Few elements of the human experience combine physical, intellectual, and emotional aspects of human interactions as thoroughly as sexuality and all the feelings that go along with it (1). Accepted norms of sexual behavior and attitudes vary greatly within and among different cultures. Health care professionals should never be judgmental of sexual behaviors that are not harmful and occur between consenting adults, even under societal pressure to view aspects of human sexual behaviors as deviant. Generally, what is "normal" and "abnormal" cannot be defined medically. However, when sexual behavior or difficulties cause significant distress for a patient or the patient’s partner, or cause harm, treatment is warranted.
(See also Overview of Male Sexual Function and Dysfunction and Overview of Female Sexual Function and Dysfunction.)
Sex and sexual identity
Sex and sexual identity are not the same thing.
Sex is defined by the traits usually used to distinguish between males and females. Sex refers especially to the physical and biologic traits that are physically evident at birth and is often captured in the phrases "assigned male at birth" (AMAB) and "assigned female at birth" (AFAB). Between 0.02% and 0.05% of neonates have ambiguous genitalia; in some of these neonates, the ambiguous genitalia makes an initial assignment of sex problematic (2). Sex is a complex concept; for a detailed review see Sarah S. Richardson, Sex Itself: The Search for Male and Female in the Human Genome, Chicago and London: University of Chicago Press, 2013.
Sexual identity/sexual orientation is the pattern of emotional, romantic, and/or sexual attractions that people have toward others. It also refers to a person's sense of personal and social identity based on those attractions, related behaviors, and membership in a community of others with similar attractions and behaviors. There are many different sexual identities, such as heterosexual (attraction to the opposite sex), homosexual (attraction to the same sex), bisexual (attraction to both sexes), and asexual (attraction to neither sex).
Gender identity is an internal sense of being male, female, or something else, which may or may not correspond to an individual's sex assigned at birth or sex characteristics. Gender identity is largely separate from sexuality in a clinical sense (see Gender Incongruence and Gender Dysphoria).
Societal attitudes about sex and sexuality
Societal attitudes about sex and sexuality, including masturbation, homosexuality, and extramarital sex, change with time.
Masturbation
Clinicians have long recognized masturbation as a normal sexual activity throughout life (3 – 6).
Masturbation is the most common of all human sexual behaviors (7). It is also a behavior seen in many other species, including other primates, ground squirrels, and other rodents (7). About 97% of men and 80% of women have masturbated, with 33% of women and 66% of men reporting masturbation at least once in the prior 4 weeks (8).
Although masturbation is harmless, guilt created by the disapproval and punitive attitudes still held by some people may cause considerable distress and impair sexual performance. Masturbation is considered abnormal only when it inhibits partner-oriented behavior, is done in public, or is sufficiently compulsive to cause distress or dysfunction in work, social, or other settings. There are no known negative physiological outcomes from masturbation (3), but excessive masturbation leading to relationship problems, particularly in males with very frequent use of pornography as a visual stimulus, has been noted (4).
Masturbation often continues at some level even in a sexually healthy relationship. People who masturbate may have an improved sense of well-being, enhanced fertility, and achieve sexual satisfaction without disease risk (5, 6).
Homosexuality
Homosexuality has not been considered a disorder by the American Psychiatric Association for 5 decades. Like heterosexuality, homosexuality results from complex biologic and environmental factors leading to an ability to become sexually aroused by people of the same sex. And like heterosexuality, homosexuality is not a matter of choice.
A 2022 Gallup poll of Americans found that the proportion of U.S. adults who identify as gay, lesbian, bisexual, or transgender has doubled since 2012 to a total of 7.1%. The proportions of those who so identify vary substantially by age cohort: 91% of those born between 1946 and 1964 ("Baby Boomers") self-identify as "straight/heterosexual" versus 76% of those born between 1997 and 2003 ("Generation Z"). See Gallup: LGBT Identification in U.S. Ticks Up to 7.1%.
Extramarital sex
Most cultures discourage extramarital sexual activity but accept premarital or nonmarital sexual activity as normal. In the United States, most people engage in sexual activity before marriage or without marriage as part of the trend toward more sexual freedom in industrialized countries. Extramarital sex occurs frequently among married people despite social taboos and the risk of contracting and passing on sexually transmitted infections to unsuspecting spouses or sex partners.
In the United States, the proportion of adults in marital relationships has declined dramatically over the past 2 decades, with 67% of adults reporting being married in 1990 compared to 53% in 2019. These changes were accompanied by a more than doubling in those cohabitating with a romantic partner (4% to 9%) and a substantial increase in those who report not being partnered with anyone (29% to 38%). See Pew Research Center, October 2021, “Rising Share of U.S. Adults Are Living Without a Spouse or Partner.”
Developmental aspects of sexuality
Helping adolescents put sexuality and sexual identity into a healthy context is extremely important. Some adolescents struggle with the issue of sexual identity and may be afraid to reveal their sexual identity to friends or family members, particularly if they have a non-heterosexual identity. Adolescents with a non-heterosexual identity are 2 to 3 times more likely to have suicidal behavior and nonsuicidal, self-harming behaviors than their heterosexual peers (9, 10). Adolescents and their parents should be encouraged to speak openly regarding their attitudes toward sex and sexuality; parents' opinions remain an important determinant of adolescent behavior in spite of the ubiquitous influences of social media and internet sources of information on sexuality. Social media may form the basis for most information and misinformation on sexuality obtained by adolescents (11).
Children exposed to verbal and physical hostility, rejection, and cruelty may develop problems with sexual and emotional intimacy. For example, love and sexual arousal may become dissociated, so that although emotional bonds can be formed with people from the same peer group, sexual relationships can be formed only with those for whom there is no emotional intimacy, typically those who are in some way depreciated (eg, sex workers, anonymous partners, people perceived to be of a lower socioeconomic class).
Role of the health care professional
Well-informed health care professionals can offer sensitive, disciplined advice on sexuality and should not miss opportunities for helpful intervention. Behaviors that place patients at risk of sexually transmitted illnesses or sexual violence must be addressed. Clinicians should discuss sexuality with their patients so that they can identify and address sexual issues, including sexual dysfunction (see Male Sexual Function and Dysfunction and Female Sexual Function and Dysfunction), gender dysphoria, and paraphilias.
Sexuality and sexual expression are often ignored in older adults (see Intimacy and Older Adults), including those who are institutionalized, even though sexual concerns are often important in this phase of life (12). Clinicians should be cognizant of the differences between identity-based and behavior-based sexual behaviors; assumptions cannot reliably be made between some people's expressed sexual identity and those with whom they choose to have sexual interactions (13). For example, men who identify as heterosexual may also have sexual encounters with other men, while not considering their behaviors homosexual (14). This may be critically important, because behaviors considered high risk for HIV and other sexually transmitted infections are not necessarily based on sexual identity or orientation.
Health care professionals should be encouraged to participate in seminars/webinars to be up-to-date on sexuality and sexual dysfunction. If a health care professional does not have the skill set to manage certain patients, instead of providing incorrect management, clinicians should make an appropriate referral.
References
1. Dewitte M: On the interpersonal dynamics of sexuality. J Sex Marital Ther 40(3):209-232, 2014. doi:10.1080/0092623X.2012.710181
2. Witchel SF: Disorders of sex development. Best Pract Res Clin Obstet Gynaecol 48:90-1022018. doi:10.1016/j.bpobgyn.2017.11.005
3. Zimmer F, Imhoff R: Abstinence from Masturbation and Hypersexuality. Arch Sex Behav 49(4):1333-1343, 2020. doi:10.1007/s10508-019-01623-8
4. Grubbs JB, Perry SL, Wilt JA, Reid RC: Pornography Problems Due to Moral Incongruence: An Integrative Model with a Systematic Review and Meta-Analysis. Arch Sex Behav 48(2):397-415, 2019. doi:10.1007/s10508-018-1248-x
5. Coleman E: Masturbation as a Means of Achieving Sexual Health, J of Psychol & Hum Sex, 14:2-3, 5-16, 2003. doi: 10.1300/J056v14n02_02
6. Ayad BM, Horst GV, Plessis SSD: Revisiting The Relationship between The Ejaculatory Abstinence Period and Semen Characteristics. Int J Fertil Steril 11(4):238-246, 2018. doi:10.22074/ijfs.2018.5192
7. Roth L, Briken P, Fuss J: Masturbation in the Animal Kingdom [published online ahead of print, 2022 Mar 22]. J Sex Res 1-13, 2022. doi:10.1080/00224499.2022.2044446
8. Mercer CH, Tanton C, Prah P, et al: Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). Lancet 382(9907):1781-1794, 2013. doi:10.1016/S0140-6736(13)62035-8
9. Poštuvan V, Podlogar T, Zadravec Šedivy N, et al: Suicidal behaviour among sexual-minority youth: a review of the role of acceptance and support. Lancet Child Adolesc Health 3(3):190-198 2019. doi:10.1016/S2352-4642(18)30400-0
10. Taliaferro LA, Muehlenkamp JJ: Nonsuicidal Self-Injury and Suicidality Among Sexual Minority Youth: Risk Factors and Protective Connectedness Factors [published correction appears in Acad Pediatr 17(8):917, 2017]. Acad Pediatr. 17(7):715-722, 2017. doi:10.1016/j.acap.2016.11.002
11. Eleuteri S, Saladino V, Verrastro V: Identity, relationships, sexuality, and risky behaviors of adolescents in the context of social media, Sexual and Relationship Therapy, 32:3-4, 354-365, 2017. doi: 10.1080/14681994.2017.1397953
12. Srinivasan S, Glover J, Tampi RR, et al: Sexuality and the Older Adult. Curr Psychiatry Rep 21(10):97, 2019. Published 2019 Sep 14. doi:10.1007/s11920-019-1090-4
13. Poteat VP, Russell ST, Dewaele A: Sexual Health Risk Behavior Disparities Among Male and Female Adolescents Using Identity and Behavior Indicators of Sexual Orientation. Arch Sex Behav 48(4):1087-1097, 2019. doi:10.1007/s10508-017-1082-6
14. Silva, T: Bud-Sex: Constructing Normative Masculinity among Rural Straight Men That Have Sex With Men. Gender & Society, 31(1), 51–73, 2017. doi: 10.1177/0891243216679934
