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Library of Congress Cataloging-in-Publication Data
ABC of sexual health / edited by Kevan Wylie. – Third edition.
p. ; cm. – (ABC series)
Preceded by ABC of sexual health / edited by John M. Tomlinson. 2nd edition. 2005.
Includes bibliographical references and index.
ISBN 978-1-118-66569-5 (pbk.)
I. Wylie, Kevan, editor. II. Series: ABC series (Malden, Mass.)
[DNLM: 1. Sexual Dysfunction, Physiological. 2. Sexual Behavior. WP 610]
RC556
616.6′9–dc23
2014049377
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: mating-ladybugs-6163495 © isgaby/iStockphoto
Why do we need an ABC of Sexual Health? The answer is straightforward; the subject is important, which is often not advised about and often not taught in medical school or at the post graduate level. When questioned as to what is important in a happy marriage, sexual relationships were considered very important and when patients had concerns they wanted more information and healthcare professionals to initiate discussion. Far too often healthcare professionals wait for the patient to raise the subject, whereas they need to be more proactive. In a recent survey, of more than 450 cardiologists, 70% gave no advice, 54% saying there was a lack of patient initiative and 43% saying they didn't have the time. In this vacuum, ABC of Sexual Health is clearly needed so that healthcare professionals can know more about this unmet need.
In 1970, the World Health Organization summarised the right to sexual health, including it as part of the fundamental rights of an individual.
So nearly 50 years later it is right that we ask ourselves “how are we doing?” The short answer is: not well enough. There are many disciplines involved and access to these should become routine, and this book forms an essential beginning.
Dr. Graham Jackson
Cardiologist and Chairman of the Sexual Advice Association
Brian Daines
University of Sheffield, Sheffield, UK
Interest in psychosexual development has tended to focus around managing problems, particularly those associated with risks and their management. These areas include sexual abuse in childhood and early adolescence, unwanted pregnancy and sexually transmitted diseases (STDs) in adolescence and early adulthood and functional sexual difficulties in adults. In contrast, the interest, for example of adolescents has been shown to be more in the rite of passage and recreational aspects of sexual activity. There has also been a concentration on childhood and adolescence, with adult psychosexual development being a poor relation and any emphasis for older people being on dysfunctions and disorders rather than the expected course of development. Development through the life cycle involves important areas such as sexual identity, couple relationship issues, fertility and ageing.
Probably, the most familiar schema of sexual development in childhood and adolescence is that proposed by Freud (Table 1.1). This still has currency in many modern textbooks despite having long been superseded, not only outside of the world of psychoanalysis, but also generally among psychotherapists. A primary criticism is that it pathologizes variations in sexual development, in particular gay and lesbian relationships. With the passage of time, Freud's emphasis on instinct and drive was replaced by highlighting the importance of relating and relationship and then broadened to recognize the importance of learning and culture. Freud's theories assume that children are caught in hidden conflicts between their fears and their desires, whereas the environmental learning view is of identification through observation and imitation. Modern psychoanalytic views include a wide range of innovative ideas such as that the various dynamics in childhood produce a psychosexual core which is unstable, elusive and never felt to be really owned.
Table 1.1 Freud on psychosexual development
| Oral stage 0–2 years Desires are focussed on the lips and mouth. The mother becomes the first love-object, a displacement from the earliest object of desire, the breast |
| Anal stage 2–4 years of age In this stage, the anus is the new auto-erotic object with pleasure being obtained from controlling bladder and bowel movement |
| Phallic stage 4–7 years of age In this third stage, awareness of and touching the genitals is the primary source of pleasure |
| Latency period 7–12 years of age During this time, sexual development is more or less suspended and sexual urges are repressed |
| Genital phase 13 years + (or from puberty on) In this final phase, sexual urges are direct onto opposite sex peers with the primary focus of pleasure of the genitals |
At the other end of the spectrum are ideas that take a societal perspective, such as consumer culture bringing sexuality into the world of commerce. Sex is used to sell products through sexiness and physical attractiveness being closely connected with the goods we buy and are seen to own. This aspect of sex and consumerism is particularly directed towards girls and women. A further development is when sex itself is marketed as pleasure or the idea of sexual self-expression is promoted. The world is sexualized, and there is a seduction into the world of responding to sexual impulse. On the Internet in particular, representations of the body become products to buy. This becomes the world into which children and adolescents are socialized and encouraged to participate. As we grow up, sexuality becomes increasingly focussed on technique and performance with a tendency for it to come to resemble work risking the loss of much of its intimate and caring qualities.
The feminist perspective is that gender shapes our personality and social life and that our sexual desires, feelings and preferences are deeply rooted by our gender status. The identification between mothers and daughters leads girls to become very relationship-orientated. This promotes the connection of sex with intimacy and the valuing of its caring and sharing aspects. It develops as a means of communication and intimacy rather than a source of erotic pleasure. In contrast, boys develop a more detached relationship with their mothers and do not have the same kind of identification with their fathers and this leads them to be more goal-orientated around sexuality. There is more of an emphasis on pleasure and on performance. It is also argued that girls' identification with their mothers makes their heterosexual identification weaker than that of boys.
The nature of childhood and adolescence has been subject to debate and controversy. Whilst all acknowledge that the nature of both has changed in Western culture over the centuries, there is some dispute about when the idea of childhood as a distinctive phase began, and it has been suggested that the idea we have currently of adolescence did not exist before the beginning of the twentieth century. It has also been argued that the concept of childhood makes children more vulnerable including to sexual exploitation and abuse. The idealization of childhood may also contribute to the sexual attraction of children to certain adults.
Aspects of the definitions of childhood and adolescent become enshrined in law particularly in defining the age of consent for sex and what kinds of sexual practices are legal. It also defines a framework for marriage, and alongside this are cultural issues about the acceptability of sexual relationships outside of this. In different countries, the age of consent varies from 12 to 21 for heterosexual, gay and lesbian relationships, but in many countries same-sex relationships are still illegal. The position is complicated by the fact that these arrangements are often subject to review and potential change.
Although it is clearly interwoven, law is only one of the forces at work here as family, religion, culture and mass media also influence teenage attitudes and behaviour. All these forces work together in ways that overlap, support and sometimes contradict one another in the emergence of a normative version of teenage sexuality.
Young children show behaviours that indicate awareness of sexual organs and pleasuring very early and preschoolers are often puzzled by sexual anatomical differences. By the age of 2 or 3, they become aware of their gender and aspects of gender role. Children often have a need for the validation and correction of their sexual learning, but adults often do not feel well-informed about childhood sexuality and, as a consequence, are not confident about how to respond in their care of children. Play such as doctors and nurses and looking at genitals are all common during the preschool and early school years and as many as half of all adults remember this kind of childhood sexual play. The discovery of such activities can give parents and caregivers an opportunity to educate and share values. An example of this would be that another person should not touch them in a way that makes them feel afraid, confused or uncomfortable. Activities between children such as those involving pain, simulated or real penetration or oral–genital contact should raise concerns and may be related to exposure to inappropriate adult entertainment or indicate sexual abuse. School-age children are usually able to understand basic information about sexuality and sexual development and may look to various sources for information, such as friends and the Internet.
Early teenage development can be characterized by concerns about normality, appearance and attractiveness. As girls' physical development is usually more advanced than that of boys of the same age, they may experience sexual feelings earlier and be attracted to older, more physically mature boys. Those who have early intercourse have been found to have lower self-esteem than virgins, unlike boys for whom intercourse is more socially acceptable. For boys, there is evidence that both peers and families can potentially either support or undermine sexual development and that health care providers may have more influence than they presume. The middle phase sees the exploration of gender roles and an awareness of sexual orientation. Fantasies are idealistic and romanticized, and sexual experimentation and activity often begin in relationships that are often brief and self-serving. Online communication is used for relationship formation and sexual self-exploration but also carries risks of unwanted or inappropriate sexual solicitation.
In late adolescence, there is an acceptance of sexual identity and intimate relationships are based more on giving and sharing, rather than the earlier exploration and romanticism. Research among students has suggested that first experiences of intercourse in late adolescence lead males to be more satisfied with their appearance, whereas females became slightly less satisfied. In all this, it is important to bear in mind the wide variability in individual adolescent development which is evident to all who work with this age group.
Impairment or delay in psychosexual development can be caused by a number of factors including:
Promoters of early sexualization include
The effects of early puberty in girls can include early sexual behaviour and an increased number of lifetime sexual partners. Research has confirmed that both early puberty and late puberty in girls are associated with low self-esteem. Disruption in development can also be brought about by:
The main developmental tasks for young adults are completing the development of adequate sexual confidence and functioning and establishing the potential for desired couple relationships. The latter may range through a spectrum of possible arrangements from marriage to one-night stands as lifestyle choices. Over the period of fertility, decisions about children are taken either as choices or responses to physical limitations. This is followed by more marked accommodation in response to ageing. The decrease in frequency of sexual activity at this point is thought to involve relational as well as physical factors. Social attitudes tend to claim sex as the province of the young and fit and that there is something distasteful about interest in sex and sexual activity beyond young adulthood, particularly in the elderly. Later in life, but potentially at any point, adjustments to illness or disability may have to be made (Table 1.2 and 1.3).
Table 1.2 Adult psychosexual development tasks
| Consolidating sexual identity and orientation (teens and twenties) |
| Developing adequate sexual confidence and functioning (late teens and twenties) |
| Establishing the potential for desired couple relationships (late teens and twenties) |
| Managing issues around fertility (twenties, thirties and forties) |
| Adjusting to the effects of ageing (forties onwards) |
| Facing and dealing with loss (forties or fifties onwards) |
| Adjusting to illness and disability (at any point but particularly in the elderly) |
Table 1.3 Learning points for clinicians
| Expressions of sexuality in childhood need to be carefully assessed to avoid missing situations that need intervention or pathologizing expression that fall within the range of normal development |
| Developmental issues and adolescent needs should not to be obscured by preoccupations about risk |
| Care needs to be taken that valid developments in sexual orientation and preferences are not pathologized |
| There needs to be an awareness of the relevance of developmental issues throughout the life cycle |
| Problems related to sexuality may be partly a result of a difficulty in transition through a developmental stage or of a past stage that was not successfully negotiated |
| It is important to be aware of the assumptions and values that underlay ideas about normal development and the potential conflict between societal concerns and individual aspirations |