Few elements of the human experience combine physical, intellectual, and emotional aspects as thoroughly as sexuality and all the feelings that go along with it. Accepted norms of sexual behavior and attitudes vary greatly within and among different cultures. Health care practitioners should never be judgmental of sexual behaviors, even under societal pressure. 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.
Sex and gender are not the same thing.
Sex refers to a person's biologic status: male, female, or intersex.
Sexual identity refers to the sex to which a person is sexually attracted (if any).
Gender refers to a person's public, lived role as boy or girl, man or woman, or something other than these two common expressions. Gender comprises both gender identity and gender role.
Gender identity is the subjective sense of knowing to which gender one belongs; ie, whether people regard themselves as male, female, transgender, or another identifying term (eg, genderqueer, nonbinary, agender).
Gender role is the objective, public expression of gender identity and includes everything that people say and do to indicate to themselves and to others the degree to which they are the gender with which they identify.
Gender role behaviors fall on a continuum of traditional masculinity or femininity, with a growing cultural recognition that some people do not fit—nor necessarily wish to fit—into the traditional male-female dichotomy. These people may refer to themselves as genderqueer, nonbinary, or one of many other terms that have become more commonly used over the past 10 years. Moreover, definitions and categorizations of gender role may differ across societies. The term cisgender is sometimes used to refer to people whose gender identity corresponds to the sex assigned them at birth.
Western cultures are more tolerant of gender-nonconforming (tomboyish) behaviors in young girls (generally not considered a gender disorder) than effeminate or “sissy” behaviors in boys. Many boys role-play as girls or mothers, including trying on their sister’s or mother’s clothes. Usually, this behavior is part of normal development. Gender nonconformity (behavior that differs from cultural norms for a person's birth sex) in children is not considered a disorder and usually does not persist into adulthood or lead to gender dysphoria, although persistently nonconforming boys may be more likely to identify as homosexual or bisexual as adults.
Societal attitudes about sexuality, sex, and gender change with time, as has occurred with the following:
Masturbation: Once widely regarded as a perversion and a cause of mental disorders, clinicians have long recognized masturbation as a normal sexual activity throughout life. It is considered abnormal only when it inhibits partner-oriented behavior, is done in public, or is sufficiently compulsive to cause distress. About 97% of males and 80% of females masturbate. 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 often continues at some level even in a sexually healthy relationship.
Homosexuality: Homosexuality has not been considered a disorder by the American Psychiatric Association for > 4 decades. About 4 to 5% of the population identify themselves as exclusively homosexual for their entire lives; an additional 2 to 5% identify themselves as bisexual. 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.
Promiscuity: Frequent sexual activity with many partners, often involving anonymous or one-time-only encounters, may indicate a diminished capacity for emotional intimacy. However, promiscuity is not in itself a psychosexual disorder. Casual sex is common in Western cultures, although the fear of AIDS, herpes simplex infections, and other sexually transmitted diseases has resulted in a decrease.
Extramarital sex: Most cultures discourage extramarital sexual activity but accept premarital or nonmarital sexual activity as normal. In the US, most people engage in sexual activity before marriage or without marriage as part of the trend toward more sexual freedom in developed 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.
Gender identity: Gender identity is the subjective sense of knowing to which gender one belongs. There is growing cultural recognition that some people do not fit—nor necessarily wish to fit—into the traditional male-female dichotomy.
Accepted norms of sexual behavior and attitudes are influenced greatly by parents.
Relations with parents may be damaged by
Children exposed to verbal and physical hostility, rejection, and cruelty are likely to 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 social class or intellectual circle, sexual relationships can be formed only with those for whom there is no emotional intimacy, typically those who are in some way depreciated (eg, prostitutes, anonymous partners, people perceived to be of a lower class).
Some adolescents struggle with the issue of sexual identity and may be afraid to reveal their sexual identity to friends or family members. Helping adolescents put sexuality and sexual identity into a healthy context is extremely important. 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.
Well-informed health care practitioners can offer sensitive, disciplined advice on sexuality and should not miss opportunities for helpful intervention. Behaviors that place patients at risk of sexually transmitted diseases or sexual violence must be addressed. Practitioners should discuss sexuality with their patients so that they can identify and address psychosexual issues, including sexual dysfunction (see Male Sexual Function and Sexual Dysfunction in Women), gender dysphoria, and paraphilias.