ABC of Sexual Health -  - E-Book

ABC of Sexual Health E-Book

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ABC of Sexual Health provides a comprehensive overview of this important, but difficult subject and includes reading resources as well as information on professional societies, patient groups and online resources. Fully revised and expanded to cover a range of new content and topics including psychological, urological, gynaecological, endocrinological and psychiatric aspects of sexual health, the effects of medication, sexual dysfunction, sexual orientation, gender identity, paraphilias, forensic sexology, dermatoses, and psychosexual therapy and education. ABC of Sexual Health is a practical guide for all general practitioners, family physicians, trainees and medical students wanting to improve communicating, examining and managing patients with sexual health problems.

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Table of Contents


Series Page

Title Page


Series Foreword


Chapter 1: Psychosexual Development


Psychoanalytic views

Consumerist view

Feminist views

Definition of childhood and adolescence

The impact of law and culture

Childhood development

Adolescent development

Factors impacting on development

Adult development

Further reading

Chapter 2: Physical Aspects of Sexual Development


Intrauterine development

From birth to puberty


Further reading

Chapter 3: Anatomy and Physiology in the Male


Fetal genital development


Functional anatomy of the adult genitalia

The four E's of male sexual arousal

Features of sexual excitation and arousal in males

Mechanism of erection – converting the flaccid urinary to the sexually erect penis

What keeps the penis flaccid?

The phases of sexual arousal

Brain imaging

Further reading

Chapter 4: Anatomy and Physiology in the Female


Foetal genital development


Functional anatomy of the adult female genitalia

Sexual response cycle

Brain imaging

Further reading

Chapter 5: The Sexual History and Formulation

The sexual history


Further reading

Chapter 6: The Clinical Examination of Men and Women



Neurological examination in men


Neurological examination in women

Further reading

Chapter 7: Male Dermatoses

Diagnosing genital rashes

Lichen sclerosus (LSc)

Pre-malignant lesions

Common inflammatory dermatoses with a genital manifestation


Penile oedema

Further reading

Chapter 8: Female Dermatoses

Common symptoms of vulval dermatoses

Care of the vulva

What to be weary of with vulval disease

Pruritus vulvae

Vulval pain

Lichen simplex chronicus

Lichen sclerosus

Allergic and irritant contact dermatitis affecting the genital region

Vulval psoriasis

Atopic vulvitis


Further reading

Chapter 9: Investigation and Management of Endocrine Disorders Affecting Sexuality


Testosterone in men

Testosterone in women

Thyroid disorders



Further reading

Chapter 10: Investigations in Sexual Medicine for Women and Men with Sexual Health Problems

Problems of sexual desire, libido and arousal in women


Further reading

Chapter 11: Definition and Diagnosis of Sexual Problems

What is a sexual problem?

The classification systems

Categories of sexual problems in the ICD-10

Categories of Sexual problems in DSM-5

The diagnosis of sexual dysfunctions

Further reading

Chapter 12: Psychiatric Disorders and Sexuality (Including Trauma and Abuse)


Psychiatric disorders associated with sexual dysfunction(s)


Managing sexual dysfunction associated with mental illness, substance abuse or sexual trauma/abuse

Further reading

Chapter 13: Medication and Sexual Dysfunction


Psychotropic drugs

Cardiovascular drugs

Drugs for lower urinary tract symptoms

Endocrine drugs

Lipid-lowering drugs

Further reading

Chapter 14: Problems of Sexual Desire in Men


Definitions of low sexual desire in men




Further reading

Chapter 15: Problems of Sexual Desire and Arousal in Women







Further reading

Chapter 16: Erectile Dysfunction


Initial assessment

Laboratory testing

Cardiovascular disease and ED

Specialized investigations

Treatment objectives

Lifestyle management

Second-line treatment

Third-line treatment

Peyronie's disease


Further reading

Chapter 17: Problems of Ejaculation and Orgasm in the Male


Premature ejaculation

Delayed ejaculation

Post-orgasmic illness syndrome

Restless genital syndrome in the male

Anhedonic ejaculation

Retrograde ejaculation

Painful ejaculation

Low ejaculate volume

Further reading

Chapter 18: Problems of Orgasm in the Female

Introduction and definitions


Anatomy and physiology


Biological risk factors

Psychological and socio-cultural risk factors




Further reading

Chapter 19: Sexual Pain Disorders – Male and Female


Pain history

Keeping a pain diary

Sexual dysfunction and the couple

Managing genito-pelvic pain

Further reading

Chapter 20: Ageing and Sexuality

The prevalence of sexual activity in older people

Physical effects of ageing

Physical effects of illness

Effects of psychiatric illness including dementia

Effects of drugs and polypharmacy

Social effects of ageing

Help-seeking behaviour

The relevance of education for health professionals


Further reading

Chapter 21: Paraphilia Behaviour and Disorders

Fetishistic behaviour

Sadomasochistic behaviour

Exhibitionistic, frotteuristic and voyeuristic behaviour

Paedophilia and further behaviour attracting forensic attention

Problematic hypersexual behaviour

Therapeutic options


Further reading

Chapter 22: Impulsive/Compulsive Sexual Behaviour

What do we call it?

Non-paraphilic ICSB

The danger of overpathologizing this disorder


Pharmacological treatment


Further reading

Chapter 23: Forensic Sexology


Offending, deviance, disorder

Assessment of sex offenders

The biological basis of sexual arousal and targets for medical intervention

Treatment algorithms

Further reading

Chapter 24: Ethnic and Cultural Aspects of Sexuality


Genital surgeries and modifications

Vaginal and penile practices

Hymen dilemmas

Rapid ejaculation

Dyspareunia and vaginismus

Heterosexual men having casual sex with men (masculine socialization)

History taking in multiethnic multicultural context


Further reading

Chapter 25: Concerns Arising from Sexual Orientation, Practices and Behaviours

Worries about same-sex sexual attractions

Responding to the unhappy homosexual

Mental health concerns

Pharmacotherapy for depression

Recreational drug use

Consensual non-monogamies

Concerns about sexual activity

BDSM/kink – assessing risk


Further reading

Chapter 26: Gender Dysphoria and Transgender Health


Transgender medical care

Further reading

Chapter 27: Psychosexual Therapy and Couples Therapy


Psychodynamic psychotherapy

Cognitive behavioural therapy

Cognitive restructuring

Relaxation and breathing exercises


Systemic therapy

Social/interpersonal skills


Combined therapies

MIST (Multi-intervention sex therapy)

Use of bibliotherapy in sex therapy


Additional resources used in addressing sexual problems

Further reading

Chapter 28: Bibliotherapy and Internet-based Programmes for Sexual Problems


Types of self-help for sexual dysfunctions


Video therapy

Online sex therapy

Online educational tools for sexual health

Further reading

Chapter 29: Sexual Pleasure

Sexual pleasure

Sexual confidence

Further reading



End User License Agreement






































































































































Table of Contents


Begin Reading

List of Illustrations

Chapter 2: Physical Aspects of Sexual Development

Figure 2.1 Male testosterone levels

Figure 2.2 Female testosterone levels

Chapter 3: Anatomy and Physiology in the Male

Figure 3.1 A schematic sagittal diagram of the adult male genitourinary tract (not to scale)

Figure 3.2 A schematic representation of an erect circumcised penis. The paired corpora cavernosa run parallel along the shaft surrounded by the membranous tunica albuginea while underneath the corpora spongiosum is fitted around the urethra and starting as the penile bulb (not shown but see Figure 3.4) and terminates as the penile glans

Figure 3.3 A diagrammatic illustration of the corpora cavernosal mechanism of erection of the penis (see text for details). The size of the arrows is an indication of the amount of blood flow into and from the vessels involved

Figure 3.4 Schematic diagrams of the medial (A) and ventral (B) aspects of the penis. The course of the corpus spongiosum is shown in (A) while the dispositions of the ischiocavernosus and bulbocavernosus striated muscles are shown in (B). The latter is a bipennate structure with its medial raphe and two rows of muscle fibers facing in opposite diagonal directions; this gives forceful contractions for ejaculation but with restricted movement. The frenulum and coronal edge of the glans are illustrated (see text for details)

Figure 3.5 A graphic ‘cusp’ representation of the sexual response cycle in the male during two serial sexual scenarios. Cusp systems have a sudden change caused by a smooth acceleration characterized mathematically by Catastrophe theory. Orgasm is an example of a ‘cusp catastrophe’ where behaviour is smooth up to the cusp the system then trips over into a completely different behaviour and orgasm occurs. In the first scenario (A) a desire phase (1) precedes the excitement phase (2) and the increasing central sexual arousal reaches a cusp that initiates ejaculation and orgasm. There is then a subsequent resolution (3) back to the basal level. During this resolution phase (3) there is a refractory period (post orgasmic refractory time, PERT) when an immediate further erection/orgasm cannot occur. A subsequent sexual arousal (B), after the ending of the PERT, has the same sequences as the previous but as shown in the diagram the central sexual arousal, thus pleasure, is usually less than the first (see text for details)

Chapter 4: Anatomy and Physiology in the Female

Figure 4.1 A highly schematic diagram of the female pudenda with the labia majora and minora removed for clarity. The periurethral glans area of the vaginal vestibule stretches from underneath the clitoris to the top of the introitus

Figure 4.2 A graphic representation of the female sexual response cycles for two scenarios. The first (A) is represented by a cusp system. Cusp systems have a sudden change caused by a smooth acceleration characterized mathematically by Catastrophe theory. Orgasm is an example of a ‘cusp catastrophe’ where behaviour is smooth up to the cusp, the system then trips over into a completely different behaviour and orgasm occurs. In A (solid line), a desire phase (1) precedes the excitement phase (2) created by sexual stimulation. The rising central sexual arousal reaches a cusp that initiates orgasm and then a partial resolution (3) of the arousal until a further bout of stimulation (2) in B arrests the resolution and a second central arousal reaches the cusp and the induction of a further orgasm. This then induces the subsequent resolution phase (3) that returns the central arousal back to near basal levels. The second scenario (C, dotted line) again has an initial desire phase (1) preceding the excitement phase (2) but this time the central sexual arousal does not reach the level required to activate the orgasm cusp, orgasm does not occur, so the resolution phase (3) takes a considerably longer time to resolve back to basal level

Figure 4.3 A highly schematic sagittal view of the female genitalia (labia majora and minora not shown). The septum between the anterior wall of the vagina and the urethra contains Halban's fascia (see text). A possible site for the controversial G-spot is shown just around the junction of the bladder and urethra

Chapter 5: The Sexual History and Formulation

Figure 5.1 Between 29% and up to 44% of people will experience a sexual difficulty at some time in their lives

Figure 5.2 Taking a sexual history

Figure 5.3 Clinician considerations

Figure 5.4 There are many resources available to assist you and your patients

Figure 5.5 Seeing a couple together also allows the clinician to gain some insight into how the couple function together and to identify unhelpful patterns of communication

Figure 5.6 Biopsychosocial model

Chapter 7: Male Dermatoses

Figure 7.1 Pearly penile papules. (Courtesy Dr D.A. Burns, Leicester, UK)

Figure 7.2 Zoon's balanitis. Asymptomatic, symmetrical moist erythema of glans and prepuce. (Courtesy of Professsor C.B. Bunker, with permissions from Medical Illustration, UK, Chelsea & Westminster Hospital, London, UK).

Figure 7.3 Lichen sclerosus. Circumferential sclerotic band of the prepuce causing ‘waisting’ and a constrictive posthitis. (Courtesy of Professsor C.B. Bunker, with permissions from Medical Illustration, UK, Chelsea & Westminster Hospital, London, UK).

Figure 7.4 Lichen planus. Papules and annular lesions with Wickham's striae on the glans and shaft. (Courtesy of Professsor C.B. Bunker, with permissions from Medical Illustration, UK, Chelsea & Westminster Hospital, London, UK).

Chapter 8: Female Dermatoses

Figure 8.1 Lichen simplex chronicus with erosions which are secondarily infected

Figure 8.2 Lichen sclerosus affecting the vulva showing pallor, haemorrhage and tearing at the posterior fourchette

Figure 8.3 Lichen sclerosus at a later stage with post-inflammatory pigmentation loss of architecture and fissures in the labia minora

Figure 8.4 Advanced lichen sclerosus showing introital narrowing and burying of the clitoris. There is also a squamous cell carcinoma on the right buttock

Figure 8.5 The subtle dermatitis over the labia majora demonstrates an allergic contact dermatitis affecting the vulva

Figure 8.6 Psoriasis affecting the vulval region showing well demarcated erythematous plaques

Chapter 9: Investigation and Management of Endocrine Disorders Affecting Sexuality

Figure 9.1 Serum testosterone

Chapter 11: Definition and Diagnosis of Sexual Problems

Figure 11.1 The biopsychosocial working hypothesis for sexual dysfunctions

Chapter 14: Problems of Sexual Desire in Men

Figure 14.1

Flow-chart for the diagnosis and treatment of HSDD.

Source: Corona and Maggi, 2012. Reproduced with permission from Medix

Chapter 15: Problems of Sexual Desire and Arousal in Women

Figure 15.1 Particularly in women, sexual desire/arousal seems to be sensitive to the interpersonal aspects of the relationship. Source: © Peter van Straaten, reproduced with permission

Figure 15.2 Treatment diagram to illustrate the recommended steps for intervention. After initial assessment, if medical problems are found, further medical examination and treatment are warranted. If psychological or couple issues are first detected, client may benefit from treatment focusing on cognitive processing, mindfulness skills and behavioural changes. In some cases, couple therapy is needed. Psychoeducation is imperative to overcome unfavourable beliefs and to define and adjust expectations. If there are little or no motivations to be sexual, sexual stimuli are not satisfactory, thoughts content is distracting or disturbing, mindfulness integrated CBT is recommended. Address sexual scripts and develop alternatives as needed. Address pleasure. Off-label medications are indicated only if previous steps were unsuccessful, after the client received full explanation on the limitations of medical treatment. Source: Binik and Hall (2007), Reprinted with permission by Guilford Press

Figure 15.3 The internal anatomy of the human vulva, with the clitoral hood and labia minora indicated as lines. The clitoris extends from the visible portion to a point below the pubic bone. (Accessed at Picture released to the public domain

Chapter 16: Erectile Dysfunction

Figure 16.1 Vacuum erection devices

Figure 16.2 Intra-cavernosal Injection

Figure 16.3 Medicated urethral system for erection (MUSE)

Chapter 17: Problems of Ejaculation and Orgasm in the Male

Figure 17.1 An approach to diagnose the four premature ejaculation subtypes

Chapter 19: Sexual Pain Disorders – Male and Female

Figure 19.1 Pain assessment algorithm. A thorough pain history and physical exam are required to determine whether pain is idiopathic or due to a known disease. It is notable that treatments may fail to relieve pain and associated symptoms, and when no cause of pain can be found, a patient is considered to have an idiopathic pelvic pain syndrome. If no organ-specific symptoms are found, referrals for pain management may be made. When specific organs are implicated, it is recommended that a comprehensive phenotypic assessment be conducted to determine the respective contributions of urological/gynaecological, psychosocial, organ-specific, infectious, neurological, pelvic floor tenderness and sexual factors. Positive domains can further direct the referral and treatment process.

Chapter 20: Ageing and Sexuality

Figure 20.1 Your sexuality is part of the person you have always been. © 2014, Graham Hagan

Figure 20.2 Despite the prevalent belief amongst teenagers, sex does not end at 30, or even at 90

Figure 20.3 Sex in old age can present a few challenges © 2014, Graham Hagan

Figure 20.4

Figure 20.5 With appropriate help, people can enjoy physical intimacy at any age.

Chapter 22: Impulsive/Compulsive Sexual Behaviour

Figure 22.1 Continuum of ICSB.

Chapter 23: Forensic Sexology

Figure 23.1 Sexual deviation. Source: Reproduced with permission from Jose Maria Andres Martin

Figure 23.2 The four domains that drive sex behaviour

Figure 23.3 Important hormones in the control of sexual interest and functioning

Chapter 27: Psychosexual Therapy and Couples Therapy

Figure 27.1 Vicious cycle of sexual pain

Figure 27.2


is key to a successful relationship. (public domain)

Chapter 29: Sexual Pleasure

Figure 29.1 Tantric artefact symbolising the mystic union of male consciousness & female energy

Figure 29.2 The ‘black box’ approach can be likened to giving our patients the ingredients to make a delicious cake & a photograph of the end result but leaving out the recipe & equipment that they need to make the cake (taken from APFELBAUM, Bernard (2012). On the need for a new sex therapy)

Figure 29.3 Sexual Confidence Model

List of Tables

Chapter 1: Psychosexual Development

Table 1.1 Freud on psychosexual development

Table 1.2 Adult psychosexual development tasks

Table 1.3 Learning points for clinicians

Chapter 9: Investigation and Management of Endocrine Disorders Affecting Sexuality

Table 9.1 Symptoms and signs of testosterone deficiency

Table 9.2 Common causes of hypogonadism

Table 9.3 Investigations for hypogonadism

Table 9.4 HRT for women risks versus benefits

Chapter 11: Definition and Diagnosis of Sexual Problems

Table 11.1 Categories of sexual problems in the ICD-10

Table 11.2 DSM-5 Classification

Chapter 12: Psychiatric Disorders and Sexuality (Including Trauma and Abuse)

Table 12.1 Antidepressants reportedly associated with sexual dysfunctions in case reports and or studies

Table 12.2 Laboratory test useful for evaluating sexual dysfunction (always consider clinical situation)

Table 12.3 Strategies for medication-associated sexual dysfunction

Table 12.4 Antidotes used to manage sexual dysfunction associated with medications

Chapter 13: Medication and Sexual Dysfunction

Table 13.1 Strategies for the management of drug-induced sexual dysfunction

Chapter 14: Problems of Sexual Desire in Men

Table 14.1 Common factors associated with HSDD in Men

Table 14.2 Drugs associated with male HSD

Table 14.3 Manifestations of sexual desire

Chapter 15: Problems of Sexual Desire and Arousal in Women

Table 15.1 Prevalence of low sexual desire in women

Table 15.2 Domains to assess for women presenting with sexual desire/arousal concerns

Table 15.3 Psychological treatments for women's sexual desire/arousal difficulties

Table 15.4 Medications that have been the focus of empirical research for improving women's sexual desire/arousal

Table 15.5 Possible mechanisms by which the placebo response improves women's sexual function

Chapter 16: Erectile Dysfunction

Table 16.1 PDE5 Inhibitors currently available for treating ED

Chapter 17: Problems of Ejaculation and Orgasm in the Male

Table 17.1 Drug treatment of lifelong and acquired premature ejaculation

Table 17.2 Causes of acquired delayed ejaculation

Chapter 19: Sexual Pain Disorders – Male and Female

Table 19.1 An approach to the pain history

Table 19.2 Potential syndromes underlying genito-pelvic pain in men and women

Table 19.3 Potential syndromes underlying genito-pelvic pain in men and women

Chapter 23: Forensic Sexology

Table 23.1 Drugs often used in sex offender treatment

Table 23.2 The use of testosterone-lowering drugs

Table 23.3 Monitoring the use of testosterone-lowering drugs

Table 23.4 Treatment algorithm based on presentation (plus psychological treatment in most cases)

Chapter 28: Bibliotherapy and Internet-based Programmes for Sexual Problems

Table 28.1 Brief selection of currently available sexual health education websites

ABC ofSexual Health

Third Edition



Edited by


Consultant in Sexual Medicine, Sheffield, UK; Honorary Professor of Sexual Medicine, University of Sheffield; President,World Association for Sexual Health



This edition first published 2015 © 2015 by John Wiley & Sons Ltd.

First edition © 1999 by BMJ Books.

Second edition © 2005 by Blackwell Publishing Ltd.

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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]




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

Series Foreword

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.

A capacity to enjoy and control sexual health and reproductive behaviour in accordance with social and personal ethics

Freedom from fear, shame, guilt, false beliefs and other factors inhibiting sexual response and impairing sexual relationships

Freedom from organic disorders, diseases and deficiencies that interfere with sexual and reproductive function

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


Richard Balon

Departments of Psychiatry and Behavioral Neurosciences and AnesthesiologyWayne State University School of Medicine, Detroit, MI, USA


Yitzchak M. Binik

Department of Psychology, Alan Edwards Centre for Research on PainMcGill University, Montréal, QC, Canada


Johannes Bitzer

Department of Obstetrics and Gynecology, University Hospital Basel, Basel Switzerland


Lori A. Brotto

Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada


Chris Bunker

Department of Dermatology, University College Hospital, London, London, UK

Department of Dermatology, Chelsea and Westminster Hospital, London, UK


Eli Coleman

Program in Human Sexuality, University of Minnesota, Minneapolis, MN, USA


Brian Daines

Department of Psychiatry, University of Sheffield, Sheffield, UK


Dominic Davies

Pink Therapy, London, UK


Seth Davis

Faculty of Medicine, University of Toronto, Toronto, ON, Canada


John Dean

Clinical Director, Gender & Sexual Medicine, Devon Partnership NHS Trust, Exeter, UK


Melissa A. Farmer

University of Toronto, Toronto, ON, Canada

Alan Edwards Centre for Research on Pain, McGill University, Montreal, QC, Canada


Julie A. Fitter

Porterbrook Clinic, Sheffield Health and Social Care NHS Foundation Trust, Sheffield, UK


Lin Fraser

Psychotherapist, San Francisco, CA, USA


Woet L. Gianotten

Erasmus University Medical Centre, Rotterdam, The Netherlands, University Medical Centre, Utrecht, The Netherlands


David Goldmeier

Sexual Medicine, St Marys Hospital, London, UK

Honorary Senior Lecturer, Imperial College London, St Marys Hospital, London, UK


Irwin Goldstein

Sexual Medicine, Alvarado Hospital, San Diego CA, USA


Don Grubin

Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK

Honorary Consultant Forensic Psychiatrist, Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK


Geoffrey Hackett

Good Hope Hospital, Sutton Coldfield, Birmingham, UK


Trudy Hannington

Leger Clinic, Doncaster, UK

The College of Sexual and Relationship Therapists (COSRT), Doncaster, London, UK


T. Hugh Jones

Robert Hague Centre for Diabetes and Endocrinology, Barnsley Hospital NHS Foundation Trust, Barnsley, UK

Department of Human Metabolism, School of Medicine and Biomedical Sciences, University of Sheffield, Sheffield, UK


Gail A. Knudson

University of British Columbia, Vancouver, BC, Canada


Ellen T. M. Laan

Department of Sexology and Psychosomatic Obstetrics and Gynaecology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands


Roy J. Levin

Sexual Physiology Laboratory, Porterbrook Clinic, Sheffield, UK


Fraukje E. F. Mevissen

Work and Social Psychology Department, Maastricht University, Maastricht, The Netherlands


Ruth Murphy

Consultant Dermatologist, Nottingham University Teaching Hospitals, Nottingham, UK


Sara Nasserzadeh

Psychosexual Therapist, Connections ABC, New York, NY, USA


Sue Newsome

Sex Therapist & Tantra Teacher, London, UK.


Sharon J. Parish

Department of Psychiatry, Weill Cornell Medical College, New York, USA

New York Presbyterian Hospital/ Westchester Division, White Plains, New York, USA


Yacov Reisman

Men's Health Clinics, Department of Urology Amstell and Hospital Amstelveen and Bovenij Hospital Amsterdam, The Netherlands


Ross Runciman

Wotton Lawn Hospital, Horton Road, Gloucester, UK


Manu Shah

Burnley General Hospital, East Lancashire, UK


Francesca Tripodi

Institute of Clinical Sexology, Rome, Italy


Jacques van Lankveld

Open University, Heerlen, The Netherlands


Marcel D. Waldinger

Division of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands


Alison K. Wood

Old Age Psychiatry, Sheffield, UK


Kevan Wylie

Sexual Medicine, Porterbrook Clinic and Urology, Sheffield, UK

Honorary Professor of Sexual Medicine, University of Sheffield, UK

President, World Association for Sexual Health, Minneapolis, USA

Chapter 1Psychosexual Development

Brian Daines

University of Sheffield, Sheffield, UK


Psychosexual development is not limited to childhood and adolescence but extends through adult life

Early psychoanalytic views of the process are still influential but more recent ideas such as consumerist and feminist perspectives offer a more societal emphasis

It is important to consider the impact of the aspects of law and culture that relate to psychosexual development

Clinicians need to be aware of the implications of these issues and the various factors impacting on development in their consultations with patients.


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.

Psychoanalytic views

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

Consumerist view

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.

Feminist views

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.

Definition of childhood and adolescence

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.

The impact of law and culture

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.

Childhood development

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.

Adolescent development

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.

Factors impacting on development

Impairment or delay in psychosexual development can be caused by a number of factors including:

physical developmental disorders

some chronic illnesses and treatments

lack of appropriate educational opportunities

absent or poor role models

Promoters of early sexualization include

inappropriate comments and attention from adults

sexual abuse

viewing pornography

sexual experiences with peers at a young age

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:

education into misleading or inaccurate information about sex

experiencing or witnessing sexually abusive or violent acts

sexual humiliations or rejections

Adult development

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

Further reading

Bancroft, J. (2009)

Human Sexuality and its Problems

, 3rd edn. Churchill Livingstone, Edinburgh ch.

Hornberger, L.L. (2006) Adolescent psychosocial growth and development.

Journal of Pediatric and Adolescent Gynecology



, 243–246.

Seidman, S. (2003)

The Social Construction of Sexuality

. Norton, New York.

Chapter 2Physical Aspects of Sexual Development

Woet L. Gianotten1,2

1Erasmus University Medical Centre, Rotterdam, The Netherlands

2University Medical Centre, Utrecht, The Netherlands


This chapter focuses on the nature aspects of female–male development and differences

Step 1 takes place at the conception when the genotypic sex is determined by XX or XY

Step 2 starts 7 weeks later with the development of the gonadal sex. Without interference of testosterone, the default is female. With testosterone, the gonads, the genitals and the brain will ‘grow male’

From birth to puberty, there is no activity of gonadal hormones

Puberty is the last phase of differentiation and preparation for adult life and reproduction

After puberty, the gonadal hormones have only activational function and no more organizational function.


Talking about sexuality is also talking about female/male differences, a major topic in the history of our human race. Depending on time and culture more or less value has been attributed to the biological, the psychological or the social influences, sometimes denying the importance of specific elements. A striking example of that nurture–nature debate happened three decades ago in Western culture. Then, the predominant idea was that education (=nurture) was the major reason for the difference between the sexes, and the biological influence was nearly completely denied. So, the toys for children were adjusted. Girls were given Dinky Toys and boys got dolls. But nature proved stronger than education. The dolls were used as the enemy and the Dinky Toys were sometimes pampered by the girls. One cannot simply erase millions of years of evolution.

Talking female–male differences is very tricky, as it easily can be seen as discriminating one group. However, one cannot educate well without understanding the differences. Two important aspects of wisdom are needed to properly deal with that: Judgement and relative value. Judgement: male is not better than female, female not better than male. Relative value: Take the size of people. Men tend to be taller than women. But some women are taller than some men. So, it is not in 100% true. Or take sexual desire (for which testosterone is the major fuel). The man, having a much higher level of testosterone, will have more sexual desire than his female partner. But that stands not 100% of the time, and not in 100% of the couples.

The very first moment of difference takes place at conception when the genotypic sex is settled. The karyotype (with chromosomal constitution XX or XY) harbours the genetic information for the next step. There is no sexual dimorphism in the first 6 weeks of development or in the primordial gonads. The next important step is the development of gonadal sex. The default is female. Without interfering, the gonads, the genitals and the brain will ‘grow female’. However, in the presence of the Y chromosome, the primordial gonads will develop into testes and then emit hormones that will steer the genitals and the brain in the male direction. When orchestrating this development of the genitals and the brain, the sex hormones have an organizational function, whereas in later life, after the development is complete, they have an activational function, guiding sexual and reproductive behaviour. The hormonal influence results in the phenotypic sex, defined by the primary and secondary sexual characteristics of that individual. Hormones play also an important role in the formation of a person's gender identity, but they are only part of the total picture as many rearing and environmental factors add spice to that development.

Next to the mainstream, there are many sideways in this process of sexual differentiation with changes in genotypic sex, gonadal sex, phenotypic sex and/or gender identity. Inconsistencies in the biological indicators of sex, traditionally known as intersex or intersex disorders, are nowadays called ‘disorders of sex development (DSD)’. Inconsistencies in gender identity without involvement of the genital tract usually are called ‘Gender Identity Disorder (GID)’. See Chapter 26 (gender dysphoria section).

In this chapter, we deal only with the mainstream development, starting with intrauterine development, then the period between birth and puberty and then puberty.

Intrauterine development

The four relevant anatomical structures for sexuality development are the gonads, the Wolffian system, the Müllerian system and the brain. In the first 6 weeks after conception, male and female developments are the same. Becoming female is in a way the ‘default process’. Without the Y chromosome, the development will continue towards female. Then the primordial gonads will develop into female gonads (ovaries), with atrophy of the Wolffian system and development of the Müllerian system into female internal genitalia. Intrauterine female development is independent of ovarian hormones!

The default system of becoming female happens also in the brain. The foetal brain grows very fast and especially in the period between 6 and 18 weeks of pregnancy, the layout for many important and permanent structures is settled. The ‘undisturbed’ (i.e. without testicular hormones) wiring in the brain ‘grows female’, giving a strong base for the later typical female behaviour. This process is not the result of oestrogens. Although oestrogens are abundantly present in both female and male foetuses, they are so strongly bound to alpha-foetoproteins that they cannot enter the foetal brain compartment.

What about male development? With chromosomal pattern XY, a gene on the Y chromosome (SRY or Sex determining Region of the Y chromosome) causes a complex cascade of steps, bending this process towards male development. This SRY contains the code for the production of a testis-determining protein, which in turn causes the primitive gonads to become testes.

Then, three very relevant processes deserve to be mentioned, all beginning at around 6 weeks after conception:

The Leydig cells of the testes start producing hormones. Testosterone (T) is responsible for stimulation of the Wolffian system to develop into male internal genitalia. Later in the foetal life, Dihydrotestosterone (DHT) is responsible for development of the male external genitalia, and INSL3 for the testicular descent.

The Sertoli cells of the testes start producing MIS (Müllerian Inhibiting Substance, also called AMH or anti-Müllerian Hormone), by which the Müllerian tubes are suppressed and disappear, preventing the development of female genitalia.

The foetal brain becomes bathed in these two hormones T and MIS, by which the wiring in the brain ‘grows male’.

This supposed ‘dimorphic wiring’ can be seen at a macroscopic level in some brain areas. At 26 weeks of pregnancy, the corpus callosum (connecting the left and the right side of the brain) is bigger in the female foetus. The sexual dimorphic nucleus of the preoptic area (SDN-POA) of the amygdala (responsible for sexual behaviour) is in the human male twice as big as in the female.

As the construction of human beings is not like in a factory assembly line, there is much variety in intrauterine development. We know for instance about the variety in intrauterine exposure to testosterone. This shows in later life in the 2D/4D ratio (the difference between the length of the second and that of the fourth finger). A higher 2D/4D ratio is an expression of lower intrauterine T-exposition. So, females have a higher 2D/4D ratio than males. Women with higher 2D/4D ratios have more verbal skills, whereas women with lower ratios have a better sense of spatial direction. On such basis, many relations are found with toy preference, personality characteristics, sexual orientation and cognitive profile (spatial, verbal and mathematical abilities). Males generally outperform females on math and spatial tasks, whereas women outperform males on verbal fluency and fine motor skills.

As mentioned earlier, talking sex differences is a sensitive topic. In stark contrast to the differences model stands the gender similarities hypothesis. This states that males and females are alike on most – but not all – psychological variables. With her meta-analyses of research on gender differences, Janet Hyde supported this gender similarities hypothesis with as few notable exceptions some motor behaviours and some aspects of sexuality, which show large gender differences and aggression showing a gender difference moderate in magnitude. What is the reason behind those differences? They are the result of thousands of generations of evolution. All geared to preservation of the species. After all that is what we have to do and what nature dictates us. This chapter concludes with a small hint in that direction. Several times a day, the male foetus has erections (from 26 weeks of pregnancy), preparing him for his evolutionary task of reproduction. Although not yet shown in ultrasound examination, the female foetus most probably will have the corresponding perivaginal hypercirculation, preparing her as well for her reproductive future.

From birth to puberty