: The
experience of first sexual intercourse and current sexual adjustment in young het-
erosexual adults. Journal of Sex Research, 49(1), 27–35.
Sanders, S. A., & Reinisch, J. M. (1999). Would you say you had sex if...?. JAMA, 281(3),
275–277.
Schlegel, A. (1991). Status, property, and the value on virginity. American Ethnologist,
18(4), 719–734.
Sprecher, S. (2013). Predictors of condom use in first sexual intercourse: A consideration
of individual, situational, relational, and cohort effects. Journal of Applied Social
Psychology, 43, E71–E84.
Trotter, E. C., & Alderson, K. G. (2007). University students’ definitions of having sex,
sexual partner, and virginity loss: The influence of participant gender, sexual
experience, and contextual factors. Canadian Journal of Human Sexuality, 16(1–
2), 11–29.
Tsui, L., & Nicoladis, E. (2004). Losing it: Similarities and differences in first intercourse
experiences of men and women. Canadian Journal of Human Sexuality, 13(2),
95–106.
Uecker, J. E., Angotti, N., & Regnerus, M. D. (2008). Going most of the way: “Technical
virginity” among American adolescents. Social Science Research, 37(4),
1200–1215.
Wiederman, M. W. (2005). The gendered nature of sexual scripts. The Family Journal,
13(4), 496–502.
Voyeurism
Voyeurism historically has been defined narrowly as the act of achieving sexual
pleasure by watching unsuspecting individuals who are naked or engaging in sex-
ual activity. However, in modern times, this has been broadened in the public eye
to mean any viewing or spying on another’s life or experience. Sexual voyeurism
is one of the most commonly reported paraphilic interests. However, there has
been little research conducted, and there is a debate as to whether voyeuristic
782 Voyeurism
fantasies and desire are pathological and deviant or an aspect of normative sexual
behavior. While having voyeuristic fantasies may not be problematic, if the fanta-
sies cause distress or if they are acted on and involve people without their consent
then this behavior is illegal and meets the criteria of voyeuristic disorder.
Voyeurism was first described in the academic literature at the end of the nine-
teenth century by Richard von Krafft-Ebing (1886) in Psychopathia Sexualis. In
the 1910s and 1920s, several psychoanalytic theorists discussed voyeuristic behav-
iors, but little to no research was done.
In recent history, voyeurism has been considered a paraphilia, or sexual devi-
ance, within the Diagnostic and Statistical Manual of Mental Disorders (DSM)
and the International Classification of Diseases (ICD). Voyeuristic behavior and
fantasy are considered one of the most common paraphilias and one of the less
pathological, provided they are not enacted upon unknowing people who have not
given their consent. Voyeurism is found predominately in males. The historical
psychoanalytic theory suggested that voyeurism was the result of a rejection of
castration anxiety and failure to identify with the father. Several more contempo-
rary theories have developed but lack empirical evidence or consensus. Lovemap
pathology theorizes the secondary behavior, or looking at naked others, becomes
a primary erotic lovemap or sexual blueprint. Courtship disorder suggests voyeur-
ism is a result of anomalies in the normative four-stage process of courtship: look-
ing for and discerning potential mates, pretactile interactions with mates, tactile
interactions, followed by moving to sexual intercourse.
More recently, there have been challenges to the pathologizing of sexual inter-
ests deemed not to be socially normative. With voyeurism, if the behavior is car-
ried out illegally or involves nonconsensual viewing of others, it meets criteria for
voyeuristic disorder. However, having a fantasy or desire or acting out voyeuristic
behavior in a consenting manner is suggested to be within the realm of normative
sexual behavior. This claim has been supported by research that has found that in
general population samples, anywhere between 4 percent and 60 percent of males
have admitted to being sexually aroused by secretly watching others in sexual
situations. Another recent study found that in a large sample of Canadian indi-
viduals, 46 percent had voyeuristic fantasies. In particular, 60 percent of the men
and 35 percent of the women surveyed endorsed voyeuristic fantasies. The authors
went on to make the distinction between a paraphilic interest or fantasy and a
paraphilic disorder by differentiating between intensity and the disruptive nature
of the thought and frequency of actual engagement in voyeuristic behavior. When
the researchers separated the sample into paraphilic interest and paraphilic disor-
der groups, only 9 percent of the total sample found their fantasies to be intense or
disruptive, and only 3 percent endorsed engaging in voyeuristic behavior often.
Alexander Kovic
See also: Exhibitionism; Fantasy, Sexual and Erotic; Kink; Krafft-Ebing, Richard von;
Paraphilias.
Further Reading
Janssen, D. F. (2018). “Voyeuristic disorder”: Etymological and historical note. Archives
of Sexual Behavior, 47(5), 1307–1311.
Vulva 783
Joyal, C. C., & Carpentier, J. (2017). The prevalence of paraphilic interests and behaviors
in the general population: A provincial survey. The Journal of Sex Research,
54(2), 161–171.
Joyal, C. C., Cossette, A., & Lapierre, V. (2015). What exactly is an unusual sexual fan-
tasy? The Journal of Sexual Medicine, 12(2), 328–340.
Långström, N. (2010). The DSM diagnostic criteria for exhibitionism, voyeurism, and
frotteurism. Archives of Sexual Behavior, 39(2), 317–324.
Metzl, J. (2004). From scopophilia to survivor: A brief history of voyeurism. Textual
Practice, 18(3), 415–434.
Metzl, J. M. (2004). Voyeur nation? Changing definitions of voyeurism, 1950–2004. Har-
vard Review of Psychiatry, 12(2), 127–131.
Vulva
The vulva is the external genitalia of people who are assigned female at birth,
consisting of the mons pubis (the fleshy, hair-bearing area covering the pubic
bone), labia majora, labia minora, clitoris, urethral opening, and vaginal opening.
The vulva is commonly mislabeled as the “vagina” by many people and the media,
but they are actually two separate parts of the reproductive organs. “Vulva” is the
correct term for the outer portion of the genitals, while “vagina” is the appropriate
term for the vaginal entrance and the internal vaginal canal. The various struc-
tures of the vulva are homologous (developed from the same initial genital struc-
ture) to the reproductive organs of people who are assigned male at birth.
The external portion of the clitoris is a small, very sensitive area located just
below the mons pubis between the labia. It can vary greatly in size, color, and
appearance. This small area is full of concentrated nerve endings and has only one
purpose: pleasure. The clitoris has even more nerve endings than the entire penis.
The clitoris is usually partially covered by a thin “hood” of skin called the clitoral
hood with the glans (head) of the clitoris protected underneath. During sexual
arousal, the clitoris becomes engorged with blood and may emerge slightly from
the clitoral hood. With its many sensitive nerve endings, the clitoris is the primary
source of sexual stimulation and orgasm for the majority of people who have
vulvas.
The labia majora (or outer lips) are the fleshy, hair-bearing pads of skin along
the sides of the vulva. They are made of fatty tissue and help to protect and cover
the more sensitive areas of the female genitals. There are also sweat and oil
glands on this surrounding tissue, which may contribute to natural genital odors.
Some people choose to remove some or all of their pubic hair on this area, and
some do not.
The labia minora (or inner lips) are between the labia majora and consist of
delicate, sensitive tissue that offers additional protection of the vaginal and ure-
thral openings, helping to prevent bacteria and foreign bodies from entering. The
labia minora do not grow hair. They come in many shapes, sizes, colors, and are
sometimes asymmetrical, all of which are normal variations. Though sometimes
less pronounced than the labia majora, the inner labia may also extend beyond the
outer labia, sometimes significantly so. A rapidly growing cosmetic surgery
784 Vulvodynia
known as labiaplasty can be performed to reduce the size of the labia minora if a
person is experiencing physical discomfort due to their length. However, this sur-
gery is most commonly performed for purely cosmetic reasons and is controver-
sial as many people feel that women are wrongly pressured by the media and
pornography to feel ashamed of their genitals or to change their appearance.
Between the labia minora and below the clitoris lies the urethral opening. The
urethra is the tube responsible for the release of urine. Many people mistakenly
assume that the vagina is where urine is expelled, but this is incorrect. There are
separate openings for the urethra and the vagina.
Below the urethral opening is the vaginal opening. The vaginal opening is the
entrance to the vagina, which is where menstrual fluid and discharge leave the
body. This is also commonly where penetration takes place during sexual inter-
course and where a baby is born during vaginal childbirth.
The vulva and vagina are “self-cleaning” organs, meaning that there is no need
for additional cleansing beyond using a mild soap on the external parts of the
genitals only. While many people are often self-conscious of their natural bodily
odors, it can actually be harmful to wash between the labia minora or to douche or
use other feminine hygiene products inside the vagina. This can lead to yeast or
bacterial infections of the vagina.
Lyndsay Mercier
See also: Clitoris; Labia; Labiaplasty; Urethra; Vagina; Vulvodynia.
Further Reading
Boston Women’s Health Book Collective. (2005). Our bodies, ourselves. New York:
Scribner.
Herbenick, D., & Schick, V. (2011). Read my lips: A complete guide to the vagina and
vulva. Langham, MD: Rowman & Littlefield.
Vulvodynia
Vulvodynia is a condition characterized by chronic pain in the vulva (the external
female genitals including the entrance to the vagina, labia minora, labia majora,
the urethra, and the clitoris). “Vulvodynia” is used as an umbrella term to describe
pain, with two main subtypes: generalized vulvodynia (pain that occurs at any
time, at any or all parts of the vulva, independent of whether the area is touched),
and vestibulodynia (pain at the entrance or vestibule of the vagina that occurs
when the area is touched, also known as provoked vestibulodynia, vestibulitis,
vulvar vestibulitis, and vulvar vestibulitis syndrome). The severity and frequency
of pain with vulvodynia varies among women.
The cause of vulvodynia is not known. It is not caused by a sexually transmit-
ted or other type of infection. Although research continues in an attempt to deter-
mine the cause of vulvodynia, several possibilities have been suggested as causes
or contributors to vulvodynia, including genetic predisposition to chronic pain or
inflammation, injury to the nerves that transmit pain signals, increased levels of
inflammation in the vulva, hypersensitivity of the vulvar cells to tissue damage or
Vulvodynia 785
infection (including yeast infections), and pelvic floor muscle dysfunction (a con-
dition wherein the muscles that support the reproductive organs are too tight or
too weak).
Women with vulvodynia may experience interference with activities such as
sitting, wearing tight clothing, tampon use, gynecological exams, and sexual
activity. Although women with vulvodynia typically experience dyspareunia
(pain with intercourse), they may continue sexual activity despite the pain, and
they tend to engage in less frequent sexual avoidance than women with vaginis-
mus (a condition involving spasm of the vaginal muscles and fear of pain with
penetration).
Vulvodynia is a diagnosis of exclusion, meaning that it is made after other
causes for the pain have been ruled out. A doctor will diagnose vulvodynia after
taking a thorough medical history, completing an exam and conducting tests to
rule out other possible diagnoses, and assessing the pain through what is known as
a cotton-swab test. This test involves the application of gentle pressure to various
points on the vulva and having the patient rate their pain for each location.
Treatment for vulvodynia involves an attempt to alleviate the pain symptoms,
since the underlying cause of the condition is unknown. There are multiple treat-
ment possibilities that have shown some effect for some women, but there is no
single treatment that is effective for all women with vulvodynia. Some women
may need to try multiple treatments and may only experience partial relief from
pain. Treatments may include lifestyle changes (including dietary modification
and elimination of possible irritants in soaps, detergents, and menstrual products),
topical medication (including anesthetics to numb the pain and hormonal creams
to improve the vulvar tissue), pain medications (including opioids and antidepres-
sants that are used for their pain-blocking mechanisms in this case, rather than
their effect on depression), pelvic floor physical therapy (treatment with a spe-
cially trained physical therapist to address muscles tension or weakness), surgery
(for women with vestibulodynia only), and sex therapy (a form of psychotherapy
that can assist women and their partners by reducing anxiety and distress that
may be both a factor in the maintenance of the problem and a result of the condi-
tion). A multidisciplinary approach to treatment, including a doctor specializing
in pelvic pain, a pelvic floor physical therapist, and a sex therapist, is
recommended.
Adrienne M. Bairstow
See also: Dyspareunia; Pelvic Floor Muscles; Psychosexual Therapy; Sexual Avoidance;
Vaginismus; Vulva.
Further Reading
American College of Obstetricians and Gynecologists. (2017). Vulvodynia. Retrieved
from https://www.acog.org/Patients/FAQs/Vulvodynia
National Vulvodynia Association. (2019). What is vulvodynia? Retrieved from https://
www.nva.org/what-is-vulvodynia/
Vulval Pain Society. (2019). Vulval Pain Society. Retrieved from http://www.vulvalpain
society.org/vps/
W
Withdrawal Method
The withdrawal method is a form of contraception used during sex, requiring the
male to withdraw his penis from the female’s vagina before he ejaculates. Unlike
other forms of birth control, it is free and does not require the use of a device (such
as condoms, birth control pills, or implants). Nonetheless, it is not a reliable form
of birth control for many reasons.
Also known by the Latin term “coitus interruptus,” withdrawal is one of the
world’s oldest documented methods of birth control, having origins in both the
Old Testament and the Talmud. This practice requires that the male withdraw his
penis from the female’s vagina when he reaches a point in sexual excitement that
he feels he is about to ejaculate. It is equally important that ejaculation occurs
away from the woman’s vulva, the external opening to the vagina, to keep sperm
from entering the vagina and potentially causing pregnancy.
Withdrawal poses both advantages and disadvantages. Because it is free and
does not require the use of a mechanism or prescription, withdrawal is viewed
as a convenient form of birth control. However, some couples also feel that the
withdrawal method disrupts sexual pleasure. A major disadvantage is that it
does not offer protection from sexually transmitted infections, including HIV/
AIDS.
Because of the risk of using withdrawal incorrectly, it is not a reliable method
of birth control. In fact, research suggests that as many as twenty-eight out of
one hundred women who practice the withdrawal method with their partner for
one year will become pregnant, and teens represent the age group for which this
method is the least effective. Many factors account for the risk of using with-
drawal incorrectly. One major problem is that its success is entirely dependent
on the male, requiring his motivation and willpower at the height of sexual
excitement as well as a high level of knowledge and experience with his own
body to predict when ejaculation will occur. Even if a male does withdraw, he
might not do so quickly enough or far enough from the vulva to prevent semen
from entering the vagina. Also, if sex is resumed after ejaculation, sperm may
still be present in the penis, possibly resulting in pregnancy. Withdrawal will
also fail in the absence of effective communication and trust between partners
before and during sex or if the withdrawal method is impaired by the use of
drugs or alcohol.
Linda Tancs
See also: Contraception; Ejaculation; Fertility; Fertility Awareness Methods of Contra-
ception; Pregnancy; Teen Pregnancy.
788 World Professional Association for Transgender Health
Further Reading
American Pregnancy Association. (n.d.). Withdrawal as birth control. Retrieved from
https://americanpregnancy.org/preventing-pregnancy/withdrawal-birth-control
-method/
Jütte, R. (2008). Contraception: A history. Boston: Polity.
World Professional Association for Transgender Health
(WPATH)
The World Professional Association for Transgender Health (WPATH) was cre-
ated in 1979 and was originally known as the Harry Benjamin International Gen-
der Dysphoria Association (HBIGDA). It was named after Dr. Harry Benjamin
(1885–1985), one of the first physicians to work primarily with individuals who
were gender dysphoric, gender diverse, or gender nonconforming, particularly in
a positive, affirming way. It is now known as the World Professional Association
for Transgender Health in order to better represent the mission and vision of the
organization. The mission of WPATH is to “promote evidence-based care, educa-
tion, research, advocacy, public policy and respect in transgender health.” Their
vision is to support professionals worldwide toward creating more equitable and
knowledgeable practices and policies around research, education, health, equal-
ity, and respect for transsexual, transgender, and gender-variant people. As an
organization, they publish the most updated versions of the standards of care;
connect practicing and researching professionals doing work on, for, and with the
transsexual, transgender, and gender-nonconforming communities; and work to
further the treatment and understanding of gender identity disorder by various
professionals.
Born in Germany, Benjamin was an endocrinologist who lived in the United
States and was interested in what at the time was called transsexualism, a diagno-
sis in which the sex a person was assigned by a doctor at birth did not match the
gender with which they identified. He was one of the first individuals to operate on
the assumption that gender identity was different than sexual orientation, an
assumption that was considered far ahead of his time. This recognition of gender
as a different construct than sexual orientation allowed him to consider the con-
cept of changing the body (with hormones and through surgeries) to fit the mind
rather than using conversion therapy to try to make the mind fit the body. His
creation of the Gender Disorientation Scale, based loosely on the Kinsey Scale
(for sexual orientation) was revolutionary at the time, giving transgender and
transsexual individuals the opportunity to be better understood by medical and
mental health professionals.
Following his research on gender as an identity and not a subset of sexual ori-
entation, Dr. Benjamin traveled internationally to perform what were called sex
reassignment surgeries (now referred to as gender affirmation surgeries) on trans-
gender and transsexual individuals. He was one of the first physicians to perform
such surgeries and to work with psychologists and other professionals on how to
support their patients throughout the process.
World Professional Association for Transgender Health 789
Based on his life work, the HBIGDA was named after Benjamin’s life passion
and accomplishments. One of the most well-known components of HBIGDA was
to put forth the Harry Benjamin Standards of Care for Gender Identity Disorders.
The first such document was published in 1979, with multiple revisions in 1980,
1981, 1990, 1998, and 2001. These standards of care were used to support health
professionals around the world in better understanding how to best provide a vari-
ety of care to transgender and transsexual individuals, including therapy, hormone
prescriptions, and gender affirmation surgeries. This document enumerated roles
for mental health professionals, physicians, and surgeons, as well as requirements
for different levels of care, including length of time living as the gender a person
was transitioning to, how many letters from mental health professionals should be
required for hormonal or surgical intervention, and even the treatment of adoles-
cents who were presenting or identifying as gender diverse. For decades, until the
early 2010s, this document was used as the main (and often only) guide for how to
best treat patients with gender dysphoria, and many health professionals required
all gender-variant patients to meet all the requirements detailed within these stan-
dards of care.
The most recent update of these standards of care, now referred to as the “Stan-
dards of Care for the Health of Transsexual, Transgender and Gender Non-
Conforming People,” was published by WPATH in 2012 in the International
Journal of Transgenderism. This newest version includes a discussion on the need
for flexibility in applying these guidelines, as people experience issues around
gender in a variety of ways. It also centers on an informed consent and harm
reduction framework, moving away from strict requirements for people to achieve
in order to be allowed access to a medical- or mental health–supported transition.
This newer version covers a larger variety of medical interventions and standards
for providing lifelong and primary care (outside of only transition-related care),
offers more suggestions from a global audience, and focuses sections on people
who are intersex (also referred to as disorders of sexual development) and those
who have been institutionalized, offering further access to gender-supportive care
for individuals in a variety of environments.
Shanna K. Kattari
See also: Benjamin, Harry; Gender; Gender Diversity; Gender Dysphoria; Nonbinary
Gender Identities; Sexual Health; Transgender; Transsexual.
Further Reading
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman,
J., … Monstrey, S. (2012). Standards of care for the health of transsexual, trans-
gender, and gender-nonconforming people, version 7. International Journal of
Transgenderism, 13(4), 165–232.
World Professional Association for Transgender Health. (2019). Home page. Retrieved
from http://www.wpath.org/
Wyndzen, M. H. (2008). Dr. Harry Benjamin’s gender disorientation scale. Retrieved
from http://www.genderpsychology.org/transsexual/benjamin_gd.html
X
X Chromosome
The X chromosome is one of the two chromosomes that determine the biological
sex of an individual, the other being the Y chromosome. The two sex chromo-
somes are among the forty-six chromosomes, organized into twenty-three pairs,
that each person normally has inside their body cells. These microscopic thread-
like structures carry the units of inheritance—genes—that determine the physical
and behavioral characteristics that parents pass to their offspring. Genes are made
of deoxyribonucleic acid (DNA).
Human females have a pair of X chromosomes in each of their body cells (also
called somatic cells), and human males have an X chromosome paired with a
Y chromosome in each of their body cells. These chromosomes are inherited from
the parents when the sperm cell fertilizes the egg cell at the time of conception.
Each egg cell has only one X chromosome, and each sperm cell has either an X or
a Y chromosome. Thus, the sex of the child is dependent on the particular sperm
cell that fertilizes the egg.
Besides determining an individual’s sex, the X and Y chromosomes each carry
numerous genes made of DNA codes that determine or influence other traits of the
individual. These traits are either X-linked or Y-linked traits. The X chromosome
has more than 800 genes, about 250 of which can cause health disorders if mutated
(occurring in an abnormal form). Among the many X-linked disorders are alpha
thalassemia mental retardation syndrome (a severe type of intellectual and devel-
opmental disability), androgenetic alopecia (a common form of hair loss), breast
cancer, colorblindness, fragile X syndrome (a severe type of learning disability),
hemophilia (a bleeding disorder resulting from an inability of the blood to clot),
muscular dystrophy (progressive muscle wasting), type 1 diabetes, and certain
types of deafness.
Most genes occur in pairs, called alleles, within the chromosome pair. For
example, a gene will have one allele on one X chromosome and a corresponding
allele on the other X chromosome within the chromosome pair of a female. One
allele is inherited from the mother and the other from the father. Some alleles are
dominant, while other alleles are recessive. If a gene occurs as two recessive
alleles, any traits resulting from the recessive alleles will be evident in the indi-
vidual. However, if a recessive allele is paired with a dominant allele, any traits
coded for by the recessive allele will be blocked by the dominant allele.
Most of the genes linked to diseases and disorders on the X chromosome are in
the form of recessive alleles. Thus, a female will not have the condition coded for
by any of these alleles if one of her two X chromosomes has the dominant version
of that allele. By contrast, because a male has only one X chromosome, there is no
792 X Chromosome
other dominant allele version to block the recessive allele’s effects. That is why
X-linked disorders are more common in males than in females.
In addition to the X-linked disorders caused by particular abnormal genes,
there are other disorders caused by missing or extra X chromosomes. Turner syn-
drome is a developmental abnormality that occurs when only one normal X chro-
mosome is present in cells. The other X chromosome is either missing entirely or
structurally abnormal. Individuals with this syndrome are unusually short, and
their ovaries do not function. Triple X syndrome, also called trisomy X, occurs
when there is an extra X chromosome in the cells. Individuals with this syndrome
have three X chromosomes instead of the normal two, which typically results in
unusual tallness and learning disabilities.
Klinefelter syndrome occurs in individuals who have one or more extra copies
of the X chromosome—for example, XXY or XXXY. The extra chromosomal
material blocks the normal production of testosterone and the normal develop-
ment of male sexual characteristics. As a result, these individuals typically have
abnormalities in their genitals as well as female-like breast and hip development
and reduced body and facial hair. Learning disabilities may also be present. The
greater the number of extra X chromosomes, the greater the learning disabilities.
The presence of both an extra X chromosome and an extra Y chromosome
results in a condition called 48,XXYY syndrome. As with Klinefelter syndrome,
48,XXYY syndrome is characterized by abnormal sexual development. Affected
individuals have malfunctioning testes and reduced levels of testosterone.
The unusual sexual conditions caused by X-chromosome abnormalities some-
times lead to ambiguous gender appearances in affected individuals. Some indi-
viduals may be raised as one gender but as an adult identify with another gender.
In certain cases, these individuals may choose to undergo gender reassignment
surgery to make their physical sex conform to their psychological sex.
A. J. Smuskiewicz
See also: Chromosomal Sex; Intersexuality; Klinefelter Syndrome; Sex Chromosomes;
Turner Syndrome; Y Chromosome.
Further Reading
Cover, V. I. (2012). Living with Klinefelter Syndrome (47,XXY), Trisomy X (47,XXX), and
47,XYY: A guide for families and individuals affected by X and Y chromosome
variations. New York: Virginia Isaacs Cover.
National Institutes of Health. (2019). X chromosome. Retrieved from http://ghr.nlm.nih
.gov/chromosome/X
Y
Y Chromosome
The Y chromosome is one of two chromosomes that determine the biological sex
of an individual, the other being the X chromosome. The two sex chromosomes
are among the forty-six chromosomes, organized into twenty-three pairs, that
each person normally has inside their body cells. These microscopic threadlike
structures carry the units of inheritance—genes—that determine the physical and
behavioral characteristics that parents pass to their offspring. Genes are made of
deoxyribonucleic acid (DNA).
Human males have an X chromosome paired with a Y chromosome in each of
their body cells (also called somatic cells). Human females have a pair of X chro-
mosomes in each of their body cells. These chromosomes are inherited from the
parents when the sperm cell fertilizes the egg cell at the time of conception. Each
egg cell has only one X chromosome, and each sperm cell has either an X or a
Y chromosome. Thus, the sex of the child is dependent on the particular sperm
cell that fertilizes the egg.
The Y chromosome has approximately sixty genes—far fewer than the 800 to
1,000 genes located on the X chromosome. The DNA of genes functions like a
code, with chemical instructions for making particular proteins. These proteins,
in turn, take part in biochemical reactions in the body that influence or determine
particular traits of the body. The traits coded for by Y-chromosome genes are
known as Y-linked traits.
Many of the genes on the Y chromosome are responsible for guiding normal
male sexual development and maintaining male fertility. The main gene that
prompts the development of a fetus into a male is the SRY (sex-determining
region Y) gene, which codes for a protein that causes fetal precursor cells to
become the cells of the testicles. Other Y-chromosome genes that have been iden-
tified include USP9Y (which plays a role in sperm cell development) and SHOX
(which guides the growth and development of arm and leg bones).
Several genes on the Y chromosome can cause disorders if mutated (occurring
in an abnormal form). Certain mutations in the SRY gene cause a condition called
gonadal dysgenesis, also known as Swyer syndrome. Individuals with gonadal
dysgenesis have XY chromosomes like a male but sex organs like a female, includ-
ing a vagina, uterus, and fallopian tubes. However, instead of having ovaries or
testicles, they have undeveloped masses of tissue known as streak gonads. These
individuals usually live as females, but they require hormone therapy in order to
develop female secondary sexual characteristics, such as breast development.
Because they do not produce eggs, they cannot become pregnant naturally.
794 Y Chromosome
However, some individuals can become pregnant with donated eggs or donated
embryos.
Another condition linked to abnormalities in the SRY gene is 46,XY sex rever-
sal, in which the individual has XY chromosomes like a male but genitals that are
sexually ambiguous. An individual may have an incompletely developed vagina
as well as incompletely developed testicles. Sperm may or may not be produced,
and a uterus may or may not be present. These persons may be raised as either
male or female, but many eventually choose to undergo surgery so that their exter-
nal genitals align with their gender identity.
Certain mutations in the SHOX gene cause conditions called Langer mesomelic
dysplasia and Léri-Weill dyschondrosteosis, both of which are characterized by
abnormally short leg and arm bones and other bone and muscle problems. Missing
genetic material in regions of the Y chromosome called AZFA, AZFB, or AZFC
lead to male infertility by causing sperm production to be absent, reduced, or
abnormal.
In addition to the Y-linked disorders caused by particular abnormal genes,
there are other disorders caused by missing or extra Y chromosomes. Males
with XYY syndrome, also called Jacob’s syndrome, have an extra Y chromo-
some, resulting in unusually high levels of testosterone in their bodies. As ado-
lescents, they are typically tall and slender and have severe acne. As adults, most
individuals are taller than 6 feet (1.8 meters) and live normal lives, many never
even knowing that they have a unique chromosomal condition. With other poly-
somy Y syndromes (XYYY, XYYYY) individuals typically have skeletal
abnormalities and intellectual disabilities. An extra Y chromosome together
with an extra X chromosome results in a condition called 48,XXYY syndrome.
Affected individuals have malfunctioning testicles and reduced levels of
testosterone.
In 46,XX testicular disorder, an individual is born with the SRY gene on one of
their X chromosomes. This condition occurs when the SRY gene from a Y chro-
mosome is mistakenly transferred to an X chromosome within the sperm cell. The
individual usually appears to be male but has abnormally small testicles or other
testicular abnormalities. Some individuals may have genitalia that are not clearly
male or female.
A. J. Smuskiewicz
See also: Chromosomal Sex; Intersexuality; Sex Chromosomes; X Chromosome.
Further Reading
Cover, V. I. (2012). Living with Klinefelter Syndrome (47,XXY), Trisomy X (47,XXX), and
47,XYY: A guide for families and individuals affected by X and Y chromosome
variations. New York: Virginia Isaacs Cover.
National Institutes of Health. (2019). Y chromosome. Retrieved from http://ghr.nlm.nih
.gov/chromosome/Y
Wade, N. (2014, April). Researchers see new importance in Y chromosome. New York
Times, A4. Retrieved from http://www.nytimes.com/2014/04/24/science/resear
chers-see-new-importance-for-y-chromosome.html?_r=0
Yeast Infection (Candidiasis) 795
Yeast Infection (Candidiasis)
Candida are ubiquitous yeast that commonly colonize humans and are the leading
fungal cause of serious infectious diseases. Several Candida species are part of
the normal flora of the skin, mucous membranes, vagina, and gastrointestinal
tract. As well as being part of the normal flora, certain species can be acquired
from the environment. Candidal disease ranges from localized skin infection to
life-threatening systemic disease. The growing incidence of serious infections due
to Candida mirrors the rising numbers of immunocompromised individuals, who
are at greatest risk for disease.
The earliest description of candidal infections is attributed to Hippocrates in
Epidemics (fourth century BCE), in which he details oral candidiasis (thrush) in
two patients. Thrush was again illustrated in medical reports in the late 1700s and
1800s. The fungus was first isolated in pure culture in 1844. The fungus was
called by several names until 1923, when Christine M. Berkhout (1893–1932)
established the genus Candida.
However, general interest in Candida remained relatively low until the second
half of the twentieth century, when the incidence of invasive disease increased at
a remarkable rate—by over 200 percent. This can in part be attributed to improved
laboratory identification methods. However, it is largely due to advances in medi-
cine, including chemotherapy, broad-spectrum antibiotics, intravenous catheters,
and intensive care units (ICUs), resulting in increasing numbers of patients with
compromised host barriers (such as the skin) and altered immunity.
The genus Candida currently includes more than 150 different species. How-
ever, few are usually associated with human disease. The incidence of disease
caused by each species has significantly varied over the past forty years, driven by
the disease spectrum of patients and the use of different antifungal drugs. Can-
dida albicans remains the most common species worldwide, typically responsible
for approximately 50 percent of infections. Candida parapsilosis and Candida
glabrata occur at similar rates, approximately 20 percent of infections, though
local variation in their rates can be quite pronounced. Candida krusei, Candida
tropicalis, Candida dubliniensis, and Candida lusitaniae are less frequent, but
nevertheless important, causes of invasive disease.
“Candidiasis” refers to all types of infections caused by Candida. The spec-
trum of disease is extremely broad, as infections caused by the fungus can involve
virtually every tissue in the body. The most common types of candidal infections
involve the skin or mucus membranes. Cutaneous infections typically occur in
warm, moist regions, such as with “diaper rash” or under the breasts. These infec-
tions are characterized by a red, itchy rash, originating as either vesicles or pus-
tules (small fluid- or pus-filled skin lesions) that then coalesce into beefy red
regions with a scalloped border and frequent small satellite lesions.
Candidal infection of the tissues around nails can lead to chronic infection of
the nail or nail bed (onychomycosis). Oropharyngeal (mouth and throat) candidia-
sis (thrush) usually occurs after antibacterial drug or steroid use and can also nor-
mally occur in newborn infants. Antibiotics and steroids primarily alter the local
microbiome (group of microbes living in a region of the body) and the host
796 Yeast Infection (Candidiasis)
response to the yeast, respectively, facilitating the growth of Candida. Risk fac-
tors for thrush include diabetes; leukemia or other cancers, especially patients on
chemotherapy; or infection by the human immunodeficiency virus (HIV). Den-
tures also increase the risk of thrush. In thrush, the oral mucosa displays patchy,
white lesions surrounded by red, inflamed tissue. Patients with HIV are at the
greatest risk of developing a more severe form of the disease in which the esopha-
gus is involved.
Vulvovaginal candidiasis (yeast infection) is the second most common vaginal
infection in the United States. Approximately 75 percent of women of childbear-
ing age will develop this problem, characterized by vaginal itchiness and some-
times a thick curd-like discharge.
Although less common, invasive or disseminated candidiasis is greatly feared
due to the associated morbidity and mortality. Candidemia (yeast in the blood)
produces illnesses that are symptomatically indistinguishable from bloodstream
infections with bacteria, including fever and changes in pulse and blood pressure.
Once within the bloodstream, Candida can localize to the heart, eyes, bone,
abdominal organs, brain, or other tissues. In addition to seeding via the blood-
stream, many of these tissues can also be locally infected with Candida after
trauma, such as after intestinal perforation.
Diseases due to Candida most often arise from a patient’s normal flora and less
frequently are due to strains acquired from a health care provider or an environ-
mental source. Important environmental sources for hospitalized patients include
respirators, air-conditioning vents, foods, and countertops or floors. Candidal
infections occur throughout life, and the spectrum of clinical illness primarily
depends on the immune status of the host. The most important risk for severe dis-
ease is the disruption of a host’s barrier, either by the placement of an intravenous
catheter, damage to tissues due to surgery, trauma, or cancer, particularly in the
setting of treatment with chemotherapy or radiation. Because intravenous cathe-
ters are ubiquitous in patient care, the risk of developing disseminated candidiasis
is extremely high in neonatal, medical, and surgical ICUs.
Once the yeast breaches the body’s natural barriers, the primary cell of the
immune system that protects the infected person is the neutrophil. Therefore, con-
ditions in which neutrophils are low (such as with leukemia, treatment of cancers,
etc.) or dysfunctional (such as with steroid use, chronic granulomatous disease,
Chediak-Higashi syndrome, etc.) significantly increase the risk for invasive
candidiasis.
Although troublesome, cutaneous and mucocutaneous candidiasis are rarely
fatal. In contrast, the mortality rate for disseminated candidiasis is about 40 per-
cent. This is especially concerning because Candida species currently are the
fourth most commonly isolated organism in blood cultures. In addition, it is esti-
mated that blood cultures only detect about 70 percent of candidemias. It has been
projected that the total number of hospital-acquired candidal bloodstream infec-
tions is up to 30,000 cases per year, resulting in more than 10,000 deaths
annually.
Diagnosis of cutaneous and mucocutaneous candidiasis is often based on clini-
cal presentation and generally achieved by direct observation of the fungus on a
Yeast Infection (Candidiasis) 797
slide with staining by potassium hydroxide. Culture is performed only in refrac-
tory disease (disease resistant to treatment) or for esophageal candidiasis. The
fungus grows well on a broad variety of standard mycological growth media. In
blood culture, however, candidemia is missed about 30 percent of the time, and
alternative testing methods have not been shown to be particularly effective.
Cutaneous candidiasis, including vaginal yeast infection, is typically treated
with a short course of a topical azole (clotrimazole, miconazole), allylamine (terbi-
nafine), or polyene (nystatin). Azoles and allylamines block ergosterol synthesis (a
key component of the fungal cell membrane), polyenes disrupt the fungal cell
membrane, and echinocandins inhibit cell wall synthesis in fungal cells.
Oral candidiasis is usually treated with solutions of clotrimazole or nystatin, or
with the oral azole fluconazole. Esophageal candidiasis is initially treated with
oral fluconazole for about two weeks, while vaginal candidiasis is treated with a
single dose of oral fluconazole or with topical antifungals. Due to concerns regard-
ing resistance, systemic infections are often initially treated intravenously with an
echinocandin (caspofungin, micafungin, or anidulafungin) or the polyene ampho-
tericin B. If the Candida species is susceptible, the antifungal is changed to an
azole, typically fluconazole.
Handwashing is uniformly a reasonable first step in reducing infectious dis-
eases. Keeping skin clean and dry significantly reduces the incidence of cutane-
ous candidiasis. Limiting the use of antibiotics also reduces the incidence of
several forms of candidiasis, especially oral and vaginal disease. In certain pop-
ulations, such as premature, low-birthweight newborns receiving intravenous
nutrition or patients with a protracted period of neutropenia (having too few
neutrophils) on chemotherapy, it is routine in many centers to administer an
azole or echinocandin.
Joshua D. Nosanchuk
See also: Bacterial Vaginosis; Vagina; Vaginal Secretions; Vaginitis.
Further Reading
Calderone, R. A., & Clancy, C. J. (Eds.). (2011). Candida and candidiasis (2nd ed.). Wash-
ington, DC: ASM Press.
Lotz, M. M., Moses, M. A., & Pories, S. E. (2009). Cancer. Santa Barbara, CA:
Greenwood.
Pappas, P. G., Kauffman, C. A., Andes, D., Benjamin, D. K. Jr., Calandra, T. F., Edwards,
J. E., Jr., ... Reboli, A. C. (2009). Clinical practice guidelines for the management
of candidiasis: 2009 update by the Infectious Diseases Society of America.
Clinical Infectious Diseases, 48(5), 503–535.
About the Editor
and Contributors
EDITOR
HEATHER L. ARMSTRONG is a lecturer (assistant professor) in sexual health at
the University of Southampton. Her research focuses on improving sexual health
and well-being, especially for sexual- and gender-minority folks. She has a PhD in
experimental psychology from the University of Ottawa and completed postdoc-
toral fellowships at the U.S. Centers for Disease Control and Prevention and the
University of British Columbia at the British Columbia Centre for Excellence in
HIV/AIDS.
CONTRIBUTORS
JEFFREY ABRACEN is chief psychologist with Central District Parole, Correc-
tional Service of Canada (CSC). He was employed as the clinical director of the
community-based Methadone Maintenance Treatment Program operated by CSC,
and until late 2011 was codirector of the Relapse Prevention Maintenance Pro-
gram offered to sexual offenders in the Central District of CSC. He has provided
training related to the community treatment and supervision of sexual offenders
to a variety of audiences and has more than forty publications in peer-reviewed
journals as well as many conference presentations. Dr. Abracen holds an adjunct
faculty position at the Ontario Technology University in the Department of
Psychology.
ROBERTO L. ABREU, PhD, is an assistant professor in the counseling psychol-
ogy program at Tennessee State University. Dr. Abreu’s research focuses on the
well-being of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people,
people of color (POC), and LGBTQ POC. Specifically, his research has focused
on Latinx LGBTQ individuals and family and community relations. Roberto’s
clinical experiences include working with children and adolescents diagnosed
with autism spectrum disorder and other emotional behavioral disorders, LGBTQ
teenagers and young adults, college students, low-income families and immi-
grants, incarcerated men and women with severe mental illness in state and fed-
eral prisons, and veterans with substance abuse disorders.
800 About the Editor and Contributors
AMAN AGAH has published film and literary reviews in the magazines Make/
Shift Magazine, Bta’arof, and on popmatters.com. She has also cotaught Introduc-
tion to Media Literacy at George Mason University. Her areas of study and inter-
est include film and literature with a focus on the gothic, as well as gender and
queer studies. She attended George Mason University and The New School in
New York.
CHRISSANDRA ANDRAE, MA, LMSW, is a queer artist and psychotherapist
living in Brooklyn, New York. Chris provides kink-, poly-, trans-, and LGBQ-
affirmative behavior therapy under the supervision of Dr. Dulcinea Pitagora as a
member of the Manhattan Alternative Wellness Collective. Sandra was the Alec
Baldwin Drama Scholar at NYU’s Tisch School of the Arts as an undergraduate
and a Creative Impact Scholar at the National University of Ireland: Uversity as a
masters-level student. Chrissandra is a graduate of the Dialectical Behavior Ther-
apy Training Program and Lab at the Columbia University School of Social Work.
NADAV ANTEBI-GRUSZKA is an adjunct assistant professor in the psychology
department at Columbia University and the City College of New York. Nadav
earned their PhD in sociomedical sciences from Columbia University, MA in
human development from Cornell University, and MA in mental health counsel-
ing from City College of New York. Nadav also works at two private practices in
Manhattan where they have the privilege of working with diverse clients and
especially LGBTQ+ individuals. Nadav has published peer-review articles on
resilience, pornography, sex work, and HIV prevention, as well as multiple ency-
clopedia entries and op-ed pieces about various LGBTQ+ issues. Nadav’s work
has been supported by numerous sources, including the American Psychological
Foundation, the American Psychological Association, and the Kinsey Institute.
CASSIA ARAUJO-LANE, BA, completed her bachelor of arts in psychology at
New York University in 2016. Araujo-Lane has five years’ experience in harm
reduction and integrated behavioral and primary care initiatives in the Bronx,
Brooklyn, and Boston, Massachusetts. She completed her premedical certificate at
Northeastern University in 2019 and currently works as a medical scribe at a urol-
ogy clinic and a primary care clinic.
ADRIENNE M. BAIRSTOW, PhD, is a psychotherapist in Toronto, Canada,
where she maintains a private practice with a focus on relationship and sex ther-
apy. She holds a master’s degree in social work from the University of Toronto,
and a master’s degree in education and a doctorate in human sexuality studies
from Widener University.
AMANDA BAKER, LMFT, MEd, is a doctoral candidate at Widener University.
She is a therapist and educator in Texas. Her therapeutic work has primarily
focused on working with teenagers, military, and trauma survivors. Her research
focuses on trauma and the impacts on intimate partner relationships and individu-
als and the impact of sexting on individuals and couples.
About the Editor and Contributors 801
REGINALD BARKER is a first-year addiction studies graduate student at Gover-
nor’s State University, University Park, Illinois, where he has also received a mas-
ter’s degree in criminal justice in May 2016. He is an investigator with the Cook
County Sheriff’s Department in Chicago, Illinois. He is also a varsity high school
baseball assistant coach at Simeon Career Academy, also in Chicago.
KAREN S. BEALE, PhD, is an associate professor of psychology at Maryville
College in Tennessee. An award-winning teacher, Karen teaches courses on
human sexuality, intimate relationships, and adolescence. Her research focuses
primarily on the predictors and outcomes of sex guilt, with the goal of improving
sexual and relationship satisfaction.
RACHEL BECKER-WARNER is an associate professor of clinical psychology in
the Program in Human Sexuality at University of Minnesota. She specializes in
sexual health and gender care, focused on helping individuals across the age span
establish and renew their sexual, emotional, and gender health and relational well-
being. Her research and practice interests include the intersection of neuro and
gender diversity, the neurobiological impact of trauma, and development of gen-
der identity for gender-diverse people.
DIANNE BERG is an assistant professor and licensed psychologist at the Pro-
gram in Human Sexuality. She has been working clinically with gender-creative
children and transgender adolescents for over fifteen years and is a published
scholar and invited speaker at regional and national conferences. She is the codi-
rector of the National Center for Gender Spectrum Health, co-coordinator of the
Transgender Health Services Program with a special emphasis in child and ado-
lescent gender health, and a member of the Child and Adolescent Committee of
the World Professional Association for Transgender Health, an international orga-
nization that asserts evidence-based practices through its published “Standards of
Care.” Dr. Berg is the coauthor of the Gender Affirmative Lifespan Approach, the
theoretical framework for the clinical research program of the National Center for
Gender Spectrum Health. She received her PhD in counseling psychology from
the University of Illinois at Urbana-Champaign.
ILYSSA BOSESKI is a psychotherapist with experience in social work and human
sexuality. She has a dual master’s degree in social work and human sexuality
education.
ELIZABETH R. BOSKEY, PhD, MPH, LICSW, is a research fellow and social
worker with the Center for Gender Surgery at Boston Children’s Hospital and has
been the sexually transmitted disease expert at Verywell (formerly About.com)
since 2007. She also maintains a small private practice where she focuses on
working with sexual-, gender-, and relationship-minority clients. Dr. Boskey is the
author of America Debates Genetic Testing, coauthor of The InVision Guide to
Sexual Health, and coeditor of The Truth about Rape. She has contributed to the
Wiley Encyclopedia of Child Health and Human Development and the SAGE
802 About the Editor and Contributors
Encyclopedia of Global Health and authored numerous peer-reviewed and popu-
lar science articles on sexual and gender health.
NOVA J. BRADFORD is a graduate student in the School of Social Work at the
University of Minnesota Twin Cities. Her research interests center on the relation-
ships between sexual health, mental health, and identity development trajectories
in transgender and nonbinary communities. As a mixed methodologist, she employs
both quantitative and qualitative analyses to explore transgender health across the
life span. As a clinical researcher, she has worked to develop and manualize gen-
der-affirmative sex therapy techniques that are responsive to the dynamic sexual
health needs of gender-diverse communities. Outside of her research, she is pas-
sionate about community organizing and policy advocacy to achieve empower-
ment and equity for transgender, nonbinary, and gender-nonconforming people.
RICHARD A. BRANDON-FRIEDMAN, PhD, LCSW, LCAC, is an assistant
professor in the Indiana University School of Social Work. His research focuses
on youth sexual identity development, sexual orientation identity, gender identity,
and social and behavioral determinants of sexual health. Most of his work involves
youth who identify as sexual and/or gender minorities and youth in the child wel-
fare system. In addition to his academic work, he maintains a private clinical
social work practice and serves on the board of directors for several agencies
focused on serving sexual and/or gender minorities and youth in the child welfare
system. Dr. Brandon-Friedman holds a bachelor of arts in psychology from the
University of Notre Dame and a master’s degree and PhD in social work from the
Indiana University School of Social Work.
DOUGLAS BRAUN-HARVEY is a sexual health author, trainer, and psychother-
apist who bridges sexual and mental health and facilitates organizational change.
In 2013, Doug Braun-Harvey and Al Killen-Harvey cofounded the Harvey Insti-
tute, an international education, training, consulting, and supervision service for
improving health care through integration of sexual health. Since 1993, he has
been developing and implementing a sexual health–based treatment approach for
men with out-of-control sexual behavior. His new book Treating Out of Control
Sexual Behavior: Rethinking Sex Addiction, written with coauthor Michael Vig-
orito, was published in 2015. Previous publications include Sexual Health in
Recovery: Professional Counselor’s Manual (2011) and Sexual Health in Drug
and Alcohol Treatment: Group Facilitator’s Manual (2009). From 1987 to 2019, he
provided individual and group therapy in his San Diego, California, private
practice.
KELWYN BROWNE is a public health sexologist working in developing coun-
tries in the area of sexual health literacy, sexual health promotion, and sexual
health education for health professionals.
TAMAR BURRIS is an independent writer and researcher. She is the owner of
Tab Writers, Inc. She has worked with the Discovery Channel, PBS, ESPN, and
About the Editor and Contributors 803
with various educational stations, publications, and websites, as both a writer and
educational curriculum expert.
LEONARDO CANDELARIO-PÉREZ, PhD, is a licensed clinical psychologist,
sexual health consultant, and health care provider in urology and gynecology, as
well as gender specialist for Health Partners and coeducational consultant for the
National Center for Gender Spectrum Health (NCGSH). Dr. Candelario-Pérez
completed their doctoral degree at Albizu University in their home country of
Puerto Rico and completed a clinical postdoctoral program in 2018 at the Program
in Human Sexuality at University of Minnesota. Currently, Dr. Candelario-Pérez
is working on developing an integrative sexual health practice within the Health
Partners’ health care system. Their clinical areas of work are in sexual dysfunc-
tion, sexual pleasure, sexual and gender identity, LGBTQI+ sexual health, sexu-
ally transmitted infections and sexuality, desire discrepancy, intersections of
identity, problematic sexual behaviors, and mental health and sexuality. As coedu-
cation consultant for the NCGSH, Dr. Candelario-Pérez is involved in the develop-
ment of training and educational materials for providers across the health fields.
Said material is based on and promotes the use of the Gender Affirmative Life
Span Approach.
KIFFER G. CARD is a Health Systems Impact Fellow with the Community-
based Research Centre. He holds a BS in epidemiology and biostatistics from
Brigham Young University and a PhD in health sciences from Simon Fraser Uni-
versity. Situated at the intersection of quantitative anthropology, social epidemi-
ology, and behavioral science, Dr. Card’s research focuses on understanding the
biopsychosocial foundations of behavior and how this knowledge can be lever-
aged to support policies that improve the health and well-being of gay and
bisexual men.
JORY M. CATALPA, MA, is a doctoral candidate and teaching and research
assistant in the Family Social Science department and a research affiliate for the
National Center for Gender Spectrum Health at the University of Minnesota–Twin
Cities. They have published and presented in the areas of queer methods and mea-
surement, body image, resilience, ambiguous loss, family boundary ambiguity,
trans family theory, transgender community belongingness, transgender sexual-
ity, and transgender identity development. Their queer theoretical methodology
seeks to apply an antinormative framework to collecting and interpreting data and
disseminating research.
STEPHANIE C. CHANDO, MEd, LSW, MSW, is a sex- and death-positive pal-
liative care social worker and sexuality educator. She is a PhD candidate in human
sexuality at Widener University, where her dissertation research focuses on the
sexuality of individuals receiving hospice care. Stephanie currently serves as the
social worker on the inpatient palliative care team at Pennsylvania Hospital in
Philadelphia. Ms. Chando is also a part-time lecturer at the University of Pennsyl-
vania’s School of Social Policy and Practice.
804 About the Editor and Contributors
CARSON CLARK is an undergraduate student at Maryville College. She is a
member of the Student Judicial Board and Maryville College Democrats and is an
ambassador for Maryville College. She plans to attend graduate school to study
women and gender issues in the law.
ALEXANDRIA COLBURN, MS, is a doctoral student in clinical psychology at
Marquette University in Milwaukee, Wisconsin, working with Ed de St. Aubin,
PhD. She holds a bachelor of arts degree in psychology and women’s studies from
St. Catherine University and a master of science degree in clinical psychology
from Marquette. She is broadly interested in conducting social justice–focused
research and clinical work that supports underserved, marginalized communities.
She is passionate about incorporating intersectionality theory into her work in
investigating the complex underpinnings and outcomes of identity-related
experiences.
CALLUM E. COOPER, PhD, is a senior lecturer of psychology at the University
in Northampton, UK. He is a chartered psychologist of the British Psychological
Society. He received a PhD in thanatology from the University of Northampton
and a PhD in parapsychology from Manchester Metropolitan University. Dr. Coo-
per holds various professional positions. He is a research affiliate of Hope Studies
Central (University of Alberta), a professional member of the Parapsychological
Association (USA), and a Council Member of the Society for Psychical Research
(UK). He has received various awards for his research in psychology and skeptical
activism within science. At the University of Northampton, he lectures and con-
ducts research on human sexual behavior, parapsychology, positive psychology,
and death and bereavement. He has authored, edited, and contributed to several
books, including Paracoustics and Psi in Psychotherapy (White Crow Books).
YOKO CRUME, PhD, MS, MSW, LCSW, is an international research and practice
consultant specializing in aging society, long-term care, housing and environment,
and mental health. Her professional experience includes an academic appointment
as associate professor for the Joint Master of Social Work program (a joint venture
between North Carolina A&T State University and the University of North Caro-
lina at Greensboro) and an appointment as the lead planner and evaluator for the
North Carolina Division of Aging and Adult Services. Crume was also the found-
ing director for the Thriving Families Project, a mental health outreach program
for Spanish-speaking families in Greensboro, North Carolina. Crume is licensed as
a clinical social worker and publishes bilingually in English and Japanese.
MONA DALAL, MD, is a resident at the NYP/Columbia University Center of
Family Medicine. She received her MD from the University of Iowa (2010) and
her BS from Northwestern University (2005). She was a health educator through
AmeriCorps from 2005 to 2006. Her interests include reproductive health, global
health, and human rights.
SILVAIN S. DANG, MA, is a PhD candidate in clinical psychology at the Univer-
sity of British Columbia, in Vancouver, Canada. His dissertation research focuses
About the Editor and Contributors 805
on the role of cultural and interpersonal factors on the sexual experiences and
functioning of Chinese and East Asian individuals in Canada. His research and
clinical interests include sexual functioning; the etiology of sexual and gender
diversity; and the role of culture, attachment style, and perfectionism on sexual
and mental health. Silvain holds a master’s degree in clinical psychology from the
University of British Columbia.
CYNDI DARNELL is an Australian clinical sexologist, narrative therapist, and
former psychotherapist now based in New York City. She holds multiple master’s
degrees in sexual health and narrative therapy from the Universities of Sydney
and Melbourne, respectively, as well as graduate studies in mental health counsel-
ing and psychotherapy. She maintains a global consulting practice to individuals
and couples in the areas of sex and relationships with a focus on pleasure and
freedom. Her work is published in the Journal of Sexual and Relationship Ther-
apy (UK) and the Journal of Sex Education (UK). She’s presently an affiliate on
the advisory board of University of Wisconsin–Stout Graduate Certificate in Sex
Therapy Program and faculty on Pink Therapy’s (UK) Foundation Certificate in
Gender, Sexuality, and Relationship Diversity Therapy.
MELANIE DAVIS, PhD, is a certified sexuality educator, counselor, and educator
supervisor through the American Association of Sexuality Educators, Counselors
and Therapists. She is the Our Whole Lives program manager for the Unitarian
Universalist Association and is an adjunct professor for Widener University’s
Center for Human Sexuality Studies. She is a founding partner in the New Jersey
Center for Sexuality Education and is copresident of the Sexuality and Aging
Consortium at Widener University. She is the author of Our Whole Lives Sexuality
Education for Older Adults; Sexuality and Our Faith: A Companion to Our Whole
Lives Sexuality Education for Grades 7–9; and Look Within: A Woman’s Journal.
She holds a master’s degree and doctorate in human sexuality education from
Widener University.
DAMIENE DENNER, MEd, ABD, is a doctoral candidate at Widener University
in Chester, Pennsylvania, studying human sexuality education. Damiene’s
research focus is on sexual violence prevention, implementation fidelity, and using
virtual reality as a teaching tool. Currently, Damiene works as a sexual health
educator in Rochester, New York, and holds a master’s in education degree from
Widener University. Damiene is a student member of the American Association of
Sexuality Educators, Counselors and Therapists and the Society for the Scientific
Study of Sexuality.
JANNA A. DICKENSON, PhD, is a postdoctoral fellow in the program in human
sexuality at the University of Minnesota. She holds a doctorate in clinical psychol-
ogy from the University of Utah. Her graduate work focused on sexual fluidity
and its neurobiological correlates, and she is the author of several papers on this
topic. In her fellowship, she helps people who feel that their sexual behavior is out
of control and researches the psychosocial factors associated with hypersexual
behavior. Dr. Dickenson has also devoted her spare time to initiatives to end
806 About the Editor and Contributors
nonconsensual sexual interactions and has chaired a local workgroup devoted to
this cause.
FRANCO DISPENZA, PhD, CRC, is an associate professor in the Department of
Counseling and Psychological Services at the Georgia State University. He is a
licensed psychologist and a certified rehabilitation counselor who works in the
areas of multiculturalism, sexuality, and disability. Employing a variety of
research and analytical methodologies (including quantitative, qualitative, and
mixed methods), Dr. Dispenza has three particular lines of research that include
lesbian, gay, bisexual, and transgender populations: (1) career and vocational
development, (2) health and psychosocial functioning, and (3) counselor compe-
tence and counseling practice. Dr. Dispenza holds a master’s degree in rehabilita-
tion counseling and a doctorate in counseling psychology.
NICOLE C. DORIA, MA, has a BA in political science (University of Guelph), a
BS in health promotion (Dalhousie University), and a MA in health promotion
(Dalhousie University). Her areas of research specialization include women’s
health and indigenous health. Nicole holds several leadership positions with the
Avalon Sexual Assault Centre board of directors in Halifax, Nova Scotia, where
she works toward preventing sexual assault/abuse and changing the current socio-
political culture that facilitates sexualized violence.
RENEE DUBIE earned a BA in philosophy from the University of California,
Santa Barbara, and a MA in political science from San Diego State University.
KEVICHA ECHOLS is a full-time faculty member in health, physical education,
and recreation at Kingsborough Community College in Brooklyn, New York. She
is an advocate and researcher of sex workers and sex worker–related issues.
DEBBIE JOFFE ELLIS was born and raised in Melbourne, Australia. A licensed
psychologist (Australia), licensed mental health counselor (New York), adjunct
professor at Columbia University in New York City, presenter, and writer, for
years she worked with her husband, the brilliant and renowned pioneer of modern
cognitive therapies Dr. Albert Ellis, giving public presentations and professional
trainings in his approach of rational emotive behavior therapy (REBT) as well as
collaborating with him on writing and research projects until his death in 2007.
Recognized as a world-renowned expert on REBT, she continues to present, prac-
tice, and write about his groundbreaking psychotherapeutic approach of REBT in
cities throughout the United States and in countries around the globe.
LAUREN EWANIUK, PhD, is a certified secondary education teacher with
nearly fifteen years of experience in the areas of social sciences and family con-
sumer sciences. She received her BSE from Millersville University, an MEd from
Gratz College, and an MEd and PhD in human sexuality from Widener Univer-
sity. Her areas of interest include sex and technology, child development, sexuality
education for adolescents, and social movements in history. Along with her
About the Editor and Contributors 807
classroom experience, she has collaborated with authors on books with topics that
include controversial issues in society and historical moments and figures in sex-
ual revolutions.
ITOR FINOTELLI JR., PhD, is a psychologist and gender and sexuality special-
ist at Rio de Janeiro State University and has a master’s degree and PhD from
Sao Francisco University. Dr. Finotelli works as a clinical psychologist in the
area of sexuality. Dr. Finotelli develops techniques, procedures, and measure-
ment instruments for the assessment of human sexuality and works in projects
and policies management for the promotion of sexual health and sexual rights.
Dr. Finotelli is former president of the Brazilian Society for Studies of Human
Sexuality and current secretary/treasurer of the World Association for Sexual
Health (2017–2021).
MARISSA C. FLORO, PhD, is a postdoctoral fellow in gender and sexual identi-
ties at Stanford University and teaches about sexuality and gender issues in ther-
apy at University of San Francisco as an adjunct faculty member in the master of
marriage and family therapy graduate program. Dr. Floro’s research work, clinical
practice, teaching, and outreach programming focuses on the intersections of
identity and how to create community, support, and belonging for those who find
themselves at these intersections. Marissa holds a master’s in mental health coun-
seling from Boston College and a doctorate in counseling psychology from Loyola
University Chicago.
ANNE M. FOGLE, MD, is a board-certified family physician who practices med-
icine in Louisville, Kentucky. She is a graduate of the University of Notre Dame
and University of Louisville School of Medicine. Dr. Fogle completed her family
medicine residency at the University of Nevada in Reno.
SHADEEN FRANCIS, LMFT, is a licensed marriage and family therapist, gradu-
ate professor, and author specializing in sex therapy and social justice. She has
been featured as a relationship expert on national media platforms like 6abc, the
New York Times , NBC, and Huffington Post , and speaks internationally on topics
like sexual self-esteem, intimacy, and relationship negotiation. Shadeen got her
start as a radio host and sex educator at McMaster University and eventually
decided to transition her love of education to lecturer positions at Thomas Jeffer-
son University and Lincoln University. Whether in her office, in an academic set-
ting, or in a community space, Shadeen’s work is inspired by her commitment to
helping people live lives full of peace and pleasure.
ARIEL A. FRIEDMAN, MA, MEd, is a second-year PhD student at Palo Alto
University, where she studies clinical psychology. She is a member of the Research
on Intersectional Sexual and Gender Identity Experiences lab. Her clinical and
research interests include LGBTQ+ psychology as well as complex trauma. She
holds an MA and an MEd in counseling psychology from Teacher’s College,
Columbia University.
808 About the Editor and Contributors
REBECCA FROST is a practicing clinical psychologist and the director of
Benchmark Psychology in Brisbane, Australia. She is an certified emotional
freedom technique couples therapist with the International Centre for Excellence
in Emotionally Focused Therapy, and in her private practice she works primarily
with couples and believes in supporting strong relationships of all types, includ-
ing parents and their children. Rebecca completed her PhD researching the dis-
tress that can be experienced by couples as a result of sexual desire problems, and
this remains a strong area of clinical interest for her. As the lead author of the
Sexual and Relationship Distress Scale, Rebecca’s postgraduate research has
been published in leading sexual health journals, presented at international con-
ferences, and is to be included in the newest edition of the Handbook of Sexuality
Measures.
KARYN FULCHER is a postdoctoral fellow in the School of Public Health and
Social Policy at the University of Victoria in British Columbia, Canada. Her
research interests encompass a range of topics related to the sexual health and
well-being of young people and sexual minorities, including pleasure-inclusive
sexuality education and access to sexual health care. She takes an interdisciplin-
ary approach to exploring these issues, drawing on anthropology, education, and
public health. She holds a PhD from the Australian Research Centre in Sex, Health
and Society at La Trobe University, where her research focused on the role of
homophobic language use in maintaining gendered social structures among high
school students.
KIMBERLY A. FULLER, PhD, is an assistant professor of social work at Cleve-
land State University in Cleveland, Ohio, and she maintains a private practice as a
licensed independent social worker with supervisory designation and certified sex
therapist. She has published several articles on the relationships of LGBTQ indi-
viduals and support. She holds two master’s degrees, in social work and human
sexuality education, and a doctorate in human sexuality studies from Widener
University.
ALESSANDRA GALLO is a clinical psychology PhD candidate at Ryerson Uni-
versity in Toronto, Canada. Her research interests include forensic mental health,
intellectual functioning and recidivism, and assessment and treatment of sex
offenders. Alessandra is a mental health counselor at Correctional Service Can-
ada, providing assessment and treatment services to federal offenders on condi-
tional release. She has coauthored articles in the area of assessment and treatment
of sex offenders and is a Joseph-Armand Bombardier Canada Graduate Scholar.
Alessandra completed her MA in forensic psychology at John Jay College of
Criminal Justice in New York City, with a focus on sexual offending.
SARAH GANNON, MEd, has been a sexuality educator, trainer, researcher, pro-
gram developer, and consultant for over six years. While her recent focus has been
on youth prevention programming, she has worked with people of all ages and
abilities toward the goal of making healthier life choices. She has presented at
About the Editor and Contributors 809
several conferences, most recently at the American Association of Sexuality Edu-
cators, Counselors, and Therapists Conference, as well as the National Sex Ed
Conference. She has presented on a range of topics, primarily inclusivity, remov-
ing shame and stigma, and supporting the LGBTQ+ community. She is currently
the cochair for Delaware’s PRIDE Council. Sarah holds a master’s of education in
human sexuality studies from Widener University.
ABBY GIRARD, LMFT, PsyD, is an assistant professor in the Program for
Human Sexuality, Department of Family Medicine and Community Health at the
University of Minnesota Medical School and is the program coordinator for the
Center for Sexual Health, Relationship and Sex Therapy program. Dr. Girard spe-
cializes in couples and sex therapy and has published numerous peer-reviewed
articles on sexual desire discrepancy, infidelity, consensual nonmonogamy, and
compulsive sexual behavior. Girard holds a master’s in marital and family therapy
from the University of San Diego and a doctorate in marital and family therapy
from the Alliant International University. Dr. Girard completed her postdoctoral
fellowship in couple sexual health at the Program in Human Sexuality within the
Department of Family Medicine and Community Health in the University of Min-
nesota Medical School.
CHRISTINA GIROD is author of Indigenous Peoples of North America: Native
Americans of the Southeast (Lucent Books, 2000), The Thirteen Colonies: Con-
necticut (Lucent Books, 2001), The Indian Americans (Gale, 2003), and Diseases
and Disorders: Down Syndrome (Lucent Books, 2000).
MARTHA GOLDSTEIN-SCHULTZ has a PhD in human sexuality studies and
works as an educational consultant for LGBTQ+-inclusive strategies for class-
rooms and school environments. Sexuality Education Consulting, LLC, serves
schools in Connecticut and Rhode Island. Martha has numerous years of teaching
experience in secondary and higher education. She has taught life span develop-
ment courses at the University of Connecticut and Quinebaug Valley Community
College. Currently, Martha is designing a course in sexuality education for health
and physical education teachers with Eastern Connecticut State University. She
is also a social justice trainer for the National Conference for Community and
Justice and a yoga instructor.
PATRICK R. GRANT, MA, MPH, is fourth-year clinical psychology doctoral
candidate (PsyD) at La Salle University and a community mental health staff ther-
apist in northeast Philadelphia, where he specializes in treating anxiety and mood
disorders among special populations, which include ethnic minorities and those
within the LGBT community. In 2016, he served as the creator and lead developer
of the Chrome 2 Color Project—an urban-based initiative that sought to reduce
rates of unintended pregnancy among LGBT-identified inner-city youth of color.
He has also contributed works to numerous editions of the Journal of Black Sexu-
ality and Relationships , which have centered on highlighting the nuanced experi-
ences of black same-gender-loving men. Patrick holds a master’s in public health
810 About the Editor and Contributors
with a completed certification in sexual health and education from Washington
University of St. Louis and a master’s in clinical psychology from La Salle
University.
JILL A. GRIMES, MD, FAAFP, spokesperson for the American Academy of
Family Physicians, is passionate about prevention of disease and patient education
for all ages and body parts. She was a presidential scholar at Texas A&M Univer-
sity and earned her MD at Baylor College of Medicine in 1991. Dr. Grimes is an
associate editor for the 5-Minute Clinical Consult, focusing on evidence-based
practical clinical information. Dr. Grimes has been on faculty for the University
of Massachusetts Medical School as a clinical instructor since 2000. Her award-
winning book, Seductive Delusions: How Everyday People Catch STDs (2008),
shares stories that speak louder than statistics and is required reading in
many Texas high schools. She is also the editor of ABC-CLIO’s Sexually Trans-
mitted Disease: An Encyclopedia of Diseases, Prevention, Treatment, and Issues.
Dr. Grimes shares advice through both popular media and scholarly forums and
particularly enjoys call-in radio shows.
JOAN H. HAGEMAN, PhD, is an international research scientist with multifac-
eted expertise in the fields of psychology, psychophysiology, neuroscience, social
sciences, hypnosis, health, and biofeedback. She is the chair of research at PSY-
more Research Institute, Inc., in Tampa, Florida; an adjunct professor at Saybrook
University in San Francisco, California; and an associate professor with North-
central University in Prescott Valley, Arizona. Her published works include “Phe-
nomenological and Evidence Based Research in Ego State Therapy” (American
Journal of Clinical Hypnosis, July 2013). Hageman holds a doctorate in psychol-
ogy from Saybrook Graduate School and Research Center (now Saybrook Univer-
sity). Her research centers on multicultural issues in human consciousness.
VERN HARNER, MSW, is pursuing a PhD in social welfare at the University of
Washington (UW). They are currently the communications coordinator for the
LGBTQ Caucus of Faculty and Students in Social Work, a member of the organiz-
ing committee for UW’s Inaugural Interprofessional LGBTQ Health Conference,
a research associate on the Trans Bodies, Trans Selves research team, and a peer
group facilitator with Ingersoll Gender Center. Drawing on their broad experience
advocating for trans and queer issues, Vern’s current work focuses on intergenera-
tional knowledge and support within transgender communities. Vern believes that
by learning how trans communities have supported one another, social workers
can be better poised to create programs leveraging these strengths.
RENÉE M. HAYNES, MD, MPH, is the district health director of the North Cen-
tral Health District in Georgia. As district health director, she oversees public
health activities across thirteen counties in central Georgia. She completed her
undergraduate work at Duke University and attended Florida International Uni-
versity for her master’s in public health. She received her medical degree from
Morehouse School of Medicine in Atlanta, Georgia. She is a family medicine
About the Editor and Contributors 811
physician and, prior to her current role in public health, worked for the Depart-
ment of Veterans Affairs in Atlanta, Georgia.
LINDA D. HINKLE is a top undergraduate student at Maryville College. She is
also a veteran, having served as a combat medical specialist in the U.S. Army for
seven years. She is currently applying to graduate school and plans to work for
Veterans Affairs as a counselor.
JACOB HUFF is currently an undergraduate student at Tennessee State Univer-
sity. His research interests include counseling of marginalized populations, major
depressive disorder, community mental health, and political psychology.
TERRY HUMPHREYS, PhD, is a full professor in the Department of Psychology
at Trent University, Peterborough, Ontario, Canada. He is the editor of the Cana-
dian Journal of Human Sexuality and a consulting editor for the Journal of Sex
Research. He is also the past president of the Society for the Scientific Study of
Sexuality, a long-standing planning committee member of the Guelph Sexuality
Conference (Canada’s largest and longest-running annual sexuality conference),
and a member of the advisory board of the World Association for Sexual Health.
His academic and research interests lie in the broad field of sexual communication
in intimate relationships. Specifically, his expertise is in the negotiation of sexual
consent in multiple contexts, sexting behavior in young adults, first sexual experi-
ences, and unwanted/coercive sexual encounters.
ALEX IANTAFFI, PhD, MS, SEP, CST, LMFT, is a certified sex therapist, family
therapist, Somatic Experiencing practitioner, clinical supervisor, writer, and inde-
pendent scholar. They are adjunct faculty at the University of Wisconsin–Stout
and the chair elect for the trans and queer interest network of the American Asso-
ciation for Marriage and Family Therapy. They were the editor in chief for the
Journal of Sexual and Relationship Therapy for eleven years and have researched,
presented, and published extensively on gender, disability, sexuality, and relation-
ships. Alex is passionate about healing justice and community-based and engaged
scholarship. They are a trans masculine, nonbinary, bi queer, disabled Italian
immigrant who has been living on Dakota and Anishinaabe territories, currently
known as Minneapolis, Minnesota, since 2008. Alex has recently coauthored the
books How to Understand Your Gender: A Practical Guide for Exploring Who
You Are and Life Isn’t Binary with Meg-John Barker (Jessica Kingsley Publishers).
They host the podcast Gender Stories.
JAY A. IRWIN, PhD, is an associate professor of sociology at University of
Nebraska at Omaha. Dr. Irwin’s research focuses on LGBTQIA+ communities,
LGBTQIA+ physical and mental health, and transgender identities. He also is
involved in educational programming around LGBTQIA+ inclusion for health
professionals, collegiate-level faculty and staff, and local communities broadly.
Dr. Irwin is a member of the Midlands Sexual Health Research Collaborative and
the Professional Transgender Resource Network, an Omaha-based collaborative
812 About the Editor and Contributors
effort to provide resources and education for professionals working with transgen-
der communities. He holds a PhD in medical sociology and a graduate certificate
in gerontology from the University of Alabama at Birmingham.
LAURA KABBASH, BA, is a fluently bilingual Montrealer whose passion for
adolescent psychology, specifically behavioral misconduct, was kindled while
directing leadership training programs at YMCA Kanawana. Following an honors
psychology program at Marianopolis CEGEP in Montreal, Ms. Kabbash gradu-
ated with an honors bachelor’s degree in psychology from University of British
Columbia, Kelowna, while completing research on the mediating effects of per-
sonality factors on the association between child abuse experiences and adult out-
comes. Ms. Kabbash is currently completing a doctorate degree in clinical
psychology at the University of New Brunswick, where her research is focused on
child sex trafficking and adolescent forensic populations.
RACHEL KALISH, PhD, is an assistant professor of sociology and criminology
at SUNY College at Old Westbury. She received her doctorate from Stony Brook
University. Her research interests include young adult sexuality, hookup culture,
and gender-based violence. Prior to her graduate work, Rachel was a rape crisis
counselor for ten years.
SHANNA K. KATTARI, PhD, MEd, CSE, ACS, (she/her/hers) is an assistant
professor at the University of Michigan School of Social Work and Department of
Women’s Studies (by courtesy), core faculty at the Center for Sexuality and Health
Disparities, and the director of the [Sexuality|Relationships|Gender] Research
Collective. She is the author of several dozen articles on sexuality and disability,
sexuality and social work, and trans experiences of health care, as well as the edi-
tor of a forthcoming book on social work and health care with trans and nonbinary
individuals and communities. She is the co-chair of the Caucus of LGBTQ Social
Work Faculty and PhD Students and former co-chair of the Council of Social
Work Education’s Council on Sexual Orientation, Gender Identity and Expres-
sions. She holds a master’s in human sexuality education from Widener University
and a PhD in social work from the University of Denver.
KRISTEN KELLY, MD, is an OB/GYN resident at UMass Memorial Hospital in
Worcester, Massachusetts. Dr. Kelly graduated from Jefferson Medical College
(Philadelphia, Pennsylvania) and went to Middlebury College (Middlebury, Ver-
mont) for her undergraduate degree. In between, she enjoyed teaching fifth/sixth
grades for five years.
M. KILLIAN KINNEY, MSW, LSW, (they/them) is a social work doctoral candi-
date and associate faculty at Indiana University School of Social Work in India-
napolis, Indiana. They are an emerging empowerment and well-being scholar
emphasizing the experiences of transgender and nonbinary individuals. Mx.
Kinney practices at the Riley Adolescent Gender Health Clinic and provides pre-
sentations, training, and consultation on LGBTQ-affirming health care at the
About the Editor and Contributors 813
local, national, and international levels. They were a past president of the Indiana
chapter of the National Association of Social Workers’ Sexual Orientation and
Gender Identity Committee and are a current member of the Council on Social
Work Education’s Council on Sexual Orientation and Gender Identity and
Expression. Mx. Kinney is an editor and author for the upcoming book titled
Social Work and Health Care with Transgender/Nonbinary Individuals and
Communities.
ALEXANDER KOVIC, PsyD, is a postdoctoral fellow at the University of Min-
nesota Medical School in the program in human sexuality. He provides for indi-
vidual, family, couples, and group psychotherapy for a wide range of concerns
related to gender and sexual health. His training has involved work in forensic
hospitals, correctional facilities, inpatient substance abuse centers, community
mental health clinics, and academic centers. His areas of clinical and research
interest include sexual identity and gender diversity; sexual trauma; addictive,
compulsive, or risky behaviors; severe mental illness; forensic evaluation, and the
management of violence. Dr. Kovic holds a doctor of psychology degree in clini-
cal psychology and a master’s in forensic psychology from the Minnesota School
of Professional Psychology–Argosy University.
NATHAN LACHOWSKY employs a social justice framework to advance health
equity, championing interdisciplinary community-based research. He is a social
and behavioral epidemiologist with ten years of experience conducting
community-based research on sexual health and HIV/AIDS with marginalized
communities across Canada and New Zealand. He is an associate professor and
Michael Smith Foundation for Health Research Scholar in the School of Public
Health and Social Policy at the University of Victoria and research director for the
Community-based Research Centre Society.
JUSTIN J. LEHMILLER, PhD, is a research fellow at the Kinsey Institute at
Indiana University. He is author of the blog Sex and Psychology and the book Tell
Me What You Want: The Science of Sexual Desire and How It Can Help You
Improve Your Sex Life. Dr. Lehmiller has also written a textbook, The Psychology
of Human Sexuality, that is used in college classrooms around the world to educate
students about the science of sex. He maintains an active research program focused
on topics including sexual fantasies, friends with benefits, and consensual nonmo-
nogamy. Dr. Lehmiller holds a master’s degree in experimental psychology from
Villanova University and a doctorate in social psychology from Purdue
University.
MARK A. LEVAND, PhD, MA, CSE, is an adjunct faculty member at various
universities in the Philadelphia area, where he facilitates undergraduate and grad-
uate courses in human sexuality. As a certified sexuality educator, he has taught
courses at the intersection of human sexuality and counseling, education, religion,
human development, and research methods. Dr. Levand often researches and
writes on topics of sexuality and Catholicism, consent, and culture. He is also on
814 About the Editor and Contributors
the education certification committee and advocacy committee for the American
Association of Sexuality Educators, Counselors and Therapists.
SYLVIE LÉVESQUE, PhD, is an associate professor at the Department of Sexol-
ogy, Université du Québec in Montréal, Canada, where her time is divided between
teaching, research, and community services. She is trained as a sexologist and has
pursued her doctoral studies in public health (health promotion). She is a perma-
nent researcher at the Réseau Québécois en Études Feministes and is a member of
the Domestic Violence: Actors in Context and Innovative Practices Research
Team. Her research interests focus on gender-based violence, intimate partner vio-
lence, reproductive coercion, promotion of reproductive and sexual health, and
parenting. She holds research grants from provincial and national agencies. She
has been working or doing research in these fields for the past fifteen years.
ANGELA LIBAL is a zoologist, cryptozoologist, and science writer. She has pub-
lished more than four hundred articles dealing with animal husbandry, biology,
and environmental science on various educational websites. She is also the author
of several books, including Forensic Anthropology (Mason Crest, 2013), Finger-
prints, Bite Marks, Ear Prints (Mason Crest, 2013), and Field Guides to Finding a
New Career: Science (Ferguson, 2010). Her areas of interest include the intersec-
tion of the natural sciences, religious and ethnological history, and folklore. She
holds a BA from Sarah Lawrence College.
CAMILLA LOGGINS is an undergraduate student at Maryville College in
Maryville, Tennessee. Loggins is the recipient of the coveted Ledford Scholarship
from the Appalachian College Association, which is funding her senior study. She
is currently applying to graduate schools and plans to work in the sector of public
health and human sexuality.
JAN LOOMAN completed his PhD in clinical forensic psychology at Queen’s
University in Kingston, Ontario, in 2000. He is currently in private practice pro-
viding assessments for sexual offenders in Kingston. Previously he worked for
Correctional Services of Canada, where he supervised the delivery of the High-
Intensity Sexual Offender Treatment Program at the Regional Treatment Centre
(Ontario) and at Providence Care Hospital on the Forensic Psychiatric Unit. Dr.
Looman’s research interests include risk assessment, treatment outcomes, and
psychopathy in sexual offender populations. He has published over sixty articles
in peer-reviewed journals on these topics.
HOWARD W. MacLENNAN JR. is the lead physician in medical readiness stan-
dards for the North Carolina Army National Guard, where his specialties include
genetics, molecular biology, and osteopathic medicine. Dr. MacLennan is a mem-
ber of the American Academy of Family Physicians, American Board of Family
Medicine, and American Osteopathic Association, and he has widely published in
a variety of medical journals. (The views expressed by Dr. MacLennan are those
About the Editor and Contributors 815
of the author and do not reflect the official policy or position of the Department of
the Army, Department of Defense, or U.S. government.)
CRISTINA L. MAGALHÃES, PhD, has a doctorate from Nova Southeastern
University (2005) and is an associate professor of clinical psychology, associate
director of the PsyD program, and coordinator of the Rockway Certificate for
LGBTQ Studies at the California School of Professional Psychology at Alliant
International University, Los Angeles. She is also a licensed clinical psychologist
in independent practice. Dr. Magalhães’s clinical, research, and teaching interests
include LGBTQ health, treatment approaches for anxiety- and trauma-related dis-
orders, and cross-cultural psychodiagnostic assessment.
JIMMIE MANNING, PhD, is a professor and chair of communication studies at
the University of Nevada, Reno. His research focuses on relational discourses,
especially those about sexuality, gender, love, and identity; connections between
relationships and efficacy in health and organizational contexts; and digitally
mediated communication. His research has been supported by funding agencies
such as the National Science Foundation and Learn and Serve America, and
he has accrued over thirty journal publications in outlets including Communica-
tion Monographs, Journal of Social and Personal Relationships, and Journal of
Computer-Mediated Communication. He has authored multiple books, including
Researching Interpersonal Relationships: Qualitative Methods, Research, and
Analysis (Sage). He received his doctorate in communication studies from the
University of Kansas.
AMANDA MANUEL is a counselor and psychotherapist in private practice. She
holds master’s degrees in arts, education in counseling psychology, and clinical
human sexuality and is pursuing a PhD in clinical human sexuality.
KIM MASTERS EVANS is a freelance writer specializing in scientific topics.
She has authored dozens of reference books, textbook lessons, and encyclopedia
articles for students at the high school and undergraduate levels. Her published
works include Energy: Supplies, Sustainability, and Costs (Gale, 2015); The Envi-
ronment: A Revolution in Attitudes (Gale, 2003); and Space Exploration: Triumphs
and Tragedies (Gale, 2007). She is also a licensed professional engineer with two
decades of experience in the field of environmental engineering. Evans holds a BS
in chemical engineering from Tennessee Technological University.
LAUREN G. MASUDA, PsyD, is a staff psychologist for Veterans Affairs Salt
Lake City Health Care System and specializes in geropsychology and health psy-
chology. Dr. Masuda holds a doctorate in clinical psychology from Baylor
University.
ELIZABETH A. MAYNARD, PhD, is a licensed clinical psychologist whose
work has explored the intersections of religion, spirituality, and sexuality. After
816 About the Editor and Contributors
many years in university and clinical work, she now serves as a foreign service
officer for the U.S. Department of State.
MARY McCLURE, EdD, LPC, has been a counselor educator since 2009, with
emphasis in teaching master’s-level students seeking licensure as professional
counselors. Since 2105, she has focused on counselor education in the addictions
specialty area as well as on master’s-level education supporting certification for
alcohol and other drug addiction work. Her work includes program and course-
work development and delivery in peer support recovery coaching.
MICHAEL J. McGEE, PhD, is an associate professor in health education at Bor-
ough of Manhattan Community College, City University of New York. Formerly
he was the executive director of the World Association for Sexual Health.
LYNDSAY MERCIER, PhD, is a sexuality educator, author, and award-winning
researcher with over fourteen years of experience working directly with adoles-
cents and young adults surrounding healthy sexuality. She received her doctorate
and master’s degree in human sexuality education from Widener University.
SUSAN MILSTEIN, PhD, is an assistant professor in the Department of Public
Health and Health Care Administration at California State University, Chico. She
is a master certified health education specialist as well as a certified sexuality edu-
cator. Dr. Milstein is the coauthor of the fifth edition of Human Sexuality: Making
Informed Decisions and is a former associate editor of the American Journal of
Sexuality Education. In addition to her work at the university, Dr. Milstein is also
the founder and lead consultant for Milstein Health Consulting, through which she
provides sexuality education and training for professionals and the general
public.
RANDI MINETOR has authored more than forty books and has served as the
ghostwriter for a number of best-selling nonfiction books. She serves as a princi-
pal copywriter for the University of Rochester Medical Center patient information
website. Minetor holds a master’s degree in film studies from the University of
Rochester and a bachelor’s degree in English and psychology from the University
at Buffalo.
LUCAS MIRABITO, MA, is currently a doctoral candidate in the clinical psy-
chology program at Marquette University in Milwaukee, Wisconsin. His clinical
training includes specialties in both substance abuse treatment and LGBTQ health.
His research lies at the intersection of these two areas, and he is broadly interested
in helping to develop and disseminate LGBTQ-adapted treatments to reduce
health disparities and increase access to affirmative care in the LGBTQ
community.
CAITLIN MONAHAN, BA, is a social and health psychology doctoral student at
Stony Brook University. She earned her BA in psychology from New York
About the Editor and Contributors 817
University in 2016. Her research interests include intergroup relations, intersec-
tionality, and stigma of marginalized groups.
MICHELE MONTECALVO, EdD, MS, MCHES, is an assistant professor in the
Department of Biology and Health Sciences at St. Francis College in Brooklyn,
New York. She is the author of the forthcoming book LGBTQ Cultural Compe-
tency for Healthcare Providers (Peter Lang). Dr. Montecalvo uses qualitative
research methods to hear the authentic voice of marginalized communities; engag-
ing learning pedagogy, health behavior change theory, and social justice frame-
works; for enhancing learning with culturally equitable programming, curricula,
and policy change. Montecalvo is a master certified health education specialist,
and she holds a master’s in public health administration and a doctorate in health
behavior studies from Teachers College, Columbia University.
TERRI NICHOLS is a freelance writer who has worked for the U.S. Forest Ser-
vice, the Student Conservation Association, and the Waterkeeper Alliance. She
has performed trail work, habitat restoration, and water quality monitoring in
California, Montana, and Wyoming. A Michigan native, Nichols holds a bache-
lor’s degree in journalism from Wayne State University in Detroit, Michigan. She
is a coauthor of America’s Natural Places: The Midwest (ABC-CLIO, 2009).
JOSHUA D. NOSANCHUK, MD, is senior associate dean for medical education
at the Albert Einstein College of Medicine at Yeshiva University. His areas of
research and expertise include medical education, fungal pathogenesis, host-
pathogen biology, regenerative medicine, and innovative therapeutics.
MATTHEW NUMER is an associate professor in the School of Health and Human
Performance at Dalhousie University and is cross-appointed to the Gender and
Women’s Studies program. He has been funded by the Canadian Institutes of
Health Research and the Social Sciences and Humanities Research Council of
Canada for his work in the areas of gender, sex, and sexuality. His research inter-
ests include substance use; the health of gay, bisexual, and other men who have
sex with men, sexual health, online technologies, LGBTQ2S health, masculini-
ties, indigenous boys’ and men’s health, and postsecondary pedagogical practices.
He has received numerous awards for his interactive teaching methods and is
widely known as an innovator in the classroom. He is a member of the board of
directors for the Halifax Sexual Health Centre, serves on the AIDS Coalition of
Nova Scotia: Gay Men’s Health Advisory Committee, and is regional adviser for
the Community-Based Research Centre for Gay Men’s Health.
DONNA ORIOWO, PhD, MEd, MSW, is a sex and relationship therapist at her
private practice, AnnodRight, in the Washington, D.C., metro area specializing in
working with black women on issues related to colorism and texturism and its
impacts on mental and sexual health. She is the author of Cocoa Butter & Hair
Grease: A Self Love Journey through Hair and Skin. Dr. Donna currently serves
on the Diversity, Equity, and Inclusion Committee for the American Association
818 About the Editor and Contributors
of Sexuality Educators, Counselors and Therapists and is a member of Women of
Color Sexual Health Network. Donna holds a BS in psychology from Morgan
State University, a master’s in social work, a master’s in education for human
sexuality, and a doctorate in human sexuality from Widener University.
TORI PEÑA is a second-year cognitive science student at Stony Brook Universi-
ty’s psychology department. She received her BS in psychology and biological
anthropology from Binghamton University in May 2018. She works under Dr.
Suparna Rajaram’s advisement, and her current research focuses on understand-
ing the nuances of social and nonsocial memory.
DULCINEA PITAGORA holds an MA in psychology from the New School for
Social Research, an MSW from New York University, an MEd and a PhD in
clinical sexology from Widener University, and is an American Association of
Sexuality Educators, Counselors and Therapists–certified sex therapist. Pitag-
ora has a practice in New York City that includes individual, couples or dyads,
and multipartner therapy. Pitagora’s practice is person centered and strengths
based; focuses on self-determination and empowerment; and is LGBQ, trans,
poly, and kink affirmative. Pitagora is an adjunct professor of sexual health at
New York University and has published articles and chapters in peer-reviewed
journals and books and presented at conferences on the topics of alternative
sexuality and gender diversity. Pitagora conducts research, lectures, and semi-
nars pertaining to these communities; is the founder of ManhattanAlternative.
com, an alternative lifestyle–affirmative provider listing; and is a co-organizer
of the AltSex NYC Conference. Pitagora is the “kink doctor” in the web series
of the same name.
REBECCA POLLY is an education professional working in the greater mid-
Atlantic region. Rebecca’s professional interests include sexuality education in
early childhood, diversity and inclusivity in trades and labor unions, and health
communications and linguistics. Rebecca currently works for Job Corps, an orga-
nization within the Department of Labor, as a career transition specialist working
with impoverished adolescents and emerging adults to develop long-term career
success. While working with Job Corps, Rebecca designed and developed an edu-
cational series on topics such as race and identity, LGBT inclusivity, and trauma-
informed youth services. She received her bachelor of science in linguistics and
cognitive science from the University of Delaware in 2014. In 2017, she earned
her master’s of education in human sexuality at Widener University. She was
recently selected to give an oral presentation at the Twenty-Fourth Congress of
the World Association for Sexual Health titled “Early and Often: Sexuality Edu-
cation in Early Childhood.” Rebecca can be reached directly by email at reba
[email protected].
AMY REYNOLDS is a writer and editor with an MA in political science from
California State University, Northridge. Her research interests include social
movements and media effects.
About the Editor and Contributors 819
DAVID J. REYNOLDS, PhD, is the military internship behavioral health psy-
chologist and deputy training director at Malcolm Grow Medical Clinics and Sur-
gery Center (MGMCSC), Joint Base Andrews, Maryland. He joined the Center
for Deployment Psychology (CDP) in 2016 after retiring from the U.S. Air Force.
Dr. Reynolds leads CDP’s chronic pain team and is a member of the insomnia
team. He facilitates training in both areas. He is also an expert in the treatment of
trauma, resiliency, and relaxation. Dr. Reynolds received his bachelor’s degree in
psychology from State University of New York College at Brockport and his mas-
ter’s and doctorate degrees in clinical psychology from the University of Cincin-
nati. He is a 2000 graduate of the MGMCSC psychology residency program. In
2006, he completed a postdoctoral fellowship in health psychology at Wilford Hall
Medical Center in San Antonio, Texas.
G. NIC RIDER, PhD, LP, is an assistant professor in the Program in Human Sexu-
ality at the University of Minnesota Medical School and the co-associate director
for research for the National Center for Gender Spectrum Health. Dr. Rider has
professional interests in the areas of gender and sexual identity development,
intersections of identities, discrimination and microaggressions, sexual trauma/
abuse recovery, and social justice advocacy. They are on the executive board for
the Asian American Psychological Association’s Division on LGBTQQ Issues.
Dr. Rider received a doctorate in counseling psychology from Howard University
in Washington, D.C. They were also the first Randi and Fred Ettner Postdoctoral
Fellow in Transgender Health at the Program in Human Sexuality, University of
Minnesota Medical School.
ALEX M. RIVERA, PsyD, is a licensed psychologist who specializes in provid-
ing culturally affirming treatment for queer and trans people of color. She cur-
rently directs a group practice in the Bay Area and acts as a research consultant
for the Asian Women’s Health Initiative Project at Boston University. Dr. Rivera
serves on the editorial board of The Counseling Psychologist and is the past chair
of the Asian American Psychological Association Education and Training Com-
mittee. She received her doctorate from the PGSP-Stanford PsyD Consortium and
has written several articles and chapters on identity and intersectionality in men-
tal health.
ELIZABETH RODNEZ, MD, is a second-year family medicine resident at Naval
Hospital Jacksonville. Having graduated from the University of Miami Miller
School of Medicine, she currently works with the U.S. Navy and plans to work on
medical mission trips. (The views expressed by Elizabeth Rodnez in this work are
those of the author and do not necessarily reflect the official policy or position of
the Department of the Navy, Department of Defense, or the U.S. government.)
SCOTT T. RONIS, PhD, is an associate professor and director of graduate studies
in the Department of Psychology at the University of New Brunswick in Frederic-
ton, New Brunswick, and he maintains a part-time private practice as a licensed
psychologist, where he works with youth and adults with problem sexual behavior
820 About the Editor and Contributors
as well as children and families with other difficulties. His research primarily
focuses on the development of problem sexual behavior, particularly among ado-
lescents, general family relationships, and youth emotional and behavioral diffi-
culties. Dr. Ronis holds a doctorate in clinical psychology from the University of
Missouri.
DARCI SHINN graduated from Widener University in 2014 with dual master’s
degrees in human sexuality and social work. From 2015 to 2017, she worked as
therapist for the Pennsylvania-based agency Resources for Human Development.
There she worked with children in the Mastery Charter School organization who
had counseling as part of their individual education plans. In 2017, Darci began
working as a per diem therapist for Oaks Integrated Care. She works with clients
presenting with a variety of sexual and/or mental health presenting problems.
Darci recently obtained her license as a clinical social worker and is gradually
working toward having her own practice. She also plans to work toward becoming
certified by the American Association of Sexuality Educators, Counselors and
Therapists in the near future.
LESLEY-ANN SMITH, PhD, is a senior lecturer in psychology at the University
of Northampton in the United Kingdom. Dr. Smith also leads two master’s pro-
grams in psychology: the MS in psychology and the MS in child and mental health
at the University of Northampton. Dr. Smith is currently researching sexual
grooming practices in young women and has published academic journal articles
and a book chapter exploring how mental health service users experience certain
spaces, (e.g., day centers, home spaces).
LORI APFFEL SMITH, MD, is an obstetrician-gynecologist in Birmingham,
Alabama. She received her medical degree from Baylor College of Medicine and
has been in practice for more than twenty years.
A. J. SMUSKIEWICZ is a freelance writer and editor specializing in science,
health and medicine, and contemporary issues. He earned a BS in biology at Gov-
ernors State University in 1988. He has worked as a biologist (including for the
Environmental Protection Agency Great Lakes Monitoring Project and the Illi-
nois Institute of Technology Research Institute), a naturalist (including for the
Forest Preserve Districts of Will County and Cook County), and an artist/designer.
His writing and editing experience includes staff positions with World Book Pub-
lishing and the American Osteopathic Association. In recent years, he has focused
much of his writing on human sexuality and LGBT issues.
RACHEL SNEDECOR is an adolescent medicine provider and board-certified
pediatrician specializing in the care of gender-diverse youth and young adults.
She has worked as a health care provider in the Gender Health Program at Riley
Hospital for Children and the Eskenazi Transgender Health and Wellness Program
in Indianapolis. Soon, she will be joining the faculty at Cincinnati Children’s Hos-
pital. Dr. Snedecor completed her medical school training at Indiana University
About the Editor and Contributors 821
School of Medicine. For her pediatric residency, she attended the University of
Louisville. She finally returned to Indiana University School of Medicine for her
adolescent medicine fellowship. Recently, she served as secretary of the executive
board of GenderNexus, a local organization serving the transgender and nonbi-
nary community of Indianapolis. Dr. Snedecor has also worked nationally as part
of the LGBT Clinical Services Committee of the Society for Adolescent Health
and Medicine. Her research areas focus on the sources of ideal body features and
the actions that they inspire in gender-expansive youth and improving health care
delivery to gender and sexual minority adolescents.
LEN SPERRY, MD, PhD, is a professor of mental health counseling and director
of clinical training at Florida Atlantic University and clinical professor of psychia-
try and behavioral medicine at the Medical College of Wisconsin. He is board
certified in psychiatry, general preventive medicine, and clinical psychology. He is
a fellow of the American Psychiatric Association, the American College of Pre-
ventive Medicine, and the American Psychological Association. Sperry is the edi-
tor in chief of the American Journal of Family Therapy and editor of Spirituality
in Clinical Practice.
ED DE ST. AUBIN, PhD, is an associate professor of psychology at Marquette
University in Milwaukee, Wisconsin. He is broadly trained in the interdisciplin-
ary study of human development and has several intellectual interests. One topic
of scholarship and teaching has been sex and gender during emerging adulthood.
He and his student-colleagues have published widely in this area, and he has
taught several courses in human sexuality, the queer self, and hookup campus
culture, receiving several teaching grants and awards for these efforts. The threads
connecting his research endeavors are the individual adult’s search for meaning
and the social justice dynamics that affect members of marginalized groups.
STEPHEN K. STEIN is an associate professor of history at the University of
Memphis. Recent publications include The Sea in World History: Trade, Travel,
and Exploration (2017), Twenty-Five Years of Living in Leather: The National
Leather Association, 1986–2011 (2012), and “The Greely Relief Expedition and
the New Navy,” International Journal of Naval History 5 (December 2006), which
won the Rear Admiral Ernest M. Eller Prize in Naval History. He is currently
working on a history of the sadism/masochism community in the United States.
JUDITH STEINHART, EdD, is a clinical sexologist who has taught human sexu-
ality courses at the undergraduate and graduate levels in colleges and universities
as well as in secondary schools. Dr. Steinhart has also provided training to health
professionals and to those who work in community-based organizations. She is a
popular presenter at national sexuality conferences. Dr. Steinhart has championed
the cause of making the field of sexuality more inclusive by opening doors and
mentoring others. She has published articles and book chapters and has been a
speaker for TEDx. She co-created the first internet question-and-answer service,
Go Ask Alice!, while working as a sexual health educator at Columbia University,
822 About the Editor and Contributors
and she coauthored the book The “Go Ask Alice!” Book of Answers: A Guide to
Your Physical, Sexual, and Emotional Health. She is currently on the faculty of
health studies, part of the Health, Physical Education, and Recreation Department,
Nassau Community College, Garden City, New York.
CHUCK STEWART teaches math and statistics courses for National University
and University of Phoenix and is an independent researcher and writer on LGBT
topics. Formerly, he worked in aerospace. His published works include ABC-
CLIO’s The Greenwood Encyclopedia of LGBT Issues Worldwide, Bankrupt Your
Student Loans and Other Discharge Strategies, and Sexually Stigmatized Com-
munities: Reducing Heterosexism and Homophobia: An Awareness Training
Manual, a manual used to create training programs for the Los Angeles Police
Academy. Stewart holds a doctorate in education with a certificate in women’s
studies from the University of Southern California.
LARA E. STEWART, DO, MPH, is a board-certified family physician. She
enjoyed focusing on the health concerns of women and young adults during her
decade of clinical practice. Dr. Stewart earned her master’s in public health in
health care management and policy and currently works as a medical author,
expert, and consultant.
VICTOR B. STOLBERG is an assistant professor and counselor at Essex County
College in Newark, New Jersey, where he previously directed the Office of Dis-
ability Support Services and Office of the Substance Abuse Coordinator. He was
a founding member of the CORE Institute and helped create the CORE Instru-
ment; he is currently a board member of the Friends of the Newark Public Library
and the New Jersey Community College Counselors’ Association. He has deliv-
ered hundreds of workshops and other presentations across the country. He has
authored, or coauthored, forty-nine scholarly articles, ninety-four encyclopedia
articles, six chapters and contributed papers, and sixty-three other miscellaneous
publications as well as several books, including Painkillers: History, Science, and
Issues and ADHD Medications: History, Science, and Issues. This amounts to a
total of over two hundred publications. He has several publications in press,
including a book with ABC-CLIO titled What You Need to Know about ADHD.
Stolberg holds nine master’s degrees from Montclair State University, New Jersey
Institute of Technology, Rutgers University, the State University of New York at
Cortland, and the University of Buffalo.
LINDA TANCS holds a master’s of law degree from Columbia University School
of Law, a doctorate in law from Seton Hall University School of Law, and a bach-
elor of arts degree in communication from Rutgers University. Her published
works include Understanding Trademark Law: A Beginner’s Guide (Thomson
Reuters, 2009), Understanding Copyright Law: A Beginner’s Guide (Thom-
son Reuters, 2011), and Understanding Patent Law: A Beginner’s Guide (Thom-
son Reuters, 2011).
About the Editor and Contributors 823
KYNDEL L. TARZIERS, MS, is a doctoral student in counselor education and
practice at Georgia State University. She currently serves as a therapist at a chil-
dren’s advocacy center, supporting child trauma victims. Kyndel’s research inter-
ests include generational and childhood trauma, trauma-informed care and
dissemination, childhood disability, and sexuality counseling. She hopes to
become a counselor educator and maintain a private practice after graduation
from her doctoral program. Kyndel holds a master’s in clinical mental health
counseling from the University of South Alabama.
DAWN S. TASILLO, MD, is an assistant professor of OB/GYN at the University
of Massachusetts School of Medicine, where she has served as OB/GYN clerkship
director since 2010. Her professional focus is on medical education; she has been
an invited speaker in a local secondary school’s bioethics class since 2009.
CHEYENNE TAYLOR, LMSW, is a licensed social worker who obtained her
MSW at Fordham University in New York City. Currently, Cheyenne practices
psychotherapy at the Manhattan Alternative Collective, where she specializes in
issues pertaining to kink/BDSM, consensual nonmonogamy/polyamory, LGBTQ
issues, issues of people of color, and sex work.
SHANE’A THOMAS, LICSW, MEd, (he/she pronouns) is a senior lecturer for the
University of Southern California’s Suzanne Dworak-Peck School of Social Work’s
Virtual Academic Center as well as a seasoned practitioner in the Washington, D.C.,
metro area. Clinically and educationally, Thomas commits time toward supporting
LGBTQI youth and those affected by HIV/AIDS through trauma-focused care as
well as training social workers, educators, and service providers around building
safer therapeutic, service, and educational spaces for clients and students, especially
those working and existing in communities that are underserved, people of color,
and LGBTQI folks. She is an advisory board member to the National Queer and
Trans Therapists of Color Network. Thomas is a proud alumnus of Virginia Tech,
Howard University, and Widener University, holding a bachelor of science in psy-
chology, a master of social work degree with a concentration in direct services (fam-
ilies and children), and a master of education with a concentration in human sexuality
studies, as well as an advanced certificate in human sexuality studies, respectively.
By 2021, Thomas will receive an EdD in organizational change and leadership
through University of Southern California’s Rossier’s School of Education.
CASEY T. TOBIN, PhD, is an associate professor in the psychology department at
the University of Wisconsin–La Crosse. Dr. Tobin’s areas of interest include sexu-
ality and sexual health, child abuse and neglect, clinical/counseling psychology,
and internship and fieldwork experiences. She holds two master’s degrees, one
in education and one in community counseling, and a doctorate in counselor edu-
cation and supervision from the University of Northern Colorado. Dr. Tobin main-
tains her licensure status as a licensed professional counselor, a national certified
counselor, and an approved clinical supervisor.
824 About the Editor and Contributors
ROSARA TORRISI, LCSWR, MEd, CST, PhD, is the director of the Long Island
Institute of Sex Therapy in New York. Dr. Torrisi is a licensed clinical social
worker and a certified sex therapist with the American Association of Sexuality
Educators, Counselors and Therapists. She graduated from Columbia University
with a master of science in social work and earned a master of education in human
sexuality from Widener University, where she also earned her PhD in human sex-
uality. She is an adjunct professor at Widener University and guest lecturer around
the country, teaching courses about sexuality, sex therapy, and disabilities. Dr.
Torrisi is an Our Whole Lives comprehensive sexuality educator for youth, young
adults, adults, and older adults. Dr. Torrisi is recognized as a welcoming and kink-
aware therapist by the National Coalition for Sexual Freedom and is also a recom-
mended therapist by the Long Island LGBT Network.
STEPHEN K. TRAPP, PhD, is an assistant professor with the Division of Physical
Medicine and Rehabilitation at the University of Utah. He primarily conducts
research on topics pertaining to rehabilitation and chronic health conditions. He
also maintains a clinic devoted to the psychological needs associated with neuro-
rehabilitation and rare health conditions. Dr. Trapp is the current chair of the
Rehabilitation Technology Special Interest Group associated with the American
Psychological Association’s Rehabilitation Psychology Division. Trapp holds a
masters in human development counseling from Vanderbilt University and a doc-
torate in counseling psychology from Virginia Commonwealth University.
JASON S. ULSPERGER, PhD, is a professor of sociology at Arkansas Tech Uni-
versity. He teaches social deviance and gerontology. He holds a master’s from
Arkansas State University and a doctorate from Oklahoma State University. In
addition to applications of structural ritualization theory, he researches the link
between sexual deviance and law formation processes. He is the coauthor of Elder
Care Catastrophe (Routledge) and current president of the Mid-South Sociologi-
cal Association. He is a recent recipient of his university’s faculty awards for
excellence in both scholarship and teaching.
LOUIS VARILIAS, MLIS, MS, is a recent graduate with a master’s in experi-
mental psychology from Seton University. His research interests extend beyond
psychology, especially into technology, society, and other fields of science.
JENNIFER A. VENCILL, PhD, is an assistant professor, licensed psychologist,
and American Association of Sexuality Educators, Counselors and Therapists–
certified sex therapist at the Mayo Clinic, where she practices primarily in the
Menopause and Women’s Sexual Health and Transgender and Intersex Specialty
Care clinics. Dr. Vencill’s research interests include health disparities and minor-
ity stress in marginalized sexual and gender communities, mixed orientation rela-
tionships, and sexual health. She serves on the editorial board of the Journal of
Positive Sexuality and is past president of the Society for the Psychology of Wom-
en’s Section on Lesbian, Bisexual, and Transgender Concerns. Dr. Vencill received
her PhD in counseling psychology from Texas Tech University and was the first
About the Editor and Contributors 825
Michael E. Metz Postdoctoral Fellow in Couples’ Sexual Health at the University
of Minnesota Medical School’s Program in Human Sexuality.
JAMES WADLEY, PhD, LPC (PA & NJ), NCC, CSTS, is professor and chair of
the Counseling and Human Services Master of Human Services department at
Lincoln University. As a scholar-practitioner, he is a licensed professional coun-
selor and maintains a private practice in Pennsylvania and New Jersey. His
recently coedited a ground-breaking book entitled The Art of Sex Therapy Super-
vision (Routledge/Taylor & Francis). He is the founding editor of the scholarly,
interdisciplinary journal, Journal of Black Sexuality and Relationships (Univer-
sity of Nebraska Press). He is also the founder and principal of the Association of
Black Sexologists and Clinicians, and his professional background in human sex-
uality education, educational leadership, and program development has enabled
him to galvanize scholars and practitioners in the field of sexology across the
world.
KOREY L. WATKINS, PsyD, works full time at Austin State Hospital, where he
provides psychotherapy and psychological assessments to children and adoles-
cents. He also provides forensic evaluations to children, adolescents, and adults.
Dr. Watkins maintains a private practice, where he works predominantly with
children, adolescents, parents, and families. He is a captain in the U.S. Army
Reserves, where he serves as a clinical psychologist. Dr. Watkins holds a doctor-
ate in clinical psychology as well as a master’s degree in counseling psychology.
He has several peer-reviewed publications and has presented on a variety of topics
in multiple countries.
TIM J. WATTS is a content development librarian at Kansas State University,
where he is responsible for content development in the social sciences, including
history, political science, and psychology.
LAUREN WESLEY is a graduate of Widener University’s Center for Human
Sexuality Studies. Lauren also earned her MA in clinical psychology from the
Chicago School of Professional Psychology and her BA from Xavier University of
Louisiana. She works with African American and Latino formerly incarcerated
men, helping them navigate reintegration and reunification with their families.
NICOLE WILLIAMS is a graduate student at Thomas Jefferson University, where
she is pursuing a master’s degree in marriage and family therapy with a concen-
tration in sex therapy. She obtained a bachelor degree in the field of psychology at
Temple University. Nicole plans on studying and specializing in the mind-body
connection and incorporating yoga therapy into her treatment for her future
clients.
C. MICHAEL WOODWARD, MPH, (he/him) is a LGBTQ+ inclusion consultant,
writer, musician, storyteller, social justice advocate, and aging queer trans guy.
Michael has published myriad books, articles, and blogs, and received the Skip
826 About the Editor and Contributors
Schrader Spirit of Activism award from Equality Arizona. He contributed the title
essay of the highly acclaimed anthology Manning Up: Transsexual Men on Find-
ing Brotherhood, Family, and Themselves (Transgress Press, 2014). He earned an
MPH in public health policy and management from the University of Arizona and
a BS in communications from Butler University.
MARISSA A. WORTH, PsyD, is a clinical psychologist. She earned her master’s
degree in clinical psychology from Pepperdine University Graduate School of
Education and Psychology and completed her doctoral studies at the California
School of Professional Psychology at Alliant International University, Los Ange-
les. Her clinical and research interests include LGBTQ treatment and advocacy,
forensic and psychodiagnostic assessment, and treatment of individuals with
severe and persistent mental illnesses.
LAUREN B. YADLOSKY, MS, is a sixth-year clinical psychology doctoral stu-
dent at Marquette University in Milwaukee, Wisconsin. She is currently complet-
ing her predoctoral internship at Montefiore Medical Center in the Bronx, New
York, where she specializes in working with high-risk children and teens. Her
research interests include applying intersectionality theory to understanding
minority stress experiences and various facets of identity (e.g., race, ethnicity,
gender, sexual orientation, class).
RACHAEL ZAFFIRO, LPC, NCC, is a licensed mental health counselor in the
state of Ohio. She received her bachelor degree in psychology with a concentra-
tion in relationships and sexual health from Maryville College, where she com-
pleted her senior thesis on the topic of sex guilt and assisted Dr. Karen Beale with
her own sex guilt research. Zaffiro received her master’s in mental health counsel-
ing from the University of Cincinnati, where she was a member of the Counseling
Academic and Professional Honor Society International, Chi Sigma Iota.
JUAN PABLO ZAPATA graduated with a BS (double majors in psychology and
public health) from the University of South Florida in Tampa in 2016. He began
the doctoral program in clinical psychology at Marquette University, working
under Dr. Ed de St. Aubin. Juan’s research interests include developing sustain-
able interventions to decrease HIV/AIDS. He is also interested in psychosocial
and behavioral factors relevant to HIV/AIDS and sexual risk among Latino men
who have sex with men. His research examines the role of cultural, structural, and
individual characteristics on HIV risk, using various research methodological
designs. He recently finished his master’s thesis, which explored the psychosocial
and sociocultural dimensions of PrEP use among gay and bisexual men in the
Midwest. He is currently working on preparation for his dissertation, which
will examine the association of PrEP and structural barriers, cultural beliefs, and
HIV-related worries and concerns among Hispanic/Latino men.
Index
Note: Page numbers in bold indicate the location of main entries.
Abortion, elective, 1–3 Abortion, surgical, 8–10
definition of, 1 definition of, 8
immigration and, 1 dilation and curettage (D&C), 4, 7, 9
prevalence of, 1 dilation and evacuation (D&E), 3–4, 8
reasons for, 1 pain medication and sedatives, 9
regulations and laws in the United reasons for, 9
States, 1–3 recovery, 9
Roe v. Wade and, 2 safety and risks, 9–10
state antiabortion statutes, 2–3 suction-aspiration or vacuum-aspiration
targeted regulation of abortion providers abortion, 7, 8–9
(TRAP laws), 2–3 Abortion, therapeutic (medically
Abortion, late-term, 3–5 necessary), 10–12
definition of, 3 definition of, 10
dilation and extraction (D&E), 3–4 elective versus therapeutic abortions,
Gonzales v. Carhart and, 5 11–12
intact dilation and extraction (IDX), 3, 5 fetal viability and, 10, 11
labor-induced abortion, 3 first-trimester, 11
Partial-Birth Abortion Act (2003) induction techniques, 11
and, 3, 5 pregnancy complications, 11
prevalence of, 3 reasons for, 10, 11
reasons for, 3, 4, 7 second- and third-trimester, 11
Roe v. Wade and, 4 Abortion, unsafe, 12–14
Abortion, medical, 5–7 causes of, 12–13
“abortion pills,” 6 contraception access and, 13
definition of, 5 death rate and, 12, 13–14
medications used for, 5–6 definition of, 12
side effects and complications, 6 medical care access and, 13
Abortion, partial-birth, 2, 3, 5, 16. See also sepsis and, 13
Abortion, late-term social and economic costs of, 13
Abortion, procedural, use of the term, 7 Abortion legislation, 14–16
Abortion, risks of, 7–8 Affordable Care Act, 16
abortion-related depression, 8 American Medical Association (AMA)
aspiration abortions, 8 and, 14
late-term abortions, 7 antiabortion activism and, 14
procedural and medical abortions, 7 Comstock Law (1873), 14, 168, 522, 584,
retained tissue, 7 594–595
side effects, 7 feminist movement and, 15
828 Index
Abortion legislation (Continued ) “sex sells,” 25
history of, 14–15 sexual behavior, 25–26
Hyde Amendment, 15–16 wish fulfillment, 26
Roe v. Wade and, 15–16 Woodbury’s Facial Soap, 25
suffrage movement and, 15 Advocate, The, 26–27
targeted regulation of abortion providers covers and interviews, 27
(TRAP laws), 2–3, 16 Goodstein, David, and, 27
See also Hyde Amendment history and founding of, 26–27
Abstinence, 16–17 Mitch, Richard, and, 27
definition of, 16 Personal Rights in Defense and
means of, 16–17 Education (PRIDE) and, 26–27
sexuality education and, 17 Rau, Bill, and, 27
Acquired immunodeficiency syndrome Rouilard, Richard, and, 27
(AIDS), 17–20 Wieder, Judy, and, 27
diagnosis of, 18 Yarbrough, Jeff, and, 27
history of the term, 18–19 Affordable Care Act, 16, 267, 288, 611
misconceptions and stigma regarding, Afterplay, 27–29
18–19 barriers to, 28
prevalence and incidence of, 18 benefits, 27–28
transmission of, 18 definition of, 27
treatment and survivability, 19 forms and behaviors, 27
See also Human immunodeficiency kink and, 28
virus (HIV) Age of consent, 29–30
Adolescent sexuality, 20–22 age of majority and, 29
puberty, 20 debate and criticism, 29
relationships, 21 definition of, 29
sexual attraction, 21 gender disparity and, 30
stages of psychosocial development and, history of, 29
20–21 prosecution and punishment, 30
World Health Organization definition of state variances of, 29, 30
adolescence, 20 Title X Family Planning Program and, 30
Adrenarche, 22–23 Agender, 30–31
androgenic hormones and, 22 definition of, 30–31
characteristic hormonal features, 22 interpretations of, 31
definition of, 22 prevalence of, 31
developmental stage of, 22 terminology, 31
premature adrenarche, 22–23 transgender and, 31
puberty and, 22 American Association of Sexuality
Adultery, 23–25 Educators, Counselors and Therapists
breach of marital contract and, 23–24 (AASECT), 32–33
Christianity and, 23 activities and programs, 32
definition of, 23 history and founding of, 32
marriage counseling and, 24 members, 32
reasons for, 24 mission of, 32
sexual activity and, 24 Schiller, Patricia, founder, 32
sexual transgression and, 23 “Vision of Sexual Health,” 32–33
Advertising, sex in, 25–26 Anal intercourse, 33–34
history of, 25 definition of, 33
nudity, 25 health risks of, 33
objectification and dehumanization, 26 lubricants and, 33–34
physical attractiveness, 25 orgasm and, 33–34
prevalence of, 25 pegging, 33
Index 829
rimming, 33 Tiller, George, death of, 5
stereotypes and misconceptions, 33–34 violence and, 5, 217
Androgen insensitivity syndrome, 34–36 Antigay prejudice, 44–46
cause of, 35 causes of, 45
complete androgen insensitivity definition of, 44–45
syndrome, 35 forms and expressions of, 45
definition of, 34 gender and cultural differences in,
disorders (or differences) of sexual 45–46
development (DSDs), 34–35 impact of, 45
gender assignment and, 36 Aphrodisiac, 46–48
management and treatment after dangers of illicit drugs as, 47
puberty, 35 dark chocolate as, 47
management before puberty, 35 definition of, 46
mild androgen insensitivity syndrome, ginseng as, 47–48
35 history and origins of, 46–47
partial androgen insensitivity syndrome, placebo effect and, 47
35, 36 uses of, 46
prevalence of, 36 Arousal, 48–50
Androgens, 36–39 definition of, 48
anabolic steroids, 39 emotions and, 48–49
definition of, 36 female arousal, 48
fetal development and, 37 hormones and, 48
as hormone therapy, 38, 39 inhibitors of, 48
as medical treatment, 38–39 male arousal, 48
in men, 37–38 psychological function of, 48–49
puberty and, 37 Artificial insemination, 50–52
in women, 37, 38 definition of, 50
Androgyny, 39–41 donor sperm, 51
Bem Sex-Role Inventory (BSRI) and, 40 history and origins of, 51–52
definition of, 39 intracervical insemination (ICI), 51
gender nonconformity and, 39, 40 intrauterine insemination (IUI), 51
intersex and, 39–40 process of, 50–51
in popular media, 40 uses of, 50
sociological behaviors, 40 in vitro fertilization (IVF) and, 51–52
stigma and discrimination, 40 Asexuality, 52–53
terminology, 39–40 definition of, 52
Andropause, 41–43 demisexual, 53
compared to female menopause, 41, 42 graysexual/gray-ace, 53
definition of, 41 as identity, 52
mental symptoms of, 42 masturbation and, 52–53
physical symptoms of, 41–42 terminology, 52, 53
purpose of, 42 Assisted reproductive technology, 53–55
Anorgasmia, 43–44 cryopreservation, 55
causes of, 43–44 definition of, 53
classifications of, 43 genomic testing, 55
definition of, 43 gestational surrogacy, 55
DSM on, 43 intracytoplasmic sperm injection (ICSI),
management of, 44 54
Antiabortion activism, 2 intrauterine insemination (IUI) and, 54
National Organization for Women and, methods of, 53
440 sperm retrieval, 53–54
physicians’ crusade against abortion, 14 in vitro fertilization (IVF), 54
830 Index
Association of Black Sexologists and Benign prostatic hyperplasia, 66–68
Clinicians, 55–57 causes of, 66–67
Black Families, Black Relationships, definition of, 66
Black Sexuality Conference, 56 diagnosis of, 67
events, 56 lower urinary tract symptoms (LUTS),
Journal of Black Sexuality and 67, 68
Relationships, 55, 56–57 prevalence and incidence of, 66
mission and vision of, 55 symptoms of, 67
Wadley, James C., founder, 55 treatment of, 68
Attachment theory of love, 57–58 Benjamin, Harry, 68–69
Ainsworth, Mary, and, 57 early career, 69
attachment styles, 57–58, 387–388 early years and education, 68–69
Bowlby, John, and, 57, 387 Harry Benjamin International Gender
The Strange Situation (experiment), Association, 69
57–58 “transsexual” coined by, 69
The Transsexual Phenomenon, 69
Bacterial vaginosis, 59–60 Bigender, 69–70
causes of, 59–60 definition of, 69–70
definition of, 59 experience and expression of, 70
menstruation and, 59 history and origin of, 70
recurrences of, 60 pronoun usage, 70
sexual activity and, 59 terminology, 70
symptoms of, 59 Binary gender system, 71–72
treatment of, 60 challenges to, 71–72
vaginitis as distinct from, 59 culture and, 71
Barrier contraceptive methods, 60–62 definition of, 71
benefits of, 60–61 intersex people and, 71
cervical cap, 61 professional psychological perspectives,
contraceptive sponge, 62 72
definition of, 60 Biological sex, 72–73
diaphragm, 61 definition of, 72
drawbacks of, 61 as social construct, 73
effectiveness of, 61–62 use of the term, 72
insertive (male) condom, 61 Biological theories of sexual orientation,
receptive (female) condom, 61 73–75
Basson, Rosemary, 62–63 birth order, 74
circular model of sexual response, 62 family studies, 74
early career, 62 genetic research, 74
notable research, 62–63 nature versus nurture perspectives,
publications, 63 74
BDSM, 63–66 Biphobia, 75–76
definition of, 63 bisexual people and, 75–76
DSM on, 64–66 definition of, 75
DungeonMaster (magazine), 65, 66 instability dimension of, 75
events, 65 intolerance dimension of, 75
history of, 64–65 mental health and, 76
National Leather Association (NLA) origin of the term, 75
and, 65 stigma and misconceptions of, 75–76
organizations and publications, 65, 66 Birth control pills, estrogen-progestin, 76–78
in popular culture, 66 benefits and drawbacks of, 77–78
safe practices, 65 “combination pill,” 76–77
Index 831
effectiveness of, 77 causes of, 89–90
in hormone replace therapy, 78 prevalence of, 89
side effects of, 77 risks of, 89, 90
types of, 77 screenings for, 90
Birth control pills, progestin-only, 78–79 symptoms of, 90
benefits and drawbacks of, 78–79 treatment of, 90
effectiveness of, 78 Breastfeeding, 91–93
in hormone replacement therapy, 79 benefits to infants, 91–92
“minipill,” 78 benefits to mothers, 92
side effects of, 78–79 breast development and, 91
Bisexuality, 79–81 challenges to, 93
definition of, 79 definition of, 91
double discrimination and, 80 induction of lactation, 91
myths and misconceptions about, milk composition, 91
79–80 myths and misconceptions about,
Black sexuality, 81–84 92–93
characteristics of, 81–82 Bulbourethral glands, 93–94
influence of black church on, 83–84 location and purpose of, 93–94
influence of election of Barack Obama preejaculate, 94
on, 83 prostate-specific antigen (PSA), 94
influence of HIV/AIDS on, 83 Bush, George W., 5
influence of media on, 83
influence of racism on, 83 Castration, 95–96
influence of slavery on, 81, 82 definition of, 95
sociopolitical constructs and, 82 eunuchs in ancient Rome, 95
Born This Way Foundation, 84–85 methods of, 95
activities and programs, 85 for sex offenders, 95–96
debate and controversy, 85 Casual sex, 96–98
Germanotta, Cynthia and Stefani attitudes toward, 96–97
(Lady Gaga), founders, 84, 85 booty calls, 96
history and founding of, 84–85 definition of, 96
kick-off event, 85 friends with benefits, 96
purpose and tenets of, 84–85 one-night stands, 96
Bornstein, Kate, 85–87 orgasm gap and, 97
activism of, 86 psychological effects of, 97
pronoun usage of, 85–86 risks of, 97
published books, 86 types of, 96
religion and, 86 Celibacy, 98–99
Breast, female, 87–89 definitions of, 98–99
amastia (failure to develop), 87–88 “incel” community (involuntary
anatomy, 87 celibates), 98
benign tumors, 88 religion and, 98
breast augmentation, 88 Cervical cancer, 99–101
cancers and other diseases, 88 diagnosis of, 100
development, 87 incidence of, 99
mammograms, 88 prevention of HPV infection,
puberty and, 87 100
size of, 87 risks and causes of, 99–100
Breast cancer, 89–91 screening for, 100
BRCA1 and BRCA2 genetic mutations, squamous cell carcinoma, 99
89 treatment of, 100–101
832 Index
Cervical cap, 101–102 signs of potentially unhealthy behavior,
advantages and disadvantages of, 102 113
costs of, 101 Chlamydia, 114–115
definition of, 101 Chlamydia trachomatis and, 114
effectiveness of, 101–102 diagnosis of, 114
proper use of, 101 prevention of, 115
sizes of, 101 as silent infection, 114
Cervical mucus method, 102–103 symptoms of, 114
procedure and function, 102–103 transmission of, 114
reasons for mucus pattern changes, treatment of, 114–115
103 Chlamydia trachomatis, 114, 391,
reasons for using, 102 491, 546
Cervix, 103–104 Chromosomal sex, 115–116
anatomy and function, 103–104 aneuploidy and, 116
cervical canal, 104 conception and, 115
external cervix, 104 definition of, 115
internal cervical, 104 puberty and, 116
size of, 104 “sex” as distinct from “gender,” 115
Chancroid, 104–106 Circumcision, 116–118
Haemophilus ducreyi and, 104–105 benefits and drawbacks of, 117–118
HIV and, 105 definition of, 116
misdiagnosis of, 105 opposition to, 117
prevention of infection, 105 prevalence of, 117
transmission of infection, 105 procedure, 116–117
Cheating and infidelity, 106–108 religion and, 117
adolescents and, 107 Cisgender, 118–119
definitions of, 106 definition of, 118
effects on individuals in dyadic origin of the term, 118
relationships, 106–107 prevalence of, 118
gender differences, 107 use of the term, 118–119
GLB individuals and, 107 Civil union, 119–120
personality traits and, 106 definition of, 119
Child sexual abuse, 108–110 Obergefell v. Hodges and, 119
definition of, 108 recognition of and legal protections for,
effects of, 109 120
hotlines, 109 Clinton, Bill
knowledge of abuser, 109 Don’t Ask, Don’t Tell policy, 173
prevalence of, 108 Elders, M. Joycelyn, and, 597
warning signs of, 108–109 partial-birth abortion ban vetoed by,
Childhood gender nonconformity, 16
110–112 presidential apology for Tuskegee
continuum of, 110 Syphilis Study, 754
definition of, 110 Clitoris, 120–121
gender dysphoria compared with, 110 anatomy, 120
gender identity development and, 110 compared with penis, 121
protective factors for, 110–111 development of, 120–121
Childhood sexuality, 112–114 myths and misconceptions
development from ages four to six, 113 about, 121
development from ages seven to removal of, 121
twelve, 113 Colposcopy, 122–123
development from birth to age four, colposcope, 122
112–113 definition of, 122
Index 833
efficacy of, 122–123 Congenital adrenal hyperplasia,
Hinselmann, Hans, and, 122 136–138
history of, 122 causes of, 136
procedure, 122 definition of, 136
reasons for, 122 nonclassic forms of, 136–137
Coming out, 123–125 salt-wasting form of, 136
challenges of, 124 treatment of, 137
coming-out process, 123 virilizing form of, 136
definition of, 123 Consummate love, 138–139
history and origin of the term, 123 definition of, 138
for polyamorous people, 124 Sternberg, Robert, and triangular theory
for transgender or gender of love, 138–139, 708
nonconforming people, 123–124 Contraception, 139–141
Commission on Obscenity and definition of, 139
Pornography, 125–126 history of, 140
history of, 125 ideal contraceptive, 140
members and chair, 125 puberty and, 139–140
purpose of, 125 social changes and, 140–141
reactions to, 125 Contraceptive implant, 141–143
Report of the Commission on Obscenity effectiveness and safety of, 142
and Pornography, 125 history of, 141–142
Communication, sexual, 126–128 side effects of, 142
effective communication, 127 Contraceptive injectables, 143–144
nonverbal communication, 126–127 benefits of, 143–144
shame and, 126 effectiveness of, 143
Companionate love, 128–129 side effects of, 144
definition of, 128 Contraceptive patch, 144–145
Sternberg, Robert, and triangular theory effectiveness and safety of, 145
of love, 128 history of, 144
Wallerstein, Judith, and types of “good side effects of, 145
marriages,” 128–129
Compulsivity, sexual, 129–131 Date rape, 147–149
causes of, 130 acquaintance rape, 148
definition of, 129 campus rape, 148
diagnosis of, 130 forcible rape compared with, 147
effects of, 129–130 intoxication and, 147
treatment of, 130–131 male victims of, 148
types of, 130 origin of the term, 147
Comstock Law (1873), 14, 168, 522, 584, prevalence of, 147
594–595 prevention and intervention strategies,
Conception, 131–133 148–149
definition of, 131 settings for, 147
necessary conditions for, 131–132 Dating, 149–152
Condoms, female (receptive), 133–134 capitalism and, 150–151
advantages and drawbacks of, history of, 149–150
133–134 industrialization and, 150
proper use of, 133 internet technology and, 151
purpose of, 133 media and, 151
Condoms, male (insertive), 134–136 in midlife, 152
advantages and drawbacks of, 134–135 origin of the term, 149
proper use of, 135–136 transportation and, 150
purpose of, 134 world wars and, 151
834 Index
Dating, cross-cultural comparison of, Diagnostic and Statistical Manual of
152–156 Mental Disorders (DSM), 165–166
arranged marriage and, 153–154 DSM-5, 165–166
chaperones and, 154 history of, 165
Christianization and, 153 original DSM, 165
definition of “dating,” 152–153 paraphilic disorders, 166
extramarital sex and, 156 sexual dysfunctions, 166
LGBTQ+ people and, 155 Diamond, Milton, 166–168
parental permission and, 154–155 family and education, 167
sexual activity and, 155–156 gender identity research, 167–168
socioeconomics and, 154 John/Joan (David Reimer) case, 166,
Demisexuality, 156–157 167, 575–576
asexuality and, 156–157 Diaphragm, 168–169
definition of, 156 advantages and drawbacks of, 169
internet communities, 157 Comstock Act and, 168
Dental dam, 157–158 definition of, 168
benefits and drawbacks of, effectiveness of, 169
157–158 fitting for, 169
materials in, 158 history of, 168
sexual uses of, 157 proper use of, 168–169
Desire, 158–160 Disabilities, sexual function and,
definition of, 158 169–172
elements of, 159 challenges and discrimination,
measurement of, 159 170–171
“normal” levels of, 159 definition of “disability,” 169–170
responsive desire, 158–159 identity and, 170
Desire, models of, 160–161 information access and, 171
circular model of Rosemary Basson, medical model of disability, 170
160–161 social model of disability, 170
linear models, 160 Dodson, Betty, 172–173
triphasic model (Helen Singer Kaplan), Bodysex Workshops, 172, 173
160 education and early career, 172–173
Desire discrepancy, 161–162 as “Godmother of Masturbation,” 172
causes of, 161–162 Liberating Masturbation: A Meditation
definition of, 161 on Selflove, 172
as relational problem, 162 Don’t Ask, Don’t Tell, 173–175
Desire disorders, 162–163 effects of, 174
diagnosis of, 163 history of, 173
female sexual interest/arousal disorder, purpose of, 173–174
162 repeal of, 174
male hypoactive sexual desire disorder, Double standards, sexual, 175–176
162 collegiate hookup culture and, 175
prevalence of, 162–163 definition of, 175
treatment of, 163 effects of, 176
DHEA, 163–165 heterosexual double standard, 175
biological function and activity, as local and subcultural
163–164 constructions, 175
dosage and safety of, 164 Douching, 176–178
effectiveness of, 164 definition of, 176
as parent hormone, 164 disease and infection risk, 177
uses of, 164 drawbacks of, 176, 177
Index 835
history and origins of, 176–177 personal life and relationships,
prevalence of, 177 190–192
purpose of, 176 published works, 191
Down low, 178–179 Studies in the Psychology of Sex, 190
African American communities and, Emergency contraception, 192–193
178–179 combination daily birth control pills
definition of, 178 as, 193
history of, 178 copper IUDs, 193
HIV and, 178, 179 definition of, 192
men, 178–179 effectiveness of, 192
women, 179 one-pill ulipristal acetate, 193
Drag, 180–182 purpose of, 192–193
cross-dressing compared Endometrial cancer, 196, 208, 333, 351,
with, 180 517, 760
definition of, 180 Endometriosis, 193–195
history of, 180–181 causes of, 194
notable drag personalities, 181 definition of, 193
as political protest, 181 diagnosing of, 194
RuPaul’s Drag Race, 181 symptoms of, 194
shows and costumes, 181 treatment of, 194
Dysmenorrhea, 182–183 Endometrium, 195–196
definition of, 182 abnormalities of, 195–196
diagnosis of, 183 definition of, 195
primary dysmenorrhea, 182 endometrial cancer, 196
secondary dysmenorrhea, 182 ischemic phase, 195
symptoms of, 183 menstrual phase, 195
treatment of, 183 proliferative phase, 195
Dyspareunia, 184–185 secretory phase, 195
causes of, 184 Epididymis, 196–197
definition of, 184 anatomy, 196–197
genito-pelvic pain/penetration disorder definition of, 196
(GPPPD) and, 184 effect of temperature on, 197
history of the term, 184 epididymitis, 197
treatment of, 184–185 purpose of, 197
trauma and injury to, 197
Ejaculation, 187–188 Erectile dysfunction, 198–199
definition of, 187 definition of, 198
female ejaculation, 187 diagnosis of, 198
male ejaculation, 187 prevalence of, 198–199
nocturnal emissions, 187 risk factors for, 198
premature ejaculation, 187 symptoms of, 198
process of, 187 Erectile dysfunction drugs,
Ellis, Albert, 188–190 199–200
early years and education, 188 causes of erectile dysfunction, 199
The Folklore of Sex, 189 priapism caused by, 200
published works, 189 sildenafil citrate, 199–200
rational emotive behavior therapy Erection, 200–203
(REBT), 188, 189 clitoral erections, 201
Ellis, Henry Havelock, 190–192 erectile dysfunction, 202
controversy, 190–191 penile erections, 200–202
education and early career, 190 Erikson, Erik, 20, 657
836 Index
Erogenous zones, 203–204 access to, 217
definition of, 203 in developing countries, 217
erogenous zone maps and hotspots, Planned Parenthood Federation of
203–204 America (PPFA), 217–218
Freud, Sigmund, on, 203 publicly funded clinics, 216–217
gender differences, 204 services offered, 216
nonspecific erogenous zones, 203 Fantasy, sexual and erotic, 218–220
in popular culture, 204 content of, 218–219
specific erogenous zones, 203 definition of, 218
type of sexual activity and, 204 Freud, Sigmund, on, 219
Erotophilia and erotophobia, 204–206 gender differences, 219
definitions of, 204–205 paraphilic sexual interests and, 219
erotophobia as a form of oppression, 206 problematic fantasies, 219
erotophobia as a personality trait, 205 sexual orientation and, 219
sexual health and, 205–206 Fausto-Sterling, Anne, 220–221
Essure coil, 207 education, 220
adverse events and end of production, published works, 220
207 research interests, 220–221
effectiveness of, 207 Feinberg, Leslie, 221–222
prevalence of use, 207 activism of, 222
Estrogen, 208–209 pronoun usage, 221
biological activity and purpose, 208 published works, 222
hormone replacement therapy, 208 Stone Butch Blues, 222
synthetic estrogen, 208 Female ejaculation, 222–224
Evolutionary perspectives on gender and alternative terms for, 222
sexual behavior, 209–211 anatomy, 222
dating and sex, 209 composition of, 223
evolutionary theory, 209 definition of, 222
gender roles, 209–210 Grafenberg spot (G-spot) and, 223
partner preferences, 210 in popular culture, 222–223
sexual strategies, 210 Skene’s gland and, 222, 223
Exhibitionism, 211–212 storage of ejaculate, 223–224
behaviors and signs of, 211–212 use of the term, 223
definition of, 211 Female genital cutting, 224–225
exhibitionistic disorder, 211, 212 all other harmful procedures to female
shame and, 212 genitalia (type 4), 224
treatment of, 212 alternative terms for, 224
Extramarital sex, 212–213 clitoridectomy (type 1), 224
definition of, 212 excision (type 2), 224
extradyadic sex, 213 human rights and, 225
nonpermissive extramarital sex, 213 infibulation (type 3), 224
permissive extramarital sex (consensual instruments used for, 224
nonmonogamy), 213 societal norms and cultural traditions,
range of behaviors, 213 225
Female sexuality, 226–227
Fallopian tubes, 215–216 biological factors, 226
anatomy, 215 cultural influences, 227
damage to, 215 definition of, 226
tubal ligation, 215 gender identity and, 227
Family planning clinics, 216–218 puberty and, 226
abortion controversy and, 217 sexual pleasure, 226
Index 837
Femininity, 227–229 5-alpha-reductase deficiency, 239–241
cultural norms and influences, 228 development without surgical
definition of, 227–228 intervention, 240
racialization of, 228–229 gender assignment and, 240–241
Feminist theory, 229–230 mechanism of, 240
definition of, 229 surgical intervention, 240, 241
definitions of feminism, 229–230 Fluidity, gender, 241–243
goal of, 230 alternative terms for, 241
intersectionality and, 230 challenges of, 242
on power and oppression, 230 definition of, 241–242
Fertility, 230–234 strengths of, 242
definition, 230 Fluidity, sexual, 243–245
female fertility, 231–232 bisexuality compared with, 243–244
fertility window (FW), 231 choice of sexual responsiveness and, 245
gamete freezing, 233 definition of, 243
infertility, 232–233 gender differences, 244
male fertility, 232 social and cultural factors, 244
menstrual cycle and, 231 Follicle-stimulating hormone, 245–246
oocyte quality, 232 in children, 246
puberty and, 231 gender differences, 245–246
sterility, 233 levels of, 245–246
woman’s age and, 231–232 menotropins (infertility treatment), 246
Fertility awareness methods of purpose of, 245
contraception, 234–235 synthetic FSH, 246
advantages and disadvantages of, Foreplay, 246–248
235 definition of, 246
effectiveness of, 234–235 effects and purposes of, 247
reasons for using, 234 erogenous zones and, 247
Fertility drugs, 235–237 games as, 247–248
bromocriptine and cabergoline, 236 mind-altering substances and, 248
clomiphene citrate, 236, 237 myths and misconceptions about, 247
follicle-stimulating hormone, 236 physical foreplay, 247
gonadotropin-releasing hormone Foreskin, 248–249
agonists, 236 anatomy, 248–249
human menopausal gonadotropin, 236 balanitis, 248–249
letrozole (aromatase inhibitor), 236 circumcision, 248, 249
luteinizing hormone, 236 definition of, 248
metformin, 236 paraphimosis, 249
methylprednisolone, 236–237 phimosis, 248
ovarian hyperstimulation syndrome role of, 248
(OHSS) and, 236 Foucault, Michel, 249–251
progesterone, 237 activism of, 250
risk of multiple births, 237 education and influences, 249–250
Fetishism, 237–239 Histoire de la sexualité (History of
causes of, 238–239 Sexuality) series, 250, 592
definition, 237 on prostitution, 548
fetish objects and collections, 238 published works, 250
fetishistic disorder, 237–238 on sexuality and sexual identity,
gender differences, 238 249–250, 406
rare types of, 239 on sexuality as socially constructed,
treatment of, 239 249, 576
838 Index
Freud, Sigmund, 251–253 providers of, 259
on clitoral stimulation, 121 purpose of, 258
DSM and, 165 Gay rights movement, 259–262
early career, 251–252 Don’t Ask, Don’t Tell policy and, 261
Ellis, Albert, and, 189 history of, 259–260
Ellis, Henry Havelock, and, 190, HIV/AIDS and, 261
191, 192 Lawrence v. Texas and, 261
on erogenous zones, 203 Milk, Harvey, and, 260–261
family and education, 251 Obergefell v. Hodges and, 261
on hysteria, 251–252 organizations, 260
influenced by Richard von Krafft- Reagan administration and, 261
Ebing, 377 Stonewall riot, 260
Madonna-whore dichotomy, 393–394, terminology, 259
548 Gay-Straight Alliance (GSA), 262–264
Oedipus complex, 252, 450–452 campaigns and events, 262
psychoanalysis (“talking treatment”), East High Gay/ Straight Alliance v.
251 Board of Education of Salt Lake City
published works, 252 School District, 262–263
on sexual fantasies, 219 Gay-Straight Alliance Network, 262
on sexual identity development, 303, history of, 262–263
310, 580, 657 notable accomplishments of, 263
theory of id, ego, and superego, 252 See also GLSEN (Gay, Lesbian, and
Victorian era and, 777–778 Straight Education Network)
Friends with benefits, 253–254 Gender, 264–266
compared with other types of casual sex biological theory, 265–266
relationships, 253–254 biosocial theory, 266
definition of, 253 body morphology, 264
reasons for, 253–254 definition of, 264
Frotteurism, 254–255 enculturated lens theory, 266
consensual-based behaviors and, 255 gender comportment, 265
definition of, 254 gender expression, 265
DSM on, 254 gender roles, 265
terminology, 254 gender theories, 265–266
typical frotteurs, 254–255 secondary sex characteristics, 264–265
victims of, 255 Gender diversity, 266–269
FTMInternational, 255–256 definition of, 267
activities and programs, 255–256 health care and, 267
The FTMI Yellow Pages, 255–256 historical context of, 266–267
mission of, 255 as human rights movement, 267–268
Sullivan, Lou, founder, 255–256 Gender dysphoria, 269–270
definition of, 269
Galactorrhea, 257–258 diagnosis of, 269–270
causes of, 257 DSM on, 269, 270
definition of, 257 symptoms of, 269
diagnosis of and treatment of, 257–258 treatment of, 270
history of, 257 Gender expression, 271–272
prevalence of, 257 androgyny and, 39, 40
symptoms of, 257 childhood gender nonconformity and,
Gay affirmative therapy, 258–259 110
guidelines for, 258 cultural influences on, 271
guiding principles of, 258 definition of, 265, 271
Index 839
forms of, 271 Devor’s stages of transgender identity
gender diversity and, 267 formation, 274
gender fluidity and, 241–242 key elements of models, 275
gender identity and, 273 Kinney’s nonbinary gender identity
genderqueer and, 280–281 development model, 274–275
masculinity and, 406 masculinity and, 406
nonbinary gender identities and, Gender roles, socialization and, 276–277
444, 445 cognitive developmental theory, 277
passing and, 487 definition of “gender roles,” 276
pronoun usage and, 541 definition of “socialization,” 276–277
public displays of affection and, 560 social learning theory, 276–277
sexual expression and, 647–648 Gender transition, 277–279
transexual and, 743–744 definition of, 278
transgender and, 740 medical intervention and surgery, 278
two-spirit and, 755 social gender transition, 278
Gender identity, 272–274 GenderPAC, 279–280
androgen insensitivity syndrome and, activities and programs, 279–280
36 dissolution of, 280
androgyny and, 39, 40 history and founding of, 279
binary gender system and, 71 purpose of, 279
chromosomal sex and, 115, 116 Wilchins, Riki Anne, founder, 279
cisgender and, 118 Genderqueer, 280–282
congenital adrenal hyperplasia and, definition of, 280
137 diverse experiences of, 280–281
cultural influences on, 272 gender transition, 281
definition of, 272 Genital dysphoria, 282–283
Diamond, Milton, on, 167 definition of, 282
evolution in gender conceptualization, gender dysphoria and, 282–283
272–273 mental health and, 283
female sexuality and, 227 “phantom” genitals and, 283
5-alpha-reductase deficiency and, transgender identity and, 282–283
239–241 Genital warts, 284–286
gender dysphoria and, 270 cause of, 284
gender expression and, 273 characteristics of, 285
gender fluidity and, 241–242 diagnosis of, 285
genderqueer and, 280–281 growth of, 285
Green, Jamison, on, 294 prevention of, 286
male sexuality and, 394 screening for, 284
Money, John, on, 430 transmission of, 284
nonbinary gender identities, 443–445 treatment of, 285–286
outing and, 467 GLAAD, 286–288
pronoun usage and, 540–541 debate and criticism, 287
questioning and, 564, 565–566 history and founding of, 286–287
Reimer, David, on, 575 media awards program, 287
sexual dimorphism and, 642 purpose of, 287
social learning theory and, 688 GLMA: Health Professionals Advancing
transgender and, 739, 740 LGBTQ Equality, 288–289
Gender identity development, 274–276 history and founding of, 288
childhood gender nonconformity and, mission of, 288
110 notable accomplishments, 288–289
definition of “gender identity,” 274 publications and resources, 289
840 Index
GLSEN (Gay, Lesbian, and Straight HHV 5 (cytomegalo virus), 298
Education Network), 289–290 HHV 6 (roseola virus), 298
activities and programs, 289–290 HHV 7, 298
governance, 290 HHV 8 (Karposi’s sarcoma-associated
history and founding of, 289 herpes virus), 298–299
purpose of, 289 prevalence of, 299
Gonorrhea, 290–292 stigma and misconceptions about, 299
diagnosis of, 291 symptoms of HSV 1 and 2, 299
gender differences, 291 transmission of HSV 1 and 2, 299
Neisseria gonorrhoeae and, 290 types of, 298–299
prevalence of, 290 Heterosexism, 300–302
prevention of, 291–292 definition of, 300
symptoms of, 291 history of the term, 300
transmission of, 290–291 homosexuality as pathology, 301
treatment of, 291 law and criminalization, 301
Grafenberg spot (G-spot), 292–293 racism and, 300
anatomy, 292 religion and, 300–301
debate and controversy, 293 sexism and, 300
discovery and naming of, 292 Heterosexuality, 302–303
location of, 292 definition of, 302–303
Green, Jamison, 293–295 history of the term, 303
activism of, 294 models of heterosexual identity
Becoming a Visible Man, 294–295 development, 303
early life, 293–294 Hirschfeld, Magnus, 304–305
education and career, 294, 295 education, 304
Report on Discrimination against Institute for Sexual Research, 304
Transgendered People, 294 LGBTQ+ advocacy, 304–305
Griswold v. Connecticut, 585, 611 published works, 304
Gynecomastia, 295–296 Homonegativity, 45, 306–308, 468
causes of, 295–296 Homophobia, 305–307
definition of, 295 causes of, 305–306
diagnosis of, 296 definition of, 305
history of, 296 externalized behaviors, 306
management of and treatment generational differences, 307
of, 296 homonegativity and, 306–307
prevalence of, 295 Homophobia, internalized, 307–309
symptoms of, 296 causes of, 307–308
definition of, 308
Hepatitis, 297–298 detection of, 308
acute hepatitis, 297 homonegativity and, 307–308
chronic hepatitis, 297 interventions, 308
diagnosis of, 297–298 Homosexuality, 309–312
hepatitis A (HAV), 297 causes of, 309–310
hepatitis B (HBV), 297–298 cultural attitudes towards, 311
hepatitis C (HCV), 297 definition of, 309
transmission of, 297 health care issues, 310
treatment of, 298 history of, 311
vaccination against, 298 myths and misconceptions about,
Herpes, 298–300 310–311
herpes simplex viruses (HSV) 1 and 2, prevalence of, 309
298–299 Hooker, Evelyn, 312–314
HHV 3 (chicken pox/shingles), 298 early life and education, 312
HHV 4 (mononucleosis), 298 research interests and career, 312–313
Index 841
“The Adjustment of the Male Overt Hymenoplasty, 327–329
Homosexual,” 313 alternatives to, 329
Hookup culture, 314–315 definition of, 327
definition of, 314 procedure, 327–328
gender differences, 315 reasons for, 328–329
gendered expectations and, 315 Hypersexuality, 329–331
hooking up as hegemonic, 314 causes of, 330
Hormone replacement therapy, definition of, 329
315–317 diagnosis of, 331
alternatives to, 316 symptoms of, 330
definition of, 315–316 thoughts and behaviors, 329–330
in gender transition process, 317 treatment of, 331
long-term HRT, 315 Hypogonadism, 332–333
short-term HRT, 315 complications of, 333
Hot flashes, 317–319 definition of, 332
causes of, 317–318 diagnosis of, 333
definition of, 317 gender differences, 332
diagnosis of, 318 primary hypogonadism, 332
in men, 318 secondary hypogonadism, 332
signs of, 317–318 symptoms of, 332, 333
treatment of, 318 treatment of, 333
Human immunodeficiency virus (HIV), Hysterectomy, 334–335
319–320 complications of, 335
diagnosis of, 319 definition of, 334
postexposure prophylaxis for, 320 minimally invasive procedures (MIPs),
prevalence and incidence of, 319 334–335
stigma and discrimination, 320 reasons for, 334
transmission of, 319 subtotal (supracervical) hysterectomy,
treatment of, 319–320 334
See also Acquired immunodeficiency surgical techniques, 334
syndrome (AIDS) total hysterectomy, 334
Human papillomavirus (HPV),
320–324 Incest, 337–338
asymptomatic infection, 322 definition of, 337
high-risk HPV infections, 321 effects of, 338
low-risk HPV infections, 321 parent-child incest, 337–338
pregnancy and, 324 between siblings, 337
prevalence and incidence of, 320 Infertility, 338–342
prevention of infection, 323–324 age and, 339
screening for and diagnosis of, causes of, 340
322–323 definition of, 338
transmission of, 321–322 lifestyle factors and, 339–340
treatment of, 323 in men, 340–341
types of, 320–321 prevalence of, 338
Hyde Amendment, 324–325 as symptom, 340
history of, 325 in transgender and gender-variant
impact of, 325 people, 341
provisions of, 324–325 in women, 339–340
Hymen, 326–327 Intercourse, 342–343
anatomy, 326 definition of, 342
imperforate hymen, 326 reproductive model of, 342
microperforate hymen, 326 sex and, 342–343
virginity and, 326–327 types of, 342
842 Index
International Classification of Diseases, effect on self-esteem, 353–354
Eleventh Revision (ICD-11), 343–344 envy compared with, 353
“Conditions Related to Sexual Health” John/Joan (David Reimer) case, 167, 431,
(chapter), 343 575–576
DSM-5 and, 344 Johnson, Lyndon B., 125
history of, 343 Johnson, Virginia, 355–356
removal of trans-related categories, 344 early life and education, 355
World Health Organization and, 343 Human Sexual Inadequacy, 356, 410
International Foundation for Gender Masters, William H., and, 355, 356, 410
Education (IFGE), 344–346 Masters and Johnson four-stage model
activities and programs, 345 of sexual response, 411–413
conferences, 345 Masters and Johnson Institute,
Lynn, Merissa Sherrill, founder, 355–356, 410
344–345 The Pleasure Bond, 356
purpose of, 344–345 published works, 355–356
Intersectionality, 230, 439, 566–567, 702 Jorgenson, Christine, 356–358
Intersexuality, 346–348 celebrity of, 357
congenital adrenal hyperplasia (CSH), Christine Jorgensen: A Personal
347 Biography, 358
definition of, 346 early life and military career, 356
external genitalia that varies from surgeries, 356–357
typical genitalia, 347 Joy of Sex, The, 358–359
intersex as socially constructed Comfort, Alexander, author, 358–359
category, 346 contents and organization, 359
intersex rights, 347–348 publication and sales, 358
surgery and, 347–348
terminology, 346 Kama Sutra, 361–362
Turner syndrome, 346–347 influence of, 361
Intimacy, sexual and relational, 348–349 publication of, 361
definition of, 348 sections and contents, 361
emotional intimacy, 349 Kaplan, Helen Singer, 362–363
forms of intimacy, 348–349 academic and research career, 362–363
sexual intimacy, 349 early life and education, 362
Intracytoplasmic sperm injection, Kaplan’s triphasic model, 363–366
350–351 debate and criticism, 365–366
drawbacks and complications of, 350 desire phase, 363–364
prevalence of, 350 excitement (arousal) phase, 364
process of, 350 Masters and Johnson’s sexual response
in vitro fertilization (IVF) compared cycle and, 363
with, 350 resolution phase, 364
Intrauterine device (IUD), 351–352 sexual dysfunction and, 364–365
advantages and drawbacks of, 351, 352 Kegel exercises, 366–367
copper IUDs, 351 perineum and, 498–499
hormonal IUDs, 351 proper technique and cautions, 366–367
insertion of, 351–352 purpose of, 366
mechanism of, 351 vaginismus and, 367
potential complications of, 352 Kellogg, John Harvey, 367–368
Battle Creek Sanitarium (The San) and,
Jealousy, 353–354 367–368
behavioral outcomes of, 354 hygiene theory of, 368
definition of, 353 Plain Facts for Old and Young, 367
destructive behaviors and, 354 Kink, 368–369
effect on cognitive processes, 353 clubs and organizations, 369
Index 843
definition of, 368 LeVay, Simon, 383–385
evolution of, 368–369 “A Difference in Hypothalamic
origin of the term, 368 Structure between Heterosexual and
in popular culture, 369 Homosexual Men,” 384
Kinsey, Alfred, 370–371 early years and education, 384
early years and education, 370 research and academic career, 384–385
Kinsey Institute, 371 LGBTQ+, 385–386
Kinsey Report, 370, 371, 628, GSA and, 386
636–637 history of the acronym, 385–386
published works, 370 MSM and, 386
research interests, 370–371 SGM and, 386
sexology and, 628 terminology, 385
Kinsey’s continuum of sexual orientation, WSW and, 386
371–374 Love, 386–388
assumptions of, 372 Bowlby’s attachment theory, 387–388
influence of, 373 definition of, 386
scale range, 372 romantic love, 386
Kissing, 374–375 Sternberg’s triangular theory of love, 387
cultural differences, 375 types of, 386–387
gender differences, 374–375 Lubricants, 388–389
role in mate selection, 374 definition of, 388
types of, 374 external lubricants, 388–389
Klinefelter syndrome, 375–376 oil-based lubricants, 389
definition of, 375 purpose of, 388
prevalence of, 375 silicone-based lubricants, 389
treatment of, 376 variances in production of, 388
underdiagnosis of, 376 water-based lubricants, 388–389
variants of, 376 Luteinizing hormone, 389–391
Krafft-Ebing, Richard von, 376–378 disorders related to, 390–391
early career, 377 LH surge, 390
influence of, 377 in men, 390
Psychopathia Sexualis, 376, 377 roles of, 390
in women, 390
Labia, 379 Lymphogranuloma venereum, 391–392
anatomy, 379 Chlamydia trachomatis and, 391
as erogenous zones, 379 disease stages, 392
labia majora, 379 lesions and, 391, 392
labia minora, 379 prevention of, 392
Labiaplasty, 380–382 symptoms of, 392
complications of, 381 treatment of, 392
prevalence and trends, 381–382
purpose of, 380 Madonna-whore dichotomy, 393–394
surgical techniques, 380–381 Christianity and, 393
Lawrence v. Texas, 261, 692 Freud, Sigmund, on, 393–394, 548
Lee’s theory of love styles, 382–383 social conditioning and, 393
agape love style, 383 Male sexuality, 394–398
eros love style, 382 definition of, 394
Lee, John, and, 382 fluidity of, 396
ludus love style, 382–383 heteronormativity and, 394–395,
mania love style, 383 396–397
pragma love style, 383 heterosexism and, 394–396, 397
primary love styles, 382 shame and, 395–396
storge love style, 382 socioeconomic status and, 396
844 Index
Maltz Hierarchy, 398–400 Johnson, Virginia, and, 355, 356, 410
advantages and disadvantages of, Masters and Johnson Institute,
399–400 355–356, 410
authentic sexual intimacy (level +3), 399 The Pleasure Bond, 356
impersonal interaction (level -1), 398 Masters and Johnson four-stage model of
impersonal interaction (level -2), sexual response, 411–414
398–399 excitement phase, 412
making love (level +2), 399 history of, 411–412
Maltz, Wendy, and, 398 impact of, 413
role fulfillment (level +1), 399 orgasm phase, 412
violent interaction (level -3), 399 plateau phase, 412
Marriage, 400–403 resolution phase, 413
cultural expectations of, 402 Masturbation, 414–415
marital ceremonies, 401 benefits of, 414–415
marital contracts, 401–402 definition of, 414
marital typologies, 401 mutual masturbation, 414–415, 432–434
monogamy and, 400 myths and misconceptions about, 415
polygamy and, 400–401 prevalence by gender, 414
virginity and, 402 reasons for, 414
Marriage, cross-cultural comparison of, risks of, 415
403–405 techniques, 414
Africa, 405 Mattachine Society, 415–417
China, 404 Hay, Harry, and, 415
definition of “marriage,” 403 history and founding of, 415–416
India, 405 Jennings, Dale, and, 415, 416
Latin America, 404–405 McCarthyism and, 416
Middle East and North Africa, 404 ONE, Inc. v. Olesen, 416
modern cultural view of marriage, ONE, Incorporated, 416
404 organizational structure of, 415
preindustrial Europe and Asia, purpose of, 415–416
403–404 Snyder, Fred M., and, 416
purpose of marriage, 403 Media and sexuality, 417–420
religious traditions, 404 adolescents and, 418–419
United States, 404 definition of “media,” 417
Masculinity, 405–407 internet, 418
definition of, 405 media literacy, 419
hegemony and, 406–407 photography, 417
social theories of, 406 profit and, 419
Mastectomy, 408–409 radio and television, 417–418
alternatives to, 408–409 Medical treatment of sex offenders,
breast reconstruction and, 408 420–422
cancer prevention and, 409 cognitive behavioral treatment and, 421
definition of, 408 cyproterone acetate (CPA), 421
gender transition and, 409 leuprolide acetate, 421
gynecomastia and, 409 medroxyprogesterone acetate (MPA),
modified radical mastectomy, 408 421
types of, 408 Megan’s Law, 422–423
Masters, William H., 409–411 Adam Walsh Child Protection and
early life and education, 409 Safety Act and, 423
Human Sexual Inadequacy, 356, 410 history of, 422
Human Sexual Response, 355, 410, 411 provisions of, 422
Index 845
Menarche, 423–424 National Abortion Federation (NAF), 1
attitudes toward, 423–424 National Center for Transgender Equality,
cultural differences, 424 435–436
definition of, 423 Keisling, Mara, founder, 435, 436
timing of, 423 mission of, 435
Menopause, 424–426 National Center for Transgender
definition of, 424 Equality Action Fund, 435–436
diverse experiences of, 425 programs and projects, 435
hormone replacement therapy and, National Health and Social Life Survey,
425 436–438
North American Menopause Society, findings of, 437
425 history of, 436–437
perimenopause, 424–425 impact of, 436
Menstruation, 426–428 National LGBTQ Task Force, 438–439
definition of, 426 Creating Change Conference, 439
follicular stage, 426–427 history and founding of, 438
hormones and, 426 mission, vision, and goal of, 438
implantation, 427 programs and projects, 438–439
luteal stage, 427 National Organization for Women (NOW),
ovarian process, 426–427 439–441
ovulation, 427 debate and criticism, 440
Miller v. California, 428–429 Friedan, Betty, and, 440
background, 428 history and founding of, 439–440
criteria to determine obscenity, 428 Murray, Pauli, and, 440
critiques and criticisms of, 428–429 programs and projects, 440
Molluscum contagiosum, 429–430 purpose and goal of, 439
cause of, 429 National Transgender Advocacy Coalition
HIV and, 429 (NTAC), 441–442
symptom of, 429 founders and notable members, 441–442
treatment of, 429–430 history and founding of, 441
Money, John, 430–431 primary function of, 441
early life and education, 430 programs and projects, 442
John/Joan (David Reimer) case and, Neisseria gonorrhoeae, 290, 491. See also
431, 575–576 Gonorrhea
Man & Woman, Boy & Girl: Gender Nixon, Richard M., 125, 508
Identity from Conception to Maturity, Nocturnal emissions, 442–443
430 in adolescents, 442
published works, 430 in adults, 442–443
research interests and contributions, cultural attitudes toward, 443
430–431 definition of, 442
Monogamy, 431–432 Nonbinary gender identities, 443–446
in ancient Greece and Rome, 432 awareness and representation of, 445
definition of, 431–432 definition of, 443
genetic monogamy, 432 gender nonconformity and, 444
serial monogamy, 432 hijra (India), 444
social monogamy, 432 māhū of (Hawaii), 444
Mutual masturbation, 432–434 nonbinary gender expression, 444
consent and, 433 nonbinary gender identity development
definition of, 432 model, 444–445
as nonpenetrative sex, 433 two-spirit people (First Nation tribal
taboo and, 433 societies), 444
846 Index
Obama, Barack potential complications of, 457–458
abstinence-only sex education funding recovery from, 458
and, 612 unilateral oophorectomy, 456–457
Don’t Ask, Don’t Tell repealed by, 174 Open marriage, 458–460
Matthew Shepard and James Byrd Jr. alternative terms for, 459
Hate Crimes Prevention Act signed communication and, 459
by, 280, 435, 685 definition of, 458
on same-sex relationships, 83 norms and rules, 459
Obergefell v. Hodges, 261 types of, 459
Obstetrics and gynecology, 447–450 Oral sex, 460–462
birth control, 448–449 alternative terms for, 460
definition of “gynecology,” 447 autofellatio, 460
definition of “obstetrics,” 447 benefits of, 462
diagnostic techniques, 448 definition of, 460
female reproductive organ problems prevalence of, 461
and, 447–448 risks of, 461
history of, 449–450 simultaneous oral sex (“69”), 461
postpartum care and, 447 Orchiectomy, 462–464
pregnancy and, 447 definition of, 462
professional training and education, 449 history of, 464
subspecialties, 449 inguinal (radical) orchiectomy, 463
treatment methods, 448 negative effects following, 463
Oedipus complex, 450–452 reasons for, 462–463
debate and controversy, 452 subcapsular orchiectomy, 463
definition of, 450 Orgasm, 464–466
female psychosexual development and, aging process and, 466
451–452 barriers to, 465–466
Freud, Sigmund, and, 252, 450–452 definition of, 464
Jung, Carl, and, 451 methods of, 465
libido and, 450–451 sensations of, 465
Persephone complex and, 451–452 Outing, 467–469
phallic phase of development and, 451 adults and, 467–468
Online dating, 452–454 definition of, 467
advantages and drawbacks of, 453–454 political repercussions of, 468
costs of, 453 risks of, 467
dating apps, 453 youth and, 467
definition of, 452–453 Out-of-control sexual behavior,
hookup culture and, 454 469–471
prevalence of, 453 compulsive sexual behavior disorder
Online sexual activity, 454–456 (CSBD), 469
benefits and drawbacks of, 455–456 definition of, 470
definition of, 454 treatment interventions, 470
forms of, 454 Ova, 471–472
gender differences, 455 aging process and, 472
Internet Sex Screening Test, 456 at birth, 471
reasons for, 455 definition of, 471
sexual orientation and, 455 fertilization of, 472
Oophorectomy, 456–458 puberty and, 471–472
bilateral oophorectomy, 457 Ova donation, 472–474
definition of, 456 debate and controversy, 473
laparoscopic surgery, 457 definition of, 472
laparotomy, 457 egg retrieval, 473–474
paired with other procedures, 457 ovarian hyperstimulation, 473–474
Index 847
payments for, 472–473 erotic activities and, 486
risks of, 474 erotic targets and, 485–486
side effects of, 474 Krauss, Friedrich Salomo, and, 485
in vitro fertilization and, 472–474 Partial-Birth Abortion Act (2003), 3, 5.
Ovarian cancer, 474–476 See also Abortion, late-term;
causes of, 475 Abortion, partial-birth
definition of, 474 Passing, 486–488
diagnosis of, 475–476 debate and controversy, 487
prevalence of, 475 definition of, 486–487
risk of, 475 nonbinary individuals and, 487
symptoms of, 475 Pedophilia, 488–489
treatment of, 476 causes of, 488–489
Ovaries, 476–477 definition of, 488
at birth, 476 diagnosis of paraphilic disorders,
definition of, 476 488
diseases of, 477 DSM-5 on, 488
menstruation and, 476–477 treatment of, 489
polycystic ovary syndrome, 477 Pelvic floor muscles, 489–490
pregnancy and, 477 anatomy, 489
premature ovarian failure, 477 disorders of, 490
puberty and, 476 function of, 490
Ovulation, 478–479 Kegel exercises, 490
definition of, 478 Pelvic inflammatory disease (PID),
disruption of, 478–479 490–492
inducing ovulation, 479 gonorrhea and, 490–491
process of, 478 prevalence and incidence of, 491
Oxytocin, 479–480 prevention of, 491
definition of, 479 risks of, 491
excess oxytocin, 480 symptoms of, 491
maternal levels of, 479–480 treatment of, 491
milk letdown and, 479 Penile cancer, 492–493
pharmaceutical oxytocin, 480 age and, 492–493
purpose of, 479–480 detection and diagnosis of, 493
reproduction functions associated with, mortality of, 492
479–480 squamous cell carcinoma (SCC) of the
penis, 492
Pansexuality, 481–483 symptoms of, 492
bisexuality compared with, 482 types of, 492
borderlands model and, 482 Penis, 493–495
definition of, 481 anatomy, 494
discrimination and, 482 disorders and defects of, 494–495
experience of, 481 puberty and, 494
plurisexuality and, 482 Performance anxiety, 495–496
Pap smear, 483–485 definition of, 495
advantages and success of, 484 forms and expressions of, 495–496
guidelines and recommendations, management of and treatment of, 496
483–484 Perimenopause, 496–497
history and development of, 483 cause of, 497
Papanicolaou, George, and, 483 definition of, 496
timing of, 483 disease-related physiological changes
Paraphilias, 485–486 of, 497
definition of, 485 symptoms of, 497
DSM-5 on, 485 treatment of, 497
848 Index
Perineum, 498–499 Polyamory, 512–515
childbirth and, 498 boundaries and, 513
definition of, 498 communication and, 513
injury to, 498, 499 compersion and, 513
Kegel exercises, 498–499 definition of, 512
role of, 498 fluid bonding and fluid monogamy, 514
Pfizer Global Study of Sexual Attitudes jealousy and, 513
and Behaviors, 499–501 modern history of, 512–513
findings of, 499 in popular culture, 514
history of, 499 swinging and, 513
PFLAG, 501–502 Polyandry, 515–516
headquarters and regional organization, definition of, 515
502 economic basis of, 515
history and founding of, 501–502 fraternal polyandry, 515–516
Manford, Jeanne, founder, 501 Polycystic ovary syndrome (PCOS),
programs and projects, 502 516–518
Pheromones, 503–504 causes of, 516–517
androstadienone, 504 diagnosis of, 517
definition of, 503 symptoms of, 517
in non-human animals, 503 treatment of, 517
perspiration and, 503–504 Polygamy, 518–519
reproduction cycle and, 503 definition of, 518
roles of, 503 economic basis of, 519
warning-type pheromones, 503 modern practice of, 518
Phimosis, 504–505 polyandry, 518, 519
definition of, 504 polygyny, 518, 519
foreskin anatomy and, 505 religion and, 518
treatment of, 505 Polygyny, 519–521
Physical attractiveness, 505–507 advantages of, 521
bodily attractiveness, 506 definition of, 519
facial attractiveness, 506 disadvantages of, 520–521
role of, 505–506 economic support for, 520
subjectivity of, 506 family approval of, 520
Planned Parenthood, 507–509 interpersonal challenges of, 520–521
debate and controversy, 507–508 prevalence of, 520
history and founding of, 507 religion and, 519–520
mission of, 507 Pornography, 521–525
Planned Parenthood Action Fund, 508 casual view of sex in, 523–524
programs and services, 507 Comstock Act and, 522
Sanger, Margaret, and, 507, 508 debate and controversy, 523–524
Title X of the Public Health Service Act definition of, 521
and, 508 history of, 522
Planned Parenthood v. Casey, 509–510 “porn addiction,” 524
background, 509 Porn Studies, 524
impact of, 509, 510 printing press and, 522
Roe v. Wade and, 509, 510, 585 Pornography addiction, 525–527
ruling, 509–510 assessment of pornography, 526
PLISSIT model of sex therapy, 510–512 causes of problematic pornography use,
goals of, 510–511 526
intensive therapy stage, 511 debate and controversy, 525–526
limited information stage, 511 definition of, 525
permissions stage, 511 Preejaculate fluid, 527–528
specific suggestions stage, 511 characteristics and composition of, 527
Index 849
definition of, 527 pronouns that neutralize gendered
sperm and, 527–528 language, 541
Pregnancy, 528–531 Prostate, 542–543
birth, 530 anatomy, 542
first trimester, 529–530 benign prostatic hyperplasia, 542
maternal bodily changes, 529–530 function of, 542
miscarriage and problems conceiving, prostate cancer, 542
529 prostatitis, 543
physiology, 528 screening and examination of, 542–543
second trimester, 530 stimulation of, 542
tests for, 529 Prostate cancer, 543–545
third trimester, 530 diagnosis of, 544
Premarital sex, 531–533 incidence of, 543
age at first marriage and, 531 mortality rate of, 543
attitudes toward, 532 risk factors for, 543–544
average age of menarche and, 531 treatment of, 544
definition of, 531 Prostatectomy, 545–546
pregnancy and, 532 definition of, 545
prevalence of, 531–532 effectiveness of, 546
STDs and, 532 methods of, 545
Youth Risk Behavior Survey on, 532 procedure, 545–546
Premature ejaculation, 533–535 Prostatitis, 546–547
causes of, 533–534 acute bacterial prostatitis (ABP), 546
definition of, 533 chronic bacterial prostatitis (CBP), 547
diagnosis of, 533 definition of, 546
embarrassment and, 534 Prostitution, 547–550
treatment of, 534–535 definition of, 547
Premenstrual dysphoric disorder (PMDD), dehumanizing constructs, 548
535–536 economic appeal of, 549
causes of, 535–536 history of, 548
diagnosis of, 535 legalization of, 549
symptoms of, 535 modern prostitution in United States,
treatment of, 536 548–549
Premenstrual syndrome (PMS), 536–537 terminology, 547
cause of, 537 Psychosexual therapy, 550–552
symptoms of, 536–537 efficacy of, 551
treatment of, 537 models of, 550–551
Priapism, 537–539 online delivery of, 551
causes of, 538 therapeutic alliance in, 550
definition of, 537–538 Puberty, 552–554
ischemic (low flow) priapism, 538 age of, 552
nonischemic (high flow) priapism, 538 body hair and, 552
treatment of, 538 cultural differences, 554
Progesterone, 539–540 definition of, 552
definition of, 539 gender differences, 553–554
as medication, 540 growth and, 552
progestin (synthetic progesterone), 540 mental changes and, 552–553
roles and functions of, 539–540 social changes and, 553
Pronoun usage, 540–541 Puberty, delayed, 554–555
avoiding use of pronouns, 541 causes of, 555
binary pronouns, 541 definition of, 554
definition of “pronoun,” 540 prevalence of, 555
gender neutral pronouns, 541 treatment of, 555
850 Index
Pubic hair, 555–557 intersectionality and, 439, 702
females and, 556 male sexuality and, 396
males and, 556 sexism and, 626
styling and removal of, 555–556 Rape, 569–571
Pubic lice, 557–559 definition of, 569
as adult, 557 forms of, 569
body lice compared with, 557–558 in Greek mythology, 569
as egg, 557 history of, 569
as nymph, 557 prevalence of, 569–570
public hair removal or trimming and, punishment for, 570
558–559 rape trauma syndrome, 571
risk factors for, 558 sexual assault and, 570
scabies compared with, 557 Rape, Abuse and Incest National Network
symptoms of, 558 (RAINN), 571–572
transmission of, 558 DoD Safe Helpline, 572
treatment of, 558 founders of, 571
Public displays of affection, 559–560 history and founding of, 571
cultural differences and attitudes, mission of, 572
559–560 National Sexual Assault Hotline, 571
definition of, 559 National Sexual Assault Online Hotline,
gender and gender expression, 560 571
stigmatization of same-sex and same- programs and services, 571–572
gender PDA, 560 Rape shield laws, 572–573
Purity pledges, 560–562 celebrity and other high-profile cases,
artifacts and events, 561 573
definition of, 560 definition of, 572–573
impact of, 561 exceptions of, 573
purity rings, 561 Rape trauma syndrome, 573–574
religion and, 560–561 acute phase, 574
definition of, 574
Queer, 563–564 history and origins of, 573–574
origin and use of the term, 563 reorganization phase, 574
political activism and, 563 underground phase, 574
queer theory, 563–564 Reagan, Ronald, 261
Questioning, 564–567 Reimer, David, 575–576
adolescents and, 564 circumcision accident, 575
definition of, 564 Diamond, Milton, and, 166–167,
forms and behaviors of, 565–566 575–576
gender minority identity and, 564–565 gender dysphoria experienced by, 575
intersectionality and, 566–567 John/Joan case, 167, 431, 575–576
models of identity development and, Money, John, and, 431, 575–576
566 As Nature Made Him: The Boy Who
Was Raised as a Girl (Colapinto), 576
Racialization, 228–229 sex reassignment surgery, 575
Racism suicide of, 576
antiracism, 221, 222, 250, 439 Religion
black sexuality and, 82–83 adultery and, 23
down low and, 179 celibacy and, 98
erotophobia and, 206 circumcision and, 117
forced sterilization and, 705 dating and, 153
gender stereotypes and, 702 heterosexism and, 300–301
heterosexism and, 300 Madonna-whore dichotomy and, 393
Index 851
polygamy and, 518 Romantic attraction and orientation,
polygyny and, 519–520 587–588
purity pledges and, 560–561 asexuality and, 588
Religion, diversity of human sexuality bisexuality and, 588
and, 576–578 sexual attraction as distinct from,
codes and rules of sexual behavior, 577 588–589
cognitive dissonance and, 578
definition of “religion,” 576 Safer sex, 589–590
dualism and morality, 577 condoms and, 589
pornography and, 578 contraceptives and, 589–590
rituals and, 578 definition of, 589
sexuality as holistic part of human sex toys and, 589
experience, 577–578 Same-sex attraction and behavior, 590–592
sexuality as socially constructed, binary gender/sex system and, 590–591
578–579 biological theories of, 591
Reparative therapy, 579–581 Christianity and, 591
conflicts with mainstream beliefs, 580 sexual orientation and, 590
debate and criticism, 579–580 social constructionist theories of,
harm from, 580 591–592
history of, 579 Same-sex marriage, 593–594
psychoanalytic theory and, 579–580 benefits of marriage, 593
Reproductive coercion, 581–582 definition of, 593
birth control sabotage, 581 history of, 593
definition of, 581 legalization of, 593
physical violence and, 581–582 Sanger, Margaret, 594–596
pregnancy coercion, 581 activism of, 594–595, 717
pregnancy pressure, 581 debate and controversy, 595–596
Retrograde ejaculation, 582–584 early years, 594
antegrade ejaculation and, 582 eugenics movement and, 595
causes of, 583 Planned Parenthood and, 507, 508, 595
definition of, 582 The Woman Rebel (newsletter), 594–595
dry orgasm and, 582 Satcher, David, 596–598
performance anxiety and, 583 “The Call to Action to Promote Sexual
symptoms of, 583 Health and Responsible Sexual
treatment of, 583 Behavior,” 596–597
Roe v. Wade, 15–16, 584–586 director of the CDC, 597
background, 584–585 early years and education, 597
elective abortion and, 2 U.S. surgeon general, 596–597
late-term abortion and, 4 Savage, Dan, 598–599
Planned Parenthood v. Casey and, 509, activism of, 598–599
510, 585 early years and education, 598
right to privacy and, 585 “It Gets Better,” 598
ruling, 585 published works, 599
sexual revolution and, 663–664 Scabies, 599–601
Roman Catholic Church sexual abuse definition of, 599
scandal, 586–587 diagnosis of, 600
Boston Globe coverage of, 586 prevention of reinfection, 600
historical background, 586 risk factors for, 599, 600
impact of, 586–587 Sarcoptes scabiei and, 599
John Jay Study, 586 symptoms of, 599
tribunal approved by Pope Francis I, transmission of, 599–600
587 treatment of, 600
852 Index
Scrotum, 601–602 estrogen, 614–615
anatomy and function, 601 hormone replacement therapy and,
disorders and diseases, 601 616
self-examination of, 601 oral contraceptives and, 615–616
Semen, 602–603 progesterone, 615
allergies to, 602–603 testosterone, 614
characteristics and composition of, 602 Sex reassignment surgery, 616–617
cryopreservation of, 603 alternative terms for, 616
ingestion of, 602 construction of a neophallus, 617
Seminal vesicles, 603–604 construction of a neovagina, 616
abnormalities, 603–604 prevalence of, 617
anatomy and function, 603 Sex tourism, 617–618
Seminiferous tubules, 604–605 definition of, 617
anatomy and function, 604, 605 human trafficking and, 618
convoluted tubules, 604 locations of, 617–618
development of, 604 Sex toys, 618–621
straight tubules, 604 definition of, 618
Sensate focus, 605–607 dildos, 619
definition of, 605 history of, 619
exercises, 605 kink and BDSM play toys, 620–621
functions of engaging in exercises, 606 materials used in, 620
Serial monogamy, 607 penis rings, 620
advantages of, 607 sexual health toys, 620
definition of, 607 vibrators, 619
Sex anxiety, 612–613 Sex work, 621–623
Sex chromosomes, 608–609 criminalization and stigmatization of,
definition of, 608 623
genetic disorders of, 608 definition of, 621
X chromosome, 608 feminism and, 621–622
Y chromosome, 608 media and, 622
See also X chromosome; Y chromosome origin of the term, 621
Sex differentiation of the brain and sexual prostitutes’ rights organizations, 622
orientation, 609–610 sexual health and, 622
embryonic development, 609 Sex workers, male, 623–624
research challenges, 609 diversity of, 624
Sex education, 610–612 history of, 624
abstinence-only education, 611 “survival sex” and, 623
Affordable Care Act and, 611 Sexaholics Anonymous, 624–625
effectiveness of, 611–612 history and founding of, 625
fact-based education, 611 program and ideology of, 625
history of, 610–611 purpose of, 624
HIV/AIDS and, 610–611 Sexism, 625–627
public opinion on, 612 ambivalent sexism, 626
Sex guilt, 612–613 definition of, 625
causes of, 613 gender and, 625–626
cognitive dissonance and, 613 hegemony and, 626
definition of, 612 history of, 627
sex anxiety compared with, 612–613 hostile sexism, 626
treatment of, 613 internalized sexism, 626–627
Sex hormones, 613–616 old-fashioned versus modern sexism,
androgens, 614 626
androsterone, 614 patriarchy and, 627
Index 853
Sexology, 627–630 secondary sex characteristics, 641
definition of, 627 variability of, 642
Dodson, Betty, 629 Sexual disorders, female, 643–644
Ellis, Henry Havelock, 628 in DSM-5, 643
Hirschfeld, Magnus, 628 in ICD-11, 643
history of, 627–628 treatment of, 643–644
Kaplan, Helen Singer, 629 Sexual disorders, male, 644–645
Kinsey, Alfred, 628 in DSM-5, 645
Klein, Fritz, 628–629 in ICD-11, 644
Masters and Johnson, 628–629 treatment of, 645
Sexting, 630–631 Sexual dysfunction, treatment of,
adolescents and, 631 646–647
adults and, 631 definition of “sexual dysfunction,” 646
definition of, 630 DSM on, 646
reasons for, 631 medical history and exam, 646
Sexual abuse, 631–633 sensate focus exercises, 647
alternative terms for, 631–632 sex therapy, 647
childhood sexual abuse, 632 Sexual expression, 647–649
definition of, 631–632 definition of, 647
impact on survivors, 632 gender expression, 647–648
reporting, 632 sexual orientation and, 648
Roman Catholic Church sexual abuse Sexual harassment, 649–650
scandal, 586–587, 633 definition of, 649
sexual harassment, 632 formal complaint process, 649–650
Sexual assault, 634–635 hostile environment, 649
definition of, 634 impact of, 650
prevalence of, 634 internal investigation, 650
rape and date rape, 634 quid pro quo, 649
Sexual avoidance, 635–636 Sexual harassment in college, 651–652
causes of, 635 consequences for perpetrators, 652
definition of, 635 impact of, 651–652
diagnosis of, 635 Title IX and, 651
treatment of, 635–636 underreporting of, 651
Sexual Behavior in the Human Male and Sexual harassment in education, 652–653
Sexual Behavior in the Human hostile environment harassment, 653
Female, 636–637 prevalence of, 653
Kinsey, Alfred, and, 628, 636–637 quid pro quo harassment, 653
research team members, 636 Title IX and, 652–653
topics and contents, 636–637 Sexual harassment in the workplace,
Sexual consent, 637–640 654–655
complications of, 639 definition of “sexual harassment,” 654
definition of, 637, 638 prevention of, 654–655
as fundamental right, 640 Title VII of the Civil Rights Act and,
myths and misconceptions about, 654
638–639 underreporting of, 654
process of, 639–640 Sexual health, 655–657
sexual desire compared with, 638 components of, 655
Sexual dimorphism, 640–642 contraception, 656
brain anatomy and, 641–642 Declaration of Sexual Rights and, 655
definition of, 640 definition of, 655
evolution and, 640–641 sexual knowledge and, 656
expressions of, 641 sexually transmitted infections, 656
854 Index
Sexual identity, 657–659 impact on survivors, 672–673
definition of, 657 policies on, 673
sexual development and, 657–658 prevalence of, 672
sexual minorities, 657–658 risk factors for, 672
sexual orientation identity and, 657, 658 Sexuality across the life span, 674–676
Sexual learning, 659–660 adulthood, 675
definition of, 659 childhood, 674–675
media and, 660 fetal development, 674
scripting theory, 659–660 older adults, 675
social learning theory, 660 preadolescence and adolescence,
Sexual orientation, 660–663 675
causes of, 662 Sexuality among older adults, 676–678
definition of, 660 health care, 677
prevalence of, 661–662 LGBTQ community, 677
sexual identity compared with, 661 statistics, 676–677
spectrum of, 661 Sexuality among younger adults,
Sexual revolution, 663–665 678–679
civil rights movement and, 664 in females, 678
culture wars and, 664 in males, 678
effects of, 665 pregnancy, 679
fashion and, 664 psychological and social development,
history of, 663–664 678–679
oral contraceptives and, 663 sexual social development, 679
popular culture and, 664 Sexualization, 680–681
Roe v. Wade and, 663–664 definition of, 680
women’s liberation movement and, flirting, 680
664 incest, 681
Sexual rights, 665–668 media and, 681
definition of, 665, 666 rape, 680–681
IPPF Declaration on, 667–668 seduction, 680
nonprofit and nongovernmental sexual harassment, 680
organizations, 665–666 Sexually transmitted infections (STIs),
reproductive justice and, 666 681–684
WAS Declaration of Sexual Rights, bacterial STIs, 682
666–667 definition of, 681
World Health Organization on, 666 diagnosis of, 683
Sexual satisfaction, 668–670 prevention of, 683
gender differences and, 669 STIs caused by parasites, 683
interpersonal exchange model of sexual treatment of, 683
satisfaction (IEMSS), 668–669 viral STIs, 682–683
relationship satisfaction and, 669 Shepard, Matthew, 684–685
sexual function and, 669 Matthew Shepard and James Byrd Jr.
Sexual script, 670–671 Hate Crimes Prevention Act, 685
applications of, 670–671 Matthew Shepard Foundation, 685
cultural scripts, 670 murder of, 684–685
definition of, 670 Slut shaming, 685–687
interpersonal scripts, 670 definition of, 685–686
intrapersonal scripts, 670 practices of, 686
Sexual slavery, 671–674 SlutWalk protest march, 686–687
definition of, 671 Smegma, 687–688
economy of, 672 composition of, 687
history of, 671 definition of, 687
Index 855
hygiene and, 687–688 definition of, 699
role of, 687 enforcement of laws, 699–700
Social learning theory, gender and, history of statutory rape laws, 699
688–689 mandatory reporting of, 700
attention and, 688–689 Stereotypes, gender, 700–702
Bandura, Albert, and, 688 definition of, 700
gender diversity and, 689 false binaries and, 702
gender identity and, 688 feminine stereotypes, 700
Society for the Scientific Study of impact of, 701–702
Sexuality (SSSS), 690–691 intersectionality and, 702
history and founding of, 690 masculine stereotypes, 700–701
membership of, 690 repressiveness of, 701
publications, 690 sex and, 701
purpose of, 690 Stereotypes, sexual, 702–705
Sodomy laws, 691–692 colonialism and, 703
Bowers v. Hardwick and, 691 definition of, 702–703
definition of “sodomy,” 691 evolutionary biology and, 703–704
history of, 691–692 impact of, 704
international sodomy laws, 692 power and, 704
Lawrence v. Texas and, 692 sociocultural factors and, 703
state sodomy laws, 692 strategies for addressing, 704–705
Somnus orgasm, 693–694 Sterilization, 705–707
definition of, 693 definition of, 705
Kinsey, Alfred, on, 693 forced sterilization, 706–707
myths and misconceptions about, myths and misconceptions about, 706
693–694 tubal ligation, 706
nocturnal emission compared with, vasectomy, 705–706
693 Sternberg’s triangular theory of love,
prevalence and frequency of, 693 707–708
Sperm, 694–695 age and, 708
effect of aging on, 695 commitment, 707
fertilization, 694 consummate love, 708
health and viability of, 695 empty love, 708
male anatomy and, 694 intimacy, 707
production of, 694 passion, 707
Spermicides, 695–696 romantic love, 708
advantages and disadvantages of, 696 seven love styles, 708
definition of, 695 Stonewall riots, 708–710
effectiveness of, 695–696 events of, 709
proper use of, 696 historical background, 708–709
Sponge, contraceptive, 697–698 impact of, 709
effectiveness of, 697 Storms’s model of sexual orientation,
history of, 697 710–711
proper use of, 697 heteroeroticism, 710
safety of, 697 homoeroticism, 710
Start-stop technique, 698–699 impact of, 711
goal of, 699 Storms, Michael, and, 710
history of, 698 Sugar daddies and sugar babies,
process of, 698 711–712
Statutory rape, 699–700 debate and criticism, 711
arrest and conviction rates, 700 definition of, 711
criminal characterization of, 699 Seeking Arrangement (website), 711
856 Index
Surrogate, sexual, 712–713 educational attainment and, 725
definition of, 712 impact of, 725
International Professional Surrogate prevalence of, 724
Association, 712 prevention of, 725–726
purpose of, 712 Teena, Brandon, 726–728
training programs and ethical codes, Boys Don’t Cry (film), 727
712–713 The Brandon Teena Story
Surrogate mothers, 713–715 (documentary), 727
choice of, 714 hate crime laws and, 727
cost of surrogacy, 715 murder of, 726–727
“declaration of parentage,” 715 Testicles, 728–729
definition of, 713 anatomy, 728
gestational surrogacy, 714 disorders and diseases of, 728
reasons for using, 714 hypogonadism, 729
surrogate agencies, 714–715 injury to, 729
traditional surrogacy, 713–714 orchiectomy, 729
Swinging, 715–716 sexual arousal and, 728
definition of, 715–716 testicular cancer, 728–729
history of the term, 716 testosterone and, 728
research on, 716 Testicular cancer, 729–731
Synthetic hormones, 716–719 causes of, 729–730
“bioidentical” hormones and, 717 diagnosis of, 730
debate and controversy, 718 screening for, 730
history of, 717 symptoms of, 730
human growth hormone, 718 treatment of, 730–731
“natural” hormones and, 717 Testing, STI, 731–732
oral contraceptives, 717 for chlamydia and gonorrhea, 731
Sanger, Margaret, and, 717 for HIV, 731
uses of, 718 for oncogenic forms of human
Syphilis, 719–721 papilloma virus, 732
diagnosis of, 720 for syphilis, 731–732
disease phases, 720 Testosterone, 732–734
evolutionary biology and, 719 aging and, 733
genital ulcer disease (GUD) and, behaviors and, 733
719 development and, 732–733
pregnancy and, 720 high levels of, 734
prevalence and incidence of, 719 low levels of, 733–734
transmission of, 720 synthetic testosterone, 734
treatment of, 720 in women, 733
Treponema pallidum and, 719 Testosterone replacement therapy,
734–736
Tantric intercourse, 723–724 gender dysphoria and, 735
definition of, 723 hypogonadism and, 734–735
history of Tantra, 723 prescription guidelines for transgender
in treatment of physical and sexual people, 735
difficulties, 723–724 risks of, 735
Targeted regulation of abortion providers Touching, sexual arousal and,
(TRAP laws), 2–3, 16 736–738
Teen pregnancy, 724–726 benefits of, 737
definition of, 724 consensually giving and receiving
disparities, 724–725 touch, 737
Index 857
masturbation, 737 Turner syndrome, 751–752
nonconsensual touch, 737 diagnosis of, 751–752
skin hunger, 736 signs and symptoms of, 751
Transexual Menace, 738–739 treatment of, 752
Gay Games, 738–739 Tuskegee Syphilis Study, 752–754
history and founding of, 738 debate and criticism, 753–754
naming of, 738 history and origins of, 752
Transexual Menace (film), 738 presidential apology for, 754
Transgender, 739–740 purpose of, 752
definition of, 739 Two-spirit, 754–756
identities, 740 definition of, 754–755
origin of the term, 739 indigenous terminology, 755
prevalence of, 739 origin of the term, 754–755
transitioning, 740 roles of two-spirit individuals, 755
Transphobia, 741–742
definition of, 741 Ulrichs, Karl, 757–758
impact of, 741 debate and controversy, 757
internalized transphobia, 741 early years and education, 757
interpersonal transphobia, 741 published works, 757
interventions for reducing, 741 “Urning” and, 757
structural transphobia, 741 Unconsummated marriage,
Transsexual, 742–744 758–759
debate and controversy, 743 causes of, 758
definition of, 742–743 definition of, 758
origin of the term, 743 treatment of, 758–759
trans men, 743–744 Urethra, 759–760
trans women, 743–744 abnormal development of, 760
Transexual Menace, 743 anatomy, 759
Transvestite, 744–745 in females, 759
behaviors and expressions, 745 in males, 759–760
“cross-dresser” and, 744 urethritis, 760
definition of, 744 Uterine cancer, 760–762
history of, 745 causes of, 760
prevalence of, 745 diagnosis of, 761
transgender as distinct from, 744 prevalence of, 760
Trichomoniasis, 745–749 symptoms of, 760
definition of, 745–746 treatment of, 761
diagnosis of, 747–748 Uterus, 762–763
prevalence of, 745–746 anatomy, 762
symptoms of, 746–747 development and, 762
transmission of, 746, 749 disorders of, 762–763
treatment of, 748–749 endometriosis, 762
Trichomonas vaginalis and, 746 fertilization and pregnancy, 762
Trump, Donald, 435, 612 hyperplasia, 763
Tubal ligation, 749–751 uterine fibroids, 763
benefits of, 750
effectiveness of, 750 Vagina, 765–766
pregnancy after tubal ligation, 750–751 anatomy, 765
recovery from, 750 development and, 765
risks of, 750 Grafenberg spot (G-spot), 765–766
techniques of, 750 role of, 765
858 Index
Vaginal lubrication, 766–767 Virginity, 778–781
dehydration and, 766–767 debate and controversy, 779
store-bought lubricants, 767 definition of, 778
transudation, 766 gift script of, 779
Vaginal ring, 767–768 LGBTQ+ people and, 780
advantages and disadvantages of, process script of, 779
767 scripts of, 779–780
effectiveness of, 768 sexual double standards and, 779
insertion of, 767 stigma script of, 779
prescription for, 767 Voyeurism, 781–783
safety of, 768 challenges to pathologizing of,
Vaginal secretions, 768–769 782
composition of, 768 definition of, 781–782
definition of, 768 history of the term, 782
medical conditions and, 769 as a paraphilia, 782
ovulation and, 768–769 Vulva, 783–784
Vaginismus, 769–771 anatomy, 783–784
definition of, 769–770 clitoris, 783
DSM and, 770 labia majora, 783
impact of, 770 labia minora, 783–784
primary vaginismus, 770 as self-cleaning organ, 784
secondary vaginismus, 770 urethral opening, 784
sex therapy for, 771 vaginal opening, 784
symptoms of, 770 Vulvodynia, 784–785
treatment of, 771 definition of, 784
Vaginitis, 771–774 diagnosis of, 785
allergic reaction to irritants, impact of, 785
774 symptoms of, 785
bacterial vaginosis (BV), 773–774 treatment of, 785
definition of, 771–772
diagnosis of, 772–773 Withdrawal method, 787–788
symptoms of, 772 advantages and disadvantages of,
trichomonal infection and, 773 787
vaginal candidiasis, 772 definition of, 787
vulvovaginal candidiasis, 772 proper technique, 787
Vas deferens, 774–775 World Professional Association for
anatomy, 774–775 Transgender Health (WPATH),
congenital absence of vas deferens, 788–789
775 Benjamin, Harry, and, 788
origin of the term, 774 Harry Benjamin Standards of
Vasectomy, 775–777 Care for Gender Identity Disorders,
definition of, 775 789
history of, 776 history and founding of, 788
procedure, 775–776 mission of, 788
recovery from, 776
Victorian era, 777–778 X chromosome, 791–792
characteristics of, 777 diseases and disorders associated with,
children and adolescents in, 777 791–792
definition of, 777 48,XXYY syndrome, 792
Freud, Sigmund, and, 777–778 Klinefelter syndrome, 792
women in, 777 role of, 791
Index 859
Y chromosome, 793–795 complications of, 795–796
diseases and disorders associated with, cutaneous and mucocutaneous
793–794 candidiasis, 795, 796
46,XX testicular disorder, 794 diagnosis of, 796–797
46,XY sex reversal, 794 history of, 795
role of, 793 invasive or disseminated candidiasis, 796
Swyer syndrome, 793–794 prevention of, 797
Yeast infection (candidiasis), 795–797 treatment of, 797
candidiasis, 795 vulvovaginal candidiasis, 796
You might also like
- Encyclopedia of Sex and Sexuality Understanding Biology, Psychology, and Culture (Heather L Armstrong) (Z-Library)No ratings yetEncyclopedia of Sex and Sexuality Understanding Biology, Psychology, and Culture (Heather L Armstrong) (Z-Library)1,211 pages
- Discovering Human Sexuality - 5th Edition Full Chapter Download100% (16)Discovering Human Sexuality - 5th Edition Full Chapter Download15 pages
- Test Bank Human Sexuality 2nd Edition Pukall0% (1)Test Bank Human Sexuality 2nd Edition Pukall8 pages
- Understanding Human Sexuality 13th Edition PDFNo ratings yetUnderstanding Human Sexuality 13th Edition PDF24 pages
- Human Sexuality Biological, Psychological, and Cultural Perspectives 2nd Edition ISBN 0367219794, 9780367219796 Verified DownloadNo ratings yetHuman Sexuality Biological, Psychological, and Cultural Perspectives 2nd Edition ISBN 0367219794, 9780367219796 Verified Download16 pages
- Homosexuality in The Philippines - Various Factors and Its Corresponding Effects On A HomosexualNo ratings yetHomosexuality in The Philippines - Various Factors and Its Corresponding Effects On A Homosexual39 pages
- Human Sexuality in A Changing World 10th Edition.c2100% (8)Human Sexuality in A Changing World 10th Edition.c2625 pages
- (Original PDF) Human Sexuality: A Contemporary Introduction Install DownloadNo ratings yet(Original PDF) Human Sexuality: A Contemporary Introduction Install Download55 pages
- Understanding of The Self - Sexual SelfNo ratings yetUnderstanding of The Self - Sexual Self53 pages
- (Original PDF) Human Sexuality in A Changing World 10th Edition by Spencer A. Rathus PDF Download100% (1)(Original PDF) Human Sexuality in A Changing World 10th Edition by Spencer A. Rathus PDF Download59 pages
- Human Sexuality and Its Problems (John Bancroft)100% (1)Human Sexuality and Its Problems (John Bancroft)549 pages
- (Original PDF) Human Sexuality: A Contemporary Introduction PDF DownloadNo ratings yet(Original PDF) Human Sexuality: A Contemporary Introduction PDF Download53 pages
- Module 4: Sexual Self Sexual Self Concept Defined: Gender Gender Identity Gender RoleNo ratings yetModule 4: Sexual Self Sexual Self Concept Defined: Gender Gender Identity Gender Role14 pages
- Understanding Human Sexuality 13th Edition PDFNo ratings yetUnderstanding Human Sexuality 13th Edition PDF29 pages
- Understanding The Self Unit II Lesson 2No ratings yetUnderstanding The Self Unit II Lesson 262 pages
- LoveSex and Relationships An Integrative Model For Sexual Education, 2nd Edition ISBN 1032344938, 9781032344935 All-in-One DownloadNo ratings yetLoveSex and Relationships An Integrative Model For Sexual Education, 2nd Edition ISBN 1032344938, 9781032344935 All-in-One Download17 pages
- Sex and Sexuality Three Volumes 3 Volumes 1st Edition Richard Mcanulty Instant Download100% (10)Sex and Sexuality Three Volumes 3 Volumes 1st Edition Richard Mcanulty Instant Download61 pages
- Gay, Straight, and in Between The Sexology of Erotic Orientation Fast Download100% (9)Gay, Straight, and in Between The Sexology of Erotic Orientation Fast Download16 pages
- Kardex: Date/ Time Medications Date Treatment/ ManagementNo ratings yetKardex: Date/ Time Medications Date Treatment/ Management2 pages
- Family Planning Guidance Booklet For CHONo ratings yetFamily Planning Guidance Booklet For CHO13 pages
- First Aid For The OB GYN Clerkship 5th Edition by Sarah Dotters Katz, Latha Ganti, Matthew Kaufman, Shireen Madani Sims ISBN 1264264933 9781264264933 Instant Download100% (2)First Aid For The OB GYN Clerkship 5th Edition by Sarah Dotters Katz, Latha Ganti, Matthew Kaufman, Shireen Madani Sims ISBN 1264264933 9781264264933 Instant Download53 pages
- Small Ruminant Research: Amanda K. Jones, Sarah A. ReedNo ratings yetSmall Ruminant Research: Amanda K. Jones, Sarah A. Reed9 pages
- Anatomy of Male Genital System in StallionNo ratings yetAnatomy of Male Genital System in Stallion15 pages
- Minimum Learning Capsule Biology Xii 2018No ratings yetMinimum Learning Capsule Biology Xii 201888 pages
- Surrogacy Laws in India and in Other Foreign Countries - PowerpointNo ratings yetSurrogacy Laws in India and in Other Foreign Countries - Powerpoint36 pages
- Methotrexate To Treat Ectopic Pregnancy Fact SheetNo ratings yetMethotrexate To Treat Ectopic Pregnancy Fact Sheet2 pages
- Physiologic and Psychological Changes During PregnancyNo ratings yetPhysiologic and Psychological Changes During Pregnancy52 pages
- Healthy Living: Fiji Year 8 Examination 2015No ratings yetHealthy Living: Fiji Year 8 Examination 201515 pages
- Exfoliative Vaginal Cytology and Vaginal Acidity Profile in Ettawa-Saanen Grade DoesNo ratings yetExfoliative Vaginal Cytology and Vaginal Acidity Profile in Ettawa-Saanen Grade Does16 pages
- "Like A Mother-Daughter Relationship": Community Health Intermediaries' T Knowledge of and Attitudes To Abortion in Karnataka, IndiaNo ratings yet"Like A Mother-Daughter Relationship": Community Health Intermediaries' T Knowledge of and Attitudes To Abortion in Karnataka, India10 pages
