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2 Sex and Sexual Orientation


3 Maria Manuela Peixoto

4
AU1 Sexual Orientation comparative studies were conducted, sample size of homo- 42
sexual was significantly lower compared to heterosexual 43

5 Sexual orientation can be defined as romantic, affective, and/ ones. Another concern was the definition of sexual orienta- 44

6
AU2 or sexual attraction to same sex, opposite sex, or both. When tion, where for some studies it was conceptualized based on 45

7 a person is romantic, affective and/or sexually attracted to sexual behaviors, for others based on self-identification, and 46

8 same sex they are usually named homosexual, when attracted for others defined by sexual attraction [2]. 47

9 to opposite sex they are usually classified as heterosexual, In 1973, it was proposed at an American Psychiatric 48

10 and when attracted to both sexes they are named bisexual. Association meeting that homosexuality should no longer 49

11 Sexual orientation can be addressed through self-­ constitute a mental illness. Later, in 1974, the American 50

12 identification, according to sexual behaviors or based on Psychiatric Association members vote for the depathologiza- 51

13 sexual fantasies. Commonly, a combination of these criteria tion [2]. Consequently, the concept of homosexuality has 52

14 was used to define sexual orientation. been removed from the DSM-III, but it was replaced by 53

15 Sexual orientation is clearly more complex than a dichot- “egodystonic homosexuality.” The “egodystonic homosexu- 54

16 omy between heterosexuality and homosexuality, and can be ality” was only retrieved from DSM in 1988. Therefore, 55

17 metaphorically described as the colors of a rainbow [1]. Alfred between 1973 and 1988, homosexuals who reported personal 56

18 Kinsey is a well-known sex researcher, who developed the distress associated to their own sexual orientation were diag- 57

19 Kinsey Sexual Orientation Scale. Kinsey interviewed more nosed with a mental disorder. This diagnosis promotes the 58

20 than 18,000 men and women from the USA and collected discrimination against homosexuals during this decade. 59

21 information about sexual behaviors. During this work, Kinsey Homosexuality gathers closer attention from social, media, 60

22 and his team found out that individuals self-identified as het- and research fields, when compared to heterosexuality or 61

23 erosexuals, for instance, may have in their past had same-sex bisexuality. When a HIV epidemic occurred in the USA, gay 62

24 sexual activity. Therefore, Kinsey proposed a sexual orienta- men were considered a risk group for HIV and sexually trans- 63

25 tion scale from “exclusively heterosexual” to “exclusively mitted infections. Homosexuality was associated to a chronic 64

26 homosexual,” with other options in between—“predominantly illness with significant and negative impact on lifestyle. In 65

27 heterosexual, only incidentally homosexual,” “predominantly order to overcome that prejudice, epidemiologists, especially 66

28 heterosexual, but more than incidentally homosexual,” “bisex- those who work in the HIV field, since at least 1990, have 67

29 ual—equally heterosexual and homosexual,” “predominantly started to apply the concept of “men who have sex with men”. 68

30 homosexual, only incidentally heterosexual,” “predominantly The acronyms MSM—“men who have sex with men,” and 69

31 homosexual, but more than incidentally heterosexual.” later WSW—“women who have sex with women” [3]. It also 70

32 Although same-sex behavior has been reported in differ- allows conducting studies that transcend the social construc- 71

33 ent societies across time, sexual orientation concept is recent, tion of sexual orientation. Nowadays, the acronyms MSM and 72

34 being reported in medical discourse during the nineteenth WSW are widely spread in the sex research field. 73

35 century. The first reference to “homosexuality” backs to


36 1868 [2]. Nevertheless, the first studies conducted raised sev-
37 eral empirical questions regarding sample collection and Asexuality 74
38 possible outcome generalization. Homosexual samples were
39 collected in clinical contexts; therefore sample bias can be According to Bogaert [4], asexuality is the absence of sexual 75
40 described, with individuals reporting more frequently higher attraction towards men and/or women, which can be 76
41 levels of psychological symptoms. Additionally, when addressed as the “absence of a traditional sexual orientation” 77

© Springer International Publishing AG 2017


W. IsHak (ed.), The Textbook of Clinical Sexual Medicine, DOI 10.1007/978-3-319-52539-6_28
M.M. Peixoto

78 ([4], p.279). Although asexuals did not experience sexual others constitute sexual scripts [8, 9]. Culturally, individuals 127
79 attraction, they can get involved in intimate relationships and are raised in order to establish intimate and romantic rela- 128
80 experience romantic attraction [5]. In a study conducted by tionships with someone from the opposite sex, and not with 129
81 Bogaert [4], using a probability sample from the UK, the someone from the same sex. Likely, vaginal intercourse con- 130
82 main findings suggested that only 1.05% of the population stitutes the major sexual behavior during sexual intercourse, 131
83 referred that they never felt sexual attraction to anyone. while other sexual behaviors (e.g., oral sex, cuddling) are 132
84 Interestingly, according to the author, the rate was similar to characterized as preliminary sexual behaviors [8, 9]. 133
85 rates of same-sex attraction, which gathers much more
86 attention from social, political, religious, or research disci-
87 plines. Nevertheless, in the past years, asexuality has  omophobia and Internalized
H 134
88 received more attention from disciplines such as psychology
89 and sexology [6].
Homophobia 135

90 Asexuality definition raises questions regarding clinical Homophobia can be defined by hostility and explicit preju- 136
91 diagnose classifications, mainly associated to “personal dis- dice against gays and lesbians. When the concept “homopho- 137
92 tress.” Asexuals do not experience sexual aversion; however, bia” is used, we are describing a discriminatory attitude 138
93 they often feel that something is wrong with them, revealing towards gay and lesbian, which implies serious political and 139
94 personal distress. Additionally, they also tend to classify less social concerns. The concept “homophobia” may be consid- 140
95 behaviors as sexual, when compared to non-asexuals, which
ered inadequate for several reasons. First of all, the suffix 141
96 is probably due to lack of associated pleasure experienced “phobia,” in psychology and psychiatry, refers to an irratio- 142
97 [7]. Although asexuality is commonly described as lack of nal fear and a persistent avoidance. For that reason, the word 143
98 sexual attraction, the definition can also include lack of sex- “homonegativity” is preferred to “homophobia.” 144
99 ual behavior or self-identification [5]. If self-identification is Internalized homophobia is defined by negative attitudes 145
100 considered, asexuality can also be conceptualized as a sexual developed by homosexuals against themselves. It is consid- 146
101 orientation. ered a major vulnerability factor for health problems in gays 147
and lesbians. Across life span, we are exposed to a heteronor- 148
mative environment, and therefore some young gays, lesbians, 149
102 Sexual Scripts and Heterosexual Bias and bisexuals develop feelings of internalized homophobia, 150
characterized by negative attitudes towards their own sexual- 151
103 Activists and social media may be responsible for sexual ori- ity. On the other hand, internalized homophobia promotes 152
104 entation being a core theme nowadays. Several steps forward psychological distress, which impairs other life areas [2]. 153
105 have been made regarding deconstruction of myths about Internalized homophobia is conceptualized as a component 154
106 sexual orientation and sexual minorities. Concerning sexual- of minority stress, by causing psychological distress associ- 155
107 ity and sexual functioning, sex researchers struggle with a ated to being part of a minority group, which is a target to 156
108 major concern: heterosexual bias. Although research about discriminatory actions. Minority stress, according to Meyer’s 157
109 sexuality among gays, lesbians, and bisexuals has increased Model (1995), is characterized by internalized homophobia, 158
110 across the years, the heterosexual script remains. The hetero- perceived stigma and experiencing discriminatory episodes. 159
111 sexual script regulates how a sexual relationship/intercourse Nevertheless, internalized homophobia appears to be the core 160
112 should happen; when the heterosexual script is used for a factor for experiencing psychological distress among sexual 161
113 better understanding of sexuality among gays, lesbians, and minority groups [2, 10, 11]. Negative experiences associated 162
114 bisexuals, specific information and details may be lost in the to discriminatory attitudes promote psychological distress 163
115 process, forming generalizations without empiric support. and poor psychological adjustment, which may lead to 164
116 Social interactions can be described and conceptualized psychological and psychiatric disorders [11]. 165
117 according to individual beliefs regarding personal expecta- The American Psychological Association [12] established 166
118 tions [8]. Therefore, a script is learned through lifetime based some guidelines regarding concepts in order to decrease the 167
119 in modeling behaviors. If we transfer the social scripts negative bias against gays, lesbians, and bisexuals. According 168
120 knowledge to sexuality field, there is a propensity for sexual to American Psychology Association, Division 44, the words 169
121 scripts being taught from men to boys, and from women to “gay” and “lesbian” are preferable to “homosexual,” because 170
122 girls, with men learning to perform perfectly in sexual con- homosexuality has been considered a mental illness over 171
123 text, and women learning to be sexually submissive [8]. decades, and therefore the word is still negatively associated 172
124 Sexual scripts constitute universal rules about how we should to mental disorders. Additionally, “homosexual” can also be 173
125 sexually behave and how we expect others to sexually discriminatory for lesbian women once it recurrently used to 174
126 behave. Gender roles, sex roles, sexual expectations among refer to men, neglecting women [12]. 175
28  Sex and Sexual Orientation

176 Same-Sex Relationships  ex Roles in Gay and Bisexual


S 227

Men Relationships 228


177 Research on same-sex couples is still considered sparse due
178 to several reasons. A major explanation is the fact that same-­ During penetrative sexual behavior, gay and bisexual men 229
179 sex marriage is still illegal in some countries or states in the engage in sex roles labeled as insertive (“top”), receptive 230
180 USA. Therefore, when researchers aim to study same-sex (“bottom”), or versatile. Gay and bisexual men who often 231
181 relationships they have to clarify the inclusion criteria for engage in anal sex where they penetrate their partners usually 232
182 describing a same-sex couple. label themselves as “top,” gay and bisexual men who often 233
183 Despite of sexual orientation, in intimate and sexual engage in anal sex where they are penetrated by their partners 234
184 relationships, men tend to appreciate physical appear- usually label themselves as “bottom,” and gay and bisexual 235
185 ance and body image, while women value contextual and men who engage in both types of anal sex are often labeled as 236
186 intimate characteristics. Additionally, in romantic and “versatiles.” Although these labels usually refer to anal sex, 237
187 intimate relationships, affectivity, shared interests, moral they can also be used to other sexual activities, such as oral sex 238
188 and social beliefs are often treasured in an intimate part- or fisting [15]. Sex labels exist to describe and identify gay and 239
189 ner. The first longitudinal study with same-sex and oppo- bisexual men preferences during penetrative sexual behaviors. 240
190 site-sex couples in civil union was conducted by Balsam Nevertheless, social and cultural associations can be inferred. 241
191 et al. [13]. The major finding suggested that same-sex In some cases, the “top” gay or bisexual men may be consid- 242
192 couples reported better dyadic adjustment and less con- ered as more dominant, comparatively to “bottom” gay or 243
193 flict situations when compared to opposite-sex couples. bisexual men, who are considered as submissive. 244
194 For lesbian couples, sex frequency activity was a major Gender roles and stereotypes associated to masculinity 245
195 predictor of better and satisfactory relationship, while for and feminity may have a role on sex labels and sexual behav- 246
196 gay couples, the length of the relationship was a signifi- iors among gay and bisexual men. According to Carballo-­ 247
197 cant predictor of satisfactory relationships, with longer Diéguez et al. [16], versatile gay or bisexual men more likely 248
198 civil unions being associated to a decrease in dyadic engaged in a “top” sex role when they perceived their part- 249
199 adjustment [13]. ners as less aggressive, with smaller penis, less taller and 250
200 Non-monogamy is more common across same-sex rela- handsome, and with lighter skin. On the other hand, if they 251
201 tionships, particularly in gay couples. Nevertheless, non-­ perceived their partners as more aggressive, more handsome, 252
202 monogamy can be established by mutual agreement and with darker skin, or with larger penis, which is considered as 253
203 rules can be defined. According to Hoff et al. [14], the rea- more masculine, they adopt a “bottom” sex role more often 254
204 sons why gay men establish rules for non-monogamous [16]. This findings support the idea that gender stereotypes, 255
205 relationships are: building trust in their relationship, pro- masculinity and feminity, play a major role in same-sex rela- 256
206 mote honesty and protect themselves in terms of sexual tionships, specially between two men. Sex roles in same-sex 257
207 health. No significant differences have been found regard- relationships may be dependent on gender representations, 258
208 ing relationship satisfaction between monogamous and with “top” gay or bisexual men being considered more 259
209 non-­monogamous couples. masculine and “bottom” gay or bisexual men being described 260
210 Extra-dyadic relationships can occur in both same- as more feminine. The main characteristics associated to 261
211 sex and heterosexual relationships. Commonly, in het- self-­labeling are the physical appearance and penis size, with 262
212 erosexual couples, extra-dyadic relationships occur in gay and bisexual men with smaller penis more often label 263
213 secrecy. An interesting characteristic of gay couples is themselves as “bottoms,” because they believe they will not 264
214 that extra-dyadic relationships can occur with knowl- being able to satisfy their partners [15]. When looking for a 265
215 edge of both partners and with mutual agreement. partner, “top” gay or bisexual men often look for partners 266
216 Although not well empirically established, extra-dyadic with more feminine characteristics, usually associated to 267
217 relationships by mutual agreement may promote sexual “bottom” gay or bisexual men, while “bottom” gay or bisex- 268
218 and relationship satisfaction. When extra-­d yadic rela- ual men usually look for partners with characteristics often 269
219 tionships occur by mutual agreement, we no longer talk associated to “bottom” gay or bisexual men [15, 16]. 270
220 about infidelity.
221 Closed relationships may help prevent transmission of
222 sexual infections, by decreasing sexual risk behavior. So Sexual Difficulties 271
223 gay couples may agree to allow a third person to be part of
224 their sex lives. Along with the mutual agreement, protective Sexual dysfunctions have been conceptualized by interna- 272
225 sexual behaviors can be negotiated with all members at the tional classification systems according to a heterosexist per- 273
226 same time. spective, which is based on classic models of sexual response 274
M.M. Peixoto

275 (e.g., [17, 18]). Therefore, penile–vaginal penetration sexual difficulties in women, the FSFI [32] is widely used in 325
276 continues to play a major role in the definition of sexual dif- both research and clinical context [32, 33]. However, the 326
277 ficulties. Nevertheless, along with sexual dysfunctions referred introduction to the measure states that sexual intercourse is 327
278 on international classification systems, complaints as “not defined as penile penetration of the vagina, which is inade- 328
279 having a steady sexual partner” or “sexual desire discrepancy” quate for women who have sex with women [34]. Therefore, 329
280 were often referred by gay men and lesbian women as the the psychometric properties of the FSFI were assessed in a 330
281 most frequent sexual problem experienced [19–22]. Therefore, sample of 350 lesbian women, with two major adaptations: 331
282 self-perceived sexual difficulties can be distinct from the the sexual intercourse definition was removed, and the period 332
283 sexual dysfunctions referred by international classification of time was modified from 4 weeks to 6 months. The decision 333
284 systems, and should be addressed in clinical context. was mainly based on previous studies that argue that lesbian 334
couples engage less frequently in sexual activity [35, 36]. 335
Findings from the study of the psychometric properties of 336

285 Assessing Sexual Difficulties the FSFI in a lesbian women sample showed good outcomes 337
[34]. More specifically, the Cronbach’s alpha values were: 338

286 Regarding measures for assessing both male and female sex- 0.84 for satisfaction; 0.89 for sexual desire; 0.93 for sexual 339

287 ual functioning, once again a heterosexist bias can be found. arousal and orgasmic function; 0.95 for lubrication; 0.96 for 340

288 One of the most common self-reported measures for assess- sexual pain [34]. 341

289 ing male sexual difficulties is the International Index of Despite of the IIEF [23] and the FSFI [32] have been 342

290 Erectile Functioning (IIEF; [23]). The IIEF is a self-reported adapted for both men who have sex with men and women 343

291 measure with 15 items assessing five domains: erectile func- who have sex with women, respectively, further studies need 344

292 tion, orgasmic function, sexual desire, intercourse satisfac- to be conducted in order to address some of the questions 345

293 tion, and overall satisfaction [23]. The IIEF [23] is a very raised above. 346

294 reliable measure for both clinical and research context [24],
295 however it has been developed according to a heterosexual
296 perspective. Therefore, Coyne and her colleagues developed Prevalence of Male Sexual Difficulties 347
297 an adapted version of the IIEF for men who have sex with
298 men (IIEF-MSM; [25]). The IIEF-MSM included the five Although prevalence of sexual difficulties has been largely 348
299 domains assessed by the original IIEF [23], with modified studied among heterosexual men, with empirical data being 349
300 questions, mainly adapted for both receptive and insertive consistent with premature ejaculation as the most frequent 350
301 anal intercourse. According to the study conducted by Coyne complaint in heterosexual men [37–42], little is known 351
302 et al. [25], with a sample of 486 men who have sex with men, regarding prevalence of sexual difficulties among gay and 352
303 HIV-positive, Cronbach’s alpha values were: 0.82 for erec- bisexual men. 353
304 tile function; 0.83 for orgasmic function; 0.89 for sexual Empirical studies addressing prevalence of sexual diffi- 354
305 desire, 0.55 for intercourse satisfaction; and 0.42 for overall culties in gay and bisexual men are fewer compared to stud- 355
306 satisfaction. Despite of satisfaction questions, the other ies conducted worldwide with heterosexual samples. 356
307 domains assessed by the IIEF-MSM revealed overall high Additionally, instruments for assessing sexual functioning 357
308 internal consistency. Regarding satisfaction questions, the were characterized by a heterosexual bias [27], and several 358
309 authors found out that the frequency of sexual intercourse methodological limitations were addressed. Duration crite- 359
310 attempts was not associated with the other items, which can rion varies in a range from experiencing once in lifetime to 360
311 be explained by the HIV status of the sample. Additionally, experiencing during 3 months over the last year. Moreover, 361
312 sexual satisfaction with a regular sexual partner was also studies did not consider associated levels of distress. Despite 362
313 unrelated to global sexual satisfaction, possibly due to types of the methodological limitations, a few studies have focused 363
314 of sexual relationships maintained by the men in the sample on assessing prevalence of sexual problems in gay men com- 364
315 [25]. The IIEF-MSM has been recently adapted, and research munity. Findings have suggested rates between 75 and 98% 365
316 has shown good outcomes [25, 26]. However, anal sex pain of gay men experiencing at least one sexual problem across 366
317 is not assessed by the IIEF-MSM [27], and according to sev- lifetime. Lower rates were found for current sexual prob- 367
318 eral studies it constitutes a major concern among men who lems, with ranges between 42.5 and 79% [30, 43–46]. 368
319 have sex with men [28–31]. One of the first studies that attempted to assessing the 369
320 For women, the Female Sexual Functioning Index prevalence of gay men’ sexual problems found that 97.5% 370
321 (FSFI; [32]) is the most frequent tool for assessing sexual experienced at least one sexual problem across lifetime, and 371
322 functioning, constituted by 19 items evaluating sexual desire, 75% currently had at least one sexual problem [30]. If sexual 372
323 orgasmic function, sexual arousal, lubrication, sexual satisfac- dysfunctions were considered, frequencies were 92 and 52%, 373
324 tion, and sexual pain. As a reliable measure for self-reported respectively [30]. Regarding lifetime sexual problems, 61% 374
28  Sex and Sexual Orientation

375 reported receptive painful anal sex, 49% referred lack of 43.3, lack of sexual desire was experienced by 26.4 and 428
376 sexual desire, 46% experienced difficulties in keeping an 34.3%, premature ejaculation occurred in 19.3 and 30.2%, 429
377 erection, 44% had premature ejaculation, 40% experienced and sexual pain was reported by 2.2 and 5.7% as a current 430
378 difficulties in getting an erection, 39% had orgasmic difficul- and a lifetime sexual problem, respectively [46]. 431
379 ties, and 14% reported insertive painful anal sex. For current Recently, Hirshfield et al. [43] conducted a web-based 432
380 sexual problems, 19% had premature ejaculation, 16% expe- study with men who have sex with men, with 89% identify- 433
381 rienced lack of sexual desire, orgasmic difficulties, and ing themselves as gay men, 10% as bisexuals, and 1% as 434
382 receptive painful anal sex, 15% had difficulties in keeping an heterosexuals. Sexual problems were assessed by asking the 435
383 erection, and 13% in getting an erection, and 3% reported participants if they experienced a list of symptoms (low sex- 436
384 insertive painful anal sex [30]. ual desire, erectile difficulties, premature ejaculation, diffi- 437
385 According to a study conducted in Hong Kong, 49.1% of culties in reaching orgasm, sexual pain, absence of sexual 438
386 gay men experienced at least one sexual problem across 3 pleasure, and performance anxiety), at a given time, over the 439
387 months in the past year, and 36% felt extremely bothered past year. Results indicated that 57% experienced lack of 440
388 about that problem [44]. Premature ejaculation was the most sexual desire, 45% erectile difficulties, 44% performance 441
389 frequent sexual problem referred, with a range of 21.8%, fol- anxiety, 37% absence of sexual pleasure, 36% orgasmic dif- 442
390 lowed by lack of sexual desire and absence of sexual plea- ficulties, 34% premature ejaculation, and 14% sexual pain. 443
391 sure, with a range of 20%, performance anxiety, erectile Younger men who have sex with men reported more prob- 444
392 difficulties, orgasmic difficulties, with ranges of 10.9, 9.4, lems related to sexual desire, premature ejaculation, absence 445
393 and 9.1%, respectively, and sexual pain, with a range of 3.6% of sexual pleasure and sexual pain [43]. 446
394 [44]. On a web-based study conducted by the same authors, More recently, a study conducted in Portugal indicated 447
395 with men who have sex with men, findings showed that anal sex pain was the most frequent sexual difficulty in gay 448
396 42.5% experienced at least one sexual problem over 3 men, followed by lack of sexual desire, retarded and prema- 449
397 months, in the past year [45]. Findings suggested perfor- ture ejaculation, and erectile difficulties [48]. When associ- 450
398 mance anxiety as the most frequent problem (18.7%), fol- ated levels of distress were considered, anal sex pain remains 451
399 lowed by sexual pain and absence of sexual pleasure (13.8%), as the most frequent sexual complaint, followed by lack of 452
400 premature ejaculation (10.8%), lack of sexual desire (8.3%), sexual desire, retarded ejaculation, erectile difficulties, and 453
401 erectile difficulties (6.3%), and orgasmic difficulties (5.6%). premature ejaculation. Moreover, significant differences in 454
402 Overall, aging was associated to erectile difficulties and prevalence were found when levels of personal distress were 455
403 fewer sexual desire problems. Also, men aged 25–34 years considered, with gay men reporting significantly less sexual 456
404 reported more frequently sexual pain [45]. difficulties when associated distress was assessed [48]. 457
405 In a study conducted in Australia, Mao et al. [47] assessed According to a recent study conducted in Croatia, regard- 458
406 gay men’s sexual problems that occurred at least over a ing prevalence of sexual difficulties among gay and bisexual 459
407 month during the last year. Contrary to what was expected, men, findings suggested that 60.2% reported at least on sex- 460
408 aging was not associated to any sexual problem, while being ual difficulty in the previous year, and 52.3% reported at 461
409 HIV-positive was positively associated to sexual problems. least one sexual dysfunction [49]. The most frequent sexual 462
410 Regarding frequency rates, 40.0–59.0% reported lack of sex- difficulty was lack of sexual interest, followed by felling 463
411 ual desire, 38.5–51.6% experienced erectile difficulties, anxiety before having sex, erectile difficulties, premature 464
412 41.5–47.0% had performance anxiety, 25.5–31.8% revealed ejaculation, absence of sexual pleasure, and retarded ejacula- 465
413 absence of sexual pleasure, 21.8–31.3% had orgasmic diffi- tion. The sexual difficulties with more associated distress 466
414 culties, 16.6–20.7% had premature ejaculation, and 6.5–7.8% were erectile difficulties, performance anxiety and retarded 467
415 experienced sexual pain [47]. ejaculation [49]. 468
416 Previous findings suggested that current sexual problems Overall, lifetime sexual problems suggested receptive 469
417 were less frequent then lifetime sexual problems. According anal sex pain, lack of sexual desire and erectile difficulties as 470
418 to a study conducted by Seibel et al. [46], 75% of men who the most frequent sexual problems [30, 46]. For current sex- 471
419 have sex with men attending a workshop about sexual health ual problems findings were contradictory, and some studies 472
420 experienced at least one sexual problem across lifetime, suggested lack of sexual desire as the most frequent sexual 473
421 while 65.1% had at least one sexual problem currently. problem [43, 47], while others indicated premature ejacula- 474
422 Current sexual problems were defined as being experienced tion [30, 44], erectile difficulties [46], and sexual pain [45] as 475
423 recurrently and persistently over the past year, and being the most frequent sexual problem. 476
424 associated to distress and life interference. Results suggested Concerning sociodemographic predictors of sexual prob- 477
425 that erectile difficulties were experienced by 38.4% as a cur- lems in gay men, studies indicated that older gay men reported 478
426 rent sexual problem, and by 40% as a lifetime sexual prob- fewer sexual problems compared to younger men, with excep- 479
427 lem. For orgasmic difficulties percentages were 32.7 and tion for erectile difficulties [43, 47, 50]. Contrary to erectile 480
M.M. Peixoto

481 difficulties, highly reported by older gay men, sexual pain was regarding gay men were good predictors of sexual behavior 528
482 extremely common among younger gay men [45]. [60]. Consequently, a new complaint associated to painful 529
483 Premature ejaculation as a clinical condition refers to receptive anal sex, known as anodyspareunia, should be con- 530
484 latency time about ejaculation after vaginal penetration. sidered [28–31]. 531
485 Therefore, it is not possible to establish this clinical diagno- Rosser et al. [30] studied sexual problems experienced by 532
486 sis in gay men [51]. Additionally, vaginal intercourse is very gay men and found out that about 61% reported painful anal 533
487 common among heterosexual couples, while gay couples sex. Given this remarkable result, they decided to assess 534
488 reported other sexual behaviors, namely masturbation, oral severity and frequency of anal sex pain, and main results 535
489 and anal sex. Therefore, it is important to understand how suggested that 63% of gay men reported occasional pain, 536
490 this difference among sexual behavior affects the ejaculatory with mild to moderate severity, and 12% experienced persis- 537
491 function. According to Jern et al. [51], sexual orientation tent pain with extreme severity [31]. The main factors associ- 538
492 does not seem to have a significant effect on delayed or pre- ated to painful anal sex were lubrication, followed by 539
493 mature ejaculation. Moreover, a previous study has found no psychological factors such as anxiety, previous stimulation, 540
494 differences between gay men and heterosexuals regarding penis size and confidence level of sexual arousal [31]. 541
495 premature ejaculation [52]. Therefore, the authors proposed a new sexual dysfunction- 542
“anodyspareunia”—characterized by recurrent or persistent 543
sexual pain felt during receptive anal sex. More recently, 544

496 Sexual Difficulties and HIV Status Damon and Rosser [28] conducted a study where they stud- 545
ied painful anal sex using a behavioral criterion and a clinical 546

497 The treatment for HIV, including antiretroviral therapy may criterion. On one hand, the behavioral criterion was based on 547

498 be associated with increased risk of sexual dysfunction in frequency and severity of pain. On the other hand, the clini- 548

499 men [53, 54]. Additionally, HIV-positive gay men presenting cal criterion was based on: (1) if experienced sexual pain 549

500 significantly more complaints related to sexual functioning very often, (2) if experienced distress and/or interpersonal 550

501 compared to HIV-negative men [26, 47]. More specifically, difficulties due to pain and, finally, (3) if no sexual pain 551

502 HIV-positive gay men reported more complaints about lack experienced was due to an involuntary spasm of the anus 552

503 of sexual desire and erectile difficulties compared to HIV-­ muscle, lack of adequate lubrication, use of drugs/medica- 553

504 negative [54–57]. However, it is not possible to infer whether tion, or medical condition. Overall, the results indicated that 554

505 these difficulties are associated directly to the clinical condi- 14% of the sample met criteria for behavioral painful anal 555

506 tion or to other factors, including the use of condoms or sex and 10% met the clinical criteria. More specifically, 21% 556

507 regarding the fear of contracting HIV [55]. Furthermore, of the sample reported that their pain occurred across life- 557

508 clinical depression is more common in HIV-positive indi- time, and about 60% considered the pain as problematic. 558

509 viduals [54]. Therefore, other psychosocial factors should Regarding the distress associated, 25% of the sample 559

510 mediate the relationship between HIV status and sexual reported extreme levels, and 18% experienced extreme inter- 560

511 problems. HIV-positive gay men state that psychological personal difficulties. Consequences were avoidance of anal 561

512 factors and side effects from HIV treatments can promote sex for a period of time (82%) and restriction of anal sex as 562

513 sexual problems [54, 56]. the penetrating partner (49%). Participants attributed the 563
pain to psychological factors, penis size, to specific anus 564
health problems, and no use of drugs. 565

514 Sexual Difficulties and Sex Roles


515 Gay men who engage in anal sex can adopt three distinctive Prevalence of Female Sexual Difficulties 566
516 roles: “top”; “bottom”; or “versatile” [58–61]. Gay men who
517 usually penetrate their partners and engage in penetrative Across worldwide, new studies emerge concerning female 567

518 behavior are considered “top,” while gay men who frequently sexual problems, but very little is known regarding lesbian 568

519 are penetrated by their partners and engage in receptive women sexual problems. Specificities regarding lesbian wom- 569

520 behavior are labeled as “bottom.” Finally, gay men who en’s sexuality should be addressed, such as sexual behaviors, 570

521 involved in the two previous described behaviors are labeled namely tribadism (genital contact), mutual masturbation, oral 571

522 as “versatile.” “Tops” more frequently prefer engage in a sex, or finger–vaginal penetration [62]. Nevertheless, both les- 572

523 sexual relationship where they were dominant and in control, bian women and heterosexuals defined vaginal penetration as 573

524 tend to select partners that worship their bodies during sexual intercourse (Horowitz and Spicer 2013). Research 574

525 sexual intercourse, and partners with a more female body; regarding lesbian women’s sexuality is mainly focused on fre- 575

526 while “bottoms” prefer a submissive sexual relationship quency of sexual activity, sexual satisfaction, and intimacy 576

527 [58]. Also, empirical data suggested that self-sex labels [63, 64]. 577
28  Sex and Sexual Orientation

578 Regardless of lack of empirical data about sexual problems in reaching orgasm, and arousal difficulties. When the same 630
579 in lesbian women, evidence suggested that, overall, lesbian prevalence analysis was conducted with associated distress 631
580 women reported fewer sexual difficulties when compared to levels the most frequent sexual difficulty was sex pain, fol- 632
581 heterosexuals [65–67]. According to a study conducted by lowed by lack of sexual desire and difficulties in reaching 633
582 Beaber and Werner [65], lesbian women reported better lev- orgasm, and sexual arousal difficulties. Consistent with 634
583 els of sexual arousal and orgasmic function [65]. Additionally, findings among gay men, also with lesbian women sample 635
584 a negative association was found for heterosexuals regarding was found a significant decreasing in prevalence of sexual 636
585 sexual functioning and anxiety levels. No significant associa- difficulties when associated distressed levels were consid- 637
586 tion was found for lesbian women, which was explained due ered [71]. 638
587 to their good communication pattern [65]. Likewise, a previ- As lack of empirical evidence was found for sexual diffi- 639
588 ous study also suggested that lesbian women reported fewer culties in lesbian women, also a gap was found regarding the 640
589 difficulties in reaching orgasm, when compared to hetero- role of age in sexual problems. According to a web-based 641
590 sexuals [66]. Despite of methodological limitations, accord- study conducted with 456 lesbian women with 50 years or 642
591 ing to Matthews, Hughes and Tartaro [67], in a study more, findings suggested that more than 40% of the sample 643
592 assessing sexual problems with a dichotomy scale “yes or did not engage in sexual activity over the past year, while 644
593 no”, sexual dysfunction index was calculated by the presence 11% referred engage in sexual activity once a week [72]. 645
594 of two or more sexual difficulties. Findings suggested a Lesbian women in steady relationships and with a regular 646
595 lower sexual dysfunction index for lesbian women. More sexual partner reported higher sexual activity frequency. 647
596 specifically, heterosexuals had more complaints associated However, in regards to sexual satisfaction, data was hetero- 648
597 to sexual pain, while lesbian women referred more difficul- geneous. About 17% of the sample referred being very satis- 649
598 ties in reaching orgasm [67]. No significant differences were fied, 21% reported moderate satisfaction, and 18% was 650
599 found for sexual activity frequency [67, 68]. dissatisfied with their sex lives. About 45% of the women 651
600 According to Lau, Kim, and Tsui [44], in a study with considered sexual activity very important under age of 55, 652
601 women who engage in same-sex relationships, over the last while only 22% considered equally important after 55 years. 653
602 year, 75.6% reported at least one sexual problem, and about Overall, Averett et al. [72] found that older lesbian women 654
603 45% felt extremely bothered about that sexual difficulty. appreciated emotional stability over physical and sexual 655
604 Lubrication difficulties were the most frequent sexual con- intimacy. 656
605 cern (39.3%), followed by lower sexual desire (30.7%) and An interesting phenomenon found on lesbian women lit- 657
606 absence of sexual pleasure (30.3%), difficulties in reaching erature was the idea that lesbian women report significantly 658
607 orgasm (24.7%), sexual pain (23.6%), and performance anx- less frequency of sexual activity, when compared to hetero- 659
608 iety (16.9%). Also, lubrication difficulties increase with sexuals or gay men. According to van Rosmalen-Nooijens, 660
609 aging [44]. Regarding self-reported sexual problems, accord- Vergeer and Lagro-Janssen [73], data from a qualitative 661
610 ing to a study conducted by Meana, Rakipi, Weeks, and study suggested that lesbian women reported a decrease of 662
611 Lykins [69], 28% of lesbian women reported difficulties in sexual activity frequency as a common phenomenon. An 663
612 reaching orgasm, 15% experienced arousal difficulties, and emotional fusion can be conceptualized in lesbian women’ 664
613 12% referred lack of sexual desire. Findings from a web-­ relationships [22, 73]. Also, women were socially raised for 665
614 based study with women who have sex with women (74.5% being sexually passive, which can promote these lower levels 666
615 were lesbian women and 17.5% self-defined themselves as of sexual activity [73–77]. Additionally, internalized homon- 667
616 bisexuals) indicated that 24.8% of the sample scored for high egativity can also contribute for lower levels of sexual 668
617 risk for sexual dysfunction [70]. ­interaction [22]. In a patriarchal society, lesbian women had 669
618 Studies concerning the role of associated levels of distress a double discrimination [78]. 670
619 of sexual problems were also scarce with lesbian women. Lesbian couples appear to be satisfied with their relation- 671
620 Nevertheless, associated levels of distress were a crucial ships. Similarity between partners in relationship was one of 672
621 variable concerning sexual dysfunctions. According to Burri the major issues. More important than individual characteris- 673
622 et al. [64], when distress levels were controlled, 9.9% of non-­ tics, were the characteristics of the relationship, such as 674
623 heterosexual women reported lack of sexual desire, 8.4% closeness [79]. Sexual satisfaction among lesbian couples 675
624 experienced difficulties in reaching orgasm, 6.5 and 6.4% was half explained by emotional intimacy [80]. Lower sex- 676
625 referred arousal and lubrication difficulties, respectively, and ual desire in lesbian women was not necessarily associated 677
626 5.9% reported sexual pain. to sexual dissatisfaction. According to Bridges and Horne 678
627 According to a very recent study conducted with lesbian [81], dissatisfaction to sexual life exists when sexual desire 679
628 women, in Portugal, lack of sexual desire represents the most discrepancy is perceived as a problem by one of the couples’ 680
629 frequent sexual complaint, followed by sex pain, difficulties element. 681
M.M. Peixoto

682 “Lesbian Bed Death” associated to erectile difficulties. Nevertheless, gay men tend 731
to express more feelings of “I’m a sexual failure,” while het- 732

683 A controversial approach for intimate and sexual relationship erosexual men reported higher levels of performance anxiety, 733

684 among lesbians was discussed in the literature. Described as when facing erectile difficulties during sexual intercourse. 734

685 a “notorious drop-off in sexual activity about two years into During this failure sexual episodes, heterosexual men reported 735

686 long-term lesbian relationships” ([75]; p.112), “Lesbian Bed more frustration, while gay men experienced more inade- 736

687 Death” lacks scientific evidence. Even so, empirical data quacy and fear of being infected with HIV [21]. 737

688 suggest that women had less sexual desire than men ([82]; Non-erotic thoughts constitute a strong resource of cogni- 738

689 Regan and Atkins 2006), and are more submissive in sexual tive distraction, which impairs sexual functioning and satisfac- 739

690 interactions [73–76]. tion, in both men and women [93, 94]. Globally, sexual 740

691 Despite of the controversy, van Rosmalen-Nooijens et al. minorities, such as gay men and lesbian women, reported non- 741

692 [73] interviewed lesbian couples without explaining the erotic thoughts as heterosexual men and women. However, 742

693 phenomenon of “lesbian bed death”. The majority of cou- being afraid of having own sexual orientation revealed consti- 743

694 ples described spontaneously a decreased in sexual activity tute an additional source of cognitive distraction during sexual 744

695 frequency as a common phenomenon in their intimate rela- activity for sexual minorities [94]. According to the pioneer 745

696 tionship. According to this qualitative research, lesbian rela- study conducted by Lacefield and Negy [94], both gay men 746

697 tionships appear to develop to a fusional relationship, where and lesbian women reported more non-erotic distractions 747

698 intimacy is the main focus, with sexual contact being sec- during sexual intercourse, when compared to heterosexual men 748

699 ondary for relationship satisfaction. A possible explanation and women. Cognitive distractions related to body-image, 749

700 can be the social and cultural pressure women suffer for sexual performance, and IST infections were more frequent in 750

701 being sexual submissives and do not engage spontaneously the sexual minority sample. 751

702 in sexual activity. Other possible explanation is the fact that The Cognitive-Emotional Model for Sexual Dysfunction 752

703 women reported lower levels of sexual desire compared to [95] has been developed for heterosexual men and women 753

704 men [73–77]. Although little is known about “lesbian bed sexual dysfunction. According to empirical studies conducted by 754

705 death,” the combination of lower levels of sexual desire in Nobre and colleagues ([96–100]; Nobre, 2003; [95, 101–112]), 755

706 women with the searching for intimacy may help explain the individuals with sexual disorders present a personality profile 756

707 occurrence of decreased levels of sexual activity in lesbian characterized by higher levels of neuroticism and lower levels 757

708 couples. of extraversion, when compared to sexually health individuals 758


[111]. Also, acting as dispositional variables for sexual disor- 759
ders development, are sexual beliefs about sexual performance, 760
709  sychological Approaches for Sexual
P sexual satisfaction and attitudes related to sexual activity 761
710 Problems in Same-Sex Couples [95, 113]. In addition to the dispositional variables, the author 762
also described episode-­related variables, elicited by negative 763
711 Regarding psychological variables affecting sexual function- sexual events, such as cognitive schemas, automatic thoughts, 764
712 ing, both depressed mood and anxiety have been described as and emotional responses [95, 113]. 765
713 associated to a decrease in both male and female sexual func- Findings with gay men and lesbian women samples have 766
714 tioning (e.g., [83–88]). The prevalence of depressed mood suggested more similarities between heterosexual and gay 767
715 and anxiety states in sexual minority groups is increased, men, and between heterosexual and lesbian women (e.g., 768
716 when compared to heterosexual groups (e.g., [89–91]). [114, 115]). Moreover, personality profiles of gay men with 769
717 Therefore, Bancroft et al. [92] explore the relationship distressing sexual difficulties are characterized by higher 770
718 between mood (depressive and anxiety states) and sexual levels of neuroticism [116], which is consistent with previ- 771
719 functioning in gay men. Findings were consistent with previ- ous findings with heterosexual men [111]. Lesbian women 772
720 ous results with heterosexual samples. For more than half of with distressing sexual difficulties also shown a personality 773
721 the sample, both depressive and anxiety states appear to be profile characterized by higher levels of neuroticism and 774
722 associated to a decreased in sexual functioning, while a small lower levels of extraversion, when compared to sexually 775
723 percentage reported an increase in their sexual performance healthy lesbian women [116]. These findings are also consis- 776
724 when depressed or when feeling anxiety [92]. tent with data collected for heterosexual women with and 777
725 Cognitive variables have been largely introduced in sex without distressing sexual difficulties [116]. Concerning per- 778
726 therapy and sex research by D. Barlow [83]. Although most sonality traits and sexual problems, sexual orientation differ- 779
727 of the studies have been conducted with heterosexual sam- ences are mostly inexistent, and health professionals and sex 780
728 ples, more recently studies with samples of sexual minorities therapists should be aware of neuroticism traits, which are 781
729 can be found. According to a study conducted by Shires and highly and positive correlated to negative affect and negative 782
730 Miller [21], both heterosexual and gay men reported distress correlated to positive affect. 783
28  Sex and Sexual Orientation

784 Along with personality traits, dysfunctional sexual beliefs found for sexual beliefs related to conservative attitudes, and 837
785 also act as dispositional variables for the development and related to aging process or to physical appearance. Some 838
786 maintenance of sexual problems. Demanding sexual perfor- hypothesis could be draw according to these findings. It is pos- 839
787 mance and unrealistic expectations are the focus of male sible that lesbian women were not so affected by body-­image 840
788 dysfunctional sexual beliefs. A recent study conducted with concerns, such as heterosexual women, for instance. 841
789 gay and heterosexual men, with and without distressing Other vulnerability factors for the development and main- 842
790 sexual difficulties, assessed the differences between groups tenance of sexual dysfunction are cognitive schemas acti- 843
791 regarding the presence of dysfunctional sexual beliefs. The vated in sexual context, when individuals face negative 844
792 main findings indicated that gay men with distressing sexual sexual episodes [95]. According to the Cognitive-Emotional 845
793 difficulties reported more conservative beliefs about sexual- Model for Sexual Dysfunction [95, 113], incompetence 846
794 ity, and more beliefs related to partner’s sexual satisfaction schemas constitute the core schema activated in sexual con- 847
795 and to sex as an abuse of “top” men’s power [114]. According text when men and women face an unsuccessful sexual epi- 848
796 to this study, gay men with distressing sexual difficulties sode. In sex research, cognitive schemas may be one of the 849
797 have more conservative attitudes towards sexuality, are more psychological variables less studied. Only a couple of stud- 850
798 concerned about partner’s sexual satisfaction, and have more ies have been found, and data is consistent for heterosexual 851
799 difficulties in dealing with sex roles during penetrative anal samples, with incompetence schemas receiving major atten- 852
800 sex. Repressive attitudes for women can be described regard- tion [102, 108, 110, 112]. So far, only one empirical study 853
801 ing dysfunctional sexual beliefs, with sexual beliefs being has been conducted regarding the role of sexual orientation 854
802 related to aging process, body-image concerns, and sexual on cognitive schemas activated in sexual context. According 855
803 performance [117]. Findings from the study conducted by to Peixoto & Nobre [115], negative cognitive schemas are 856
804 Peixoto and Nobre [114] shown that lesbian women with activated in sexual context, by gay men and lesbian women, 857
805 distressing sexual problems struggle with beliefs about sex- when facing unsuccessful sexual episodes. Moreover, for 858
806 ual desire and pleasure being considered a sin. This finding gay men with distressing sexual difficulties, the cognitive 859
807 is consistent with some previous studies suggesting that les- schemas more frequently activated in sexual context, when 860
808 bian women in committed relationships have less sexual negative sexual episodes occur are difference/loneliness 861
809 desire and less sexual contact [73–76]. schemas and undesirability/rejection schemas. Curiously, 862
810 Dysfunctional sexual beliefs, or sexual myths, have been although incompetence schemas were more frequent in gay 863
811 studied over three decades, with the work of Zilbergeld [118] men with distressing sexual difficulties, compared to sexu- 864
812 being considered a pioneer study. Based on clinical work ally healthy gay men, no significant statistical differences 865
813 with men facing sexual disorders, Zilbergeld [118] illus- were found [115]. Data from women revealed that lesbian 866
814 trated several sexual myths reported by men, mainly related women with distressing sexual difficulties activate more 867
815 to sexual performance demands and unrealistic expectations schemas related to incompetence, difference/loneliness, and 868
816 about sexual performance and sexual intercourse. Heiman undesirability/rejection, when compared to sexually healthy 869
817 and Lo Piccolo [117] also described sexual beliefs reported lesbian women [115], which is congruent with previous data 870
818 by women with sexual difficulties, suggesting that gender with heterosexual women [108, 110]. 871
819 roles can also be found in myths related to sexuality. Finally, during sexual activity both automatic thoughts 872
820 According to the authors, women more frequently are con- and emotional responses help to maintain sexual difficulties 873
821 cerned and have dysfunctional attitudes towards sexuality ([105–107, 120–123]; Nobre and Pinto-Gouveia 2003, 874
822 related to being submissive in sexual context and to aging 2006c). Empirical research focusing on non-erotic thoughts 875
823 process or to physical appearance [117]. Empirical research and cognitive distraction with gay men and lesbian women 876
824 about sexual beliefs with gay men or lesbian women is has been conducted [94], but assessing frequent negative 877
825 almost inexistent. Hart and Schwartz [119] described possi- automatic thoughts during sexual activity reported by hetero- 878
826 ble sexual beliefs reported by gay men with erectile disorder, sexual men and women in samples of gay men and lesbian 879
827 which have been related to sexual performance demands, to women is a very recent topic of research. According to a very 880
828 sexual scripts, and to sex roles during penetrative sexual recent published study about negative automatic thoughts 881
829 intercourse. Besides beliefs related to sex roles adopted by during sexual activity in gay men and lesbian women, the 882
830 gay men during penetrative sexual intercourse, dysfunctional main findings suggested that gay men with distressing sexual 883
831 sexual beliefs presented by gay and heterosexual men are difficulties more frequently reported, during sexual inter- 884
832 focused on sexual performance demands and unrealistic course, failure anticipation and erection concern thoughts, as 885
833 expectations. For women, only one empirical study was well as lack of erotic thoughts [124]. These results are con- 886
834 found, and findings only indicated beliefs related to sexual sistent with data from heterosexual samples ([99, 100, 102, 887
835 desire and pleasure as a sin as a common sexual belief for 105, 106]; Nobre and Pinto-Gouveia 2003). For women, data 888
836 lesbian women with sexual difficulties. No evidence was suggested that lesbian women presenting distressing sexual 889
M.M. Peixoto

890 difficulties reported more frequently thoughts related to the efficacy of psychological interventions for erectile 940
891 sexual abuse, to failure and disengagement, to partner’s lack dysfunction in gay men, according to the clinical work con- 941
892 of affection, to sexual passivity and control, and less erotic ducted by the authors, cognitive-behavioral approaches, 942
893 thoughts, when compared to sexually healthy lesbian women focusing on performance anxiety management can produce 943
894 [124]. Regarding emotional responses during sexual activity, good outcomes [119]. 944
895 previously studies suggested that heterosexual men and Empirical data supporting psychological interventions for 945
896 women with sexual dysfunction reported more negative working clinically with lesbian couples with sexual difficulties 946
897 emotions and less positive emotions [98, 100, 101, 106]. is also inexistent. Therefore, paying attention to specificities 947
898 Data from a recent study with gay men and lesbian women regarding sexual beliefs, cognitive distraction, types of rela- 948
899 partially supported these hypotheses. For lesbian women tionship and sexual behaviors is also a main concern. 949
900 with distressing sexual difficulties, a similar pattern was Although no (randomized) clinical trials assessing the effi- 950
901 found regarding emotional responses during sexual activity, cacy of psychological interventions for sexual dysfunctions 951
902 but that pattern was not found for gay men [125]. Altogether, among same-sex couples can be found, the main findings from 952
903 data suggested that during sexual activity, gay men and les- recent sex research have shown that cognitive-behavioral 953
904 bian women with distressing sexual problems tendentiously approaches may lead to good outcomes (e.g., [119]). Being 954
905 reported more negative automatic thoughts, less erotic aware of specificities on sexual behaviors, types of relation- 955
906 thoughts, and form women’s sample more negative and less ships, sex roles, or cognitive distraction will allow health pro- 956
907 positive emotions. For gay men, the thoughts content was fessionals to conduct coherent and consistent interventions 957
908 mainly related to sexual performance, which is also consis- with same-sex couples. 958
909 tent with more dispositional variables, like dysfunctional
910 sexual beliefs. For lesbian women, the thoughts content was
911 mainly the same as for heterosexual women. References 959
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