— Over the past two decades, the proportion of those who identify as bisexual increased from 1.2% to 4.5%.
By Ross Pomeroy
A new study published in the Journal of Sex Research shows that bisexuality — being attracted to or engaging in sexual behavior with people of both sexes — has tripled in the U.S. over the past three decades.
Bisexuality is generally considered an invisible sexual orientation because bisexual individuals are often in monogamous relationships, so they simply appear either hetero- or homosexual.
The upward trend in bisexuality in America seems set to continue, as over 6% of 18-29 year-olds but fewer than 2% of respondents over age 40 identified as bisexual in the latest data.
A new study published in the Journal of Sex Research shows that bisexuality — being attracted to or engaging in sexual behavior with people of both sexes — has tripled in the U.S. over the past three decades.
University of Portland undergraduate student Sophia Neuweiler initiated the research for her senior thesis. She teamed up with Martin Monto, a professor of sociology specializing in gender and sexuality, to analyze data from the General Social Survey (GSS). Conducted by the National Opinion Research Center at the University of Chicago, the GSS has been used to monitor changes in social characteristics and attitudes among Americans for more than 50 years. Its biennial sample groups are designed to be representative of the demographic and socioeconomic makeup of U.S. households.
A surge in bisexuality
Neuweiler and Monto found that between 1989 and 1994, 3.1% of the 6,354 respondents reported having both male and female sex partners since age 18. Between 2012 and 2018, that rate had climbed to 9.3% among the 6,609 survey takers. Moreover, during the pandemic-affected 2021 survey year, 9.6% of respondents reported partners of both sexes as adults.
Engaging in sexual activities with members of both sexes after age 18 is not necessarily indicative of true bisexuality, however. For example, someone who identifies as gay or lesbian might have had opposite-sex partners in early adulthood before coming out later in life. Thus, the researchers checked to see if there was a corresponding increase in the proportion of Americans who actually identify as bisexual. The GSS began asking respondents about their sexual orientation in 2004. Between then and 2010, 1.2% of those surveyed identified as bisexual. By 2021, the rate had nearly quadrupled, rising to 4.5%.
“Society draws lines around sexual behavior, and these lines, though often in dispute, may move over time,” the researchers wrote. “These changing norms appear to have affected the proportion of people who identify as bisexual and likely also affected actual sexual behavior.”
Neuweiler and Monto note that the increase in bisexuality in the survey data might also stem from a rising willingness to acknowledge it. Same-sex sexual activity has been heavily stigmatized in the U.S. and around the world for the past century. Though such prejudices have lessened of late, the “global closet” is still vast. A 2019 study estimated that five out of six people around the world who identify as lesbian, gay, or bisexual keep their orientations hidden from all or most of the people in their lives.
Bisexuality generally has been considered an invisible sexual orientation because bisexual individuals are often in monogamous relationships, so they simply appear either hetero- or homosexual. Moreover, bisexuality historically has been stigmatized by both heterosexual and homosexual individuals, who have insisted that it’s impossible to be sexually attracted to both sexes. In fact, genital arousal studies show that it is.
Trending
The upward trend in bisexuality in America seems set to continue, as over 6% of 18-29 year-olds but fewer than 2% of respondents over age 40 identified as bisexual in the latest data. Increasing content on social media, podcasts, and TV shows that dispel society’s overarching heteronormativity may be a factor. The abrupt shock of the COVID pandemic may also have played a role. In an interview with the BBC, New York City-based clinical psychologist Jennifer Guttman noted that of her 65 clients, 10 to 12 re-thought their sexuality during the global “reset,” compared to just one who had done so before the pandemic.
When you hear the words “vanilla sex,” what do you think? What kinds of adjectives come to mind? If you’re like many people, you might have a generalized or inaccurate perception of what vanilla looks like: Some people assume it’s uninteresting, boring, or only practiced by people of certain age groups, but that’s far from the truth. No matter what social media or TV shows have taught you about vanilla sex, the term actually has a straightforward, useful meaning—and no, it’s not meant to shame people who aren’t particularly kinky.
The word “vanilla” is used in the kink community as a way to distinguish stereotypical sex from kinky, fetishistic, or BDSM environments, says Sarah Melancon, PhD, a sociologist, sexologist, and sexuality and relationships expert for SexToyCollective.com. Having this term is important because it helps differentiate what sex looks like to different people, she explains.
“People [who practice vanilla sex] don’t really call it vanilla sex, they’re calling it sex. They don’t need to designate it, because it’s just what sex is to them,” says Melancon. And, BTW, there’s nothing wrong with that. There are even a few benefits to vanilla sex, but more on that in a moment.
Ahead, experts share insight on what it really means to be vanilla, its benefits, and common misconceptions about this kind of sex.
Meet the Experts:
Sarah Melancon, PhD, is a sociologist, sexologist, and sexuality and relationships expert for SexToyCollective.com.
The definition of vanilla sex can be subjective, but broadly speaking, it’s anything that falls under the umbrella of “normative” sex. “Some people define it as just PIV [penis-in-vagina] intercourse, but most people would expand that to include oral sex as well,” says Gigi Engle, a sex and intimacy expert for 3Fun. “It’s your standard sex, essentially.”
Why “vanilla,” though? ” Etymologists have struggled with its origin, but despite the wrangling, most sex historians agree that the kink world circa 1970s gets the credit for using ‘vanilla’ to refer to conventional sex,” says Gloria Brame, PhD, a sex therapist, board-certified sexologist, and author of Different Loving Too: Real People, Real Lives, Real BDSM.
In the ’70s, flavors like vanilla were used because it was an easy way of explaining how everyone likes different things—not just in the bedroom, but in life. Using a food with many variations, such as ice cream, was easier for people to understand. “By the 1980s,” adds Brame, “the term took hold throughout the rapidly-growing BDSM communities and finally reached mainstream usage.” (The more you know!)
These days, “vanilla” can also refer to what someone may or may not like in the bedroom. “[It’s] sex that isn’t kinky. So if you say you have vanilla sex, what you’re saying is ‘I’m not into kink,’ and there’s nothing wrong with that,” says Engle.
What are some misconceptions about vanilla sex?
Unfortunately, there’s a lot of unnecessary judgement surrounding the idea of vanilla sex, which can result in shame. “People will be embarrassed that they’re vanilla or they’ll say it as if it’s a bad thing,” says Engle. “But vanilla is a delicious flavor! It’s fine if that’s what you want to be.”
Below are some of the most common misconceptions, debunked.
It’s boring. Can sex be boring? Absolutely, but the fact that it’s vanilla isn’t what makes it that way. “Any sex that you have repeatedly can become boring. As humans, we crave novelty… changing up the routine is helpful for that,” says Engle. In short, you don’t have to engage in wild, risky, or explosive sex to have a great sex life. You can do something as simple as trying out a new position, bringing in a toy, or even switching up where you have sex.
It’s less evolved. Some people feel like vanilla sex is barely scraping the surface of any kind of sex at all. This idea can also stem from the judgment of others, even if the person having vanilla sex is satisfied. “For some people, it is the end point. For others, [vanilla sex] is part of an evolutionary process,” says Melancon. But whether or not vanilla is one of your go-to flavors, “it’s no less evolved than anything else,” she adds.
It’s not for queer people. Because of stereotypes around queer sex and the misconception that vanilla sex is just PIV intercourse, many people assume that queer couples don’t engage in vanilla sex. But because vanilla sex is just non-kinky, it’s possible to be queer and prefer vanilla sex, says Engle. “A lot of queer people have basic, queer sex, and it might not even be inclusive of sex toys,” she explains.
It’s not pleasurable. Because a lot of people define vanilla sex as straightforward PIV intercourse, there’s a misconception that, within cis-heterosexual dynamics, vanilla sex is less pleasurable for women. But in fact, women are more likely to orgasm during sex when they receive oral, try new sex positions, and engage in deep kissing, according to a 2017 study from Archives of Sexual Behavior—all of which can be incorporated into vanilla sex (and often are).On the flip side, there’s also a widespread idea that men don’t find vanilla sex enjoyable since it might not live up to the performative standards set in porn. This isn’t true: In fact, a lot of the sex highlighted in porn could still be considered vanilla, notes Engle. “Vanilla sex doesn’t always mean passionate and loving. It can still be rough sex and be considered vanilla,” she says.
Ultimately, people of all genders can enjoy and get off from vanilla sex. “Good sex is subjective,” Engle says. “It really depends on the people who are having it and the things they like to do.”
What are the benefits of vanilla sex?
No matter what kind of sex you’re having, the most important thing is that it’s enjoyable. But, if you haven’t had a lot of vanilla sex, there are some possible benefits to giving it a try.
Just the simplicity of engaging in vanilla sex can be an approach to mindfulness in the bedroom, Melancon says. “It’s just you enjoying your ability to feel sexual sensations and enjoying an experience. So I think it can be really intimate,” she adds. “It can help us be more present and feel a different level of connection.”
It may allow people to engage their senses more, says Melancon. For example, you may be able to zone in on the sound of your partner breathing, the scent of their body, or the taste of their mouth.
If you prefer to engage in kinkier sex (which, no shame!), having some vanilla experiences can still help your sex life. “Couples who are very into kink sometimes don’t have time for everything, so it can be beneficial to keep your sexual relationship alive to also have vanilla sex involved,” says Engle. This may also be the case for those with kids or busy lifestyles.
What if my partner and I aren’t on the same page about vanilla sex?
So, one of you prefers vanilla sex and the other is kinkier—while it might seem daunting to address these differences, this is where compromise comes into play. To start, know that sexual compatibility is important. And while people are often told to stick things out when there’s an incompatibility, it’s not something you have to tolerate long-term. “Not being on the same page [sexually] is a legitimate reason to end a relationship,” says Engle. “It’s totally okay to end a relationship if it comes to that, and you can’t find a compromise.”
The good news, though, is that it’s possible to compromise in a way that leaves all parties happy and satisfied, according to Engle and Melancon. As long as there’s a good degree of overlap in sexual interests and kinks, successful compromise is possible, says Melancon. Being honest with yourself about what you do and don’t like will also help you communicate your sexual desires and boundaries better with your partner.
If you’re not sure how to explore your interests outside of the bedroom with your partner, Engle suggests finding a “yes, no, maybe” list online and taking time to go through what might be on or off the table.
You should also be mindful of when and how you bring up sexual incompatibilities with your partner. “It’s all about timing, tone, and turf,” says Engle. “You want to make sure you’re in a neutral place—not in the bedroom, not in the middle of the work day. Set time aside, sit down in the living room where it’s neutral, and come to the conversation with a really open mind.”
When it’s time to start the conversation, Engle notes that getting your partner’s consent is essential. This can sound like, for example, “Hey babe, sex is important to me and our relationship, and I really want to explore this with you. Are you in a place where you’d be open to having that conversation?” From there, you can exchange interests and work on a compromise together.
So, is there anything wrong with vanilla sex?
No, there is absolutely nothing wrong with vanilla sex. Vanilla sex can be just as rich, intimate, pleasurable, and fulfilling as any other sex. Whether you’re into kink or vanilla, it’s all of equal value, so long as consent and respect are part of the foundation.
“[In a] sex-positive world, we want to be so accepting of everyone. But in the process of that, it can make normative sex look boring or uninteresting,” says Melancon. “There are [many] ‘flavors,’ so to speak… It doesn’t mean that anyone is less than.”
Human sexuality has long been a subject of fascination and curiosity in the scientific community. Researchers from different fields have sought to understand why we are attracted to certain people and how our sexual orientation develops.
From Sigmund Freud to Judith Butler, the road to a science of sexuality is a fascinating history of ambition and culture wars, error and scientific breakthrough.
Psychoanalysts believe desire follows specific laws and follows predictable patterns, while queer theorists argue that laws have exceptions and advocate for a more creative view of sexuality.
My research proposes an information theory of desire that straddles the line these two groups by arguing we should consider the object of our desire as information.
Psychoanalysis can help us understand how this particular kind of information is stored, while queer theory can help us understand how this information is organized and re-organized internally.
Birth of psychoanalysis
Sigmund Freud, originally trained as a physician, believed in the scientific basis of sexuality. He was the first to regard sex as the subject of a serious discussion. Starting in 1902, colleagues gathered every Wednesday in his apartment to discuss the psychoanalytic practice he established.
“The source of its vitality does not lie in any hazy mixture of science and sectarianism, but in having adopted as a fundamental principle that which is the highest principle of all scientific activity. I mean honesty.”
Though Freud retained Andreas-Salomé’s loyalty until the end, he didn’t share her optimism about the uniting power of honesty and thought divisions at the heart of his movement would delegitimize it.
In France, psychoanalyst Jacques Lacan urged his colleagues to return to Freud’s methods. Consumer culture silenced similar voices in North America.
Psychotherapy lost its scientific motto — the pursuit of truth — and became a matter of pursuing happiness. Keenly aware how the big screen dumbed down Freud’s psychology, Marilyn Monroe — a serious reader of psychoanalysis — turned down starring in a movie about him out of respect.
Despite the politically correct turn away from “why gay?” to “how gay?” in post–1970s clinical research, and the anti-psychological turn in feminism known as the Freud Wars of the 1980s, the prospect of a science of sexuality almost vanished until queer theorists made its case again in the 1990s.
This disconnect between what we see and the meaning we give it is a chance for sexuality to break with habit and become unpredictable.
The challenge of our current moment
Nowadays, many regard sexuality as too complicated or too subjective to become a science. Freud’s theories are often dismissed as pseudoscience.
But this outlook is dangerous to the pursuit of science. According to Elizabeth Young–Bruehl, a queer psychoanalyst who practised in Toronto until her death in 2009, we have abandoned Freud’s depth psychology and his theory of the unconscious and promoted instead superficial psychological theories.
Homophobia and caricatures of psychoanalysis originated with our relationship to science, not Freud’s. Though he was keen on establishing a science of sexuality, he regarded that science as historical rather than experimental.
Historical sciences aim to reconstruct past events and favour the uniqueness of detail and individual cases. Experimental sciences, on the other hand, are concerned with the future and whether an event will repeat itself.
Information theory of desire
Why do individuals come out as gay or bisexual at a particular point in their lives, but not earlier? Why do some first same-sex experiences shape a queer identity while others do not?
An information theory of desire might offer insights into these questions. When queer people talk about the defining moment when they came out to themselves, it can be useful to think of self-acceptance as a kind of computing command — an input that demands a radical re-organization of someone’s information network or identity.
Life events become inputs, and sexual orientations and gender identities become information networks. Certain same-sex experiences may only result in partial changes to the information network, while others may lead to the complete re-configuring of someone’s identity.
What can we discover with a science of sexuality? Freud’s loyal friend Andreas-Salomé was right to regard honesty as the highest principle of any scientific activity. Without it, we would be dealing with incorrect inputs or information networks viewed upside down.
Pride Month is not just a celebration of sexuality — it’s also a celebration of science.
There they are, in their Chevrolet Colorado, five dudes bouncing up and down as the truck grinds through the rugged American high country. Two guys up front, three in the back. Shania Twain is blasting. The fellow in the middle is singing along. “Oh, I want to be free, yeah, to feel the way I feel. Man, I feel like a woman!”
The other guys look deeply worried. But the person in the back just keeps happily singing away, even as the dude next to him moves his leg away. Just to be on the safe side.
This commercial aired back in 2004, and even now it’s not clear to me if it’s offensive or empowering, hilarious or infuriating. Twain says she wrote “Man! I Feel Like a Woman” after working at a resort where some drag queens were performing. “That song started with the title,” she said. “Then it kind of wrote itself.”
It’s a fun tune, and I admit I kind of loved seeing that commercial. But at its heart is an issue central to our current political moment.
When someone says they feel like a woman, what exactly does that mean?
Across the country, conservatives are insisting that — and legislating as if — “feeling” like a woman, or a man, is irrelevant. What matters most, they say, is the immutable truth of biology. Missouri’s attorney general, Andrew Bailey, wants to restrict gender-affirming health care for all transgender people, including adults.A new dress code at the Texas Agriculture Department commands that employees wear clothing “in a manner consistent with their biological gender.” In Florida, a law signed by Gov. Ron DeSantis (R) keeps “biological males” from playing on the women’s sports teams in public schools.
This term, “biological males,” is everywhere now. And it’s not used only by right-wing politicians. People of good faith are also wrestling with the way trans people complicate a world they thought was binary. They’re uncertain about when, and how, sex matters, and just how biological it is. Some want to draw a bright line in areas where maleness and femaleness might matter most — in sports, or locker rooms, or prisons. Others are trying to blur lines that used to be clearer. At Wellesley College last month, for instance, a nonbinding student referendum called for the admission of trans men to a school that traditionally has been a women’s college. The president of the college, Paula Johnson, pushed back.
So what, then, is a biological male, or female? What determines this supposedly simple truth? It’s about chromosomes, right?
Well, not entirely. Because not every person with a Y chromosome is male, and not every person with a double X is female. The world is full of people with other combinations: XXY (or Klinefelter Syndrome), XXX (or Trisomy X), XXXY, and so on. There’s even something called Androgen Insensitivity Syndrome, a condition that keeps the brains of people with a Y from absorbing the information in that chromosome. Most of these people develop as female, and may not even know about their condition until puberty — or even later.
How can this be, if sex is only about a gene?
>Some people respond by saying that sex is about something else, then — ovaries, or testicles (two structures that begin their existence in the womb as the same thing).
What do we do then, with the millions of women who have had hysterectomies? Have they become men? What about women who’ve had mastectomies? Or men with gynecomastia, or enlarged breasts.
Are these people not who they think they are?
It may be that what’s in your pants is less important than what’s between your ears
In the past decade, there has been some fascinating research on the brains of transgender people. What is most remarkable about this work is not that trans women’s brains have been found to resemble those of cisgender women, or that trans men’s brains resemble those of cis men. What the research has found is that the brains of trans people are unique: neither female nor male, exactly, but something distinct.
But what does that mean, a male brain, or a female brain, or even a transgender one? It’s a fraught topic, because brains are a collection of characteristics, rather than a binary classification of either/or. There are researchers who would tell you that brains are not more gendered than, say, kidneys or lungs. Gina Rippon, in her 2019 book “The Gendered Brain,” warns against bunk science that declares brains to be male or female — it’s “neurosexism,” a fancy way of justifying the belief that women’s brains are inferior to men’s.
And yet scientists continue to study the brain in hopes of understanding whether a sense of the gendered self can, at least in part, be the result of neurology.A study described by author Francine Russo in Scientific American examined the brains of 39 prepubertal and 41 adolescent boys and girls with gender dysphoria. The experiment examined how these children responded to androstadienone, a pungent substance similar to pheromones, that is known to cause a different response in the brains of men and women. The study found that adolescent boys and girls who described themselves as trans responded like the peers of their perceived gender. (The results were less clear withprepubescent children.)
This kind of testing is important, said one of the researchers Russo quoted, “because sex differences in responding to odors cannot be influenced by training or environment.” A similar study was done in measuring the responses of trans boys and girls to echolike sounds produced in the inner ear. “Boys with gender dysphoria responded more like typical females, who have a stronger response to these sounds.”
What does it mean, to respond to the world in this way? For me, it has meant having a sense of myself as a woman, a sense that no matter how comfortable I was with the fact of being feminine, I was never at ease with not being female. When I was young, I tried to talk myself out of it, telling myself, in short, to “get over it
But I never got over it.
I compare it to a sense of homesickness for a place you’ve never been. The moment you stepped onto those supposedly unfamiliar shores, though,you’d have a sense of overwhelming gratitude, and solace, and joy. Home, you might think. I’m finally home.
The years to come will, perhaps, continue to shed light on the mysteries of the brain, and to what degree our sense of ourselves as gendered beings has its origins there. But there’s aproblem with using neurology as an argument for trans acceptance — it suggests that, on some level, there is something wrong with transgender people, that we are who we are as a result of a sickness or a biological hiccup.
But trans people are not broken. And, in fact, trying to open people’s hearts by saying “Check out my brain!” can do more harm than good, because this line of argument delegitimizes the experiences of many trans folks. It suggests that there’s only one way to be trans — to feel trapped in the wrong body, to go through transition, and to wind up, when all is said and done, on the opposite-gender pole. It suggests that the quest trans people go on can only be considered successful if it ends with fitting into the very society that rejected us in the first place.
All the science tells us, in the end, is that a biological male — or female — is not any one thing, but a collection of possibilities.
No one who embarks upon a life as a trans person in this country is doing so out of caprice, or a whim, or a delusion. We are living these wondrous and perilous lives for one reason only — because our hearts demand it. Given the tremendous courage it takes to come out, given the fact that even now trans people can still lose everything — family, friends, jobs, even our lives — what we need now is not new legislation to make things harder. What we need now is understanding, not cruelty. What we need now is not hatred, but love.
When the person in that Chevy ad sings, Oh, I want to be free … to feel the way I feel. Man, I feel like a woman!, the important thing is not that they feel like a woman, or a man, or something else. What matters most is the plaintive desire, to be free to feel the way I feel.
Surely this is not a desire unique to trans people. Tell me: Is there anyone who has never struggled to live up to the hard truths of their own heart?
— Low sex drive in men linked to chemical imbalance
By Sandee LaMotte
While hanging out with his college roommates, Peter (not his real name) realized he felt differently about sex than other heterosexual men.
“I’ve never been somebody who was interested in pornography, but I’d laugh along with their jokes,” said Peter, now 44, who is British. “Of course I never mentioned that … as a man, you’d be kicked out of the herd.”
As he developed “proper, serious relationships” with women, Peter discovered he didn’t have the sexual drive many of his partners did.
“I would make excuses around getting tired or feeling stressed, that kind of thing,” he said. “It wasn’t an issue with attraction to my partner. It just didn’t enter my mind to initiate sex.”
In 2021, Peter saw an ad recruiting male volunteers for a new study on hypoactive sexual desire disorder, or HSDD. Researchers planned to inject the study’s participants with kisspeptin —a naturally occurring sexual hormone — to see if it increased their sex drive. Kisspeptin plays a key role in reproduction; without adequate levels of the hormone children do not go through puberty, for example.
In a long-term, committed relationship with a woman he says has a higher sexual appetite, Peter signed up, intrigued by the thought that a biological imbalance might help explain his behavior.
In the week after the final session, Peter said, something amazing occurred.
“All of a sudden, I wanted to initiate intimacy. I can only presume it was driven not by my mind remembering something, but my body wanting something,” he said. “I did initiate sex more and it improved things with my partner incredibly.”
Experts believe HSDD affects at least 10% of women and up to 8% of men, although those numbers may be low, said Stanley Althof, a professor emeritus of psychology at Case Western Reserve University School of Medicine in Cleveland, Ohio and executive director of the Center for Marital and Sexual Health of South Florida.
“Men are embarrassed to go to the doctor to begin with, and you’re supposed to be a macho guy,” said Althof, who was not involved in the kisspeptin study.
“So it’s difficult for men to say, ‘Hey, I’ve got a problem with my sex drive.’ That’s why the majority of male patients I see with HSDD are sent in by their partners.”
To be diagnosed with the disorder, a person must have no other issues that might cause a change in libido, such as erectile dysfunction or premature ejaculation.
“Losing interest due to performance issues is common, but HSDD is its own thing,” Althof said. “It’s an absence of erotic thoughts and a lack of desire for sex that has to be present for six months. It also cannot be better explained by another disorder or other stressors: It can’t be due to depression. It can’t be due to a bad relationship. It can’t be due to taking an antidepressant.”
One more key point: A man or woman must have clinically significant distress to have HSDD, said clinical psychologist Dr. Sheryl Kingsberg, a professor in reproductive biology and psychiatry at Case Western Reserve University, who was also not involved in the kisspeptin study.
“Some people aren’t bothered by their lack of interest in sex, so we wouldn’t treat them for HSDD,” said Kingsberg, who is also chief of behavioral medicine at MacDonald Women’s Hospital and University Hospitals Cleveland Medical Center.
“The women coming into my office are deeply distressed,” she said. “They tell me ‘I used to have desire but it’s gone. I could be on a desert island with no pressures, but I just don’t have the appetite. I want it back.’ Those women have HSDD.”
Dr. Waljit Dhillo, a professor in endocrinology and metabolism at Imperial College London, has been studying the relationship between low sexual desire and the hormone kisspeptin for years, first in animals, then in people.
Prior studies by Dhillo of healthy men with no libido problems found giving them kisspeptin boosted levels of testosterone and luteinizing hormone, which is important for gonad function.
His newest study, published in the journal JAMA Network Open in February, enrolled 32 men with verified HSDD. Peter was one of them.
“So many people say to themselves, ‘It’s just me. I’ve got a problem.’ But actually, HSDD may be how your brain is wired,” said Dhillo, who is a dean at the United Kingdom’s National Institute for Health and Care Research Academy in Newcastle upon Tyne.
“The biology is telling us there’s increased activation of inhibitory areas in the brain — the same areas that tell us it’s not OK to walk around in public naked — and those areas are switching off sexual desire. How can we tackle that? We give a hormone that would naturally give you increased sexual desire, essentially hijacking the normal system.”
The men participating in the new study visited Dhillo’s lab twice. On each occasion, they were fitted with a device to objectively measure arousal, given an injection and asked to watch pornography while their brains were scanned via functional magnetic resonance imaging (fMRI).
Neither the subjects or the researchers knew if that day’s injection was kisspeptin or a placebo.
“It was extraordinarily surreal, lying there with something resembling a hangman’s noose around your bits and watching a mixture of ’70s to modern-day pornographic images and videos,” Peter said. “You’d get about five or six seconds of one type of image or video, rate your arousal for the researchers, and then move on to the next.”
Brain scans showed a significant dual effect after the kisspeptin injection, Dhillo said. Activity in the areas of the brain that inhibit behavior slowed, while areas of the brain connected to sexual interest lit up.
“As a group, the men had a 56% higher sexual response to sexual images after the kisspeptin than the placebo,” Dhillo said. “And we found no side effects at the very, very small dose that we are using.”
Peter noticed a difference immediately after finishing the treatments. His sex life was so robust, in fact, that it wasn’t long before his partner was pregnant with their first child.
As published, the study did not follow the men long-term to see if the effects of kisspeptin lasted. For Peter, however, its impact has been life-changing.
“I have found there’s been a lasting effect for me,” he said. “I do find I have a much better sexual appetite even now some years after the treatment.”
Even the arrival of a baby boy didn’t deter his new interest in sex.
“The cliche is when you have kids, your sex life takes a bit of a hit,” he told CNN. “But that hasn’t been the case for us. In fact, we’re pregnant with our second child, due in July.”
While Peter had a positive long-term result, it’s too soon to say kisspeptin injections were the reason, Althof said.
“When you hear dramatic results like Peter’s, I would be cautious in saying that is the typical outcome. While it’s wonderful that it happened for him, these fMRI studies are difficult to interpret and not conclusive,” he said.
“Sexual desire is very complicated — I say it’s a combination of brain function, hormones and love, wine and roses,” Althof added. “This study is promising, but it needs replication in larger groups.”
And even if future research does confirm kisspeptin’s benefits, medical treatment is not a substitution for healthy communication about sex between partners and with health care providers, Dhillo said.
“These are society’s taboos, but actually, the more we talk about real (sexual) issues that affect real people, the more we find it’s actually quite common,” he said.”If you’re not troubled by low libido, it’s not an issue at all, but if you are troubled by it, this can lead to marital breakdown, unhappiness and reduced quality of life.”
Sex is a natural part of life, but when was it ‘invented’? What has been the role of sex in human history? These questions are complex and multifaceted, and require an exploration of the biological, social and cultural aspects of sexuality. This article will provide an overview of the history of sex, from prehistoric times to the present day.
To understand the history of sex, it is important to look at both ancient civilizations and prehistoric times. Ancient civilizations such as Mesopotamia, Greece, and Rome had very different attitudes towards sex than those of modern societies. Prehistoric times, on the other hand, are less well-understood, but evidence suggests that sex was an important part of life for early humans.
An Analysis of the Origins of Sex
An Analysis of the Origins of Sex
The origins of sex are complex, and involve both biological and social/cultural aspects. On the biological side, sex is essential for reproduction. Through sexual reproduction, organisms can pass on their genetic material to the next generation. In addition to reproduction, sex may also have evolutionary benefits, such as increasing genetic diversity and providing protection against parasites and disease.
On the social/cultural side, sex is a powerful force that shapes and influences society. Different cultures have different norms and values around sex, and these norms can vary greatly across time and place. For example, in some cultures, premarital sex is frowned upon, while in others it is accepted or even encouraged. These social norms play a major role in shaping our understanding and experience of sex.
How Ancient Civilizations Viewed Sex
Ancient civilizations had very different attitudes towards sex than those of modern societies. For instance, in Mesopotamian cultures, sex was seen as a necessary part of marriage and procreation. The ancient Greeks and Romans had a more relaxed attitude towards sex, and viewed it as a source of pleasure and recreation. Other ancient civilizations, such as the Egyptians and Chinese, had their own views on sex, which were often rooted in religious beliefs.
A Timeline of the Development of Human Sexuality
The development of human sexuality has been shaped by both biological and social/cultural forces. To understand this development, it is useful to look at a timeline of key moments in the history of sex.
Prehistoric times: During the Paleolithic era, early humans likely engaged in sex for both reproductive and recreational purposes. This is supported by evidence of fertility symbols, cave paintings, and other artifacts.
Ancient civilizations: As civilizations developed, so too did attitudes towards sex. Ancient cultures such as the Mesopotamians, Greeks, and Romans had different views on sex, which were often influenced by religious beliefs.
Modern times: In the last few centuries, there has been a shift away from traditional views on sex, towards more liberal attitudes. This has been driven by changes in social norms and technology, such as the introduction of birth control and the rise of the internet.
Investigating the Evolution of Human Sexuality
Investigating the Evolution of Human Sexuality
The evolution of human sexuality is a complex process that involves both biological and social/cultural factors. On the biological side, sex is essential for reproduction, and may also have evolutionary benefits. On the social/cultural side, sex is shaped by different attitudes and beliefs. These attitudes and beliefs can vary greatly across time and place, and have a major impact on our understanding and experience of sex.
The Social and Cultural Impact of Sex
The Social and Cultural Impact of Sex
The social and cultural impact of sex cannot be understated. Different cultures have different perspectives on sex, which can range from strict taboos to more liberal attitudes. These attitudes shape our understanding of sex, and can influence our behavior and decisions. In addition, social norms can play a role in determining what is considered “normal” or “acceptable” when it comes to sex.
Examining the Biological Aspects of Sex
Examining the Biological Aspects of Sex
In addition to its social and cultural aspects, sex has important biological implications. On the most basic level, sex is essential for reproduction. By engaging in sexual activity, organisms can pass on their genetic material to the next generation. In addition, sex may have evolutionary benefits, such as increasing genetic diversity and providing protection against parasites and disease.
Conclusion
Sex is an integral part of human life, and its history is complex and multifaceted. This article has explored the biological, social and cultural aspects of sex, from prehistoric times to the present day. It has shown that sex is shaped by both biological and social/cultural forces, and that different cultures have different perspectives on sex. Finally, it has highlighted the importance of understanding the history of sex, as it can provide insight into our understanding and experience of sex today.
Decades ago in college, I had a lively discussion with friends about the “Four Food Groups,” a food classification system we had all grown up with in the ‘70s and ‘80s. The so-called “Basic Four” (defined as meats, dairy, fruits/vegetables, and grains) was just one in a series of ever-evolving teaching tools created by the USDA to nudge Americans toward healthier eating habits.
One friend was earnestly critiquing the system. “The Basic Four reflects the outsized influence of the meat and dairy industries,” she said, going on about structures of power in government agencies. “The whole system is wrong,” she exclaimed. “When you look at food in nature, there are actually 12 food groups.”
Another friend sighed. “In nature,” she asserted, “there are no food groups.” Food groups are made-up categorization systems we apply to edible stuff because we find it useful. There are infinite ways we can create food groups (by color, flavor, growing region, plant/animal source, vitamin content, etc.). There could be four, 40, or 400 categories, depending on our goals.
In other words, food groups shouldn’t be mistaken for telling unwavering “truth” about food. They are just convenient systems we use to make meaning from our world. And it doesn’t hurt here to note that the way we choose to group anything usually reflects certain underlying values and assumptions.
Categorizing Sex
Now let’s consider the concept of “sex.” For our purposes, I’m not talking about “sex” as an activity we can enjoy. Rather, I am talking about “sex” as a system that we use to categorize bodies.
In most of our cultural and scientific language, when we refer to the “sex” of humans, we’re usually offered two options, female or male. When we’re taught about sexual anatomy and reproduction in our sex ed classes, we are presented with two sets of drawings to represent genitals and reproductive organs.
The trouble with this system is that the observed reality of natural variations in human bodies isn’t that simple. Yes, we most often observe people who fit common patterns of “male” and “female” in terms of their gonads, genitals, chromosomes, and hormonal levels. But intersex people, who make up about 1.7% of the population, have sex traits or reproductive anatomy that varies from those typical definitions of male or female.
There is no single way to be intersex; it is an umbrella term encompassing a variety of differences in genitalia, hormones, internal anatomy, or chromosomes. Some intersex characteristics can be seen at birth, while others become evident at puberty, when trying to conceive a child, or through genetic testing. There are over 40 known intersex variations, and we’re still learning. The science of sex has become more nuanced in recent decades. Human sexual development is a complex process that involves multiple stages and a cascade of biological processes. Is it really a surprise that folks in our communities reflect natural variations beyond two strict outcomes?
There is no doubt that the categories of female and male can at times be useful. But there are also times when insisting on the rigidity of those categories is limiting and damaging. Serious trouble creeps in when folks insist that female and male are the “only,” “true,” or “natural” options. Our politics is currently rife with such essentialist language, reinforcing the erasure, stigma, and harm that intersex folks are often subjected to in our society.
Unnecessary surgeries on intersex youth
One form of injustice that intersex people have faced for decades is the imposition of binary sex norms by the medical establishment in the form of “normalizing” surgeries. These are non-lifesaving procedures that aim to change natural variations in genital appearance based on ideas about what a “normal” body looks like. Most of these surgeries are done when a child is under 2 years old, denying people important choices about their own bodies—choices that can affect fertility, sexual function, and emotional well-being.
In a new study, researchers are categorizing penises in terms of how much they grow during erections.
They label penises that are relatively large when flaccid as “showers” while those that are smaller at first and then grow substantially during erections as “growers.”
They say the classifications could be useful in some surgeries.
Size isn’t everything.
And, according to new research, when it comes to erections, where men start isn’t necessarily an indication of where they finish.
Some men are considered “showers” — having a visibly larger penis when flaccid — while others are “growers” — appearing smaller at first, but exhibiting a larger penis size when erect.
European researchers are actually defining the terms scientifically to see how many men fall into each category.
Urologists from three hospitals in Madrid, Spain, studied 225 men, taking ultrasound scans of their flaccid and erect penises.
They concluded that men whose penis increased in size by more than 56% when erect can be considered “growers” while those whose penises increased by less than 31% should be categorized as “showers.”
However, less than half of the men studied fit either definition.
Researchers led by Dr. Manuel Alonso-Isa of University Hospital HM Puerta del Sur in Madrid found that 24% of men were “growers” while 25 percent were “showers.”
The rest fell in the middle.
“This study gives credence to the concepts of the fact that some patients will have more of enlargement of their penis than others with an erection,” said Dr. Stanton Honig, the director of male urology at Yale University in Connecticut.
”It does not comment as to whether men who have shorter penises are more likely to grow than men with longer penises, so further work is necessary here,” he told Healthline.
Why the study is important
The study had a serious purpose.
The researchers said that the findings could help physicians make surgical decisions.
“It is important to be able to predict if a patient is a grower or a shower as when we see them, they are usually in a flaccid state,” said Alonso-Isa. “If they grow a lot when they get an erection, it might mean they need a different surgical approach compared to someone who doesn’t grow much.”
Men who had longer penises when flaccid were more likely to be “showers,” the study found, while growers tended to have thinner layers of the tissue known as tunica albuginea, which surrounds the spongy erectile tissue inside the penis.
“This makes sense as the tissue is being stretched further,” said Alonso-Isa.
However, researchers were unable to establish any relationship between shower/grower tendencies and factors such as age, weight, or smoking status.
Experts said having a baseline definition of penile-growth characteristics could have medical and mental health benefits for men.
“This is a frequent area of concern for our patients and the emphasis should be on normalizing baseline and erectile length for all,” said Maarten Albersen, a urologist at the University of Leuven in Belgium.
How men may view the research
Dr. Nicole Prause, a sexual psychophysiologist whose expertise includes genital physiology, said the classifications in the study are “purely clinical judgment.”
“They are not tied to any other meaningful physiological, psychological, or relationship characteristic,” she told Healthline. “To me, the distinction appears to be just physiological: those with a shorter penis when they are flaccid are much more likely to have a larger relative increase.”
“What is interesting is that men are more likely to express dissatisfaction with their flaccid size,” she said. “This suggests that men, since they tend to be shorter when they are flaccid, are focusing on the ‘worst case’ rather than being excited to have such a large increase.”
Penis size not connected to sexual performance
From a human sexuality standpoint, the question of whether a man is a “shower” or a “grower” is largely irrelevant, Nancy Sutton Pierce, a California-based clinical sexologist, told Healthline.
That penis size is still a primary concern for men reflects “the false pretense the sexual gratification of women relies on the measurement of the penis,” said Pierce.
“If the women’s clitoris isn’t being stimulated in some way, shape, or form, she isn’t going to be having a lot of fun no matter how big or how small the penis is,” she said.
She advised men that “you are more than your penis size.”
As it does regularly, Gallup asked Americans last year if they identified as straight, lesbian, gay, bisexual or transgender. About 7 percent of Americans said they identified as one of the latter four categories, essentially the same percentage as identified that way in 2021.
There was an interesting divide, though. When Gallup broke out responses by age, it found that younger Americans were much more likely to identify as LGBT (the Gallup poll excluded “queer,” so no “Q”) than older ones. Only about 2 percent of those in the Silent Generation (born during or before World War II) identified as LGBT. By contrast, about 20 percent of Gen Z (should be known as Lockdowners) chose one of the LGBT options.
This phenomenon is not new. The divide between older and younger Americans on self-identification has been a subject of debate for some time and is often cited in rhetoric targeting the perceived liberalizing effect of education and culture. As Florida considered legislation passed last year that limited discussion of same-sex relationships in schools, the dangerous idea that kids were being actively encouraged to be gay became prevalent in right-wing rhetoric.
There is a simpler explanation, one that grants adults the agency of their choices. Decades of hostility to same-sex relationships loosened in recent years, and younger Americans grew up in a country that was less hostile to gay relationships than it used to be. And, therefore, they’re more comfortable expressing their sexual identities openly.
We can see the trend in acceptance of same-sex relationships in the General Social Survey (GSS), a national poll fielded every two years. (The 2020 survey was postponed to 2021 because of the pandemic.) Since the early 1970s, respondents have been asked how they view sexual relations between members of the same sex. After rising slightly in the 1980s — no doubt influenced in part by the AIDS epidemic — there has been a steady decline in the percentage of Americans who say same-sex relationships are always wrong. Importantly, that decline has been seen in every generational group, even those who haven’t attended elementary school in half a century.
We only have good data for members of Gen Z and younger groups in the past two GSS polls. Since only a relatively small group of members of that generation were surveyed in 2018, there’s a greater margin of error for that year. That probably helps explain the seeming jump in the 2021 figure.
Importantly, there is a correlation between the extent to which generations view same-sex relationships as always wrong and the extent to which members identify as LGBT in Gallup’s data. Gen Z is least likely to view those relationships as wrong (the dot farthest to the left on the graph below) and most likely to identify that way (highest). (The graph also indicates where the Gen Z dot would be using the 2018 GSS data. It’s visible as a light red dot behind the “G” in the label for the vertical axis.)
In the abstract, this could be seen as evidence in favor of the idea that young people were being trained to view LGBTQ relationships as acceptable. But this does not account for the downward shift in opposition to same-sex relationships among members of other generations.
It also ignores other lessons from American history. In 2015, The Washington Post presented this graph, showing how identification of children as left-handed rose during the 20th century and then plateaued at about 1 in 8 kids.
Kids weren’t being groomed to be lefties. Quite the opposite: When my mother was young, she was told to learn to write with her right hand. Over time, that idea fell out of favor and lefties could simply be lefties. The percentage of the population that is left-handed stabilized.
Perhaps what’s happening with LGBTQ identification is analogous. Perhaps the change isn’t that kids are being encouraged to be gay when they aren’t; perhaps it’s that they feel free to identify that way if they are — a freedom older Americans didn’t enjoy. A freedom some still see an unacceptable for themselves or in their peer groups.
Maybe what Gallup is doing, then, is simply more accurately measuring reality.
Talk about getting into the weeds.A study recently published in the Journal of Cannabis Research came to an interesting conclusion: that cannabis could potentially be used to treat sexual dysfunctions. In the study, which was an online survey of 811 people, over 70% of respondents reported increased sexual desire and orgasm intensity with marijuana use. And over 40% of the women surveyed indicated “increased ability to have more than one orgasm per sexual encounter.” Now, these results may sound dope. But before you ditch the haircut, the candles, the steady paycheck, or anything else that may enhance sexual arousal in favor of the ganja, consider the limitations of this study.
This study entailed administering an online survey to a convenience sample of adults ages 18 years and older who had indicated histories of cannabis use. In fact, 62.6% of the respondents reported using cannabis on a daily basis with 59.8% intentionally using cannabis before engaging in sex. Now, this probably wasn’t a typical sample of people. A convenience sample doesn’t mean that these were folks found outside a convenience store. It meant that the research team from East Carolina University (Amanda Moser, MS, Sharon M. Ballard, PhD, and Jake Jensen, PhD) and North Carolina State University (Paige Averett, PhD) simply chose folks who happened to be conveniently available rather than a random sample from all-comers, so to speak. So it’s difficult to tell how biased this sample may have been. Thus, results from this survey may not really represent what the general population might say.
Survey respondents did range in age from 18 to 85 years. But it did skew younger with an average age of 32.11. They were predominantly White (78.9%) and college-educated (80.1%) with 64.9% identifying as female. Close to a quarter (23.1%) of the respondents identified as LGBTQIA+. Nearly three-quarters (73.7%) of the respondents indicated that they were in monogamous sexual relationships.
The survey asked folks a bunch of questions about their cannabis use as well as their sensuality and experiences, functioning, and levels of arousal during sex, including masturbation. This included specific questions about achieving orgasms and maintaining erections and lubrication.
Of the 811 respondents, 601 felt that cannabis either slightly or significantly increased their sexual desire with such perceptions being higher for women than men. And 582 believed that cannabis slightly or significantly increased the intensity of their orgasms with no clear difference between men and women. Cannabis seemed to help folks feel like they were more masters of their own domain too, so to speak, with a majority of respondents (507 or 62.5%) reporting either slightly or significantly increased pleasure while masturbating.
So did the research team get a sense of what might have been going on here? Well, 71.9% of respondents did report slight or significant increases in the sense of taste with cannabis use. In this case, increases in taste didn’t mean that they started dressing like Anne Hathaway. Rather, they had a heightened sensitivity to tasting things with their tongues and mouths. A similar percentage (71.0%) of respondents reported slight or significant increases in touch.
This also might have been a “relax do do it” situation, too, as 87.7% of respondents reported slight-to-significant increases in relaxation during sex. Two tents may be helpful in camping, but being too tense is not going to help you orgasm and enjoy sex. Thus, it would make sense that relaxation could help enhance sex.
Speaking of relaxation, the survey results did address one standing concern that men may have about cannabis and their penises. There is the belief that the muscle relaxation properties of cannabis could decrease the ability of a penis to achieve and maintain an erection. Of course, an erection isn’t a muscle-bound thing. Your penis, if you have one, doesn’t have that much muscle so don’t try lifting a barbell with it. Instead, an erection is blood filling the corpora cavernosa of the penis like air in a balloon animal thing. Well, based on the survey results, it wasn’t hard to see that cannabis didn’t seem to bring any erection fraud to the respondents. Most of the male respondents indicated no decrease in the ability to achieve (93.4%) or maintain (92.4%) an erection.
Of course, this study was far from avocado toast, meaning that it was far from perfect. Again, it was a convenience sample of cannabis users. So it could have selected for people who already believed that marijuana enhanced their sex lives. As you can imagine, if you already believe that something, like dressing up like Captain America, will aid your sex life, there’s a decent chance that it will via the placebo effect.
Furthermore, survey responses don’t always reflect what people truly feel or experience. Whenever you ask someone a question that includes the word “erection,” you may not always get an honest answer. For example, if you were to ask someone in the supermarket, “Where do you keep the cauliflower and are you able to maintain an erection,” chances are you will find the answer to only one of those things.
It would have been more accurate to have directly observed all of the study participants during sex, but that could have been really creepy and resulted in a lot of, “Hey, schmoopie, who’s that person with the tablet in the room with us?” questions followed by, “Oh, it’s just for some study that I signed up for so that I could get money to buy you dinner.”
The study also didn’t include any objective measures of arousal and orgasms. These would include physiological data like heart rate and body temperature or the number of times one utters something like, “Don’t stop”, “Oh, my gosh,”, “Oh, Jason Mamoa,” or “linguini” during sex. Uttering “linguini” during sex, though, could mean that the person is really excited or just really hungry.
Moreover, the survey did not ask about a number of other things that may have affected the sexual experience. For example, there was no sense of what medications and other substances each person was taking. And speaking of marijuana, it wasn’t clear what the person was eating as well. There are other things that can affect sex, too, such as amount of physical activity, general health, job satisfaction, the presence of a support network, the level of interest between the partners, the number of pillows on the bed, and whether “Slave to Love” by Bryan Ferry is playing in the background.
Finally, the survey didn’t measure the dosage of marijuana used. Naturally, a gram of marijuana would be quite different from 100 metric tons. Accordingly, future studies may want to help establish how the dosage of marijuana may relate to the aforementioned effects.
While this study is not the first to show associations between marijuana use and increased sensation and relaxation, it doesn’t necessarily mean that you should discard other means of increasing sexual excitement and start using marijuana. It’s still not clear what repeated use of marijuana may eventually do to your body. For example, studies have suggested that cannabis use could potentially have long-term effects on your brain, as summarized by the National Institute for Drug Abuse (NIDA). And while sacrificing your brain for your penis and vagina may seem like a fair trade, you should wait for more studies to truly determine what this trade-off may be. Nevertheless, this study does raise the possibility that cannabis could eventually be helpful for those with true sexual dysfunction that can’t otherwise be solved. That’s assuming that other options have been weeded out already.
— The average length of an erect penis has increased 24 percent over 3 decades, from 4.8 to 6 inches, but researchers worry that negative environmental factors may be responsible.
While recent research has shown that average sperm counts and testosterone levels have been in decline for men over the past few decades, erect penile length has surprisingly been trending in the opposite direction, according to a new global study.
A team led by Michael L. Eisenberg, MD, the director of male reproductive medicine and surgery and a urology professor at Stanford University School of Medicine in California, analyzed penis measurements from 75 studies conducted between 1942 and 2021, which recorded this anatomical data from more than 55,000 men ages 18 to 86.
In the context of studies that have found decreasing sperm counts and testosterone levels, “We expected that we would see a similar declining trend when we looked at penile length,” says Dr. Eisenberg, who is also a specialist in male sexual function, “but we found quite the opposite.”
Researchers Looked at 20 Studies Involving 18,000 Males
The results, published February 14 in the World Journal of Men’s Health, identified an increase of 24 percent in the average erect penis length between 1992 (when the first erect lengths were recorded) and 2021. The change over those 29 years increased from an average of 4.8 inches to an average of 6 inches. The calculations were determined from 20 studies that recorded those measures in more than 18,000 males in that time period.
The pooled data also included measures for flaccid length and stretched length (a way to estimate erect penile length). All measures included were conducted by investigators and none were self-reported. The study team noted that erect length increased significantly over time in several regions of the world and across all age groups, while no trends were identified in other penile size measurements.
Eisenberg suggested that stretch lengths did not follow the same trend as erect lengths because there were differences in how measurements were taken, including how hard a clinician pulled for measuring. Techniques for measuring erect penises, however, appeared quite consistent.
Environmental Factors May Play a Role in Increasing Penis Lengths
“Our reproductive system is one of the most important pieces of human biology. If we’re seeing this fast of a change, it means that something powerful is happening to our bodies,” says Eisenberg. “We should try to confirm these findings and if confirmed, we must determine the cause of these changes.”
He suggested that a number of environmental factors may be involved, such as exposure to hormone-disrupting chemicals in our surroundings (pesticides, for example). Some research has indicated that chemical exposure may be linked to boys and girls going into puberty earlier, which may affect genital development, according to Eisenberg.
He added that research has found an association between early pubertal timing and high rates of obesity and sedentary behavior, so that may be a driver behind the trend as well.
Could the Rise of the Internet Have Played a Part?
Larry Lipshultz, MD, the chief of the Scott Department of Urology’s Division of Male Reproductive Medicine and Surgery at Baylor College of Medicine in Texas, who was not involved in the study, found the results surprising given that most environmental and lifestyle factors seem to inhibit reproductive health.
He did propose, however, that the advent of the internet, starting in the mid-1980s, could possibly have played a role.
“You might possibly blame online porn, but that’s just a theory,” says Dr. Lipshultz. “The more someone has erections, there might be greater potential for better erections. The tissue would stretch more, hence would get longer.”
Bigger Is Not Necessarily Better
While some may view an increase in penis length as good news overall, Raevti Bole, MD, a urologist affiliated with the Cleveland Clinic who specializes in male sexual medicine and erectile dysfunction, stresses that people may put too much value on penis size.
“Overall I think the results are good in that they don’t show a deterioration [of the penis] — but at the end of the day penile length is very subjective, and I think there can be a negative to focusing on this,” says Dr. Bole, who was not one of the study researchers. “There’s a real emphasis on size in popular culture and social media, so I think it’s important for doctors to reinforce that bigger is not necessarily better. My point is size doesn’t necessarily correlate to sexual satisfaction. Patients can feel bad about penis size, and that’s a problem.”
More Research Is Needed
The next big step in terms of research for Eisenberg is to look at other patient populations (such as children and adolescents) to see if there are similar changes, because it may turn out to be an early indicator of a change in human development.
“Also, if there’s granular data on lifestyle factors or environmental exposures, we could try to understand why this may be happening,” he says.
Fetishes are non mainstream sexual interests in non genital body parts, inanimate objects, or behaviours. But why do some people have fetishes while others do not? Are fetishes acquired, inherited, or both? This topic is debatable, but evidence suggests that fetishes may be inherited.
What are fetishes?
Using an extensive sample survey, Claudia Scorolli — an associate professor and researcher in the Department of Philosophy and Communication Studies at the University of Bologna — and her colleagues classified the objects of fetishism into three categories and six subcategories. The three categories are body, objects, and behaviours.
The six subcategories are parts or features of the body like feet or weight — including body modifications like tattoos; an object usually in association with the body, like shoes or headphones; an object not usually associated with the body like dirty dishes or candles; a person’s own behavioural habits like biting fingernails; the behaviour of other persons like smoking; and interactional behaviours like domination, humiliation, and roleplay.
Some may think fetishes are rare, as they are non mainstream sexual excitements. However, recent findings counter this belief. In a 2016 study of 1,040 Canadians, 26 per cent of participants reported engaging in some form of fetish activities at least once in their lives.
In other studies, over 60 per cent of male college students and more than 50 per cent of female college students reported fantasizing about a behavioural fetish known as BDSM — bondage, domination, submission, sadism, and masochism. These results may make it less embarrassing to admit and discuss fetishes.
Despite these statistics, fetishism was once considered to be a mental illness, similar to non heteronormative sexualities and non cisgender identities. But now, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, fetishism is considered a disorder only when it causes “significant distress or impairment in social, occupational, or other important areas of functioning.” Gloria Brame, a sexologist and self-proclaimed fetishist, iterates that fetishism isn’t a hobby, but a legitimate sexual identity instead.
Unfortunately, fetishism researcher Giselle Rees has found that people with fetishes are still stigmatized and discriminated against as unhealthy, sick, or ‘crazy.’ Rees explains that one popular myth about people with fetishes is that they “need their fetish to have sex.” As such, those with fetishes are considered “abnormal.” However, Rees explains that people with fetishes can regularly engage in and enjoy conventional intercourse without their fetish.
What causes fetishes?
While initial theories claimed that fetishes resulted from early life experiences, later experiments contradict this thesis.
In 1966, Stanley Rachman — a psychologist at the Institute of Psychiatry, Maudsley Hospital and former professor emeritus in the Department of Psychology at the University of British Columbia — conducted a study to investigate whether a fetish was a conditioned response. Participants were first shown photographs of naked women, followed by a picture of women’s black boots. Following this, the image of black boots was found to induce sexual arousal successfully.
Anthropologist Katharine Gates theorizes that some fetishes are a result of simulation of the brain circuit involving smell and memory. Since the olfactory, memory, and emotion centres of the brain are tightly connected, a certain smell could become a trigger that connects with emotional contents and memories. This theory may explain air freshener fetishes, as well.
Further, neuroscientist Vilayanaur Ramachandran provides a neurological explanation for foot fetishes. In the brain, sensory information from the feet is processed adjacent to sensory information from the genitals. In this regard, there may be some “neural crosstalk” between these two brain areas. Fetishization is less likely to occur for body parts whose cortical representations are far from that of the genitals.
Do fetishes have a genetic component?
Fetishes tend to be permanent. In their 2007 paper, Scorolli and her team proposed that body-related fetishes may be genetic, while object-related fetishes may be more related to early-life events.
A behavioural fetish may reflect an individual’s personality. An example of such a personality trait is sensation-seeking. The Kinsey Institute’s research fellow Justin Lehmiller identified a pattern of interest in BDSM fetish among sensation-seekers.
Sensation seeking has a genetic basis related to the dopamine receptor D4 (DRD4) gene, which encodes the dopamine receptors that receive and relay biochemical signals from dopamine. A rare mutation of the DRD4 gene with 7-repeat sequences (7R) results in a version of the gene that encodes dopamine receptors less sensitive to dopamine. This means that people with the DRD4 7R+ allele need to participate in more thrilling activities to achieve the same level of pleasure as someone with the normal DRD4 gene.
Besides sexual fetishes, the DRD4 gene also influences several sexual behaviours, such as virginity status, sexual fantasies, sexual unfaithfulness to a committed partner, extra-relationship sex partners, and sexual novelty. In general, compared to individuals with the normal DRD4 allele, those with 7R+ are more active in sex and have more risky sexual behaviours.
This shows that there might be interesting evidence about behavioural fetishes as they relate to personality traits and their genetic basis, but more evidence is needed to corroborate and strengthen this relationship. For now, it appears that early life experiences, learned behaviour, neurological connections, and genetics all contribute to fetishism. With the progressive destigmatization of fetishism, there will likely be more research about the origin of fetishes.
As far as LGBTQIA people are concerned, what is old is new again. Recent pushes to restrict classroom representation of sexuality and gender identity, to intimidate libraries out of queer-friendly programming, and to legislate away the right to choose gender reassignment might appear new on the surface, but they reflect anxieties that have been part of Western culture for centuries, and that have everything to do with what we consider natural.
The last time sexual anxieties in the USA ran this high was in the 1990s. Back then, the AIDS crisis was in full swing, the military instituted its controversial “don’t ask, don’t tell” policy, and a “gay gene” was falsely reported as having been discovered in fruit flies. In that decade RuPaul’s gorgeously Amazonian presence made a lot of heterosexual men wonder about their sexuality, and Ellen DeGeneres came out, only to see her sitcom promptly canceled. Amid all this, under the guise of “protecting family values,” in 1991 the US government shelved an $18 million survey on teen sexual health, and another study of adult sexual diversity.
It amounted to a moratorium on all government-funded research into sexual identities and desire, with one notable exception. The governmental agency that was permitted to continue its research on homosexuality was … the Department of Agriculture. They’d been looking into what was known among farmers as the “dud stud” phenomenon: 8.5 percent of rams would choose only other males as sexual partners, time and again. He might be healthy and virile and have plenty of sperm to spare, but without any desire for females a “dud stud” wouldn’t sire lambs, and the farmer would be out of their investment (from $350 for a cheapie to $4,000 for a prize stud).
Bovid homosexual desire has long been familiar to ranchers, who watch out for females mounting other females as a simple way to determine when they’re in heat, and use steers to arouse bulls before artificially extracting their semen. Valerius Geist, a prominent mammologist, realized in the 1960s that wild bighorn sheep live in “essentially a homosexual society,” the males and females coming together only during the relatively brief rutting season. That means spending the rest of their lives in sex-segregated herds, where they engage in homosexual sex—not just quick mounting but full-on intercourse. He didn’t publish the research at the time, noting later that it was too difficult to “conceive of those magnificent beasts as queers.”
Geist probably assumed he was encountering an anomaly, but homosexual behavior in animals had been befuddling observers for centuries. Some ancient Greek thinkers believed hyenas had a special orifice for homosexual encounters, and in the 7th century, theologian Isidore of Seville was troubled by the homosexual activities of partridges, “for male mounts male and blind desire forgets gender.”
Reports of such homosexual behavior didn’t stop Thomas Aquinas from arguing, in the 13th century, that homosexuality was unnatural precisely because it did not occur in animals. His rhetoric about the “unnaturalness” of homosexuality, historian John Boswell notes, was politically useful and aligned with another moment of sexual anxiety: a surge in anti-gay legislation throughout Europe between 1250 and 1300, in which the death penalty for sodomy was introduced in country after country.
The assumption that homosexuality doesn’t exist in nature has led to very real consequences, such as the Bowers v. Hardwick Supreme Court case of 1986, which upheld the conviction of two men for sodomy, whose sentencing had cited the “unnaturalness” of their behavior. (The last sodomy law in the US was struck down only in 2003, and it remains a criminal, and sometimes capital, offense in parts of the world.)
During the last gay panic in the 1990s—and certainly back in the 13th century—we lacked today’s mainstream scientific acknowledgment of animals’ same-sex encounters. It’s been an important three decades for zoology. As a recent study in Nature Ecology & Evolution pointed out, the number of animal species with substantiated same-sex sexual behavior is 1,500 and counting.
For our near relative the bonobo, female-female genital rubbing is the most frequent sex act, one that takes place amid a matriarchy of sexually connected mothers. Shorebirds like albatross, gulls, and terns have same-sex parents in up to a third of nests; male bottlenose dolphins bond for life, cementing their union through frequent, and acrobatic, sex. Overturning long-standing assumptions that homosexual behavior was an evolutionary dead end, a growing scientific openness to animal bisexuality has resulted in compelling new theories. Foremost among these is the idea that oxytocin-producing sex is a powerful tool for reconciliation and alliance formation, whether that sex is hetero- or homosexual.
During my closeted teenage years in the 1990s, I would covertly look up “homosexuality” in encyclopedias, only to discover that it was a psychological failure of humans with bad parental attachments, without analog in nature. That echoed the rhetoric of otherwise kindly adults around me, who were grateful the “gay plague” of AIDS was getting rid of a social problem. I made it to the other side of my shame by coming to accept and even love my “unnaturalness.” It was only years later that I discovered the diversity that had been in nature all along. In writing my most recent book, Queer Ducks (and Other Animals): The Natural World of Animal Sexuality, I chose to make it accessible to teen readers, for whom internalized messaging about “unnaturalness” can be a life or death concern. (A survey last year by The Trevor Project found that 45 percent of LGBTQIA teens have seriously considered suicide.)
I made it to the other side of my shame by coming to accept and even love my “unnaturalness.” It was only years later that I discovered the diversity that had been in nature all along.
I had these concerns on my mind when I spoke to a young wildlife ecologist, Logan Weyand, who, while working with various bovid species, has observed plenty of same-sex mounting, intersex animals, and individuals that eschew sex altogether. Though Weyand was assigned female at birth, he never felt comfortable in his body and transitioned to male during his freshman year of college. He’s still on a journey around his gender identity, selectively closeting himself, especially at his research site in Idaho, where passing can be a safety concern.
Amid the need to navigate others’ judgments about LGBTQIA identities, Weyand finds himself longing for the times when he spends weeks away from civilization, “with the animals totally by myself, and not being judged. When I’m watching animals, I can go sunrise to sunset and not take my face away from the scope for hours.” Out there in the field, mud up to his ankles, Weyand worries only about getting good data. The sheep and moose he studies don’t care one bit about his sexual identity.
It’s a recurrent theme for many of the LGBTQIA scientists I’ve spoken to for my research. In a world where queer humans are often asked to identify or explain themselves, the radical acceptance of nature is a relief. In the animal world, everything just is.
About 1.7 percent of all people are born with intersex characteristics, an umbrella term for sex traits—such as external genitalia, internal reproductive organs, and chromosomal configurations—that don’t line up with society’s artificially tidy binary concepts of male or female bodies. Some of these characteristics are visible at birth: for example, genitals that are notably different from the norms or hard to classify as definitively male or female. Some only make their presence known during puberty, like when people don’t develop in the ways they might’ve expected. Some are so internal and subtle that they’re only identified during an autopsy. In any case, it’s usually impossible to tell if someone has intersex traits just by looking at them in everyday life. Still, living with intersex characteristics can have major impacts on people’s lives—including their sex lives.
To be clear, an intersex characteristic isn’t a medical condition or disability. It’s just one of many natural variations in the way diverse human bodies look and operate. Some factors that lead to intersex variations, like atypical hormone production, can at times also cause serious medical issues that require treatment, but most differences themselves are purely neutral. Yet society’s obsession with categorizing people into one of two binary genders at birth—and with erasing or ignoring anything that complicates the clean (over)simplicity of that binary—means many people with intersex traits grow up with the notion that there is supposedly something wrong with them, but they shouldn’t talk about it. Often, they’re also pressured or forced into “normalizing” themselves to match typical male or female anatomy: Across the world, kids with visible intersex traits are regularly subjected to objectively unnecessary and often harmful surgeries to reshape or remove their genitals, expressly to make them look “normal” and supposedly help them fit into society.
A fair number of people with intersex characteristics don’t feel these traits have much effect, if any, on their sex lives. But several intersex differences can lead to unique experiences of sex and pleasure. And many “normalization” surgeries drastically reduce or eliminate people’s genital sensations, and/or lead to chronic pain and dysfunction in erogenous zones. Thanks to the extreme culture of shame and silence around these traits and experiences, it’s difficult for people with intersex traits—or who are grappling with the effects of unnecessary surgeries—to learn about their bodies, much less articulate and advocate for their sexual wants and needs. Popular misconceptions and stigmas, as well as the risk of someone reacting poorly to diverse genitals or a body that doesn’t work in the ways they’d expect it to, also make it hard for some people with intersex traits to feel comfortable exploring intimacy, or to feel sexy and sexual.
In recent decades, several intersex organizations have formed to push back on pathologization and stigmatization and to help people with intersex characteristics find community and support. But most of their public advocacy and education to date has (understandably) focused on ending unnecessary and harmful surgeries—so there’s still not a tonof publicinformationout there on the issues people with intersex characteristics can face when navigating sex, and how to manage them.
To help bring more visibility to these issues and experiences, VICE reached out to Addy Berry, an intersex woman, and her wife Leea to talk about the ways they’ve approached sex and intimacy. Every intersex experience is unique, so Addy and Leea’s story is hardly universal. But Addy also studies the sexual experiences of people with intersex traits as a PhD candidate and an activist, and shared some of the wider insights she’s gleaned through her research, advocacy, and education work over the years.
This interview has been edited for length and clarity.
Addy: When I was born, my urethra opened on the underside of my phallus, close to the testes. I underwent surgery as a child to reroute it. In medical papers published as late as 2022, doctors have attempted to justify that type of surgery by saying it’s important for boys to be able to pee with their friends—which is a wild justification for a surgery that they perform when no one goes back to see what the long-term effects were on other people. [Editor’s Note: This is one of the most common surgeries performed on infants and toddlers with intersex characteristics.] It’s actually pretty difficult for me to pee anywhere now because there’s a mass of scar tissue within my urethra due to that surgery. So moving my urethra hasn’t done me a whole lot of good.
Doctors insist they can do things like reduce the size of a clitoris—in the past they’d fully remove it—and it’ll all be fine, when there’s no way for them to know that will be the case. Young people I’ve talked to who’ve undergone those surgeries report a lot of pain and also a lot of psychological issues related to the procedures and their long-term effects.
I was also put on hormones pre-puberty, under false pretenses. I didn’t act in accordance with the gender I was assigned—ever—and I got punished for that. Transgender and intersex are not the same thing, but a lot of us were assigned a gender despite uncertainties, and the surgeries done to make us fit that gender then don’t really suit us.
Growing up, my father said things to me like, “You weren’t born with a proper penis,” which is how I knew what my scars were from. And my mother referred to me as an abomination. The effects of all that stigma and shame come up in almost all of the interviews I do—it all has a big effect on your sexuality. I felt the effect on my sense of sexuality pretty early on in life.
Without much sensation in my genitals, likely thanks to that surgery, sex for me was never genital-centric. I could perform penetrative sex, but it doesn’t really do me any good. I was drawn to BDSM, and particularly female domination, from an early age. I’m essentially a masochist. Not everyone in the BDSM community links their involvement back to trauma, but for me I think it’s tied to my history of treatment as an autistic and intersex child who tended to be gender non-conforming and who was raised by a superstitious, sadistic Catholic woman with a lot of issues.
Due to what I was put through in my childhood, I developed into a physically masculine person, and I’d get involved with girls who liked me because of what I looked like—but who’d get angry at me for being feminine even though I was always open about who I am and I didn’t really act masculine. One partner told me that having sex with me was “like having sex with a girl,” and I was like, “Well…” They get angry at you for being the thing you said you were rather than the thing they wanted you to be. There was a lot of incompatibility in my intimate life. And then I found Leea, and there’s been so much compatibility between us that I almost wonder how she’s real. How did we find each other? We should have bought all of the lottery tickets that day. [Laughs.]
Leea: I like to read personal ads because it’s interesting to me to see what people put in them to find a mate. It’s like a love CV or something. I saw this really cute, well-written, dirty Craigslist ad one day, talking about BDSM stuff and with a cute picture, and I said “Oh that’s cool” and moved on. A few days later, I saw the same ad, but all the dirty bits were gone, and I thought that was cute too. I’d never felt inclined to write back to an ad before, but I replied, “Hey, I thought your dirty ad was cuter.” We started texting and then met for a coffee date and really hit it off.
My dad has a cousin who has intersex characteristics. I’m not sure what they are exactly, but as far as I understood it she’d undergone surgery to make her more female, but because of those surgeries she couldn’t have a child, so they adopted. She told my mother about it because they were good friends, and most of my family knew a bit about it, but nobody talked about it or asked questions. It was kind of a family secret. So I knew intersex characteristics existed before I met Addy, but that was about it. Fairly quickly, it became obvious she was trans but not out.
Addy: Because of my kiddos.
Leea: But it took a while to realize, “Oh, Addy’s intersex.”
Addy: Yeah, we talked about the surgeries I went through early on and all of that, but I hadn’t attached intersex language to that yet, for myself even.
Leea: Addy had to do a lot of figuring things out because she always knew she’d had these surgeries but she’d never been told specifically what had happened.
Addy: I’d known other words, and I found intersex later. The modern intersex movement has only existed as long as we’ve been able to find and reach each other online.
“The modern intersex movement has only existed as long as we’ve been able to find and reach each other online.” —Addy
Leea: Still, from early on I understood a lot about Addy—and none of it was an issue for me. We’ve just constantly had discussions about where we are. And Addy likes to talk a lot anyway.
Addy: [Laughs.] It came up early on that you weren’t interested in penetrative sex as well.
Leea: I’d dated a lot of people, and by then I was clear on the sex I wanted to have. I was over men. I don’t give a shit about sex the way a man typically wants to have it. That’s part of why Addy was the one for me. I found someone with whom sex wasn’t centered on the male gaze.
Addy: In the beginning, we also established that I’m not just a submissive but a masochist, and a pretty feminine person. While Leea is pretty feminine physically, she has more traditionally masculine aspects and aptitudes to her. Outside of this relationship, I’m brave, and I take care of tough things. But in this relationship, I find great comfort in being submissive to Leea.
Leea: It’s hard to remember specific conversations from that far back, but we still constantly discuss things, and the BDSM play we have today has evolved from the play we had 5, 10 years ago as we realize we like some things more or less than we did in the past and adjust.
Addy: For example, through exploration, we’ve found that medical play can be pretty cathartic for me—probably because of my history.
I’ve also experienced pretty severe depression for most of my life, and it’s very hard to get mental health help as an intersex person because not many people are qualified to help with the specific type of trauma you’ve been through. I’ve never found a therapist who’s capable of adequately addressing my trauma. But we’ve found that, when I’m in a depressive state, a caning can bring me right out of it. For example, a person I used to work with once asked me—right in front of Leea—“So if I pulled down your pants right now, what would I be looking at?” After that, I was not in a good place. But BDSM lifted up my dopamine or serotonin or something. Whatever it is, I don’t know. If we could get an MRI machine in here, that’d be interesting.
Leea: It’s really exciting as we explore more and more together. We’ve decided to dedicate this year to taking care of us, putting boundaries on who can come over to our place and when, so we can do things like exploring more BDSM play together. We want to go to more dungeons, too.
Ultimately, Addy being intersex doesn’t define anything in our relationship. It’s a part of who she is, and a part of what makes her the person I love. And because she works on intersex issues, it is something we’re always talking about. It plays a role in our life. But it isn’t who she is.
Addy: A lot of the people I’ve talked to who’ve really struggled are straight intersex people who live in a world where sex is all about a penis going into a vagina. A lot of intersex people have small penises, so living in a world full of comments insulting people for having small penises, where they learn that’s inherently bad and shameful, really sucks. For me and a lot of other intersex people who are queer, we’ve been forced to develop a wider vocabulary around sex.
Leea: The fact that we’re a queer couple has also, I think, given us more space to have conversations about things like the different kinds of sex we want to have. I feel really bad for a lot of straight couples because there isn’t a lot of space for conversations around what is good sex, how each partner is feeling, and what works and doesn’t work for them.
Addy: We have had to adapt our sex around the effects of the surgeries, and the effects of the stigma and shame I went through. But personally, I’ve never understood the idea in society that people should be ashamed of differences like this. I didn’t choose to be intersex or to be trans. So why should I be ashamed of those things? Or of being a submissive to, really, a goddess? Or for having done sex work? I don’t harm anyone. I work to make the world a better place.
I think my parents should be ashamed of how they treated me. The medical establishment should be ashamed. Society at large should be ashamed. I don’t see why I should carry shame.
As a clinical geneticist, Paul James is accustomed to discussing some of the most delicate issues with his patients. But in early 2010, he found himself having a particularly awkward conversation about sex.
A 46-year-old pregnant woman had visited his clinic at the Royal Melbourne Hospital in Australia to hear the results of an amniocentesis test to screen her baby’s chromosomes for abnormalities. The baby was fine—but follow-up tests had revealed something astonishing about the mother. Her body was built of cells from two individuals, probably from twin embryos that had merged in her own mother’s womb. And there was more. One set of cells carried two X chromosomes, the complement that typically makes a person female; the other had an X and a Y. Halfway through her fifth decade and pregnant with her third child, the woman learned for the first time that a large part of her body was chromosomally male. “That’s kind of science-fiction material for someone who just came in for an amniocentesis,” says James.
Sex can be much more complicated than it at first seems. According to the simple scenario, the presence or absence of a Y chromosome is what counts: with it, you are male, and without it, you are female. But doctors have long known that some people straddle the boundary—their sex chromosomes say one thing, but their gonads (ovaries or testes) or sexual anatomy say another. Parents of children with these kinds of conditions—known as intersex conditions, or differences or disorders of sex development (DSDs)—often face difficult decisions about whether to bring up their child as a boy or a girl. Some researchers now say that as many as 1 person in 100 has some form of DSD.
When genetics is taken into consideration, the boundary between the sexes becomes even blurrier. Scientists have identified many of the genes involved in the main forms of DSD, and have uncovered variations in these genes that have subtle effects on a person’s anatomical or physiological sex. What’s more, new technologies in DNA sequencing and cell biology are revealing that almost everyone is, to varying degrees, a patchwork of genetically distinct cells, some with a sex that might not match that of the rest of their body. Some studies even suggest that the sex of each cell drives its behaviour, through a complicated network of molecular interactions. “I think there’s much greater diversity within male or female, and there is certainly an area of overlap where some people can’t easily define themselves within the binary structure,” says John Achermann, who studies sex development and endocrinology at University College London’s Institute of Child Health.
These discoveries do not sit well in a world in which sex is still defined in binary terms. Few legal systems allow for any ambiguity in biological sex, and a person’s legal rights and social status can be heavily influenced by whether their birth certificate says male or female.
“The main problem with a strong dichotomy is that there are intermediate cases that push the limits and ask us to figure out exactly where the dividing line is between males and females,” says Arthur Arnold at the University of California, Los Angeles, who studies biological sex differences. “And that’s often a very difficult problem, because sex can be defined a number of ways.”
The start of sex
That the two sexes are physically different is obvious, but at the start of life, it is not. Five weeks into development, a human embryo has the potential to form both male and female anatomy. Next to the developing kidneys, two bulges known as the gonadal ridges emerge alongside two pairs of ducts, one of which can form the uterus and Fallopian tubes, and the other the male internal genital plumbing: the epididymes, vas deferentia and seminal vesicles. At six weeks, the gonad switches on the developmental pathway to become an ovary or a testis. If a testis develops, it secretes testosterone, which supports the development of the male ducts. It also makes other hormones that force the presumptive uterus and Fallopian tubes to shrink away. If the gonad becomes an ovary, it makes oestrogen, and the lack of testosterone causes the male plumbing to wither. The sex hormones also dictate the development of the external genitalia, and they come into play once more at puberty, triggering the development of secondary sexual characteristics such as breasts or facial hair.
Changes to any of these processes can have dramatic effects on an individual’s sex. Gene mutations affecting gonad development can result in a person with XY chromosomes developing typically female characteristics, whereas alterations in hormone signalling can cause XX individuals to develop along male lines.
For many years, scientists believed that female development was the default programme, and that male development was actively switched on by the presence of a particular gene on the Y chromosome. In 1990, researchers made headlines when they uncovered the identity of this gene, which they called SRY. Just by itself, this gene can switch the gonad from ovarian to testicular development. For example, XX individuals who carry a fragment of the Y chromosome that contains SRY develop as males.
By the turn of the millennium, however, the idea of femaleness being a passive default option had been toppled by the discovery of genes that actively promote ovarian development and suppress the testicular programme—such as one called WNT4. XY individuals with extra copies of this gene can develop atypical genitals and gonads, and a rudimentary uterus and Fallopian tubes. In 2011, researchers showed that if another key ovarian gene, RSPO1, is not working normally, it causes XX people to develop an ovotestis—a gonad with areas of both ovarian and testicular development.
These discoveries have pointed to a complex process of sex determination, in which the identity of the gonad emerges from a contest between two opposing networks of gene activity. Changes in the activity or amounts of molecules (such as WNT4) in the networks can tip the balance towards or away from the sex seemingly spelled out by the chromosomes. “It has been, in a sense, a philosophical change in our way of looking at sex; that it’s a balance,” says Eric Vilain, a clinician and the director of the Center for Gender-Based Biology at the University of California, Los Angeles. “It’s more of a systems-biology view of the world of sex.”
Battle of the sexes
According to some scientists, that balance can shift long after development is over. Studies in mice suggest that the gonad teeters between being male and female throughout life, its identity requiring constant maintenance. In 2009, researchers reported deactivating an ovarian gene called Foxl2 in adult female mice; they found that the granulosa cells that support the development of eggs transformed into Sertoli cells, which support sperm development. Two years later, a separate team showed the opposite: that inactivating a gene called Dmrt1 could turn adult testicular cells into ovarian ones. “That was the big shock, the fact that it was going on post-natally,” says Vincent Harley, a geneticist who studies gonad development at the MIMR-PHI Institute for Medical Research in Melbourne.
The gonad is not the only source of diversity in sex. A number of DSDs are caused by changes in the machinery that responds to hormonal signals from the gonads and other glands. Complete androgen insensitivity syndrome, or CAIS, for example, arises when a person’s cells are deaf to male sex hormones, usually because the receptors that respond to the hormones are not working. People with CAIS have Y chromosomes and internal testes, but their external genitalia are female, and they develop as females at puberty.
Conditions such as these meet the medical definition of DSDs, in which an individual’s anatomical sex seems to be at odds with their chromosomal or gonadal sex. But they are rare—affecting about 1 in 4,500 people. Some researchers now say that the definition should be widened to include subtle variations of anatomy such as mild hypospadias, in which a man’s urethral opening is on the underside of his penis rather than at the tip. The most inclusive definitions point to the figure of 1 in 100 people having some form of DSD, says Vilain.
But beyond this, there could be even more variation. Since the 1990s, researchers have identified more than 25 genes involved in DSDs, and next-generation DNA sequencing in the past few years has uncovered a wide range of variations in these genes that have mild effects on individuals, rather than causing DSDs. “Biologically, it’s a spectrum,” says Vilain.
A DSD called congenital adrenal hyperplasia (CAH), for example, causes the body to produce excessive amounts of male sex hormones; XX individuals with this condition are born with ambiguous genitalia (an enlarged clitoris and fused labia that resemble a scrotum). It is usually caused by a severe deficiency in an enzyme called 21-hydroxylase. But women carrying mutations that result in a milder deficiency develop a ‘non-classical’ form of CAH, which affects about 1 in 1,000 individuals; they may have male-like facial and body hair, irregular periods or fertility problems—or they might have no obvious symptoms at all. Another gene, NR5A1, is currently fascinating researchers because variations in it cause a wide range of effects, from underdeveloped gonads to mild hypospadias in men, and premature menopause in women.
Many people never discover their condition unless they seek help for infertility, or discover it through some other brush with medicine. Last year, for example, surgeons reported that they had been operating on a hernia in a man, when they discovered that he had a womb. The man was 70, and had fathered four children.
Cellular sex
Studies of DSDs have shown that sex is no simple dichotomy. But things become even more complex when scientists zoom in to look at individual cells. The common assumption that every cell contains the same set of genes is untrue. Some people have mosaicism: they develop from a single fertilized egg but become a patchwork of cells with different genetic make-ups. This can happen when sex chromosomes are doled out unevenly between dividing cells during early embryonic development. For example, an embryo that starts off as XY can lose a Y chromosome from a subset of its cells. If most cells end up as XY, the result is a physically typical male, but if most cells are X, the result is a female with a condition called Turner’s syndrome, which tends to result in restricted height and underdeveloped ovaries. This kind of mosaicism is rare, affecting about 1 in 15,000 people.
The effects of sex-chromosome mosaicism range from the prosaic to the extraordinary. A few cases have been documented in which a mosaic XXY embryo became a mix of two cell types—some with two X chromosomes and some with two Xs and a Y—and then split early in development. This results in ‘identical’ twins of different sexes.
There is a second way in which a person can end up with cells of different chromosomal sexes. James’s patient was a chimaera: a person who develops from a mixture of two fertilized eggs, usually owing to a merger between embryonic twins in the womb. This kind of chimaerism resulting in a DSD is extremely rare, representing about 1% of all DSD cases.
Another form of chimaerism, however, is now known to be widespread. Termed microchimaerism, it happens when stem cells from a fetus cross the placenta into the mother’s body, and vice versa. It was first identified in the early 1970s—but the big surprise came more than two decades later, when researchers discovered how long these crossover cells survive, even though they are foreign tissue that the body should, in theory, reject. A study in 1996 recorded women with fetal cells in their blood as many as 27 years after giving birth; another found that maternal cells remain in children up to adulthood. This type of work has further blurred the sex divide, because it means that men often carry cells from their mothers, and women who have been pregnant with a male fetus can carry a smattering of its discarded cells.
Microchimaeric cells have been found in many tissues. In 2012, for example, immunologist Lee Nelson and her team at the University of Washington in Seattle found XY cells in post-mortem samples of women’s brains. The oldest woman carrying male DNA was 94 years old. Other studies have shown that these immigrant cells are not idle; they integrate into their new environment and acquire specialized functions, including (in mice at least) forming neurons in the brain. But what is not known is how a peppering of male cells in a female, or vice versa, affects the health or characteristics of a tissue—for example, whether it makes the tissue more susceptible to diseases more common in the opposite sex. “I think that’s a great question,” says Nelson, “and it is essentially entirely unaddressed.” In terms of human behaviour, the consensus is that a few male microchimaeric cells in the brain seem unlikely to have a major effect on a woman.
Scientists are now finding that XX and XY cells behave in different ways, and that this can be independent of the action of sex hormones. “To tell you the truth, it’s actually kind of surprising how big an effect of sex chromosomes we’ve been able to see,” says Arnold. He and his colleagues have shown that the dose of X chromosomes in a mouse’s body can affect its metabolism, and studies in a lab dish suggest that XX and XY cells behave differently on a molecular level, for example with different metabolic responses to stress. The next challenge, says Arnold, is to uncover the mechanisms. His team is studying the handful of X-chromosome genes now known to be more active in females than in males. “I actually think that there are more sex differences than we know of,” says Arnold.
Beyond the binary
Biologists may have been building a more nuanced view of sex, but society has yet to catch up. True, more than half a century of activism from members of the lesbian, gay, bisexual and transgender community has softened social attitudes to sexual orientation and gender. Many societies are now comfortable with men and women crossing conventional societal boundaries in their choice of appearance, career and sexual partner. But when it comes to sex, there is still intense social pressure to conform to the binary model.
This pressure has meant that people born with clear DSDs often undergo surgery to ‘normalize’ their genitals. Such surgery is controversial because it is usually performed on babies, who are too young to consent, and risks assigning a sex at odds with the child’s ultimate gender identity—their sense of their own gender. Intersex advocacy groups have therefore argued that doctors and parents should at least wait until a child is old enough to communicate their gender identity, which typically manifests around the age of three, or old enough to decide whether they want surgery at all.
This issue was brought into focus by a lawsuit filed in South Carolina in May 2013 by the adoptive parents of a child known as MC, who was born with ovotesticular DSD, a condition that produces ambiguous genitalia and gonads with both ovarian and testicular tissue. When MC was 16 months old, doctors performed surgery to assign the child as female—but MC, who is now eight years old, went on to develop a male gender identity. Because he was in state care at the time of his treatment, the lawsuit alleged not only that the surgery constituted medical malpractice, but also that the state denied him his constitutional right to bodily integrity and his right to reproduce. Last month, a court decision prevented the federal case from going to trial, but a state case is ongoing.
“This is potentially a critically important decision for children born with intersex traits,” says Julie Greenberg, a specialist in legal issues relating to gender and sex at Thomas Jefferson School of Law in San Diego, California. The suit will hopefully encourage doctors in the United States to refrain from performing operations on infants with DSDs when there are questions about their medical necessity, she says. It could raise awareness about “the emotional and physical struggles intersex people are forced to endure because doctors wanted to ‘help’ us fit in,” says Georgiann Davis, a sociologist who studies issues surrounding intersex traits and gender at the University of Nevada, Las Vegas, who was born with CAIS.
Doctors and scientists are sympathetic to these concerns, but the MC case also makes some uneasy—because they know how much is still to be learned about the biology of sex. They think that changing medical practice by legal ruling is not ideal, and would like to see more data collected on outcomes such as quality of life and sexual function to help decide the best course of action for people with DSDs—something that researchers are starting to do.
Diagnoses of DSDs once relied on hormone tests, anatomical inspections and imaging, followed by painstaking tests of one gene at a time. Now, advances in genetic techniques mean that teams can analyse multiple genes at once, aiming straight for a genetic diagnosis and making the process less stressful for families. Vilain, for example, is using whole-exome sequencing—which sequences the protein-coding regions of a person’s entire genome—on XY people with DSDs. Last year, his team showed that exome sequencing could offer a probable diagnosis in 35% of the study participants whose genetic cause had been unknown.
Vilain, Harley and Achermann say that doctors are taking an increasingly circumspect attitude to genital surgery. Children with DSDs are treated by multidisciplinary teams that aim to tailor management and support to each individual and their family, but this usually involves raising a child as male or female even if no surgery is done. Scientists and advocacy groups mostly agree on this, says Vilain: “It might be difficult for children to be raised in a gender that just does not exist out there.” In most countries, it is legally impossible to be anything but male or female.
Yet if biologists continue to show that sex is a spectrum, then society and state will have to grapple with the consequences, and work out where and how to draw the line. Many transgender and intersex activists dream of a world where a person’s sex or gender is irrelevant. Although some governments are moving in this direction, Greenberg is pessimistic about the prospects of realizing this dream—in the United States, at least. “I think to get rid of gender markers altogether or to allow a third, indeterminate marker, is going to be difficult.”
So if the law requires that a person is male or female, should that sex be assigned by anatomy, hormones, cells or chromosomes, and what should be done if they clash? “My feeling is that since there is not one biological parameter that takes over every other parameter, at the end of the day, gender identity seems to be the most reasonable parameter,” says Vilain. In other words, if you want to know whether someone is male or female, it may be best just to ask.
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