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Basic manual of sexology and sexual pathology


Academic year: 2022

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High Medical Educational Establishment of Ukraine

“Ukrainian Medical Stomatological Academy”

Department of Urology, Medical Sexology with Anesthesiology and Intensive Care

Basic manual

of sexology and sexual pathology

Recommended by Public Institution “Central Methodological Cabinet of High Medical Education of the Ministry of Health of Ukraine”

as a manual for students of high medical educational institutions of III-IV levels of accreditation



УДК 616.89 – 008.442 – 054.6 : 378(07)

Recommended by Public Institution ―Central Methodological Cabinet of High Medical Education of the Ministry of Health of Ukraine‖ as a manual for students of high medical educational institutions of III-IV levels of accreditation.

Protocol № ______ from ____.____.2015

Authors of basic manual: Doctor of Medical Sciences, Professor of Department of Urology, Medical Sexology, Anesthesiology and Intensive Care of High Medical Educational Establishment of Ukraine ―Ukrainian Medical Stomatological Academy‖

E.G.Sonnyk. and Ph.D., Associated Professor Y.V.Sarychev.

Reviewed by :

- Chief Scientist of the Scientific Department of Minimally Invasive Surgery of State Scientific Institution ―Scientific and Practical Center of Preventive and Clinical Medicine‖ of the State Administration, Professor of Department of Urology of National Medical University n. O.O.Bogomolets, Doctor of Medical Sciences, Professor M.I.Boiko;

- Head of the Department of Sexology and Medical Psychology of Kharkiv Medical Academy of Postgraduate Education, Doctor of Medical Sciences, Professor E.V.Krishtal;

- Associate Professor of Department of Foreign Languages with Latin Language and Medical Terminology of High Medical Educational Establishment of Ukraine

―Ukrainian Medical Stomatological Academy‖, Ph.D., Associated Professor V.G. Kostenko.

E.G.Sonnyk, Y,V.Sarychev. Basic manual of sexology and sexual pathology (for students of high medical educational institutions), Poltava, 2015 – 156p.

The manual reviews the main theoretical and practical aspects of medical sexology and sexopathology, taking into account the current state of the problems. This manual is adapted to typical learning program, both conventional and up-to-date methods of diagnostics and therapy of sexual disorders are detailed. The separate sections of the manual highlight issues of male infertility and family planning methods according to last World Health Organization recommendations.



Preface……….. ………… 4 Lesson 1.

Development of human sexuality. Physiological characteristics of the sexual response in men and women………..….

Lesson 2

Sexual harmony and its components………..………….

Lesson 3

Analysis of sexual harmony in couples

Questions of sexological evaluation of partners …….………

Lesson 4

Sexual disharmony in couples and its classification………

Lesson 5

Female hypoactive sexual desire disorder………

Lesson 6

Female sexual arousal disorder. Female orgasm dysfunction….

Lesson 7

Sexual dysfunction in men………...


Sexual deviations. Criminal sexology………..

Lesson 9

Male infertility: etiology, diagnosis and treatment………..

Lesson 10

Family planning……….……….………..

List of used and recommended literature……….…………

Dictionary and abbreviations

of sexological and psychological terms ………...













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29 47 57 73 97 107 123 138 151




Basic manual is designed for students of high medical educational institutions under the new curriculum of the basics of sexology and sexual pathology (Kyiv, 2009). Authors report that the existing scientific and academic literature on sexology is not always and not fully meet the curriculum of the discipline that leads to certain difficulties in its study. The authors tried to take into account the specific peculiarities and problems arising in the field of study of sexology and sexual pathology among students.

Current requirements for the training of specialists of different disciplines - urologists, psychiatrists, endocrinologists, gynecologists and others require the possession of the basics of medical sexology: sexological examination of patients, multidisciplinary scientific organization of effective interaction in the diagnostics and treatment of sexological patients, deep theoretical knowledge of sexology in general. The present study guide allows future doctors to navigate between the main sections of sexology and sexual pathology.

In this paper, the general questions of human sexuality, sexual harmony of couple and the features of sexological examination are closely connected to etiology, pathogenesis and treatment of sexual dysfunction in men and women; sexual disharmony of couples and their correction and prevention are thoroughly reviewed. The principles of psychotherapy, sexological care and management of clinical patients are exposed to deontological analysis according to practice of sexologist. The guide reveals how traditional approaches relate to the theoretical and practical aspects of medical sexology.

Besides that, modern methods of diagnosis and treatment, including male infertility, are widely reported. Methods of family planning are described according to last WHO recommendations (2013). Presentation of educational material include specific aspects of sexological problems among the urologists, sexologists, psychiatrists, gynecologists and others.

Generally, the aim of this work is the formation of future doctors understanding of the opportunities, forms and methods of sexology and sexual pathology, understanding its place and role in diagnostics, treatment and rehabilitation of sexological patients.

The authors are grateful for the critics of the presented work and must take them into account in the future. We thank the reviewers for their support and valuable advice during the preparation of this work and colleagues for assistance when creating manual.




Duration of lesson: 2 academic hours.

The purpose of the activity: to familiarize students with the formation of human sexuality, with the physiological characteristics of sexual response in men and women.

Place of employment: training room, a computer room.

Equipment classes: tables, figures, videos.

Medical sexology – interdisciplinary branch of sciences that studies the causes, conditions of development and clinical manifestations of disorders of sexual health for the purpose of diagnosis, rational treatment, psychological management, effective prevention, as well as the development of mental health issues of sexuality.

Medical sexology covers a number of problems associated with normal expression of human sexuality, as well as general and specific questions of pathology.

The increase in attention of the doctors of different specialties to medical sexology is because of high importance of its problems both in terms of biomedical side of public health and in terms of social and psychological well-being of the couples.

Relatively high level of general education of population, the powerful potential of modern media have caused an increase in general and medical culture of the society, and the need for wider circulation in medical institutions, for the different questions about intimate relationships.

Years of clinical experience show that certain circumstances, on the one hand, allowed diagnosing a particular pathology of the sexual sphere in men and women in the early stages, and on the other – to identify a significant number of cases of sexual disharmony of couples which are not directly associated with sexual dysfunction of one or both partners.


Disorders of sexual function in men and women is a kind of disease that is relatively common, and the importance of which is obvious to patients.

Development and introduction of effective methods of prevention and treatment of sexual disorders in men and women is one of the most urgent tasks of modern clinical medicine.

Giving a definition of sexual health, it is believed that it consists of such constituent elements:

1) the ability to control and get enjoyment of sexual and reproductive actions in accordance with the norms of social and personal ethics;

2) freedom from fear, shame and guilt, misconceptions and other psychological factors which depress the sexual response and disturb sexual relations;

3) the absence of organic disorders, diseases that hinder the implementation of sexual and reproductive functions.

At a special meeting of WHO experts have been proposed and adopted such definition of sexual health: ―Sexual health is a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health 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. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled‖ (WHO, 2006a).

This definition describes not only regulatory mechanisms, but also the possible causal factors responsible for the harmony and disharmony of sexual life.

Until now, the development of medical sexology was carried out mainly by separate study of the etiology, pathogenesis, clinical manifestations and course of sexual disorders in men and women. At the same time, sexual function is a function of the human pair (couple), which realization is directly dependent not only on the general condition of the organism and, in particular, the functioning of the nervous and endocrine systems of men and women, but also on their mutual adaptation and emotional background.


Multiple studies that gained widespread both theoretical and practical aspects of medical sexology are dedicated to problem of sexual disorders in men and women.

Methods of diagnostics, treatment, prevention of the sexual disorders are constantly optimizing.

But still different issues of sexual health services exist. There are various opinions on the diagnostic nomenclature and classification of clinical disorders of sexual function in men and women, as well as sexual disharmony of couples.

Most of the works in the field of medical sexology are related to, as a rule, the separate disease of males or females, without taking into account the nature of the conjugation of sexual function. At the same time its usefulness, which is due to the state of health of each partner and the nature of their relationship is a very important aspect of the intimate life of the couple.

Based on this, a tendency to solve problems in the diagnostics and treatment of sexual disorders was outlined basing on the specifics of this function.

Undeniable is a need for a deep comprehensive study of the conditions of sexual disharmony occurrence, the reasons for its development and forms of expression, as well as ways and means of correction. The study of these issues is necessary to select the most reasonable approach to the construction of the differential treatment of men and women, as well as an effective correction and ways prevention of sexual disharmony. The importance of these issues is also due to their great social significance because sexual pathology, and in particular, sexual disharmony in couples, which has a significant negative effect on the mentality of the partners and leads to conflicts can become one of the most serious obstacles to the creation of a strong family relations.


Formation of sexuality is a complex process that begins in the embryonic period of ontogenesis and ends with puberty. From the first days of life the social and psychological factors affect the psychosexual development, the main ones are sexual self-consciousness, sex role behavior and sexual orientation.


State scientific and methodological center on sexual pathology developed the concept of psychosexual dysontogenesis which can properly explain the causes and conditions of its violations and to create a corresponding therapeutic and preventive measures.

Human sexual development is carried out in two directions - psychosexual and somatosexual. Psychosexual development of men and women has some features due to sex differences and polarization of male and female roles.

Modern sexology identify several stages of sexuality formation.

The prenatal period, in which the differentiation of gonads, genitalia and brain structures occurs.

Parapubert period (1-7 years), when the child is aware of sexual identity, begins to distinguish the surrounding sexes and irreversibility of sex. At this age, the curiosity towards the sexual characteristics and to genitals appears(sexual self-conscious forms).

Prepubertal period(7-13 years) is characterized by the generation of sex role study behavior installations through the game, stereotyping the state role behavior.

For adolescence (12-18 years) platonic dreams and fantasies, courtship, platonic companionship (formation of platonic libido), and then the erotic fantasies, erotic caresses and games (formation of erotic libido)are typical.

During the transitional period of sexuality (16-26 years), formation of sexual libido is typical (there are sexual fantasies, masturbation, sexual initiation, sexual excesses, etc.).

Period of mature sexuality (26-55 years) is characterized by a regular sex life, entering a period of semi-physiological rhythm.

In the involutional period (56-70 years) decreased sexual activity is seen, libido regresses to the level of erotic and platonic.

There are certain critical periods of sexual development: 6-32 weeks of intrauterine life; 2-4 years, 7-8 years, 12-15 years, 16-24 years, 51-60 years.

If the first two phases of sexual development deviations can occur under the influence of endogenous pathogenic factors (e.g., the use of hormones by mother), at


stages III-IV exogenous factors are prevalent, in particular, sociogenic (wrong education, violation of family relations) and psychogenic ones, too.

Formation of sexual identity is determined in great way by sexual differentiation of the brain in the prenatal period, and further development of the individual and micro- social environment.

For the full process of differentiation of the brain males require a certain concentration of serum androgen in fetal period and the duration of its effect, the lack of estrogens, the absence of exogenous harmful influences and, in particular, the effects of various pharmacological agents in this period.

Microsocial environment of the child in infancy is limited usually by family members, among which the leading role is played by the mother. Contact with the mother is the most important for a child between the ages of 6 months to 3 years.

During the formation of the child’s attachment to his mother adequate relationships with others is developed.

Stereotyping of sex-role behavior of children in a great manner is determined by the correct sex-role parental behavior, communication with peers and participation in a variety of games. This contributes to a masculine or feminine character traits and selection of adequate sex role behavior. It is necessary to indicate that the child’s behavior, especially sex-role, is strongly related with the formation of his/her character and personality.

Formation of psychosexual orientation in adolescents causes the selection of an object of attraction and implemented in puberty on a background of intensive functioning of the endocrine system and the active development of personality traits.

The first phase of the three stages of psychosexual formation, the development of psychological installation, includes the accumulation of information related to the understanding of the existence of sex, gender roles and features surrounding sexual behavior in the process of interpersonal communication.

The second phase (training and consolidation) of psychosexual development is characterized by the acquisition of skills in game situations, in respect of sex determination and sex role behavior.


The third stage is the realization of sexual desire; the main criterion of completion of this stages is the upgrade of skills in practice.

One of the main laws of formation of sexuality is a change in the relationship of the individual significance of biological and social factors in the process of psychosexual development. Another law is that each stage of development include some elements of the next phase of development.

Violation of early stages of psychosexual development leads to its major deformations that affect the formation of personality. At the same time, the influence of pathogenic factors in the final stage of sexuality can lead only to minor, light violations.

Individual psychosexual development is strongly influenced by social norms of behavior, family, school, children and youth groups, friends with whom children spend their free time, as well as the media (literature, television, videos, internet).

Normal somatosexual development has a certain sequence of manifestation of secondary sexual characteristics in boys and girls, which gradually reach the level of development of a mature man and a woman.


In the structure of sexual behavior important role is played both by biological, psychological and emotional components. Not only internal factors, but also the individual skills are of undoubted importance.

It is known that environmental factors playa certain influence on the process of puberty and subsequent sexual behavior. First of all, socio-economic factors are of great importance. In particular, it is noted in the last decade, when the so called phenomenon of ―acceleration‖ is often observed.

It should be noted extrareceptive stimuli have a certain effect on the sexual behavior of men and women, among them are: tactile sensation due to stimulation of the erogenous zones, certain visual, auditory and olfactory stimuli, as well as a variety of social and psychological factors, which also have influence. It should be noted that the sensory factors may be non-specific and additional components of the mechanism that


determines the sexual behavior of the individual. Complex chain of interrelated physiological processes that underlie sexual function and, in particular, ensure the implementation of intercourse, have the character of a cycle, which consists of a specific sequence of physiological stages.

There are four phases of the sexual cycle: growing excitement, plateau, orgasm and fall of nervous excitement.

Sexual cycle is accompanied by general reactions of the body: facial flushing, myotonia, tachycardia up to 110-180 beats per minute, elevation of systolic (20-80 mmHg) and diastolic blood pressure (20-40 mmHg), tachypnea (up to 60 breaths per minute), an increase in minute breathing volume up to 50 litres.

Sexual response in females. The first phase of the sexual act - a phase of increasing excitation –corresponds to psychological and physical stimulating effect, which lead to increased sexual tension and a willingness to have sex. First of all, the swelling of the labia minora and vaginal vascular congestion (in parous women) is observed. This leads to thinning of the labia majora and distancing them from the entrance to the vagina. In response to sexual stimuli Bartholini glands produce a slimy substance. The clitoris increases in size due to vascular congestion. In the vagina mucoid transudation associated with the expansion of venous plexus takes place. The inner two thirds of the vaginal canal elongate and stretch. Uterine body enlarges and pulls up and back. Mammary glands increase, the nipples tighten. These symptoms occur in 10-30 seconds after the onset of sexual stimulation and suggest the occurrence of sexual arousal.

During the plateau phase facial flushing strengthens, it spreads to other parts of the body, is accompanied by swelling of the labia minora, which become red-violet in color. The vascular congestion of the vagina increases. The body of the clitoris is pulled under the front edge of the symphysis, and then decreases to normal size. In the outer third of the vagina orgasmic cuff is forming. There is an increasing of erection of breast nipples with increasing of their venous pattern.

In the orgasmic phase there are three stages, taking into account the subjective feelings of women: the first stage begins from the feeling of fading, which is due to the


concentration of pleasant sensations that come from the clitoris and genital area. In the second stage, the irradiation of pleasurable sensations spreads throughout the body.

Third stage is characterized by a sense of contraction, muscle spasms in the entrance of the vagina and throbbing in the area of the symphysis. Enhanced muscle tension is observed throughout the body. From 5 to 8 strong orgasmic contractions of internal genitals with an interval of 0.8 seconds take place. Flushing of the skin reaches its maximum intensity.

During the final phase reverse development of described physiological changes is carried out to the original state. A feeling of satisfaction and relaxation occurs.

Sexual response in males. In the phase of increasing excitation perfusion of the corpora cavernosa increases, dilation of the glans penis and corpora cavernosa is seen.

An erection of the penis develops. A small amount of secretion belongs to paraurethral and bulbourethral glands. The scrotum reduces, shrinks, the testicles are pulled up, the tone of the muscles of the perineal area and sphincter of the bladder grows up. The facial flushing, erection of the breast nipples are observed.

In the plateau phase erection increases. Testicles swell and tighten up, increases the overall muscle tone.

During orgasm the spasm of the sphincter of the bladder happens. There comes a rhythmic contraction of m.bulbocavenosus, m. ischiocavernosus and deep transverse muscles at intervals of about 0.8 seconds. Number of contractions depends on the degree of sexual arousal. Orgasm is accompanied by ejaculation by contraction of the ejaculatory tract, epididymis and testis itself, vas deferens, seminal vesicles and prostate. The volume of the bulb of the urethra increases up to 2-3 times. In the start of ejaculation internal sphincter of the bladder closes, preventing the penetration of sperm into the bladder. Relaxation of the external sphincter of the bladder promotes entry of sperm into the stretching bulb and then to urethra. As a result of contraction of the muscles of the perineum and sphincter of urethra ejaculate is expelled from the area of the prostate urethra to the penile urethra, and 2-3 contractions eject the semen out.

In the final phase flushing of the skin disappears, heart rate, breathing, blood pressure normalizes, erection of the penis disappears.


G.S.Vasil’chenko proposed such division of stages of copulative cycle, that was based on the natural sequence to include all functional elements that provide physiological response during the sexual cycle.

He identified four components of copulative cycle:

1. Neurohumoral component is associated with the influence of deep brain structures and endocrine glands. It provides libido and accordingly all the excitability of the nervous system that regulate sexual activity;

2. Mental component is associated with the activity of the cerebral cortex, determines the direction of sexual desire, facilitates an erection until introitus and provides specific manifestations of human sexual activity, in particular, compliance with the specific conditions of behavioral and ethical requirements;

3. Erection component represents the final executive that provides the mechanical side of sexual intercourse; anatomical and physiological substrate are the spinal centers of erection and corresponding extraspinal areas of the nervous system, as well as the penis;

4. Ejaculatory component is based on the integration of structural elements of the prostate with its own nervous apparatus to paracentral areas of the cerebral cortex. This component ensures the execution of the main task of biological sexual activity - production of the male impregnates the beginning.

Unlike of male and female sexuality. Human sexual function has a wide range of individual characteristics. It is prone to the influence of both biological and social and psychological factors. In this regard, unlike of sexuality in men and women should be considered based on their anatomical and physiological and psychological characteristics, as well as the impact on sexual function of ambient conditions.

In the consideration of female sexuality we have to take into account the changing social conditions - smoothing of differences in education, attitudes, interests, needs of modern men and women. It is necessary to mark the equal rights of women, their independence in economic terms, increased demands to their partners, the induction of a positive attitude toward sexuality, reliable modern means of preventing pregnancy,


absence of rigid social restrictions, failure of ―double standards‖. All this factors change the psychosexuality of women towards the reduce of characterized features of their sexual behavior, which are determined by the influence of the moral values of society and the rules of public morality.

In females, there is a close relationship of sexual desire with higher values, with the spiritual life, with personality. This may explain the instability of her sexual needs and psychosexual satisfaction. The presence of the love to her partner is a prerequisite for the development of sexuality in women. In males, the lack of love, too, can have a negative impact on sexual satisfaction, but to a lesser extent than in females.

For women, the character of the man, his behavior, her relations with him, the stability of the relationship, emotion, tenderness are of great importance. Women less than men tend to create extramarital affairs, although this difference tends to smooth out. Lack of harmony feelings and relationship causes frustration in women greater than a failed sexual intercourse.

For men, a woman’s appearance, her attractiveness, charm, figure are stronger incentives than similar features for women.

Sexual fantasies in women as during foreplay such as during coitus aree poorer than in men. Women reveal less interest in pornography, the latter has significantly less stimulating effect on them than men. Masturbation in women is much rarer. Male, sexual consciousness is formed more straightforward than female one. During the formation of the conceptual stage of sexuality, there are differences in the nature of children’s games for boys and girls. Romantic stage of sexuality in women is more pronounced and prolonged. Platonic and erotic libido are more expressed in them.

Erogenous zones in women are more generalized in comparison to men. Women may experience a pleasant sensation of gentle touches to many parts of the body, while the male erogenous zones are concentrated mainly in the area of the penis. Women are more individual in their sexual reactions and manifestations. The difference in the frequency of orgasm is an important difference between the sexual life of men and women. Men, unlike women, don’t get psychosexual pleasure without orgasm.


Sexual development of boys differs by age and rate from development of girls. It is occurs 1-2 years later, but has a more rapid course. Boys aged 11-15 years undergo a period of youthful hypersexuality, which is characterized by increased sexual excitability and an increase in sex interest and erotic fantasies. The girls first express the need for psychological intimacy with men and only then erotic feelings. However, in recent decades, the differences in sexual behavior of boys and girls decreased significantly, there has been a shift towards masculine behaviors.

The increase in arousal during intercourse in women is more sketchy than men.

Regression can be influenced by exogenous factors – outside thoughts, negative interaction, discrepancy of sex role behavior of the partner, the range of acceptance and the technics of intercourse. In women, for the occurrence of orgasm, the psychological component of the copulatory cycle is a crucial factor, and neurohormonal - plays only supporting role.

Potential ability to orgasm in women is higher in comparison with men. Erogenous zones, which lead to orgasm are more diverse, while the male orgasm is often achieved only during stimulation of the penis. Some women are able to experience multiple orgasms, and, unlike men, subsequent orgasms experienced are stronger. In females, education and profession related to intellectual activity have a positive impact on the manifestation of libido and orgasm; in men, these factors have no effect. There is evidence that the libido and orgasm are more expressed in women with humanitarian education, least of all – in housewives. Women associated with physical labor, occupy an intermediate position. Also known, that anorgasmia in women is often a consequence of strict upbringing as a child.

Age sexuality. In human sexuality the are four main periods, each of which is characterized by certain sexual phenomena: puberty (wet dreams, masturbation), transitional (excesses), the period of mature sexuality (conditionally normal rhythm) and involution (decrease in sexual activity).

It should be noted the relative nature of age-related manifestations of sexuality (conditional rules), because it has a great influence by a number of endogenous and environmental factors (primarily social and psychological).



1. Please give the definition of medical sexology.

2. What are the main elements in the concept of sexual health?

3. What are the stages of formation of sexuality according to modern sexology?

4. Give a description of each stage of the formation of sexuality.

5. What are the critical periods of sexual development? What factors have the greatest impact on those periods?

6. What causes the formation of the stereotype of sex-role behavior?

7. Describe the female sexual response.

8. Describe the male sexual response.

9. Name four components of copulatory cycle. Describe the importance of each component.

10. What are the major differences in male and female sexuality? What factors influence women’s and men’s sexuality?

11. What are the main periods of human sexuality in relation to the age characteristics?



Duration of lesson: 2 academic hours.

The purpose of lessons: learn to identify sexual harmony of a couple and different aspects (components) of this harmony: the social, socio-psychological, sexual, behavioral, informational and evaluative, psychophysical, physiological.

Place of employment: training room, a computer room.

Equipment classes: tables, overheads, training literature, videos.

Sexual harmony of the couple – is a socio-psychological, psychological, sexual and behavioral and physiological sexual mutual adaptation of couple, which is characterized by a level of sexual desire and sexual activity, which corresponds to the sexual constitution and temperament of male and female, and leads to optimal summation of erotic sensations, orgasm and complete psychosexual satisfaction.

All these aspects, except for the physiological, display features of human sexuality. The need for reproduction in humans is in some way separated from the need for sexual pleasure and communication.

System analysis of sexual harmony of the above mentioned components can reveal the causes and patterns of their disorders occurrence – of sexual disharmony and, as a result, opens up the possibility of proper diagnostics and following correction.

Social, psychological and socio-psychological components of sexual harmony.

Complete equality of women in recent years, their active participation in society changed their role in the family, formed a high level of spiritual and ethical demands and the new nature of couple relations in the modern family. The stability of the couple is influenced to a great extent by internal factors, such as the mutual relationships, the feeling of love, responsibility and duty; and the external factors, such as economic dependence, legal restrictions, national traditions and public opinion, which lose their strength with the democratization of public life.


With an increase in the level of education and social change the pubertal development of both men and women is considerably accelerated, but sexual relations occur later, especially in women. This phenomenon is determined rather by public than biological factors. There has been a number of changes in family relations:

redistribution of some functions of the family to other public institutions, reducing the size of the family, the democratization of family relations, the increased importance of emotional ties between men and women and reducing the role of wealth.

The problem of marriage and family in our time, has not only lost its relevance due to the importance of specific functions of the family for society, but also attracts more interest of psychologists, sociologists, lawyers, doctors in connection with the restructuring of family relations nowadays.

Family relationships are mediated by a common activity. The family, as well as a team, has specific features – in our days it is characterized by a rigid role structure in comparison with other groups and expressed emotional interpersonal ties. There are three levels of cohesion and compatibility:

1) of characters, temperament, sociability;

2) of functionally-role expectations;

3) the highest level in the form of domain-targeted and value-orientation unity, cooperative identification and adequacy of responsibility.

Currently, mutual adaptation of the couple has increased the role of the social and psychological factors that affect on their future compatibility. Harmony of personal relationships and the correct behavior contribute to the development and establishment of harmonious sexual relations.

The strength of the conjugal union is largely determined by the number of common, often matching (identical or complementary) qualities of the individual male and female. Herewith, the dependence of sexual behavior from the individuality is still poorly understood. Therefore, the study of the problem of adaptation of couples received much attention permanently.

The strength of the family, mutual happiness is largely dependent on the personal qualities of men and women and their social development, education and the ability to


use his experience and knowledge in their everyday life. Happy couples rarely suffer from sexual disorders, particularly from anorgasmia in women. Sympathy and mutual love, in most cases, is one of the main reasons of normal sexual relations and creation of a strong couple. Love is one of the main motives for marriage. It promotes the creation of a similar lifestyle of partners and is a significant factor in the normal sexual life. The feeling of love can not be innate. Love as the need and ability of a person –is an integral part of the human psychics. Love, affection and sexual satisfaction are closely linked.

Ancient Greeks identified several types of love: ―eros‖ - love between a man and a woman which gives pleasure only if the partner uses of the object of love; ―agape‖ - love that is spiritual, not sexual, in its nature, which is directed only to the benefit of the love object; ―storge‖– love-tenderness, family love; ―philia‖ - a love-friendship.

I.M.Sechenov identified three consequent phases in the development of sexual love. The first phase - platonic love, in which ―the sexual nature is extremely poor due to the fact that, along with bright and, as a result, biased visual and auditory sensations lie uncertain, even dark sexual desires‖.

The second phase - the love-ownership in which the passion of human ―flames up even faster, brighter, because instead of dark, uncertain sexual instincts come bright, vibrant feelings of love‖.

The third phase –is a love when ―passion has faded, even in those happy occasions when both sides in line with the ideals of reality ... But love is not destroyed: through frequent repetition of the reflex, in which the mental meaning is representation of a beloved person with those, or other, or with all its qualities, this image is connected with all the movements of the loved soul, and becomes really half of it‖.

Next, I.M.Sechenov noted, that a person who has gone through all these natural phases of sexual love, would be unlikely able to feel in love for a second time.

―Repeated attraction - a sign of dissatisfaction with previous‖.

Modern psychologists describe love as deeply intimate feeling directed at another person or human community. In love, as in focus, biological and spiritual, personal and social, intimate and universal features are opposite.


Love is a high degree of emotional positive attitude that makes it stand out among the other object and places in the center of vital needs and interests of the subject;

strained, intense and relatively strong feeling of the subject, due to physiological sexual needs, manifested in social formed effort to be represented by their personal significant features in the life of another partner in such a way to arouse a mutual sense of the same intensity, tenseness and continuity.

Often the presence of specific features of character in one of the partners that cause negative attitudes can provoke the conflict between man and woman. Research in the field of character traits compatibility of the couple by N.K.Agisheva showed that in order to achieve harmony of relations, the personality traits, due to education, should be similar. Creating a harmonious relationship between man and woman becomes possible only if they have complementary features, but not the same.

Character traits can be divided depending on the attitude to people, to things, to ourselves, to the team and individuals, as well as adaptive communication properties.

Women usually provide a greater warmth of feeling, softness, propensity to home; men are the carriers of masculinity, strength, they are more stricter. Besides this, feminine character traits include passivity, lack of confidence, conformity (awareness of variability of own opinion), modesty, timidity, sentimentality, dreaming. Masculine traits are emotional restraint, autonomy, isolation, explosiveness, aggression, self- confidence.

The problem of determining the character types and their classification is extremely complicated.

Coincidence of needs that are caused by both biological and social factors is of great importance for the social and psychological adaptation of the couple. Several types of needs can be distinguished: 1) physiological (sex, food, self-preservation, the need to obtain satisfaction); 2) socio-psychological (communication, activities); 3) social (professional career, culture, education, aesthetic needs, self-assertion, the implementation of their own capabilities, talents, the need for creative activity); 4) psychological (self-confidence, independence, curiosity, self-assertion).


Harmony of sex in couples greatly depends on the nature of interpersonal relationships, which are determined by the level of social, socio-psychological and sexually-behavioral adaptation of men and women, as well as the psychological characteristics of the individual, the dominant motivation and value orientations.

In the structure of interpersonal interaction there are three interrelated components that are in some way different in the opinion of different researchers: practical, affective, gnostic (A.A.Bodalev); behavioral, affective, cognitive (Y.L.Kolomna);

regulatory, affective, informative (B.A.Lomov). Besides this, there is a variety of phenomena of interpersonal interaction: mutual understanding, reciprocal actions, relationships, interpersonal communication, compatibility. Motivation of partner’s relationship is based on the need for selective interpersonal communication.

Compatibility of partners is characterized, above all, by the maximum satisfaction to each other. Affective component of interaction is a leading factor. The relationship of cognitive and affective components become apparent in harmonizing of self- evaluations.

The need of communication is not only the social essence of humans, but also its individual characteristics. Herewith, this desire to communicate depends on the type of the nervous system and characteristical features.

After analyzing the literature on the psychological preconditions of happiness in partner’s relationships, E.V.Novikov has identified a number of characteristics of communication between men and women:

1) openness –the ability to freely discuss a variety of topics;

2) intimacy - the importance and depth of the topics that are discussed;

3) trust;

4) a high level of empathy in the couple;

5) constructivism – the ability not to win, but to find mutually acceptable solutions;

6) reflexivity –perception of these feelings and emotions, which are valuable.

One of the important features of the relationship between man and woman is empathy. There are three types of empathy: relationships, compassion and complicity.

Their presence - a prerequisite of harmonical relations between spouses.


Unconscious motives and intrapsychic adaptation of the couple often play the role in the genesis of sexual disharmony. Without dwelling on the characteristics of psychological defense mechanisms (denial, retreat, displacement, replacement of motives, reducing the overall level of instincts, conceptualization, ―the mechanism of conditional enjoyments or desires‖, ―disease care‖ and others), we should denote only that the psychological defense –is a reaction of the individual onto traumatic impact, and it’s character is conditioned by the interaction of conscious and self-aware attitudes, personality characteristics of men and women.

When sexual harmony of the couple is exposed to disorder, following options of psychological protection of the individual are possible: (V.V.Krishtal, N.K.Agishev):

1. Deviation of social behavior (hypersocialization, hyposocialization, antisocial behavior, including alcoholism, and others);

2. Deviation of social and psychological relationships (jealousy, betrayal justification, aggression, redemptive behavior);

3. Psychological deformation: a) exacerbation of personality traits; b) disperception; c) evaluative deformation (explanatory system, underestimation, overestimation, distorted assessment of the own state).

4. Deviation of sexual behavior (expansion of the range of acceptance in prelude, frustration, masturbation, promiscuity, petting, flirt, avoidance of sexual intercourse).

5. Somatic deviation - the development of psychosomatic diseases.

6. Psychic deviation - psychogenic illness (neurosis).

Each of these variants has different forms of psychological defense. But often there are combined psychological defense variants, which depend on the personal characteristics of the partners, the experience in the individual life, interpersonal and metapersonal characteristics.

Sexually-behavioral component of sexual harmony.

Sexually-behavioral adequacy in couple is an important condition of sexual harmony. There is a range of values that correspond to the suitability of a prelude to


sexual intercourse, sexual techniques and the final period of coitus. Prelude to sexual intercourse has a stimulating and activating effect on sexual desire and a feeling of orgasm. This period is important to properly influence on the erogenous zones, rather than duration of this influence.

One of the most common causes of violation of sexually-behavioral component of sexual harmony is the mismatch of sexual motivation. Motive is the incitement to activity responding to the needs of the subject, which is the basis for the selection of actions, and determines the direction of a person’s behavior. As it known, the development of motive occurs through change and expansion of the range of activities which replaces objective reality. Motive specifies the needs and instincts, which are the source of activity.

There are following reasons: 1) primitive, which are based on satisfying the elementary selfish feelings of pleasure; 2) the motives that come out of a sense of self- preservation; 3) satisfaction of biological (instinctual) needs; 4) satisfaction of social needs.

G.S.Vasil’chenko distinguished several types of sexual motivation:

1) homeostabilizing type – sexual behavior is based on the establishment of peace and comfort in such a way, that sexual issues does not interfere with the fulfillmentof other tasks, estimated above;

2) the type of game – harmoniously combines the romantic and sexual elements in the sexual act, introduces an element of play, fantasy;

3) pattern-regulated type – establishes a certain constant standard of sexual intercourse;

4) genital type –is typical for persons with reduced intelligence, who do not see the difference between sexual desire and erection, considering the latter sufficient ―reason to act‖.

Mismatch of sexual motivation may be a cause of sexual disharmony.

Certain types of men and women can be distinguish. Some combination of these types may be the basis of sexual harmony of couples or, on the contrary, contribute to it’s disorders.


S.S.Liebig developed the following classification of psychological types of men and women:

1. Women-Mother.Usually looking for the weak, the sick, strives to take care of such a partner, to defend, ―raise‖, cheer, inspire. Weakness and misery of men can serve as a strong sexual stimuli. Even anxiety, emotional instability, whimsicality can be the part in the structure of prelude.

2. Woman-Woman. There are two versions of this type:

a) aggressive type: desire to fight with the partner, first in everyday relations and then in sexual intercourse. Such a woman prone to irony, likes to take the upper hand over the man, in the prelude expects obedience, even humiliation, some confusion;

b) passive-slave type: the ideal of such a woman –―strong man‖,she seeks to obey,

―dissolve‖ in him, in dreams she fantasizes about a man who ―has her‖; in the prelude prefer aggression, pressure, force, even to the infliction of pain.

3. Woman-Daughter. Ideal of such type of woman – a man much older in age, strongnot so much sexually, but in everyday life, experienced; in his presence tends to feel weak, ―small‖. In prelude prefers ―art‖, ―knowledge, that higher than power‖and is prone to psychological stimulant effects (voice, music, etc.).

The respective types of men:

1. Man-Father. Elderly, elegant, with great sexual experience, has a well-trained voice, tells fascinating. In prelude and caresses evaluates elements of woman’s

―impact‖, weakness, ―guessing‖ her desires, needs. Those caresses can compensate already have low sexual potential.

2. Man-Man. Can be distinguished onto two types:

a) aggressive, prone to the elements of ―violence‖, ―possession‖, shows rude, brutal, categorical, sometimes can hurt;

b) passive submissive - tends to idealize the ―strong woman‖; in her talk, clothes allocates symbols of power, authoritarism, some masculinity (sportswear, boots, big sunglasses, men’s hairstyle, etc.). Underlines its humility, dependence, seeks to fulfill the instructions, awaits for punishment from the woman.


3. Man-Son. Dependent and subordinate, sometimes mentally and physically infantile. Emphasizes to indecisiveness, can be finicky, mannered.

From the above classifications can be seen that relations of Man-Father and Woman-Daughter can be almost harmonious, due to congruence of the desired and the obtained. The same conclusion can be drawn about the relationship of Women-Mother and Man-Son, women of aggressive type and men of passive slave type. Clearly, that Man-Father and Women-Mother will not have harmony, and the relationship between men and women who belong to the passive-slave type, represent one of the extreme variants of sexual disharmony.

Informative-evaluative component of sexual harmony.

Psychological readiness for living together, a basic knowledge of the marital relationship, culture and communication of feelings, as well as the right knowledge in questions of mental hygiene of sexuality that form the informative and evaluative components of sexual harmony, are of great importance in achieving it. Violation of this component can affect not only to mental, but also to physical well-being. There is a definite correlation between the mistake awareness of mental hygiene of sexuality, misjudgment of partner’s sexual manifestations and general health. Dissatisfaction in aspects of feelings and relationships between men and women often leads to numerous complaints, the real reason of which is often hidden, consciously or unconsciously.

Total ignorance of wide information the young people about the physiology and psychology of sexual function and sexual health, on the one hand, direct or indirect iatrogenesis – on the other, act as the most common causes of sexual disharmony of couples.

Psychophysiological component of sexual harmony.

Physiological factors - temperament and sexual constitution are of equal importance in ensuring sexual harmony than the above mentioned psychological, social and other components.


Temperament can be defined as dynamic features (intensity, speed, tempo, rhythm) of mental processes and condition of the individual. Mismatch of temperaments of men and women can have a negative impact on their psychological and sexual adaptation.

The types of the nervous system by I.P.Pavlov, not only in quantity, but also on the main characteristics correspond to the four classic types of temperament. Comparing certain types by his classification with the typology of the Hippocrates - Galen, the famous Russian physiologist described them as follows:

1. Strong, balanced, movable type - sanguine. His nervous system has a great strength of the nervous processes, they are balanced and significantly mobile. Because of this those people are quickly, easily adapt to the changing conditions of life. It is characterized by high resistance to the difficulties of life.

2. A strong, balanced, inert type - phlegmatic. His nervous system is also characterized by considerable force and balance of the nervous processes, together with low mobility. Being in aspect of mobility opposite to sanguine, phlegmatic react calmly and slowly, not prone to changes in their environment; similar to the sanguine they have good resistance to strong and sustained strenuous activities.

3. Strong unbalanced type with a predominance of excitation - choleric. His nervous system is characterized, in addition to considerable force, by a predominance of excitation over inhibition. Distinguishes by more amount of vital energy, but lack of moderation, he is irascible and short-tempered.

4. Weak type - melancholic. People who belong to this type, are characterized by weakness of processes of excitation and inhibition, they have poor resistance to relatively large positive and negative incentives. Through this melancholic often are passive and inhibited. They effect of strong irritants can cause a variety of behavioral disorders.

Another property that is associated with the temporary characteristic of the nervous system, is the speed of occurrence and termination of nervous processes.

According to dynamics of neural processes, O.G.Ivanov-Smolensky identified four types of the reflex activity of the cerebral cortex:


1) labile - both positive and inhibitory conditioned connections are formed equally easily and quickly;

2) inert - both positive and inhibitory connections are created slowly;

3) excitable - positive connections are formed easily and quickly; braking, on the contrary, it is difficult and slow;

4) braking - positive connections are formed slowly; braking, on the contrary, is easy and fast.

Temperament is determined by the type of nervous system and its lability.

Therefore, when analyzing the causes of sexual disharmony doctor must keep in mind the above types and properties of higher nervous activity in men and women.

Sexual constitution - one of the most important factors that determines the sexual harmony of the couple, or, conversely, its disharmony. The latter often is the result of sexual constitution of the couple type mismatch. Because of this, the definition of sexual constitution of each of the partners is of practical importance for the diagnosis and correction of disorders of sexual harmony.

G.S.Vasil’chenko considers sexual constitution is as a set of persistent biological properties that are influenced by hereditary factors and conditions of development in the prenatal period and during early ontogenesis. Sexual constitution limits the range of individual needs at a certain level of sexual activity and causes the individual’s resistance against pathogenic factors that affect the sexual sphere.

Physiological component of sexual harmony

The influence of social and psychological factors on human sexuality can not be separated from the biological factors, as they are closely linked, and play a significant role in determining sexual relationship, defining a large variability of human sexuality.

Physiological component can be disrupted by disorders of neurohumoral, mental and nervous regulation of sexual function, as well as the pathology of the urogenital system in one or both of the partners.

Physiological state of the component is determined by the state of sexual harmony and mutual satisfaction of sexual function in men and women.



1. Give the definition the sexual harmony of the couple.

2. What are the components of sexual harmony of the couple?

3. What are the levels of compatibility and unity of the couple?

4. Describe the consequent phases of sexual love by I.M.Sechenov.

5. What is the role of communication in the harmonious relationship in the couple?

What characteristics of communication between men and women are important in this aspect?

6. Describe the options for psychological protection of the partners during sexual disharmony.

7. |Please describe sexually-behavioral component of sexual harmony.

8. Give the classification of psychological types of men and women.

9. Describe the informational and evaluational components of sexual harmony.

10. What is the importance of psycho-physiological component of sexual harmony?

Characterise types of temperament by I.P.Pavlov.

11. What are the types of the reflex activity of the cerebral cortex? What is the significance of each type in the formation of sexual harmony of the couple?

12. Give the definition of sexual constitution.

13. What features has a physiological component of sexual harmony?





Duration of lesson: 2 academic hours.

The purpose of the activity: to provide students with a systematic analysis of sexual harmony and learn to evaluate the all their components; to familiriaze the srtudents with modern questionnaires - the international index of erectile dysfunction (IIEF) and Female Sexual Function Index (FSFI) and methods of their evaluation.

Place of employment: training room, a computer room.

Equipment classes: tables, training literature, videos.

Sexual function, as already noted, is the only couple function, which is characterized by its multi-dimensional structure. Thus, the study of sexual harmony is a complicated and rather difficult task. Without proper understanding of the sexual harmony in all its aspects is impossible to study and establish the causes and circumstances of sexual disharmony. V.V.Krishtal and N.K.Agisheva had developed systematic structural analysis of sexual disharmony, which provides, depending on the level of interaction between the partners, the allocation of the following components:

social, psychological, social, sexual, behavioral, psychophysiological and physiological.

In assessing the social component allocated socio-cultural, information and evaluation component. The first of these includes the determinants of social attitudes, ideological values of the couple, the cultural level of men and women. Informative and evaluative components are related to the awareness of the couple in matters of mental hygiene sexuality.

Socio-psychological component defines a custom contact of the couple and indicates compliance in family roles, interests, value orientations.

Sexual-behavioral component of sexual harmony includes factors that determine the orientation of sexual desire and the extent of erotic games, the range of


acceptability, technics of coitus. The assessment of this component should display the status of the two constituents: psychosexual behavior and erotic component.

Psychosexual behavior is caused by social, psychological, mental and neurohumoral factors that determine sexual identity, gender role and psychosexual orientation of the couple. Erotic component is determined by the degree of compliance with sexual partner and erotic contact with the partner.

Psychophysiological components are assessed in accordance to temperament and type of sexual constitution of the couple. Physiological component covers state and mutual consistency of sexual function of men and women.

System analysis of sexual harmony consists of two stages: the first - estimation its components and assembling according to these criteria for each couple; the second - to determine the degree of violation of components, which makes it possible to clarify the role of each of them in the genesis of sexual disharmony.

To assess the condition of components and composite sexual harmony scheme the following criteria were developed.

State social component depends on the level of socio-cultural adaptation of the partners and their degree of awareness of mental hygiene sexuality.

A. criteria to evaluate the social components of sexual harmony The socio-cultural component:

1) compliance with ethical and aesthetic attitudes of the couple;

2) the presence or absence of compliance of lifeview and beliefs of the partners;

3) compliance with social attitudes;

4) compliance with the cultural level of the spouses.

Informative and evaluative component:

1) the presence or absence of a correct idea of sexual manifestations, and normal sex life;

2) knowledge of the physiological and pathological oscillations of sexuality.

B. criteria to evaluate the psychological component of sexual harmony

1) The presence of these features in one of partners that cause negative attitude of the other.


2) corresponds to each of the partners in the desired manner in the representation of another;

3) Compliance with intelligence in the couple.

C. Criteria for assessment social and psychological component of sexual harmony:

1) The presence or absence of a sense of love for each other;

2) compliance of family-role behavior of partners;

3) compliance of the dominant motivation;

4) compliance with the value orientations;

5) compliance of desires in leisure activities;

6) compliance of material and social status requests of each partner.

D. Criteria for assessment of sexually-behavioral components of sexual harmony Psychosexual development is estimated by:

1) sexual identity;

2) sexual behavior;

3) psychosexual orientation.

Erotic component - by:

1) the presence or absence of mutual adaptation in preparation for coitus,

2) both partners have mutually acceptable ways to implement sexuality and it is the one of the best enhances of the sexual arousal for each partner;

3) correspondence to the frequency and amplitude of frictions option, which provides optimal sexual feelings of the couple;

4) the presence or absence of action, optimizing the final period of coitus;

5) the ratio of sexual behavior of each of the couple expected shape (of expectations).

E. Evaluative criteria of psychophysiological component sexual harmony 1) Compliance with the temperament;

2) Matching of the type of sexual constitution.

F. Criteria to evaluate the physiological component of sexual harmony

1) compliance with the anatomical and physiological characteristics of the sexual sphere of the couple;

2) compliance with the sexual constitution of partners;


3) the presence or absence of symptoms, evidence of violations of copulative cycle in the couple.

To assess the state of the copulative cycle in men G.S.Vasil’chenko proposed the following criteria.

GENERAL 1) Libido:

- expression at the time of the survey (1st indicator SPS) - ageof awakening libido;

2) the age of the first ejaculation;

3) masturbation (if any - clinical type of masturbation);

4) changes in the level (rate) of sexual activity:

5) excesses (maximal count and the age at which took place last coitus);

6) sexual abstinence:

7) whether there has been an awakening sexuality of his partner, and if so, over what period of time after the onset of sexual activity (indirect criterion);

8) the expression of secondary sexual characteristics;

9) trohanter index (and other morphological data).

Approximation of the diagnosis from the disease to diagnosis of patient is the highest stage of diagnosis, which should display causes, conditions and trends in the development of the disease, clinical features, and also take into account the nature of the pairness of sexual function, the level of social, psychological, social, psychological, sexual and behavioral adaptation of partners and the degree of awareness of mental sexuality hygiene.

Therefore, after a survey of partners there is a strong need to formulate a couple diagnosis and a diagnostic conclusion about the couple.

Conducting a systematic structural analysis allows properly assess the option of sexual disharmony and to determine the form of sexual dysfunction for both partners, the level of mutual adaptation and the degree of awareness of mental hygiene sexuality that provides the opportunity for the most effective treatment and preventive measures.


Determining the level of social and psychological and sexual-behavioral adaptation of couple

Of significant diagnostic importance there is the determination of the level of socio-psychological adaptation of the couple and the characteristics of their interpersonal relationships. O.T.Filatov offered special tables for studying forms of compatibility and the nature of interpersonal relationships, men and women.

Forms of compatibility of couples

I. Constitutionality and biocompatibility:

a) constitutional (appearance);

b) physiological;

c) sexual.

II. Psychological compatibility:

a) characterological;

b) intelligent.

III. Social compatibility:

a) interest;

b) orientation of the individual;

c) the individual consciousness.

Axiological aspect of compatibility in couple

I. General interpersonal relationships, which are dependent on:

- human qualities;

- features sexual partnerships;

- role positions in the family;

- material support;

- social status.

II. Interpersonal relationships between men and women, who do not have children:

a) the evaluation aspect of a man’s wife as a woman;

- wife;


- hostess;

- worker;

- public figure.

b) estimated aspect of male partner:

- men;

- employee;

- public figure.

III. Interpersonal relationships of couples who have children:

a) the evaluation aspect of a man's wife as a woman;

- wife;

- hostess;

- worker;

- public figure.

b) estimated aspect wife of her husband, as the host, - men;

- employee;

- public figure.

Currently, universal questionnaires to fully assess the sexual function of men and women are created. The integral instruments for assessment sexual disfunctions of males and femal all over the world nowadays are the International Index of Erectile Function (IIEF) by R.Rosen (1997) and Female Sexual Function Index (FSFI) by R.Rosen (2000).

Below the type and structure of questionnaires are shown.

The International Index of Erectile Dysfunction (IIEF)

Instructions: These questions ask about the effects your erection problems have had on your sex life, over the past 4 weeks. Please answer the following questions as honestly and clearly as possible. In answering these questions, the following definitions apply:



Sexual activity includes intercourse, caressing, foreplay and masturbation

Sexual intercourse is defined as vaginal penetration of the partner (you entered the partner)

Sexual stimulation includes situations like foreplay with a partner, looking at erotic pictures, etc.

Ejaculate is defined as the ejection of semen from the penis (or the feeling of this)

Mark ONLY one circle per question:

1. Over the past 4 weeks, how often were you able to get an erection during sexual activity?

0 No sexual activity

1 Almost always or always

2 Most times (much more than half the time) 3 Sometimes (about half the time)

4 A few times (much less than half the time) 5 Almost never or never

2. Over the past 4 weeks, when you had erections with sexual stimulation, how often were your erections hard enough for penetration?

0 No sexual stimulation 1 Almost always or always

2 Most times (much more than half the time) 3 Sometimes (about half the time)

4 A few times (much less than half the time) 5 Almost never or never

Questions 3, 4 and 5 will ask about erections you may have had during sexual intercourse.

3. Over the past 4 weeks, when you attempted sexual intercourse, how often were you able to penetrate (enter) your partner?

0 Did not attempt intercourse 1 Almost always or always

2 Most times (much more than half the time) 3 Sometimes (about half the time)

4 A few times (much less than half the time) 5 Almost never or never



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