Sexual Health: Disorders, Orientation, Therapy, and Pregnancy

Causes of Sexual Problems

Intrapsychic (Psychological) Factors

Intrapsychic (psychological): Early family messages about sex, shame, guilt, fear, sexual trauma or abuse, low self-esteem, performance anxiety.

Interpersonal and Relational Factors

Interpersonal / relational: Poor communication, poor conflict resolution, suppressed anger → decreased passion, power struggles, infidelity, jealousy, distrust.

Cultural and Psychosocial Factors

Cultural / psychosocial: Religious teachings, family-based sex messages, poor sex education, sexual myths such as “Real sex = intercourse”, “Sex = orgasm”, “Men always want sex”, “Sex should be spontaneous”, “Talking ruins the mood”.

Organic (Physical) Causes

Organic (physical): Cardiovascular disease, diabetes, neurological injury, hormonal issues, medications (HUGE).

Quality of Sexual/Erotic Contact

Quality of sexual/erotic contact: Bad sex can cause “dysfunction”. The DSM-5 notes that stimulation quality matters; this is often ignored by clinicians.

Drug-Related Sexual Problems

Drug-related sexual problems:

• SSRIs / SNRIs: Decreased desire, decreased arousal, inhibited orgasm; affect men and women.
• Other drugs: Blood pressure medications, cancer treatments, antihistamines (decreased lubrication), alcohol → erectile dysfunction (“whiskey dick”).
• Hormonal contraceptives: Depo-Provera → decreased desire; Diane (cyproterone acetate) → decreased desire (originally used for chemical castration). Women are often NOT warned.

DSM-5 Classification

DSM-5 classification (memorize table logic):

• Desire / Arousal (Women): Sexual Interest/Arousal Disorder (SIAD) — desire and arousal combined.
• Men: Desire and arousal are still separate.
• Orgasm: Premature (early) ejaculation, delayed ejaculation, orgasmic disorder (women).
• Pain: Genito-Pelvic Pain/Penetration Disorder (GPPPD) — combines dyspareunia and vaginismus.

Low Desire

Low desire: Rarely a “pure” disorder. Often caused by exhaustion, stress, relationship conflict, pain, drugs, or poor sex. Addyi (“pink Viagra”) has minimal effect, no strong evidence, and is controversial.

Arousal Problems in Women

Arousal problems in women: Lack of lubrication is not the same as lack of arousal. Breastfeeding and menopause → decreased estrogen → dryness. Antihistamines and oral contraceptives can cause dryness. Lubricant helps dryness, not desire. Oil-based lubricants destroy latex condoms.

Erectile Disorder

Erectile disorder causes: Vascular disease, diabetes, medications, stress, anxiety, relationship issues, lack of arousal.

Treatment: PDE-5 inhibitors (Viagra, Cialis, Levitra). These are not aphrodisiacs, require sexual stimulation, and have best outcomes when combined with sex therapy.

Orgasmic Disorders

Orgasmic disorders:

• Premature ejaculation: DSM-5 defines ejaculation ≤ 1 minute, occurring ≥ 75% of the time, for ≥ 6 months, causing distress. Causes are unclear; unrealistic expectations are common. Poor fixes include double condoms and numbing creams. Best approach: pleasure-focused sex and reduced performance pressure.
• Delayed ejaculation: Difficulty or inability to orgasm—often able to orgasm alone but not with a partner. Common causes: SSRIs/SNRIs, performance focus, using erection without arousal. Solutions: increase pleasure, broaden stimulation, address medications.

Orgasmic Disorder in Women

Orgasmic disorder in women:

• Primary: Never had an orgasm. Main cause: lack of clitoral stimulation; poor sex education. The clitoris is the primary organ for pleasure.
• Secondary: Used to orgasm, now cannot—often medication or relationship related.

Sexual Pain Disorders

Dyspareunia: Pain during sex, often in women. Many causes: STIs, endometriosis, dryness, infections, cervical contact. Pain → decreased desire → avoidance.

Genito-Pelvic Pain / Penetration Disorder (GPPPD): Combines pain and muscle tightening (formerly vaginismus). Muscles involuntarily contract; often fear-based and may be an adaptive response rather than simply a “dysfunction.” Causes include sex-negative messages, fear of pregnancy, poor anatomy knowledge, and sexual trauma. Treatment: pelvic floor therapy, dilators, sex therapy—NOT just forced penetration.

Sex Therapy and Techniques

Sex therapy (Masters & Johnson): Key concepts include performance anxiety and spectatoring (watching yourself perform). Sensate focus exercises (VERY TESTED) progress from touching without genitals to touching including genitals, to nondemand genital pleasuring. Goal: reduce anxiety, increase pleasure, and restore intimacy.

Variations in Sexual Behaviour

Variations in sexual behaviour: Variation is not disorder. A behaviour is only a disorder if it causes distress or impairment, or involves nonconsenting others.

What Is Normal Sex?

What is normal sex: There is no single definition. Three ways normal is defined:

• Statistical – what most people do. Problem: people underreport taboo behaviours.
• Cultural – what society accepts. Changes over time.
• Harm-based (best approach) – consensual and no harm. Modern sex research uses consent + harm, not morality.

Paraphilias and Paraphilic Disorders

Paraphilias: Atypical sexual interests that can exist without being a disorder. Paraphilic disorder: Interest plus distress/impairment or acting on urges with nonconsenting others. Must last ≥ 6 months.

Courtship Disorders

Courtship disorders:

• Voyeuristic disorder: Sexual arousal from watching unsuspecting people. Key factor = lack of consent. Interest is common; disorder is rare.
• Exhibitionistic disorder: Arousal from exposing genitals; arousal comes from victim’s reaction; more common in men.
• Telephone scatologia: Verbal exhibitionism—obscene phone calls; arousal from reaction.
• Frotteuristic disorder: Rubbing/touching nonconsenting people, often in crowded places. Interest is common; disorder requires distress or harm.

BDSM, Algolagnic Behaviour, and Sadism/Masochism

Algolagnic behaviour / BDSM / kink: Bondage, dominance, submission, sadomasochism. Not a disorder if consensual. Participants usually show normal mental health; distress often comes from stigma.

Sexual sadism disorder: Arousal from causing suffering. It is a disorder only if there are nonconsenting victims or distress/impairment.

Sexual masochism disorder: Arousal from being hurt or humiliated. Disorder only if distress or impairment. Consent is the dividing line.

Paraphilias with Atypical Targets

Pedophilic disorder: Sexual interest in prepubescent children (≤ 13). Diagnosis requires distress or acting on urges. Pedophile ≠ child sexual offender; child sexual offender ≠ pedophile. Key facts: grooming is more common than violence; online abuse still causes harm. Risk factors: sexual deviance, antisocial traits, intimacy deficits.

Fetishistic and Transvestic Disorders

Fetishism: Arousal from objects or specific body parts (e.g., feet). It is a disorder only if distress or impairment occurs; many people have non-problematic fetishes.

Transvestic disorder: Cross-dressing that is sexually arousing and distressing. Cross-dressing alone is not a disorder and is not the same as being transgender.

Hypersexuality

Hypersexuality: Excessive sexual behaviour that interferes with life and causes distress. There is no DSM-5 diagnosis; frequency alone is not a disorder—impairment is key.

Causes of Paraphilias

Causes of paraphilias: No single cause. Main explanations include conditioning (learning and pairing arousal), cognitive distortions (justifying harm), neurological differences (especially in pedophilia), and early experiences (not always abuse).

Assessment and Treatment

Assessment & treatment: Goal = risk management, not necessarily cure. Tools: interviews, sexual history, psychological testing, phallometry (sometimes). Treatments: CBT, relapse prevention, medications (sometimes); chemical castration is controversial.

Sexual and Affectional Orientations

Sexual orientation: Focuses mainly on sexual attraction and is too narrow.

Affectional orientation (preferred term): Includes sexual attraction, emotional attachment, and romantic love. Recognizes people can love without sex and have sex without love.

Measuring Orientation

Measuring orientation: The Kinsey scale ranges 0–6 (0 = exclusively heterosexual, 6 = exclusively same-gender/sex-oriented) and is based mainly on behaviour. It is oversimplified. Orientation can be measured using six components: sexual attraction, sexual fantasies, sexual preference, propensity to fall in love, being in love, and sexual partners.

Sexual Identity

Sexual identity: The label a person chooses (examples: gay, lesbian, bisexual, heterosexual, queer, asexual). Identity is not the same as behaviour or desire. People may change labels over time, choose labels for safety or social acceptance, or avoid labels altogether.

Queer Identity

Queer identity: An umbrella term that rejects rigid labels and is rooted in social constructionism. It emphasizes fluidity. Labels are adjectives, not nouns; they describe experience, not essence.

Asexuality

Asexuality: Little or no sexual attraction. It is NOT a dysfunction and NOT the same as celibacy. Key findings: prevalence ~0.4–1%. Many asexual people fall in love, have relationships, may masturbate, and genital arousal can still occur. No distress → not a disorder. Subtypes include grey-asexual and demisexual. Asexuality is lack of sexual attraction, not lack of capacity for love.

Prejudice Against SGD Individuals

Prejudice against sexual and gender diverse (SGD) individuals:

• Heterosexism: Assuming heterosexuality is normal or superior.
• Homophobia: Fear or dislike of gay/lesbian people.
• Biphobia: Prejudice against bisexual people.
• Queerphobia: Hostility toward SGD individuals.
• Internalized homophobia: Absorbing negative societal messages.

Effects of prejudice: Depression, anxiety, internalized shame, higher suicide risk, violence and hate crimes. Research vs real life: hate speech → violence → mental health harm, especially dangerous for youth.

Conversion Therapy and Affirmative Therapy

Conversion therapy: Attempts to change same-gender/sex orientation to heterosexual. Research consensus: no credible evidence it works long-term and it causes high harm (depression, suicidality, shame, identity confusion). Major organizations label it unethical; even former proponents have apologized.

SGD-affirmative therapy: Supports identity and focuses on well-being rather than orientation change.

Development of Affectional Orientation

Nature vs nurture:

Biological Factors

Biological: Brain differences (hypothalamus size differences, corpus callosum differences, differing brain activation patterns), genetics (twin studies show higher concordance in identical than fraternal twins), and birth order effects (more older brothers → higher chance of same-gender/sex orientation in men). Biology influences probability but not destiny.

Psychosocial Explanations

Psychosocial explanations: Social interactions shape understanding; identity and meaning develop through experience. There is no evidence that parenting style, sexual abuse, or same-gender parents cause orientation.

Key findings: Most gay people are raised by heterosexual parents; abuse does NOT change orientation; women show more fluidity than men.

Sexual Identity Development Models

Sexual identity development models: Cass model has six stages and is historically important but rarely used today.

Stages in Cass model:

• Identity confusion: First awareness of same-gender attraction; feelings of confusion, denial, and anxiety. Key question: “Could I be gay?”
• Identity comparison: Compares self to heterosexual norm; feels different or isolated and may minimize attraction. Key question: “Maybe I’m different, but not gay.”
• Identity tolerance: Acknowledges same-gender attraction and begins seeking similar others; private acceptance begins. Key question: “I probably am gay.”
• Identity acceptance: Increased comfort with identity, selective coming out, more contact with LGBTQ+ community. Key question: “I’m okay with being gay.”
• Identity pride: Strong identification with LGBTQ+ identity; may reject heterosexual norms and engage in activism. Key question: “Being gay is important and positive.”
• Identity synthesis: Sexual identity is integrated into the overall self and is no longer central or oppositional. Key question: “My sexuality is one part of who I am.”

Ecological Model of Identity

Ecological model: Identity is shaped by society, culture/spirituality, family, peers, and internal cognition, affect, and behaviour. Stages: questioning, self-reflection, connection to SGD culture, reconnection to dominant culture, and consolidated identity.

Attraction

Attraction: The motivation to approach or want closeness with another person. It can be sexual, romantic, sensual, or emotional.

Factors that influence attraction:

• Proximity: We are more attracted to people we see often (mere-repeated-exposure effect).
• Physical attractiveness: Strong predictor of initial attraction; more important for short-term relationships and for men (heterosexual) on average. It starts attraction but does not predict long-term satisfaction well.
• Reciprocity & uncertainty: We like people who like us. Uncertainty can sometimes increase attraction by making people think more about the other person, but later research shows uncertainty can also reduce desirability. Attraction is strongest when interest is clear but not overwhelming.
• Similarity (homophily): We prefer people similar to us in age, education, values, and attitudes. Assortative mating: long-term partners tend to be similar. Perceived similarity matters more early on.

Menstrual-Cycle and MHC Effects

Menstrual-cycle effects (heterosexual context): Some studies show women prefer more masculine features when most fertile, and men find women more attractive during the fertile phase. Scent preferences change across the cycle. Meta-analyses show social factors may matter more than hormones.

“Opposites attract?” — MHC (Major Histocompatibility Complex): People may prefer partners with dissimilar MHC genes, which might lead to healthier offspring and avoid inbreeding; linked to scent preferences.

Intimacy and Attachment

Intimacy: Closeness + commitment involving emotional sharing, trust, caring, and physical closeness. It must be mutual but not necessarily equal.

Types of intimacy (PAIR model): Emotional, social, sexual, intellectual, and recreational. Intimacy is a process, not a fixed state.

Attachment Theory

Attachment theory: Adult relationships are influenced by early caregiver attachment. Bartholomew’s two-dimensional model uses dimensions of model of self (self-worth) and model of others (trust in others).

Four attachment styles:

• Secure: Positive self + positive others. Comfortable with intimacy and independence; highest relationship satisfaction.
• Preoccupied: Negative self + positive others. Clingy, approval-seeking, high anxiety.
• Fearful: Negative self + negative others. Wants intimacy but avoids it due to fear of rejection.
• Dismissing: Positive self + negative others. Emotionally distant and values independence over closeness.

Secure attachment is the best predictor of satisfaction; avoidance and anxiety predict lower sexual and relationship satisfaction.

Hooking Up and Casual Sex

Hooking up / casual sex: Casual sexual encounters without commitment. Common among university students, can include kissing through intercourse, and often alcohol-related.

Emotional outcomes: Both positive and negative; women report more negative emotions on average. Attachment style matters: anxious attachment leads to worse outcomes. Hooking up is not the same as intimacy.

Love: Types, Brain, and Theories

What is love? No single definition. Common features: trust, caring, commitment, friendship, and sexual attraction (especially in romantic love).

Cross-cultural views: Individualist cultures often see love as the basis for marriage; collectivist cultures emphasize family duty and arranged marriages. Passionate love is near-universal, but valuation differs.

Types of Love

Types of love: Passionate love (intense longing, high arousal), companionate love (warm, stable friendship, trust + commitment), and combinations described by Sternberg’s triangular theory (intimacy, passion, commitment).

Love styles (John Lee): Eros (passionate), Storge (friendship-based), Ludus (game-playing), Pragma (practical), Mania (obsessive), Agape (altruistic). Eros tends to predict higher satisfaction; Ludus lower satisfaction.

Love and the Brain

Love & the brain: Passionate love activates dopamine reward systems and deactivates fear and judgment areas (“love is blind”). Long-term love activates attachment-related areas. Rejection activates the same brain regions as drug craving, explaining obsessive thinking after breakups.

Theories of Love

Sternberg’s triangular theory: Three components: intimacy, passion, and commitment. Types of love include liking, infatuation, empty love, romantic love, companionate love, fatuous love, and consummate love (all three). Nonlove includes none of the components.

Love as a story: We learn “love stories” from culture; relationship satisfaction is higher when partners’ stories match. Maladaptive stories reduce satisfaction.

Two-Factor Theory and Objectum Sexuality

Two-factor theory of love: Love = physiological arousal + cognitive label. Misattribution of arousal can lead to fear being mistaken for attraction (e.g., Capilano Suspension Bridge study).

Objectum sexuality: Romantic/sexual attraction to objects; rare and little researched, but it shows diversity of love.

Optimal Sexuality and Jealousy

Optimal sexuality: “Great sex” is about emotional connection, trust, and intimacy. Orgasm and technique are not central.

Jealousy: Emotional response to the threat of losing a partner. Types: sexual jealousy and emotional jealousy. Evolutionary views suggest men show more sexual jealousy and women more emotional jealousy, but attachment style also matters.

Social Media and Jealousy

Social media & jealousy: Platforms like Facebook and Snapchat increase jealousy; ambiguity and access to information are triggers. Anxious attachment predicts more “creeping.”

Nonconsensual Nonmonogamy (NCNM)

Nonconsensual nonmonogamy (NCNM): Strongly socially disapproved but still common. It predicts distress, depression, and divorce and is both a cause and consequence of relationship breakdown.

Pregnancy: Gestation and Trimesters

Pregnancy (gestation): Pregnancy lasts ~40 weeks and is divided into three trimesters. Early pregnancy is the most vulnerable period for development because major organs form early—damage early can have serious consequences.

First Trimester

First trimester: Embryonic development.

Month 1: Major organs begin forming: heart, digestive system, central nervous system.

Month 2: Umbilical cord becomes visible; embryo attaches to placenta; facial features, hands, and feet develop; major blood vessels form; liver, pancreas, and kidneys form. By the end of the first trimester the embryo is called a fetus: limbs and digits are clearly visible; fingernails, toenails, hair follicles, and eyelids present. Biological sex can often be identified via ultrasound. Most major organs develop in the first trimester. Maternal illness, drugs, or environmental exposure during this time can have severe effects.

Effects of Pregnancy — First Trimester

Effects of pregnancy — first trimester: Common experiences include breast tenderness, tingling, fullness, nausea and vomiting, fatigue, appetite changes, food cravings or aversions, increased urination, constipation/irregular bowel movements, and increased vaginal secretions. “Morning sickness” is a misleading term—nausea can occur any time of day. Large studies show morning sickness is linked to healthier pregnancies and a lower risk of miscarriage and stillbirth; those who experience nausea/vomiting are less likely to miscarry.

Second Trimester (Weeks 13–27)

Second trimester: Fetal movement is detectable ~13–16 weeks (sometimes); primiparous women (first pregnancy) may feel it later (18–20 weeks). By the 5th month a heartbeat can be heard with a stethoscope; by the 6th month the eyes open. By 24 weeks the fetus is sensitive to light and sound. The fetus still cannot survive independently before ~24 weeks, and survival rates improve with NICU care.

Effects of pregnancy — second trimester: Often reported as the most comfortable trimester. Nausea/vomiting usually decrease, though indigestion and constipation may occur. The growing fetus puts pressure on organs. The placenta produces hormones that prepare the body for breastfeeding; breasts enlarge and nipples/areolae darken. Stretch marks may appear on the abdomen and breasts.

Third Trimester (Weeks 28–40)

Third trimester: Brain and nervous system development are largely complete by the end of the 7th month. The fetus’s skin may be wrinkled and covered with vernix (a waxy substance for temperature regulation). By the end of the 8th month average fetal weight ≈ 2500 g (5.5 lbs); average full-term newborn in Canada ≈ 3400 g (7.5 lbs).

Fetal position: The fetus usually turns head-down (cephalic presentation). Not all fetuses are head-down: breech (feet or bottom first), shoulder presentation, or transverse lie (fetus lies sideways). Medical interventions include external cephalic version (manual turning). Braxton-Hicks contractions are “false labour” and common late in pregnancy.

Effects of pregnancy — third trimester: Most uncomfortable trimester: difficulty breathing, back pain, leg cramps, frequent urination, shortness of breath, swelling (edema) in hands and feet, hemorrhoids. Average weight gain ≈ 25–35 pounds (underweight individuals should gain more, overweight individuals less); excess weight gain increases complication risk.

Biological Theories of Sexuality

Biological theories: These explain sexuality by focusing on genes, hormones, brain processes, and evolution. They argue many aspects of sexuality are influenced by biology, though not determined solely by it.

Genetic Theory

Genetic theory: Genes influence sexual development and sexual behaviour. Genetics affect hormone production, reproductive cycles, ovulation, ejaculation, conception, and pregnancy. Genetics also play a role in sexual orientation and gender identity.

Evidence for genetic influence: Twin studies show higher concordance in identical twins (48–52%) than fraternal twins (16–22%) or adoptive siblings (6–11%), indicating a genetic contribution but not determinism. Some studies suggest genes on chromosome 8 and the X chromosome may influence sexual orientation in men; evidence is inconclusive.

Genetic disorders & sexuality: Example: Klinefelter’s syndrome (XXY) in genetic males can affect fertility and sexual development.

Genetic Causes of Sexual Problems

Genetic causes of sexual problems: Some sexual problems have biological/genetic components (e.g., erectile dysfunction, dyspareunia) and are often treated medically or with combined sex therapy.

Sociobiological Theory (Evolutionary)

Sociobiological / evolutionary theory: Human sexual behaviour evolved to maximize reproductive success via natural and sexual selection.

Parental investment theory (very tested): Females generally invest more biologically (pregnancy, childbirth, caregiving) so females prioritize resources and protection; males may prioritize number of partners or long-term bonding. This leads to different mating strategies.

Mating strategies: Males may pursue multiple partners with minimal care or invest heavily in one partner and offspring; females tend to be more selective, choosing partners who increase offspring survival.