1. Positive Sexuality: A Presentation to Family Medicine Physicians by Frederick “DocPete” Peterson Sexual Health Program, The Flexman Clinic, Dayton, Ohio Department of Specialty Medicine Heritage College of Osteopathic Medicine, Ohio University Health Promotion & Disease Prevention, Department of Veterans Affairs

2. Positive Sexuality Overview: Problem Statement One: The Lack of Communication Problem Statement Two: Negative Sexuality Positive News about Sexual Science Positive News about Female Sexuality Positive News Male Sexuality Sexual Satisfaction & Wellness

3. Positive Sexuality Objectives: At the conclusion of this session, participants will be able to: Identify at least two components of the definition of sexual identity Identify at least two components of the definition of sexual expression List at least two measures of sexual health & wellbeing

4. Positive Sexuality Cautions: You may blow your mind! Participants are cautioned to remember that… The empirical study of the human sexuality is relatively new and therefore is in its infancy as a science There is much more we don’t know about sexual identity, expression and function than we do know and this is especially true for female sexuality The model of the Sexual Hypercube as an explanation of sexual interaction is one among many

5. Positive Sexuality Problem Statement One The Lack of Communication The lack of communication about sex while growing up, especially the lack of positive communication, imposes a strong message that sex is not an appropriate subject for discussion and creates discomfort within people regarding most things sexual. (a condition informally referred to as “sexophrenia”)

6. Positive Sexuality Problem Statement Two Negative Sexuality Along with the lack of exposure children have to positive models of communication about sex, for many people there is a sense of sex as a necessary negative (evil) in life. Sex education in schools is less than a few decades old, and when provided is usually abstinence-based and fear-based emphasizing prevention of pregnancy & STI

7. Before Sexual Science in America Historical “whole-sale pathologizing” of women, people of color, and people with disabilities which include, but are not limited to: Eugenics Movement (Galton, Davenport, Goddard, Roosevelt) Masturbation was a disease leading to disease till mid-20 th century Forced & legalized sterilizations of people of minority status Mass institutionalization of all forms of “substandard” people Pseudo-rationale for racial segregation and “miscegenation” laws Repression of sexual rights, especially sexual expression

8. The Development of Sexual Science Scientific study of sexuality is little more than 100 years old (Iwan Bloch and Magnus Hirschfeld 1907). American’s historical focus has been on defining sexuality based on straight abled-body male WASP identity and obsessively pathologizing all “others” via social institutions of law, education, medicine and religion. - women - members of racial/ethnic minorities - members of the varied disability communities - LGBT individuals, especially men changing sex status

9. The Development of Sexual Science Three publications that permanently changed American consciousness about sexuality: Sexual Behavior of the American Male (Kinsey, 1948) Sexual Behavior of the American Female (Kinsey, 1953) Human Sexual Response (Masters & Johnson, 1966)

10. Positivity Sexuality Ms. Jorgensen is the first & best known American who underwent sexual reassignment (1952). George W. Jorgensen was an U.S. Army WWII veteran.

11. The Development of Sexual Science Sexual Health A state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. WHO, 2004

12. 1. Right to Sexual Expression. 2. The Right to privacy. 3. The right to be informed. 4. The right to access to needed sexual services such as contraceptive counseling, medical care, genetic counseling, and sex counseling. 5. The right to chose one’s marital status. 6. The right to have or not have children. 7. The right to make decisions that affect one’s life. 8. The right to develop to one’s fullest potential. Sex & Disability Project of George Washington University (Chipouras, S. et al. Who Cares? A Handbook on Sex Education & Counseling Services for Disabled People (1979). Positive Sexuality Bill of Sexual Rights

13. Relationship Bill of Rights I have the right to be treated with dignity and respect. I have a right to follow my own values and standards I have the right to say no and not feel guilty. I have the right to experience and express my feelings. I have the right to feel safe. I have the right to take time for myself. I have the right to change my mind. I have the right to ask for what I want. I have the right to ask for information. I have the right to make mistakes. I have the right to do less than I am humanly capable of doing. I have the right to be me and feel good about myself. I have the right to leave conversations with people who make me feel put down or humiliated I have the right to act only in ways that will promote my dignity and self-respect. I have the right to feel scared and say “I’m afraid”. I have the right to end the relationship. I have the right not to be responsible for others’ behavior, actions, feelings, or problems. I have the right to expect honesty from others I have the right to all of my feelings I have the right to make decisions based on my feelings, my judgments, or any reason that I choose. I have the right to change and grow. I have the right to be happy. I have the right to make friends and be myself around people. I have the right to be angry at someone I love. I have the right to both experience and let go of fear, guilt, and shame.

14. Introduction to Sexual Identity

15. Introduction to Sexual Expression

16. Introduction to the Sexual Hypercube

17. The Search for a Definition: A Review of College Textbooks Major college sexuality textbooks were reviewed (N=27) Eighteen (66 percent) did not include sexual identity in the index and did not provide a definition of sexual identity in the body of the text. Nine texts (33 percent) did have a definition of sexual identity. Peterson & Carter, 2010

18. The Search for a Definition: A Review of College Textbooks This finding was astounding as society looks to college textbooks as authoritative sources on a given topic. What we found was the majority of the textbooks did not define what is considered a core concept of sexuality (sexual identity). On the other hand, this is the state of the field as the scientific study of sexuality has just pasted its centennial.

19. Definition of Sexual Identity Sex Identity is the sense of who one is as a sexual being and is an overarching sexual health concept comprised of a person's sex orientation (male/female continuum), sexual orientation, and sex role orientation. Sexual Identity is inclusive of a person’s overall sexuality over the entire lifespan, a central part of their overall identity, and is influenced by both social-cultural and biological factors. Here’s a quick look at these three components……

20. Positive Sexuality Sex Orientation (male/female continuum sex status) – A person’s fundamental status on a male to female continuum, which is composed of eight factors, both biological and psychosocial.

21. Positive Sexuality Sexual Orientation (sexual attraction pattern) – This is a personal quality which determines to whom one’s sexual, affectionate, and/or love interests are directed.

22. Positive Sexuality Sex Role Orientation (gender role). This refers to personal qualities and responses to the role expectations that society associates with a person’s sex designation, and is manifest in a person’s gender-role attitude and gender-role behavior.

23. Introduction to Sexual Identity

24. Positive Sexuality Sex Orientation (male/female continuum sex status) A fundamental status on a male to female continuum, which is composed of eight factors, both biological and psychosocial. How is a person’s sex status designated?

25. Sex Orientation Sex Orientation (male/female continuum) How is a person’s sex status designated? Estimated Number of Typical and Variant Sexual Development Paths BiologicalPsychosocial Chromosomal Gender Identity Hormonal Sex Assigned at Birth prenatal and pubescent Anatomical Sex Raised As internal or external organs

26. Sex Orientation Estimated Number of Typical and Variant Sexual Development Paths BiologicalPsychosocial Chromosomal = 3 Gender Identity = 3 (XX, XY, or variant) (male, female, variant) Hormonal (x2) = 6 Sex Assigned at Birth = 2 (masculine, feminine, or variant (male or female - variant infants development at prenatal and pubescent) are often “reassigned”) Anatomical (x2) = 6 Sex Raised As = 3 (masculinized, feminized, or variant (male or female, or variant development of internal or external organs) “combined” development)

27. Sex Orientation (male/female continuum) How is a person’s sex status designated? Estimated Permutations of Typical and Variant Sexual Development Separated into “Biological” (5) and “Psychosocial” (3) Categories Chromosomal 3 Hormonal (Prenatal) x3 (Carry-over) 243 9 Gender Identity x3 Hormonal (Pubescent) x3 729 27 Sex Assigned at Birth x2 Anatomical (Internal) x3 1,458 81 Sex Raised As x3 Anatomical (External) x3 243 Estimated Permutations 4,374

28. Should we re-run the numbers? Estimated Number of Typical and Variant Sexual Development Paths BiologicalPsychosocial Chromosomal = 10 Gender Identity = 3 (male, female, variant) Hormonal (x2) = 6 Sex Assigned at Birth = 2 (masculine, feminine, or variant (male or female - variant infants development at prenatal and pubescent) are often “reassigned”) Anatomical (x2) = 6 Sex Raised As = 3 (masculinized, feminized, or variant (male or female, or variant development of internal or external organs) “combined” development)

29. Sex Orientation Chromosomal & Hormonal Variations Estimated prevalence of 10 most frequent sexual development variations (Estimated frequencies per every 100 live births) XO (Turner Syndrome)0.03690 XXY(Klinefelter Syndrome)0.09220 XY(Androgen Insensitivity Syndrome -AIS Full)0.00760 XY(Androgen Insensitivity Syndrome -AIS Partial)0.00076 XX(Congenital Adrenal Hyperplasia - Classic CAH)0.00779 XX(Congenital Adrenal Hyperplasia - Late Onset CAH)1.50000 XXVaginal Agenesis (females born without a vagina)0.01690 True Hermaphroditism (both ovaries & testicles)0.00120 Idiopathic Hermaphroditism0.00090 Non-XX or non-XY (except for Turner & Klinefelter)0.06390 Estimation of Frequency for All Causes1.72815 (from Fausto-Sterling, 2000) - Not Included are other combinations such as XYY (Jacobs 1:1500), Triple-X (XXX), Mosaic (XX/XXX or XY/XXY)

30. Sex Orientation (male/female continuum) How is a person’s sex status designated? Estimated Permutations of Typical and Variant Sexual Development Separated into “Biological” (5) and “Psychosocial” (3) Categories Chromosomal 10 Hormonal (Prenatal) x3 (Carry-over) 810 30 Gender Identity x3 Hormonal (Pubescent) x3 2,430 90 Sex Assigned at Birth x2 Anatomical (Internal) x3 4,860 270 Sex Raised As x3 Anatomical (External) x3 810 Estimated Permutations 14,580

31. Estimated Permutations across the eight dimensions of sex orientation (male-female designation) could be a few hundred or several thousand (4,374 to 14,580). The Point: We do not know However, evidence strongly suggests sex orientation (male/female designation) naturally occurs across a continuum so it is more accurately represented as a gender mosaic, certainly not by a binary dichotomy.

32. Introduction to Sexual Identity

33. Positive Sexuality Sexual Orientation (sexual attraction pattern) – This is a personal quality which determines to whom one’s sexual, affectionate, and/or love interests are directed. Sexual orientation is the most familiar of the three components of sexual identity yet is still commonly misunderstood.

34. Sexual Orientation How does one determine and/or measure sexual orientation? It is more complicated than with whom one chooses to sleep. 1.Behavioral (choice of sexual partner) 2.Fantasy (uncensored private attraction) 3.Physiologically (the ummm factor) 4.Emotional (being in-love factor)

35. Sexual Orientation The Kinsey Scale of Heterosexuality-Homosexuality

36. A More Inclusive View Sexual Orientation Two by Two Matrix of Sexual Attraction High Attraction to Males Low Attraction to Males High Attraction bisexual attraction You could be straight if a man to Females You could be lesbian if a woman Low Attraction You could be gay if a man asexuality to Females You could be straight if a woman (Low attraction to either)

37. This is NOT your grandfather’s VA! We Serve ALL Veterans That Have Served Our Country

38. Positive Sexuality Sex Role Orientation (gender role). This refers to personal qualities and responses to the role expectations that society associates with a person’s sex designation, and is manifest in a person’s gender-role attitude and gender-role behavior.

39. Sex Role Orientation (gender role) Two x Two Matrix of Sex Role Orientation (based on the work of Dr. Sandra Ruth Lipsitz Bem)

40. Sex Role Orientation (gender role) Is self-identifying as Gender Queer a sex orientation or something different?

41. Positive Sexuality as Part of Personal Growth & Overall Health A Sexual Health Program For Women Hypoactive sexual desire disorder (HSDD) Arousal Disorders Orgasmic Disorders Dyspareunia

42. Positive Sexuality as Part of Personal Growth & Overall Health A Sexual Health Program For Men Hypoactive sexual desire disorder (HSDD) Rapid Ejaculation Erectile Dysfunction Delayed or Inhibited Orgasm Disorder Sexual Compulsivity

43. Positive Sexuality as Part of Personal Growth & Overall Health A Seven-Step Sexual Health Program for Expanding One’s Positive Sexual Self-Esteem Increased Self-Acceptance Enhanced Personal Satisfaction

44. Positive Sexuality as Part of Personal Growth & Overall Health Always Remember Rule # 1

45. Positive Sexuality as Part of Personal Growth & Overall Health Always Remember Rule # 1 Never hurt the Doctor!

46. Positive Sexuality as Part of Personal Growth & Overall Health Step # 1 Learn key tenets of Sexual Health It is important to understand the cultural & historical influences on your sexual identity as well as current sexual science

47. Positive Sexuality as Part of Personal Growth & Overall Health Step # 2 Take a Baseline Measure of your satisfaction for your personal sexual health (see list of available measures)

48. Positive Sexuality as Part of Personal Growth & Overall Health Step #3 Sexual Self-Image Exercise This is an experiential self-assessment of how well one can appreciate and celebrate the positivity of the physical body. Get NAKED in front of a mirror and look at (and feel) all parts of the body from the tip of your head to the tip of your toes noting ONLY POSITIVE ATTRIBUTES Record a list of positive attributes in order to measure one’s growth of positive self-image and acceptance.

49. Positive Sexuality Sexual Health & Sexual Identity as Part of Personal Growth Step #4 Sensual Exploration Exercise This is also an experiential exercise but instead of how well one can accept and appreciate the physical body – it is about how well one can explore the sensual capacities of the body. There is no goal or expectation of experiencing orgasm in this exercise. Get NAKED in a warm bath or warm bed, touching the skin from the tip of the head to the tip of the toes noting ONLY POSITIVE feelings and thoughts that are generated. Record the list of positive attributes to measure one’s growth of positive self-image and acceptance.

50. Positive Sexuality as Part of Personal Growth and Overall Health Step #5 Sensual Fantasy Exploration Exercise This is also an experiential exercise but it is mostly inside the mind. There is no goal or expectation of experiencing orgasm in this exercise. When and wherever one has privacy, intentionally generate fantasy stories that bring pleasure. Record list of positive sensual fantasies to measure one’s growth and capacity for personal satisfaction.

51. Positive Sexuality Sexual Health & Sexual Identity as Part of Personal Growth Step #6 Personal Pleasuring Exercise This is another experiential exercise - not about appreciating one’s physicality but rather enjoying feelings of sensual & sexual pleasure. While there is no requirement of experiencing orgasm in this exercise, there is permission to feel sexual to one’s fullest capacity – enjoying any part of the body in which these feeling are created. Get NAKED in a warm bath or warm bed, touching one’s skin in places previously noted that feel the most sensuous and sexual. Afterwards, record one’s growth of positive sensual celebration.

52. Positive Sexuality Sexual Health & Sexual Identity as Part of Personal Growth Step #7 Sharing Your Sensual Self This is the real-deal in terms of experiential sharing if and only if one choses to do so. All interpersonal interactions must follow the guidelines of consensual touch and the Relationship Bill of Rights as a guide in terms of negotiating the touching with a partner. Again - there is no requirement of experiencing orgasm in this encounter but one can feel sexual to one’s fullest capacity – enjoying any part of the body in which these feeling are created. Afterwards, record one’s growth of positive sensual celebration.

53. Positive Sexuality as Part of Personal Growth & Overall Health Screening Tools for Measuring Sexual Health “Am I Normal?” Ten-item Screening Tool International Index of Erectile Function (IIEF) Female Sexual Function Index (FSFI)

54. Positive Sexuality as Part of Personal Growth & Overall Health “Am I Normal?” Screening Tool Have you ever felt guilty regarding any of your own sexual behavior? How satisfied are you with your level of accurate knowledge about human sexuality? How satisfied are you with your own physical appearance (attractiveness of your body)? Did you ever have questions about your own sexual orientation? Have you questioned whether you were masculine or feminine enough? Have you ever questioned yourself about being "good enough" as a lover? Were you ever physically abused as a child or assaulted as an adult? Were you ever sexually abused as a child or sexually assault as an adult? How satisfied are you with regards to your ability to prevent yourself from engaging in sexually compulsive behaviors (sometimes referred to as “sex addiction” behaviors)?

55. Positive Sexuality as Part of Personal Growth & Overall Health Assessment Instruments for Measuring Sexual Health Family Support for Healthy Sexual Development Sexual Health and Wellness Satisfaction Scale (SHAWS) Problematic Sexual Behavior Inventory

56. Positive Sexuality as Part of Personal Growth & Overall Health Sexual Health and Wellness Satisfaction Scale (25 item self-assessment or structured interview) Measures personal satisfaction across four major domains of sexual health: Self-Satisfaction Relational Satisfaction Medical Satisfaction Sexual Identity

57. Introduction to Sexual Identity

58. Introduction to Sexual Expression

59. Introduction to Sexual Hypercube

60. Key Focus of Positive Sexuality Improved Intrapersonal Satisfaction Resolution of sexual dysfunction and effects of sexual trauma. More personal satisfaction and greater sense of health. Greater self-acceptance through less internal conflict & negative self-image. Improved Interpersonal Relations Greater sexual satisfaction with one’s partner. Promote greater understanding and acceptance of others. Less fear, prejudice, and violence toward those we perceive as different from us.

61. Personal Stories of Sexual Empowerment are featured and solicited for forthcoming The Gender Revolution & the New Sexual Health: The Sexual HyperCube, Sexophrenia, and Beyond

62. Reference Notes While specific references are provided to particular sources (listed on References slide); this work is based upon the work of many different sexologists as well as scholars who do not identify as sexologists: * Alfred Kinsey * William Masters & Virginia Johnson * John Money * Harry Benjamin * Carl Jung * John Bancroft * Eli Coleman * Sandra Lipsitz Bem * Daryl Bem * Beverly Whipple * Lisa Diamond * Judy Seifer * Gerald Weeks * Cindy Meston * Greg Herdt * Gene Able * Barry McCarthy * Brian Sykes * Lawrence Kurdek These individuals influenced the creation of the sexual identity cube, sexual expression cube and the sexual hypercube model Positive Sexuality

63. References Brown, G.R (1988). Transsexuals in the military: Flight into hypermasculinity. Archives of Sexual Behavior 17(6):527-537. Coleman, E. (2004). Promoting sexual health: A presentation to the World Health Organization, Geneva, Switzerland. Coleman, E. (2009). International Journal of Transgenderism (Volume 11, Number 1) Edwards, W. & Coleman, E. (2004). Defining sexual health: A descriptive overview. Archives of Sexual Behavior 33(3):189-195. Evans, N. J., Forney, D. S., Guido, F. M., Patton, L. D., & Renn, K. A. (2010). Student development in college: Theory, research, and practice (2nd ed.). San Francisco, CA: John Wiley & Sons, Inc. Fausto-Sterling, Anne (2000). Sexing the body: Gender Politics and the construction of sexuality. New York: Basic Books. Haffey, B., Peterson, F., Bley, J., & Glaus, K. (2007). Addressing the sexual health concerns of sexual minority clients. Found in L. Vandercreek, F. Peterson & J. Bley (Eds.), Innovations in Clinical Practice: Focus on Sexual Health. Sarasota, FL: Professional Resource Press. Peterson, F. (2007). The Complexity of Sexual Diversity: Sexual Identity Cube and Self-Awareness Exercise. Found in L. Vandercreek, F. Peterson & J. Bley (Eds.), Innovations in Clinical Practice: Focus on Sexual Health. Sarasota, FL: Professional Resource Press. Peterson, F. & Carter, R. (2010). Re-conceptualizing and Redefining Sexual Identity in Light of Intersectionality and Lifespan Transitions. Annual Convention of the Ohio Psychological Association, November, 2010.. McCammon, S., Knoz, D., & Schacht, C. (2004). Choices in Sexuality. Independence, KY: Atomic Dog Publishing. World Health Organization. (2004). Progress in Reproductive Health Research – A New Focus for WHO. Geneva. Zucker, K. & Lawrence, A. (2009): Toward Version 7 of the World Professional Association for Transgender Health’s Standards of Care, International Journal of Transgenderism (Volume 11, Number 1) Sexual Identity, Expression, & Hypercubes Dr. Fred Peterson

64. Positive Sexuality Questions? Answers? Margaritas? Contact: 937-479-0008 Docpete1000@aol.com

65. Positive Sexuality Two of the three primary components of the sexual identity are: A.Sex Orientation (male/female continuum) and sexual fantasty B. Sex Orientation (male/female continuum) and sexual orientation C. Sex role orientation and sexual behavior D. Sex role orientation and sexual orientation

66. Positive Sexuality Two of the three primary components of sexual expression are: A.Sexual fantasy and sexual behavior B. Sexual fantasy and sexual orientation C. Sex role orientation and sexual behavior D. Sex role orientation and sexual orientation