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Biological Causes

The term "impotence" refers to a sexual dysfunction in which a man is not able to achieve or maintain an erection sufficient to penetrate the vagina and successfully complete intercourse. Most clinicians use the term "erectile difficulty" or "erectile dysfunction" rather than "impotence" because of the generally negative connotations of the word. All of these terms are used here to describe difficulties in achieving and maintaining erections.

The American Psychiatric Association's Diagnostic and Statistical Manual (DSM III-R.) describes the criteria for male erectile disorder as either a "persistent or recurrent partial or complete failure in the male to attain or maintain erection until completion of the sexual activity, or [a] persistent or recurrent lack of a submissive sense of sexual excitement and pleasure in a male during sexual activity." The latter criterion refers to problems related to sexual desire. The terms referring to erectile difficulties can be applied to both heterosexual and homosexual relationships and are not limited to attempts at vaginal intercourse.

The occurrence of impotence may be either primary or secondary. In cases of primary impotence, which is rare and usually associated with organic conditions, the male has never been able to successfully achieve an erection for intercourse.

These men are usually able to have erections under other circumstances, such as through masturbation, and may report erections upon awakening from sleep. In secondary impotence, the male has a history of successful intercourse but reports episodes of erectile difficulty during which he is unable to function. Masters and Johnson looked for a failure rate of 25 percent before making the diagnosis of secondary impotence. Secondary impotence is more commonly seen and may have multiple causes as well as significant psychological and relational side effects.

The incidence of impotence is difficult to estimate because of the reluctance of men to report the problem. Kinsey found impotence to be rare in men under 35 years of age but increasingly frequent as they grew older, appearing especially after age 45 and more so after 55. By age 70, 27 percent of the men interviewed reported erectile difficulty; by age 75, the figure was 55 percent. In a more recent study of 100 men of varying ages, Frank found 7 percent of the subjects reporting difficulty obtaining erection and 9 percent reporting an inability to maintain erection.

While figures vary and sex research continues, many clinicians feel that over a lifetime any male may experience an occasional episode of erectile failure, often for one or more of the following reasons: fatigue, anxiety, ignorance of his own sexual functioning or that of his partner (e.g., lacking information about the sexual-response cycle and placing unrealistic expectations on performance), feeling rushed, having too much food or alcohol, not being attracted to his partner, being too goal oriented (e.g., insisting on being able to "give" his partner an orgasm every time), engaging in "spectatoring" (i.e., watching himself perform and trying to "will an erection"), engaging in inappropriate internal self-talk that sets him up for failure, or simply trying to have sex while not at the proper interest or arousal level. Although episodes are common in a given population, they are often the cause of significant concern to a male and his partner if a proper understanding of the causes is not achieved. A single episode of erectile failure, if not properly understood and dealt with appropriately, can set off a cycle of doubt that marks future sexual attempts with anticipatory anxiety, which in itself creates a negative environment and can instigate and perpetuate future failure.

Whatever the incidence of impotence, its causes and effects may be many. It was not too long ago that most cases of impotence, especially secondary impotence, were considered to be of psychological origin. It is true that significant psychological issues (e.g., fear of failure), relationship issues between the sexual partners (e.g., anger), fear of disease, fear of pregnancy, and guilt can lead to erectile failure. Anxiety and guilt about sex itself, often having a basis in religious beliefs, can be a contributing cause of erectile difficulties.

Deeper psychological issues may be important, such as poor self-esteem, traumatic childhood sexual experiences, family-of-origin issues (including negative sexual attitudes), conflicts with women, gender-identity and sexual-orientation conflicts, the presence of a paraphilia or "sexual perversion," significant depression or emotional illness, fear of intimacy, or guilt about pleasure. These are just some of the components that in given cases result in impotence. Erectile difficulties can also be related to external circumstances, such as to a particular partner, where the male is able to function quite adequately with one sexual partner but not with another.

Biological Causes

Many causes of impotence are biologically related. Today, sophisticated techniques are uncovering organic causes of impotence, whereas previously psychological mechanisms were blamed. Some authors suggest that 10-15 percent of cases of impotence are organically based, while many practitioners feel the percentage is higher, as much as 50-60 percent. The mechanisms of the body—hormonal, vascular, and neural—that cause and maintain erection are vulnerable to the influences of many conditions and agents. Problems that affect these bodily systems as they relate to sexual functioning must be evaluated as part of the diagnosis of impotence.

A partial list of physical conditions that could contribute to erectile difficulties includes any severely debilitating illness associated with the loss of libido (e.g., cardiorespiratory disease). Diabetes, which affects the vascular and neurological system, is another primary illness associated with impotence. Endocrine conditions such as myxedema, thyrotoxicosis, pituitary disease, and Addison's disease have also been associated with impotence. The level of testosterone, the male hormone, may be related more to levels of sexual desire than to sexual performance. Some common physical causes of secondary impotence, according to Kolodny, are the following:

Anatomic: Congenital deformities, hydrocele, testicular fibrosis

Cardiorespiratory: Angina pectoris, coronary insufficiency, myocardial infarction, pulmonary insufficiency, rheumatic fever

Genitourinary: Peyronie's disease, phimosis, priapism, prostatitis, perineal prostatectomy, urethritis

Hematologic: Hodgkin's disease, leukemia, sicklecell anemia

Infectious: Gonorrhea, mumps, genital tuberculosis

Neurologic: Cerebral palsy, multiple sclerosis, parkinsonism, peripheral neuropathies, cord tumors or transections, sympathectomy

Vascular: Aneurysm, arteritis, sclerosis

Miscellaneous: Chronic renal failure, cirrhosis, obesity, toxicologic agents (e.g., lead, herbicides)

Drugs have become a major concern as contributors to erectile difficulties. At times, prescribed medication may render the patient at risk for experiencing sexual side effects. Alternate medications may be available, but not all patients are able to find substitutes that meet their medical needs while not compromising their sexual functioning. Sometimes it is the interaction of different drugs that affects the sexual system adversely. Some drugs are dose related in their influence on sexual functioning. In certain cases, a drug known to inhibit sexual functioning may actually improve it.

Many commonly prescribed medications have been reported to cause sexual problems: sedatives, hypnotics, anti-anxiety drugs, narcotics, antipsychotic medications, antidepressants, antihypertensives, diuretics, anticancer drugs, and antiandrogens. Some of the drugs are known to contribute to impotence more than others, and physicians can at times make recommendations that do not compromise the health of the patient. Alcohol and many illegal drugs, including cocaine, amphetamines, marijuana, and heroin, have also been found to cause erectile difficulties.


Diagnostic tests are available to assist the physician in diagnosing the presence of organic conditions that cause impotence. These tests involve evaluation of different body systems and include endocrine, neurological, and vascular studies. One of the most recent and helpful diagnostic techniques involves physiological monitoring of erection patterns in men during sleep. These nocturnal penile tumesence (NPT) studies evaluate reflexive erections that all males have during rapid eye movement (REM) sleep. The REM erections, as they are called, occur at regular intervals during sleep and for varying durations, according to the age of the individual. For the most part, men with organic impotence have a disturbance in their REM erections, while men with psychogenic impotence tend to have normal patterns of erections. NPT studies are carried out in sleep laboratories and can be very useful in making accurate diagnoses and planning treatment.


Psychogenic impotence has long been the target of various forms of psychotherapy and sex therapy. Traditional forms of psychoanalytic therapy are less used today because more effective forms of treatment have been developed. They include an eclectic intervention that combines behavioral, cognitive, and couples therapy to reduce the anxious, maladaptive behavioral and cognitive patterns leading to the sexual dysfunction. The theory and practice of sex therapy have taken on an international scope, with much research and many innovations in practice and technique emerging each year.

Organically based impotence has also been successfully treated with a variety of interventions, including a medication (Yohimbine) that assists erection as well as injections of papaverine and phentolamine agents directly into the penile musculature to act on the venous system to induce erection. This technique is especially useful in men who have had spinal cord damage resulting in trauma to the nerves in the pelvic area that are needed for erection. A noninvasive technique that is gaining acceptance among sex therapists and urologists involves the use of an external vacuum device. Placed over the penis, the vacuum pump assists in trapping the flow of blood and allows for a temporary erection sufficient for intercourse.

Surgical techniques have also been developed to correct certain vascular problems that cause erectile difficulties. One of the major surgical advances is the use of penile prosthetic implants that allow a male to obtain and maintain an erection at will. The implant allows the male to achieve what looks like a natural erection.

Whatever the form of treatment for impotence, its overall affect on the male must be taken into consideration. During the course of developing erection problems, whether they are organic or psychological, a complicated pattern of behavior and feeling develops between the male and his partner. These patterns can result in much misunderstanding and resentment and need to be attended to as part of the overall recovery from this sensitive male sexual condition.


American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 3rd ed. rev. Washington, D.C.: American Psychiatric Press, 1987.

Frank, E., et al. Frequency of Sexual Dysfunction in "Normal" Couples. New England Journal of Medicine, Vol. 299, No. 3 (1978), pp. 111-15.

Kaplan, H.S. The New Sex Therapy. New York Brunner/Mazel, 1974.

Kinsey, A., W. Pomeroy, and C. Martin. Sexual Behavior in the Human Male. Philadelphia: Sanders, 1948.

Kolodny, R., W. Masters, and V. Johnson. Textbook of Sexual Medicine. Boston: Little, Brown, 1979.

Masters, W., and V. Johnson. Human Sexual Inadequacy. Boston: Little, Brown, 1970

Masters, W., and V. Johnson. Human Sexual Response. Boston: Little, Brown, 1966.

Smith, A. Causes and Classification of Impotence. Urological Clinics of North America. Vol. 8 (1981), pp. 79-89.

Wagner, G., and R. Green. Impotence. New York: Plenum Press, 1981.

Julian W. Slowinski



Incest is sexual behavior between people who are too closely related by blood or family ties to be able to marry. Most of the time when we think of incest victims, we think of children. However, according to the definition, two related adults could also be involved in incestuous relationships, such as adult siblings or an adult daughter and her father.

Incest involving children is one form of child sexual abuse. Child sexual abuse is greatly underreported. Authorities receive reports of child sexual abuse in 25 percent of girls and 17 percent of boys under the age of 18. Many more children are undoubtedly abused sexually but do not report it. Not all of these offenses are committed by someone to whom the victim is related. Children are most often sexually abused between the ages of three and eleven. Most children who experience incest have more than one forced sexual encounter.


Children may experience forced sexual contact, such as inappropriate kissing or hugging, oral-genital contact, vaginal or anal penetration, and any discipline (e.g., spanking) that involves the genitals. Noncontact sexual abuse includes exhibitionism, voyeurism, coercion to view or participate in child pornography, obscene sexual language, obscene sexual telephone calls, and any other type of intrusive behavior (e.g., not allowing a child to undress or use the bathroom in privacy).

Most cases of child sexual abuse are incest. In very few incest cases is violence or physical force used. Most of the time, the offender uses bribery, tricks, threats, and manipulation to convince the child that what is occurring is acceptable and should remain a secret.

Incest is never the child's fault. The offender takes advantage of the child's trust and lack of knowledge about sex. A child may become complicit in the abuse, but that is not the same as consent.


The effects of child sexual abuse are traumatic and can be devastating, especially if the child's report of abuse is not believed. Children rarely lie about sexual abuse. Generally, they do not tell anyone about it.

Incest survivors experience feelings that include anxiety, confusion, betrayal, depression, fear, guilt, helplessness, responsibility, shame, hopelessness, anger, and distrust. These feelings can lead to problems with relationships or intimacy, sexual dysfunctions in adulthood, inability to trust others, low self-esteem or self-image, multiple personalities, social withdrawal, substance abuse, eating disorders, suicidal behaviors, dissociation, self-mutilation, prostitution, promiscuity, or regression to a younger age.

Many survivors of incest and child sexual abuse do not remember the experience. Repression of painful memories is common. However, even those who do not remember may have emotional flashbacks of the event. Memories may be triggered by sights, sounds, events, smells, places, or times that are related to the abuse. Remembering is often a sign of strength and may indicate that the survivor is able to cope with the memory.

If the child of a parent survivor of incest also becomes a victim, the parent may remember his or her own victimization. Recollections are common at three times in a survivor's life: when the first consensual sexual experience occurs, during a first pregnancy or childbirth, or when a child reaches the age when the parent survivor was first abused. Recovery from incest victimization starts after a disclosure, and professional help is usually necessary for maximum recovery.

Controversies surround beliefs about incest. For example, it has been argued that incest between consenting adults is a victimless activity and should not be illegal. Yet sexual relations between an adult daughter and her father still contain an element of power that does not allow the daughter to exercise free choice; there must be an element of coercion or force involved. Regardless of the correctness of this argument, incest is currently illegal and considered immoral by all religions.


Bass, E., and L. Davis. The Courage to Heal. New York: Harper & Row, 1989.

Lew, M. Victims No Longer. New York: Harper & Row, 1990.

Sanford, L.T. The Silent Children. New York: McGrawHill, 1980.

Andrea Parrot


These are demons associated with witchcraft that have sexual overtones. An incubus, from the Latin incubare, "to lie upon," was the male form, while a succubus, from the Latin succubare, "to lie under," was the female form. Often, lascivious dreams or "wet dreams" were attributed to the action of an incubus or a succubus. They were often reported to exist in monasteries and convents. Sometimes the devil himself was said to appear as a goat with his penis in the rear to enable him to back up to the female and rub against her.

In some accounts of the incubus and succubus, they are one and the same creature. The succubus receives semen from a man and then turns into an incubus to spend the semen on a woman.


Bullough, V.L. Sexual Variance in Society and History. Chicago: Univ. of Chicago Press, 1976.

Vern L. Bullough


It is difficult to generalize about North American Indians. They belonged to many different cultures, spoke dozens of languages, followed different ways of life, and subscribed to disparate religious practices. Likewise, sexual conduct varied widely among tribes. Some Indian cultures tolerated a great variety of sexual expressions and identities; other tribes closely circumscribed sexual behavior. This entry describes the range of sexual behavior found in North America and gives some attention to the impact of European colonization on Indian sexual practices.

On the whole, American Indian societies were more permissive than any of the European Christian nations that began the conquest of Native America in the late 15th century. Among Indians, virginity was not necessarily prized in either sex. Sexual experimentation was regarded as ordinary adolescent behavior, and many tribes permitted—indeed expected—young people to gain sexual experience before marriage. After marriage, some tribes tolerated extramarital sex in both husband and wife, although others prescribed punishments for adultery.

Many tribes accepted polygyny, but this practice was usually reserved to a few powerful men. Most Indians obtained divorce easily by simply declaring that the marriage was over. Serial monogamy was a common marriage pattern throughout North America. A few tribes incorporated ritual sex into their religious life, while other groups regarded sex as a purely private matter. In native society, sexuality was thought to be spiritual as well as an ordinary aspect of worldly life. Spiritual experiences and dreams often revealed gender to individuals, or even to their mothers.

All tribes had sexual divisions of labor and defined gender roles that were often distinct from European norms and which influenced Indian sexual behavior. Indian women were hardworking, productive members of their societies. In some tribes, women farmed, gathered wild plants, prepared food—including the game that their husbands provided—and made clothes, baskets, and pottery utensils. Some societies permitted women to be chiefs and shamans; in other tribes these pursuits were reserved for males. Men hunted, fished, and sometimes farmed. In most tribes, men were the acknowledged political and spiritual leaders. Most Indian tribes provided for an alternate gender, the berdache. The berdache were biological males who dressed as women and did women's work. Often they married Indian men. The husbands and lovers of the berdache were not regarded as homosexuals even though they had sex with males.

As in other cultures, Native American sexual life and identity developed during childhood. The process varied from tribe to tribe in native North America, but most children learned about sexuality from adult behavior and talk. In the Qipi Eskimo society of the eastern Arctic, for example, parents taught about sex through play and example. Mothers and fathers openly touched, kissed, and admired their babies' genitals during infancy. Sexual play among Eskimo children continued well into adolescence. Children talked openly about sexual experiences, and parents took these discussions as a sign of normal child development. Nevertheless, parents discouraged masturbation during childhood. These people did not admire berdache behavior and thought that masturbation was a precursor to homosexuality.

Other tribes esteemed sexual variance. The Navajo, for example, placed great value on hermaphrodite (or nadle) children. Nadles were considered to be lucky and ensured the health of a Navajo family. As the nadle child grew older, so did the respect of the community toward the nadle until it bordered on reverence. Cross-gender behavior was not limited to men. Although much less is known about female cross-gender behavior, some native women assumed the role of men and participated in every aspect of male life, including, in some tribes, war and tribal councils. These women often took wives and observed, as husbands, taboos at the time of their wives' menstruation; at the same time they denied their own menstruation. The Kaska in Canada not only accepted cross-gender behavior but encouraged it. At the age of five, if her parents chose, a female child was dressed—and taught to act—as a boy. After the girl learned to hunt, her degree of proficiency fostered respect in society. Cross-gender individuals denied having the physical attributes of their biological sex. According to tribal views, these people were not just pretending to be men; they were men, just as berdache were women.

While many tribes permitted cross-gender behavior, most Indians adhered to biologically determined sex roles. Puberty marked the onset of adult sexual roles for men and women alike, although marriage might not occur for some time. Many tribes formally recognized the dawn of sexual maturity for young men and women. For men, late adolescence was often a time when older men initiated them into male societies. Young men also had to prove their competence as providers and, in some cases, as warriors before they could marry. Many tribes celebrated the onset of menses in young women. Menarche marked the beginning of a young woman's fertility and was palpable evidence of female power. A woman from the Fox tribe recalled being told to hide herself and that she could drain the power of a man if she looked his way during menstruation. Mountain Wolf Woman of the Winnebago tribe remembered being told to run away into the woods when she first menstruated. She was supposed to remain alone and not to look at anyone, especially men, for a glance from a menstruating woman could contaminate their blood.

While some tribes feared the power of menstruating women, negativism did not characterize Indian attitudes about menstruation and female power. For example, the Lakota Sioux incorporated the buffalo, a sacred symbol of life, birth, and survival, into the ritual celebrating menarche. During the buffalo ceremony, a shaman guided the young woman toward a new stage in her life. During a period of seclusion in which she assumed a sacred state, the shaman joined her, and symbolically they became buffalo man and buffalo woman. They drank a mixture of chokecherries and water that symbolized menstrual blood and the renewal of life. Afterwards, the woman reentered the profane world with a public celebration commemorating her new maturity. The seclusion of the woman at the onset of menarche and during menses reinforced her status as a mature woman with a reproductive role.

Sexual maturity was one of the qualifications for courtship and marriage. Tribal courting styles varied considerably. For example, among the Pima of central Arizona, the young man, accompanied by a married friend, visited the home of his prospective bride. The friend pleaded the suitor's case to the woman's family while he remained silent. After several nights of this wooing, the suiter became the woman's husband if she accepted him. Among the Hopi, a prospective suitor came to see his beloved while she ground corn in the grinding house. The couple talked through a window, and, if they agreed, they met later that night. Eventually, the woman invited her prospective groom on a picnic where she presented him with quomi, a specially prepared loaf of sweetened cornmeal. This was a formal proposal of marriage, and by accepting her gift, he agreed to become her husband. Then they asked for parental approval.

Among the Oglala Sioux, a marriageable woman waited outside her tipi at sunset, while her older kin remained inside and observed her suitors. Prospective suitors approached her, carrying a courting blanket, and—if she was especially popular—formed a line in front of her. Each man placed his arms around her, enveloping her in his blanket, and had a private conversation with her. He had to be brief yet convincing because others waited their turn. The choice of partner then rested with the woman, whose parents generally accepted her decision. The ultimate goal of courtship was marriage. Ordinarily, suitors sought parental approval, but if it was not forthcoming the lovers might elope.

As with other aspects of sexual behavior, marriage rituals differed from tribe to tribe. Marriage formalized a sexual partnership between the couple as well as trading and political alliances between families. Once a young Pima woman accepted a man, he stayed in his bride's home for four days. They then returned to his parents' home. The next morning at dawn, his mother gave the bride a large basket of wheat to grind and make into tortillas by sunrise. His family accepted her upon completion of this task, and the couple was married. The groom presented her with a blanket, and his parents gave her presents.

Marriage among the Oglala was a complicated affair involving a series of gift exchanges between the families. The groom's family gave the young woman many valuable gifts, which she distributed to her parents. Her parents then gave her gifts to distribute to his parents. Afterwards, her family erected a special tipi for the couple, under the direction of her grandmother; the prospective husband furnished it. The women in his family clothed her in a new buckskin dress that his mother made, the family held a huge feast for everyone in the tribe, and the couple were married.

Reproduction was an important part of the marriage relationship, and the absence of children or the birth of deformed or stillborn infants was a matter of grave concern. If an Apache couple did not have children, the community attributed male impotence to bewitchment. Less commonly, Apaches believed that the woman's mother caused her barrenness. Divorce was the common solution for such unhappy problems. Some California tribes killed deformed infants and occasionally the mothers who bore them.

Except in special cases, most Indians believed that the partners in married couples should have sexual relations only with each other. In practice, however, extramarital affairs occurred, and some tribes imposed sanctions on transgressors. Husbands beat, mutilated, and sometimes killed errant wives. In some societies, tribesmen who seduced other men's wives had to pay the wronged husband. As a general rule, husbands who misbehaved were not punished, although historical accounts tell of Indian women who beat their unfaithful husbands.

Adultery was a punishable offense, but many tribes permitted extramarital sexual relations in particular situations. Among the Pueblo Indians and Plains tribes, men commonly gave their wives to visitors for a night. This was a way of demonstrating peaceful intentions and cementing trade relations. On the plains, men who received sexual service were expected to reciprocate with a gift that symbolized a reciprocal relationship between the parties rather than a payment for sex. Among the Mandan and Hidatsa of the upper Missouri River, women copulated with powerful males to physically transfer power to their husbands. Some gamblers wagered sexual access to their wives. It should be noted that women were not free agents in these arrangements. While a husband could give, win, trade, or lose his wife's sex, a woman ordinarily could not do the same for herself without risking the wrath of her husband.

Many tribes incorporated sex in tribal rituals. The Mandan, Hidatsa, Atsina, Blood, and Arapaho tribes had men's societies in which the initiate ceremoniously gave his wife to an older member. In the Black Horn Society of the Blood tribe, an older man who was retiring from the society selected a young man to whom he wished to transfer his membership. The retiree compelled the appointee, regardless of his wishes, to participate in the transfer ceremony. In a public rite, the wife of the retiree painted the new member and his wife, and gave them new clothes and regalia; the appointee and his wife then proceeded to dance with their new insignia. Then there was a private ritual. The new member's wife, wearing only a robe, carried a pipe to the tipi of her ceremonial father, the older man who was transferring his membership. After smoking the pipe, the "father" and the woman left the camp, laid down, and again prayed with the pipe. He then touched his penis to her vagina. If she had led a virtuous life, he bawled like a bison and then copulated. During intercourse, he transferred a piece of prairie turnip to her mouth from his. Then the woman returned to her husband in the Horn tipi; there she remained quietly and fasted for a day. Her "father" concluded the ceremony by painting her, one pattern indicating performance of the first half of the ritual, another pattern signaling completion of the entire ritual and, therefore, honor to the woman and her husband.

The Mandans employed ceremonial intercourse in the Buffalo Dance, which they believed attracted large buffalo herds and brought prosperity to the camp. The tribe thought that intercourse between a well-respected woman and a man of recognized power transferred power from the buffalo to the woman and her husband. The Pueblo Indians also incorporated sexual intercourse in annual ceremonies that were meant to ensure fertility and social harmony.

Pueblo Indian clowns indulged in comic sexual acts and ridiculed any aspect of Indian life; even the sacred was targeted for ridicule. Clowning served an important purpose in Pueblo society. Some religious ceremonies could not begin until everybody had laughed, and the clowns' sexual antics released tension in societies where group harmony and self-control were of prime importance. Thus, a ribald clown copulating with a donkey might precede a carefully choreographed religious ceremony of profound spiritual significance.

The European invasion of America posed a challenge to traditional Indian sexual mores. Indian sexuality reinforced Europeans' negative stereotypes of Indians and helped to justify conquest and colonization. Sexual wantonness—as Europeans saw it—demonstrated that Indians needed Christianity and European civilization. According to European norms, the ideal woman was chaste, submissive, and asexual, while the ideal man was sexual, aggressive, and dominant. Christian marriages were supposed to be lifelong and monogamous bonds absolute. Imbued with Christian sexual values and a desire to convert Indians to the Protestant and Catholic religions, missionaries attempted to persuade Indians that customary sexual practices were violations of divine law. Catholic missionaries for Spain and France waged unremitting war against Indian sexual practices that contravened Church teachings. Friars gave special attention to polygamy, homosexuality, and extramarital sex but seldom succeeded in eradicating these customs. Instead, many Indians continued to observe customary practices in secret while outwardly observing the forms of Christianity. In the 19th century, Protestant clergy and federal agents carried on the fight for sexual orthodoxy.

European traders who were more interested in commercial advantage than spiritual redemption also transformed Indian sexual behavior. They interpreted the reciprocal exchange of gifts and sex as an act of prostitution. Likewise, the sacred nature of sexual ritual and the transfer of power through coitus were lost on Europeans who interpreted Indian sexuality as lustful while taking advantage of the carnal opportunities that Indian society provided. White traders who entered Indian country without women frequently took Indian wives, at least until white women became available and native women were discarded. Worse, white traders' demand for Indian women led to a trade in captives who were sold to white purchasers. Sacagawea, the Shoshone woman who accompanied the Lewis and Clark expedition across the West, was the most famous of these enslaved women.

Twentieth-century Indian sexual behavior has not been thoroughly described. Many Indians are Christians who observe the sexual requirements of their denominations. The sex lives of other Indians reflect older values and beliefs. The berdache tradition, for example, continues in evidence on some reservations, and some urban Indian homosexuals regard themselves as berdache. Like everyone else in the United States, Indians have experienced the impact of mass culture, and there can be little doubt that it has affected Indian sexual behavior. Nevertheless, Indian sexuality continues to reflect the variety of native tradition.


Alien, P.G. The Sacred Hoop: Recovering the Feminine in American Indian Traditions. Boston: Beacon Press, 1986.

Blackwood, E. Sexuality and Gender in Certain Native American Tribes: The Case of CrossGender Females. Signs, Vol. 10 (Autumn 1984), pp. 27-42

Briggs, J.L. Eskimo Women: Makers of Men. In C.J. Matthiason, ed., Many Sisters: Women in Cross-Cultural Perspective. New York: The Free Press, 1974.

Coontz, S. The Native American Tradition. In B. Carroll, ed., The Social Origins of Private Life. London: Verso, 1988.

Devereauz, G. Institutionalized Homosexuality of the Mohave Indians. Human Biology, Vol. 9 (1937), pp. 498-527

Gutiérrez, R. When Jesus Came the Corn Mothers Went Away: Marriage, Sexuality and Power in New Mexico, 1500-1846. Stanford, Calif.: Stanford Univ. Press, 1991.

Kehoe, A.B. The Functions of Ceremonial Intercourse Among the Northern Plains Indians. Plains Anthropologist, Vol. 48 (1970), pp. 99-103.

Niethammer, C. Daughters of the Earth: The Lives and Legends of Native American Women. New York: Collier Books, 1977.

Ronda, J.P. Lewis and dark Among the Indians. Lincoln: Univ. of Nebraska Press, 1984.

Roscoe, W. The Zuni Man Woman. Albuquerque: Univ. of New Mexico Press, 1991.

Schlegel, A. Male and Female in Hopi Thought and Action. In A. Schlegel, ed., Sexual Stratification: A Cross Cultural View. New York: Columbia Univ. Press, 1977.

Tedlock, D., and B. Tedlock. Teachings from the American Earth: Indian Religion and Philosophy. New York: Liveright, 1975.

Terell, J., and D.M. Terell. Indian Women of the Western Morning: Their Life in Early America. New York: Dial Press, 1974.

Rebecca Bales
Tina Weil
Charles C. Murdock


Sexual Response and Behavior
Toilet Training
Sexual Socialization

For humans in the prenatal stage, the genetic components necessary for sexual development are present at the point of fertilization. Female fetuses have two X chromosomes, and male fetuses have an X and a Y chromosome. If a Y chromosome is present, a testosterone bath occurs in utero to cause sexual differentiation. All fetuses begin to develop in the same way, and if the testosterone bath did not occur early in fetal development, all would become females. Following the testosterone bath (in the case of male fetuses), sometime after the sixth week of gestation, the genitals begin to develop in both males and females.

Sexual Response and Behavior

Human beings are sexual beings even before birth. Ultrasound images of male fetuses indicate penile erections in utero, and some males are born with erect penises. Infant girls are able to have clitoral erections. It is estimated that at least half of all boys experience orgasm by the age of four, although they do not ejaculate in childhood because they lack the hormones necessary to do so at that time. Babies typically begin to masturbate with their hands once they can control their movements, at about eight months of age, and also by rubbing against objects or their cribs.


Today in the United States, approximately half of all male infants are circumcised (i.e., the foreskin covering the glans of the penis is surgically removed). This procedure may be selected for religious or social reasons (e.g., so the boy will look like his father). Many people argue that circumcision is both unnecessary and barbaric. Circumcision is not the norm in most other countries.

If circumcision is chosen for a male, and the penis is injured or severed in the process, parents may decide to raise the child as a girl, using hormones and surgical procedures to change the outward appearance of the genitalia. Such instances are extremely rare, but it is often easier for a child whose penis has been accidentally removed to be raised as a female than to cope with the lack of the symbol of masculinity (i.e., the penis) in this culture.

When adults play the name-the-body-parts game with babies, they tend to bypass the sexual organs and parts. Adults will likely ask the child to name the eyes, nose, mouth, ears, belly button, knees, elbows, feet, and hands; the penis, vulva, and nipples will not be mentioned. This type of omission gives the child important messages about sexual body parts: that they are not to be discussed and perhaps are even something to be ashamed of. This message is also communicated when parents admonish a child for masturbating, rather than telling a child that masturbation is a private behavior to be done in a private place.

Touching and skin contact play an important role in an infant's normal, healthy development. An infant begins to learn sexual messages through the nurturing and bonding process. Being nursed, played with, and cuddled affects a child's development, awareness, and experience of sexuality. Babies who are not touched or nurtured become depressed and antisocial, and they fail to thrive and grow normally. They have trouble developing a sense of well-being and may even become sick and die if they are deprived of skin-to-skin contact.

In infancy, babies learn to receive and express love through the skin. Skin-to-skin contact in infancy and childhood is a precursor to the closeness and intimacy they will derive from such contact in adulthood. The skin is the organ that allows humans to express love, eventually including erotic, sexual love.

Toilet Training

The experiences of diapering, cleaning the genitals, and toilet training can have lasting effects on the view babies develop of their gender, sexuality, and sexual body parts. If the caretaker frowns and says something negative each time a child's genitals are exposed with a dirty diaper, that child may develop negative attitudes about his or her genitals. After all, every time the genitals are exposed, the child is given a negative message. An infant is too young to understand that the unpleasant faces and messages reflect the presence of feces rather than the genitals. Adults may also give messages about gender during potty training, such as saying to a boy that he should stand up, just as daddy does, and to a little girl that she should sit on the seat the way mommy does.

Sexual Socialization

Sexual socialization—learning how males and females are to interact with each other and how to behave in sexual situations—begins at birth. It is a dynamic process, with information being obtained by observation, by being taught, or by experiencing what the culture considers appropriate behaviors for males and females. These expectations vary from culture to culture.

Children learn to respond as sexual beings as early as infancy. Parents tend to treat male and female children differently, reflecting the parents' expectations of how boys and girls, and men and women, should act socially and sexually. During infancy, the child receives cues about gender from adults. Parents dress girls in pink and boys in blue, and say things like "Big boys don't cry" or "Act like a lady." Studies show that parents tend to hold, play with, and touch girl babies differently from the way they handle boy babies. In addition, adults tend to give boys and girls different toys, which prepare them for later interactions with others and the world. Little boys are rarely taught to knit, although that is an activity many girls are taught. Girls are much more likely than boys to be given dolls; boys are more likely to receive trucks. Chromosomes, hormones, and sex organs do not predispose girls to be better at knitting or to enjoy it more than boys do, or boys to want to play with trucks. These differences are established through sexual socialization.


Calderone, M.S., and E.W.Johnson. The Family Book About Sexuality. New York: Bantam Books, 1983.

Halverson, H.M. Genital and Sphincter Behavior of the Male Infant. Journal of Genetic Psychology, Vol. 56 (1940), pp. 95-136.

Kinsey, A., W. Pomeroy, and C. Martin. Sexual Behavior in the Human Male. Philadelphia: Saunders, 1948.

Andrea Parrot


Causes of Infertility
Infertility in Men
Infertility in Women
Treatment of Men
Treatment of Women
Emotional Impact of Infertility
Financial Issues

Infertility is currently defined as the lack of ability to conceive a pregnancy or carry a pregnancy to term after having unprotected sexual intercourse for one year. (For couples over age 30, the period to be considered is six months, because older couples have less time for lengthy infertility testing and corrective procedures.) Approximately one in five couples suffers from infertility at some time during their childbearing years. Of those couples with infertility problems, approximately 40 percent have a female problem and approximately 40 percent have a male problem; in the remaining 20 percent of cases, both members of the couple experience some type of infertility.

Each year, an increasing number of persons seek treatment for infertility; however, it is unclear whether the number of infertile persons is increasing or more people are seeking assistance. Currently, 2.4 million U.S. couples who want to have a child must seek medical assistance or turn to other options such as adoption. New infertility cases are estimated at 160,000 per year, with 200,000 to 300,000 patients currently receiving treatment.


The chance of achieving a successful pregnancy is slightly more than 30 percent with a perfectly timed menstrual cycle, since some eggs do not become fertilized and some of the fertilized eggs do not grow well in the early developmental stage. For a woman to become pregnant, she must ovulate (i.e., an egg must leave the ovary); the fimbriated (fingerlike) ends of the Fallopian tubes must pick up the egg and move it inside a tube; the sperm must swim through the cervix and uterus and into die Fallopian tube. One sperm must penetrate the egg. The fertilized egg, now an azygote, must move down the tube into the uterus and attach itself to the uterine lining where it is called an embryo. Healthy sperm are believed to live two to three days in a woman, and an ovum is thought to be fertilized 12 to 24 hours after ovulation.

Causes of Infertility

Infertility often results from sexually transmitted diseases (e.g., gonorrhea, syphilis, chlamydia) or other infections (e.g., tuberculosis) that cause scarring and blockage of the Fallopian tubes in women or the vas deferens in men, thereby preventing the passage of ova or sperm. Sometimes an intrauterine device is implicated in the spread of infection to the pelvis, causing pelvic inflammatory disease (PID). Certain viruses, such as herpes simplex, and venereal warts can also lead to problems by damaging the cervical mucus. The rate of infertility following infections increases with age, because the likelihood of contracting a sexually transmitted disease increases with the number of sexual partners.

Men need to produce approximately 60 million sperm per ejaculate to be considered fertile. Most healthy young men produce at least 200 million sperm per ejaculate. However, because sperm count decreases with age, the chances of becoming infertile increase with age. In addition, stress, diet, radiation, excess heat (e.g., saunas), mumps after puberty, a varicocele (i.e., a varicose vein in the scrotum that raises the temperature of the testicles), undescended testicles, drug use, and wearing jockey shorts can interfere with the production of sperm.

Any mechanical problem that interferes with sperm placement can cause infertility. If men are unable to ejaculate because they have erectile dysfunctions, they may be unable to place the sperm in the woman's vagina. Men who seek to reverse a vasectomy may experience low sperm count or infertility if the reversal is unsuccessful or the man has developed antibodies to his own sperm.

Aging women may fail to ovulate, and they are more likely to carry genetic abnormalities. Therefore, the risk of miscarriage increases with age. Other conditions that contribute to infertility in women include endometriosis (i.e., a condition in which part of the endometrial lining of the uterus migrates into the abdominal cavity), vagina acidity (which interferes with sperm motility), thick cervical mucus, cervical polyps, amenorrhea, uterine abnormalities, vaginismus (i.e., die muscles at the entry of the vagina squeeze so tightly that penetration by the penis is impossible), lack of ovulation (sometimes as a result of low levels of the body fat necessary to metabolize sex hormones), smoking, and drug use.

Infertility in Men

The diagnostic workup in a man starts with a complete medical history and physical examination. Attention should be paid to the following factors: significant diseases (e.g., mumps after the age of puberty), undescended testicles, varicocele, or a hernia that has not been repaired. A comprehensive sexual history is done, including level of sexual activity, approximate age of onset of puberty, and incidence of sexually transmitted diseases.

Usually, the first test for infertility in the male is analysis of a semen sample, obtained through masturbation, to determine the presence and quantity of sperm, the ratio of normal to abnormal sperm, and the evidence, if any, of an autoimmune response. The ratio of active sperm cells to the total is extremely important, as is the quality of the cells' movement. Both these indices constitute aspects of motility. Sperm counts as low as 20 million per cubic centimeter can be considered normal provided other parameters are within the normal range. A standard scale is used to evaluate the characteristics of the ejaculate sample (see Table 1).

Table 1. Limits-of-Adequacy Criteria*



Ejaculate volume

1.5-5.0 cc

Sperm density

> 20 million/ml


> 60%

Forward progression

>2 (scale 1-4)


No significant microscopic sperm clumping
No significant white cells or red cells
No increased thickening of the seminal fluid (hyperviscosity)
* on at least two occasions.

Males can also be tested for the presence of seminal fructose, which can indicate blockage or some failure in development, which can be confirmed through X-ray. Sometimes, a postcoital, or Huhners's, test is done to evaluate sperm survival in cervical mucus just before ovulation. This test also detects possible antisperm antibody formation. Because only preovulatory mucus nourishes sperm and allows it to remain active, scheduling of the activity is required.

Blood testing in the male evaluates levels of testosterone, follicle-stimulating hormone (FSH), and luteinizing hormone (LH). Low FSH and LH levels suggest problems stemming from the hypothalamus or the pituitary gland. High levels suggest a problem in the testicles. A picture of the sperm transport system can be obtained through a procedure called a vasogram, which is usually performed under a short-acting anesthetic. The scrotal sac is opened, dye is inserted into the vas deferens, and an X-ray is taken. A culture of the urethral opening is done to identify any infection.

Immunological factors may play a role in male infertility. An increased incidence of antisperm antibodies has been found in infertile men, and suppression of these antibodies with cortico-steroid treatment has resulted in both improved sperm quality and an increased pregnancy rate.

The investigating practitioner may recommend sperm penetration assays. The ability of the sperm to penetrate an ovum is measured by the hamster test, which uses hamster ova. However, failure to penetrate hamster eggs and failure to penetrate human eggs are not always equivalent.

Infertility in Women

Female infertility may be caused by structural disorders of the Fallopian tubes or uterus, hormonal imbalances, or problems with the cervix. Physical occlusion of the Fallopian tubes, structurally preventing the egg and sperm from meeting, occurs with the scarring and adhesions from PID. Other defects in the tubes can prevent the egg and sperm from passing through them. Structural abnormalities of the uterus may prevent a woman from carrying the fetus to term. A tumor of the uterine wall may be amenable to surgical correction.

Imbalances involving the four major fertility-related hormones—FSH, LH, estrogen, and progesterone—are the source of the problem in 20 percent to 30 percent of infertility patients. These hormonal imbalances can cause ovulatory disturbances and habitual spontaneous abortions usually during the first trimester; they may also result in a failure of the follicle to mature or failure of the embryo to become implanted in the endometrium.

The cervix can be the cause of infertility if there is stenosis (narrowing). Poor mucous production, which inhibits the transport of sperm, is another cervical disorder. Cervicitis, or inflammation of the cervix, may kill sperm or inhibit their movement.

The diagnostic process for women, as for men, involves a number of steps. The reproductive organs can be checked visually and manually by means of a pelvic examination. A history is obtained, including menstrual history, sexual development, previous pregnancies, and sexually transmitted diseases. The basal body temperature (BBT) is plotted each morning before any activity is started. The pattern of the BBT indicates if and when ovulation occurs and provides a data base for scheduling and interpreting hormonal and other tests.

Blood tests, along with the utilization of ultrasound to track follicle growth in the ovary, facilitate charting of the entire menstrual cycle. At the beginning, middle, and end of the cycle, four hormones are tested: FSH, LH, estrogen, and progesterone. Screening tests for prolactin are also done. This hormone should be found only following childbirth, so its presence suggests problems related to the pituitary gland.

Sometimes, an endometrial biopsy is done to further evaluate the menstrual cycle and the quality of the uterine lining for implantation of the embryo. Visualization of the Fallopian tubes for blockage may also be done by means of a hysterosalpingogram (HSG), which takes place in the X-ray department. Contrast dye is slowly injected into the uterine cavity, and the tubes are visualized on a television screen through fluoroscopy. Both of these procedures can be done on an outpatient basis, although cramping may occur.

If further information about the pelvic organs is needed, a laparoscopy may be performed. A general anesthetic is used, and a small incision is made near the navel. A telescopelike instrument is inserted into the pelvic cavity to visualize the area. Since the HSG may miss adhesions and scar tissue and cannot diagnose endometriosis, the laparoscopy may be necessary to detect evidence of scarring from pelvic disease. Direct visualization of the uterine cavity for tumors, adhesions, or congenital anomalies may be done at the time of the laparoscopy.

Treatment of Men

The treatment of male infertility may require surgery or medication or may involve techniques for improving the quality of the sperm. Surgery is directed toward improving the production of sperm or improving its delivery from the site of maturation (testis) and storage (epididymis) to the egg (ovum). Scrotal varicocele is reported in 21 percent to 41 percent of infertile males, three times the rate of occurrence in healthy men. Corrective surgery has been reported to improve semen quality in 67 percent of patients: the average pregnancy rate following varicocele repair is approximately 40 percent with the average pregnancy occurring six to nine months after surgery. Surgery has also been used to reverse vasectomies and the reported pregnancy rate is now 45 percent to 70 percent with the new microsurgery. Surgical construction of a new link between the epididymis and a distal portion of the vas has resulted in an 11 percent pregnancy rate when the obstruction is at the head of the epididymis and 30 percent when the obstruction is at the tail. Some men have an ejaculatory-duct obstruction, which may be removed in a simple transurethral procedure. New devices based on European prototypes are being developed for cases in which normal sperm pathways are beyond surgical repair. However, success rates are still quite poor.

Medically, male infertility can be treated with hormonal replacement in 5 percent of men and with high-dose cyclic steroid therapy following vasovasotomy procedures. The use of antihistamines and alpha-sympathomimetic drugs has been reported to improve sperm emission in as many as 40 percent of male patients. Forty percent of men presenting with infertility have both normal genitalia and a normal hormone profile, with no apparent reason for their poor semen analysis. Sometimes anti-estrogens (e.g., clomiphene citrate and tamoxifen) increase the levels of LH and FSH. Drug therapy has brought reported improvements in sperm density and motility, with pregnancy rates ranging from 8 percent to 41 percent. Testolactone, which blocks the conversion of testosterone to estradiol, has resulted in reported pregnancy rates of 25 percent to 33 percent. Human chorionic gonadotropin (HCG), a treatment for unexplained low sperm count, has increased sperm count and motility. Some drugs used in the treatment of infertility in the 1950s and 1960s (e.g., arginine, bromocriptine corticosteroids, thyroxin, and oxytocin) are seldom used now.

The testes are heat sensitive and must remain about 4 degrees cooler than the normal body temperature. Scrotal hypothermia is a new treatment being advocated for infertile men. Patients wear a device for 12 to 16 hours daily that cools the scrotum by an evaporation process. However, its efficacy remains speculative.

Treatment of Women

In the case of the woman who is otherwise normal and has a fertile partner, induction of ovulation, or stimulation of ovulation is performed. During monthly ovulation, hormones are released from the hypothalamus and the pituitary. The hypothalamus releases gonadotropin-releasing hormone (Gn RH). This hormone signals the pituitary gland to release FSH and LH, which is responsible for the development of ovarian follicles. Two drugs, Clomidane and Serophene, have been given if the cause of the problem is in the hypothalamus. Another drug, Pergonal, directly stimulates the ovaries. It has been known to cause multiple gestation in 20 percent of cases, and 5 percent of those result in three or more fetuses. The incidence of birth defects or congenital anomalies has been reported in clinical trials of 287 completed pregnancies as 1.7 percent, which is similar to that reported in the general population.

A drug called Metrodin, which contains FSH, is used for ovulation induction when the LH level is elevated and the FSH level is low to stimulate the ovarian follicle. Ectopic pregnancies have been reported with the use of Metrodin, but again the rate of birth defects did not exceed that found in the untreated population. In clinical trials, 83 percent of cases involved single births and 17 percent multiple births.


Technologies may be part of the solution to infertility. These technologies include artificial insemination (AI), in vitro fertilization (IVF), and gamete intrafallopian transfer (GIFT), with all sorts of variations (see the glossary at the end of this entry). AI and IVF are the most common procedures. Another technique, in vitro fertilization and embryo transfer (IVFET), allows the use of sperm from males who have semen of reduced quality and is reputed to be as successful as using embryos fertilized with sperm from men with normal semen. Intrauterine insemination (IUI) involves the placement of large numbers of motile spermatozoa at the approximate time of a female's menstrual cycle. IVF and GIFT have been successful when the male sperm count was the cause of the infertility. Even under the most favorable circumstances, however, these procedures result in less than a 50 percent success rate, so repeated attempts are the norm.

Emotional Impact of Infertility

Infertile couples may experience a "crisis of infertility" characterized by excessive anxiety, damaged self-esteem, grief, uncertainty about the future, and estranged relationships both with each other and with family and friends. The trauma of the diagnosis is also influenced by social and cultural norms. Most people, long before they become sexually active with a partner, assume fertility. They concern themselves with questions of choice: Do I want to have children? When will I have them? With a diagnosis of infertility, choice, in the most fundamental sense of the word, is stripped from the individual or couple.

They become different. People who are childless are often regarded with suspicion or pity. To have children is considered natural. To discover that it is not possible, even temporarily, potentially strips the individual and couple of one of the most important and expected societal roles: that of parent.

Prior to attempting to investigate infertility, the couple must overcome their denial that something is wrong. Societal assumptions and myths are not very useful. Couples are encouraged to relax and let nature take its course, or they are told that if they adopt a baby, they will be able to have their own biological child. They may have to work through these false assumptions and myths before medical intervention can be useful.

After the diagnosis is made, they often experience the same stages of mourning as do people following the death of a loved one. Although both members of the couple may experience the stages of denial, anger, grief, and acceptance, they rarely experience these stages simultaneously. They are mourning the loss of a dream; in the case of miscarriage or stillbirth, they are mourning the loss of a fetus who was tangible to them and whom they may have already felt. These emotional reactions are often dramatic and disruptive to relationships. Some couples split as a result of the strain of infertility or because one member believes he or she might have been a parent already with another partner. In some cases, the infertile partner wants to leave the relationship out of guilt, believing that the fertile partner deserves to become a parent. Although some relationships are strong enough to withstand this emotional trauma, all involuntarily infertile couples who want children are emotionally traumatized.

Furthermore, partners respond to infertility differently. In a qualitative study of married couples' reactions to infertility, wives were found to experience it as a cataclysmic failure and to withdraw from interactions with the fertile world, focusing on the problem of infertility, thinking about it daily, reading about it constantly, and being willing to do whatever was necessary to solve the problem. In contrast, husbands saw infertility as a disconcerting event, something they could accept and put into perspective. This was true regardless of which partner had the reproductive impairment.

Wives were the initiators and leaders in the treatment process, and couples tended to see infertility as a problem for wives. Frustration and lack of communication were consequences of the confrontation between the couple.

Financial Issues

Financial considerations are important to young couples, and most have neither the private resources nor the insurance coverage to pay for diagnosis and treatment. For those with insurance coverage, payment may be based on creative billing and the use of terminology. For example, if the problem causing the infertility is related to a hormonal imbalance, treatment may be covered if the form reads "hormonal insufficiency" rather than "infertility." However, many insurance companies refuse to cover infertility services, claiming that the condition is not an illness. Counterarguments by infertility support groups describe infertility as a body-system malfunction that is as eligible for medical insurance coverage as any other system failure. Some states now require insurance carriers to cover the cost of infertility. Texas limits the coverage of IVF to married women, allowing insemination only with their husband's sperm. This rule eliminates coverage for a woman who has a tubal occlusion and is married to a man with a low or nonexistent sperm count. Massachusetts limits the mandate to private insurance carriers, thus eliminating women who are covered by medical or other governmental programs. Some states limit the coverage for experimental treatments.

Costs are formidable, and a comprehensive diagnostic workup is basic to the treatment plan. According to recent data, the average cost of diagnosis per successful pregnancy is approximately $10,700. Medications to treat infrequent or absent ovulation cost $1,000 to $1,500 per month and require painful injections over a period of 9 to 12 days. IVF can cost $5,000 to $7,000 per attempt.


Artificial insemination by donor (AID) has had some unexpected consequences. An unmarried woman obtained sperm from a man who said he had no intention of becoming involved with the resultant child; later, when he sued for visitation rights, the courts ruled that he was entitled to see the child, and he was given the right to be designated the child's father on the birth certificate. When a married woman undergoes AID, the courts have ruled that the man to whom the woman is married is the lawful father of the child. Some states have introduced laws restricting the number of times a particular donor is allowed to father a child.

IVF is unregulated by federal, state, or professional standards and may be potentially dangerous to the consumer. A 1985 survey reported that of 54 IVF clinics responding to a questionnaire, one-half had never sent a woman home with a baby, after having treated more than 600 women. Successes in IVF clinics may be reported as pregnancies per retrieval rate (i.e., the number of eggs fertilized rather than the number of babies born). Other clinics report the percentage of pregnancies per embryo transfer but do not report the number of patients who arrive at that stage. The IVF rate is about 20 percent of achieved egg fertilizations and about 13 percent to l5 percent of actual births.


Agglutination of sperm

Sticking together of sperm


Absence of ovulation
(menses may occur with anovulation)

Artificial embryonation
("embryo adaption")

Process by which artificial insemination of a woman results in an embryo. The embryo is flushed out five days after conception and implanted in a second woman (typically, the wife of the man who donated the sperm)

Artificial insemination

Introduction of donor semen by donor (AID) into a woman's vagina for the purpose of conception

Artificial insemination by husband

Introduction of the husband's semen into the vagina for the purpose of conception


Absence of sperm in the ejaculate


Alteration of sperm during their passage through the female reproductive tract that gives them the capacity to penetrate and fertilize the ovum


Site where tissues (i.e., sperm, oocytes, and embryos) are stored in the frozen state

Egg (oocyte) donation

Surgical removal of an egg from one woman for transfer to the Fallopian tubes or uterus of another woman

Embryo transfer

Introduction of an embryo into a woman's uterus after in vitro or in vivo fertilization

Gamete intrafallopian transfer (GIFT)

Procedure wherein clomiphene citrate, Pergonal, or Metrodin is used to stimulate ovulation, and then the egg is removed by means of laparoscopy. The egg is immediately mixed with washed sperm, usually from the husband, and is then transferred into the Fallopian tubes, where fertilization may take place

Hamster test (sperm penetration assay)

Test used to determine the ability of a man's sperm to penetrate a hamster egg, with the result considered to be evidence of the sperm's general penetrating ability

Hostility factor

Inability of sperm to survive in the vaginal or cervical environment long enough to swim upward toward the ovum, due to overly acidic secretions or immunological reactions

Human menopausal gonadotropin (hMG) (Pergonal)

Natural product containing both FSH and LH that is extracted from the urine of postmenopausal women and used to treat both male and female infertility by stimulating the development of oocytes in ovulatory patients

Idiopathic (unexplained) infertility

Term used to describe infertility that cannot be explained

Immunological Response

Presence of sperm antibodies in the woman or man that tend to destroy sperm action through immobilization or clumping

In vitro fertilization (IVF)

Procedure in which an egg is removed from a ripe follicle and fertilized by sperm cells outside the human body. After the fertilized egg is allowed to divide for about two days, it is inserted back into the uterus, producing the "test tube baby"

In vivo fertilization

Fertilization of an egg by a sperm within the woman's body


Direct visualization of the ovaries and the exterior of the Fallopian tubes and uterus by means of a surgical instrument inserted through a small incision below the navel


Condition in which sperm are produced and found in the semen but are dead and cannot fertilize eggs

Oocyte retrieval

Surgical procedure in which a needle is inserted into the follicles to collect eggs, which are then placed in a medium-filled culture dish

Ovary retention

Failure of the egg to be released even though the follicle has ruptured

Ovulation induction

Use of female hormone therapy to stimulate oocyte development and release

Postcoital test (Huhner test or PK test)

Diagnostic test for infertility in which vaginal and cervical secretions are obtained following intercourse and analyzed under a microscope

Rubin test (tubal insufflation)

Test in which CO2 gas is blown into the uterus under pressure and allowed to escape out of the Fallopian tubes, if open

Secondary infertility

Inability to conceive or carry a pregnancy after having successfully conceived and carried one or more pregnancies

Sperm bank

Site where sperm is stored in frozen form for future use in artificial insemination

Sperm washing

Technique that separates sperm from the seminal fluid


Rough measure of how easily sperm cells can enter and penetrate the cervical secretions by the elasticity of the cervical mucus

Surrogate carrier

Woman who gestates an embryo that is not genetically related to her and then gives the child to its genetic parents

Surrogate mother

Woman who becomes pregnant through insemination with the sperm of the husband of an infertile woman and then following birth, turns the child over for adoption by the couple


Varicose vein of the testicles, which may be the major cause of male infertility

Zygote intrafallopian transfer (ZIFT)

Transfer of a zygote into a Fallopian tube by means of laparoscopy


Arditti, R., R.D. Klein, and S. Minden, eds. Test-Tube Women: What Future for Motherhood? London: Pandora Press, 1984.

Bauman, R. Power and Choice: Sexism and Racism in Reproductive Science and Technology. Woman of Power, Vol. 11 (1984), pp. 67-70.

Blank, R.H. Making Babies: The State of the Art. Futurist journal, Vol. 19 (1985), pp. 11-17.

Cook, E.P. Characteristics of the Biopsychosocial Crisis of Infertility. Journal of Counseling and Development, Vol. 65 (1987), pp. 465-70.

Cooper, G.S. An Analysis of the Costs of Infertility Treatment. American Journal of Public Health, Vol. 76 (1986), pp. 1018-19.

Corea, G., et al. Man-Made Women: How New Reproductive Technologies Affect Women. Bloomington: Indiana Univ. Press, 1987.

Garner, C., and G. Patton. Pathways to Parenthood. Norwell, Mass.: Serono Symposia, 1989.

Greil, A., T. Leitko, and K. Porter. Infertility: His and Hers. Gender and Society, Vol. 2 (June 1988), pp. 172-99.

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Henifin, M.S. Women's Health and the New Reproductive Technologies. Women and Health, Vol. 13 (1987), pp. 1-7.

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Rhodes, R. Women, Motherhood and Infertility: The Social and Historical Context. Journal of Social Work and Human Sexuality, Vol. 6 (1987), pp. 5-20.

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Soûles, M.R. The in Vitro Fertilization Pregnancy Rate: Let's Be Honest with One Another. Fertility and Sterility, Vol. 43 (1985), pp. 511-13.

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Susan B. Bond
Andrea Parrot
Ann Seidl


The Institute for Advanced Study of Human Sexuality was formally incorporated as a private nonsectarian graduate school on June 8, 1976, in San Francisco. On August 13, 1976, the State of California qualified the Institute to grant graduate degrees in the field of human sexuality. The first class of students began work on October 1, 1976. Approximately one year later, following evaluation by a committee on postsecondary educational standards appointed by the State of California, the Institute received approval of the following degrees by the Superintendent of Public Instruction of the State Department of Education under California Education Code Section 94310 (b): Master of Human Sexuality (M.H.S), Doctor of Arts in Human Sexuality (D.A.), Doctor of Human Sexuality (D.H.S.), and Doctor of Philosophy in Human Sexuality (Ph.D.). In June 1981, after an on-site visit, the degrees were again approved, but the Doctor of Arts degree was changed to a Doctor of Education in Human Sexuality (Ed.D.) degree.

In 1982, the Institute was granted full accreditation by the National Association of Private Nontraditional Schools and Colleges (NAPNSC). In 1987, the Institute was granted full institutional approval by the State of California, and in February 1989, after careful review, the Institute was reaccredited by the NAPNSC.

What became the Institute had its origin in 1962, when the United Methodist Church, in cooperation with the United Church of Christ, the United Presbyterian Church, the American Baptist Church, and the Southern Presbyterian Church, commissioned a study of the nature and needs of persons in early adulthood. Four cities were chosen for field study, and the Reverend Ted McIlvenna, a United Methodist minister with considerable social-research background, was chosen to direct the San Francisco arm of the project. The issue of sexual identity, especially homosexuality, was a primary area of the project's research. The main conclusion of the study was that one could not understand homosexuality without understanding human sexuality.

Further consultations were held at the Institute for Sex Research, in Bloomington, Indiana (the Kinsey Institute); at the headquarters of the United Methodist Church, in Nashville, Tennessee; at the National Institutes of Mental Health in Washington, D.C.; and in London, England, with representatives from the Dutch Ministry of Culture, the World Council of Churches, and the British Department of Health, as well as a representative from the Vatican, a bishop of the Church of England, a representative of the French Ministry of Health, and five delegates from the United States. One of the conclusions of the London meeting was that persons in the helping professions were woefully lacking in knowledge about human sexuality and that a center specifically designed for training professionals should be established.

In the spring of 1967, a meeting was held at the Institute for Sex Research in Bloomington that included representatives from the original sponsoring church bodies, the National Institutes of Mental Health, the Glide Foundation (an operating foundation), and four other foundations. At the meeting, the Glide Foundation in San Francisco agreed to become the home of the National Sex Forum (NSF), with a mission to study what helping professionals needed to know about human sexuality, the development of effective educational methodologies, and the design of innovative training materials. The NSF began officially in October 1968, as part of the Glide Urban Center.

By the end of the first year, it was obvious that most professionals needed specific training in human sexuality, that there was a lack of educational material, and that the available information had not been organized in any specific way. In October 1969, a team of 12 people committed themselves to the formal study of sexology. Each of these people brought to this study a unique background, and each chose a specialty in addition to general sexological study. The group consisted of two clergy, three physicians, three therapists, one child psychologist, and three sexual educators. Of this group, nine people finished their committed study by 1976, and six of these nine became the core faculty of the Institute. In 1975, the political and economic pressures of the church relationship became so severe that NSF sponsorship was transferred to the Exodus Trust, a California nonprofit trust that has as its sole and exclusive purpose the performance of educational, scientific, and literary functions in relation to sexual, emotional, mental and physical health.

The NSF early became known for developing the Sexual Attitude Restructuring (SAR) process, an innovative method for educating adults about what people do sexually and how they feel about it. Although the SAR process has been misunderstood and misused by untrained imitators, it has proven very effective when used by competent sexologists. The NSF also is the largest supplier of professional educational material dealing specifically with human sexual behavior. The films, slides, audio- and videotapes it developed are used by more than 8,000 professionals and institutions throughout the world.

In the period from 1969 to 1973, the sexological study team worked closely with the University of Minnesota Medical School program in human sexuality, directed by Richard Chilgren, M.D., and the University of California Medical School program in human sexuality, directed by Herbert Vandervoort, M.D. By the beginning of 1974, the NSF staff and sexological study team came to the conclusion that there needed to be an interdisciplinary institute for the education and training of sexologists and that such an institution had to be freestanding, with its own board of directors, and not be beholden to any outside group.

Four tasks were assigned to the sexological study team. McIlvenna was assigned the task of moving the NSF and the future Institute into a new structure. Vandervoort was given the task of organizing the academic work completed by the sexological study team. Laird Sutton was assigned to build the graphic-resource library, and Marguerite Rubenstein, Loretta Haroian, and Phyllis Lyon accepted the challenge of defining the professional training requirements in the emerging field of sexology. As the planning group completed their tasks, a facility was acquired, a library was developed, and additional faculty were included, notably Wardell B. Pomeroy and Erwin Haeberle were added to the resident faculty. The Reverend Lewis Durham, former head of the Glide Foundation and an expert on alternate life-styles, became the dean of students. The Institute also contracted for part-time services of other leading experts.

The Institute also made a special effort to include other experts. Three times each year, the Institute invited ten experts who had contributed to the emerging field of sexology. These experts were asked to lecture and have their lecture documented on videotapes. These lectures now form the most extensive oral history of contemporary sexology available. In addition, another 20,000 hours of material have been gathered to supplement the basic core curriculum. Finally, it was essential to find a structure and a board that could actively support and protect the objectives of the Institute, withstand changes in the political climate, maintain academic freedom, and preserve standards.

Currently, the Institute for Advanced Study of Human Sexuality offers four graduate degree programs for people wishing academic training in the field of human sexuality. In addition, the activities of the former NSF have been divided into several departments of the Institute, perhaps the most important of which is the adult continuing education program, which provides individual courses for professionals needing training for licensure or relicensure, as well as courses for laypersons who desire to expand their knowledge and experience in human sexuality.

Under the Institute's programs, it is possible for students to continue their professional education without leaving their present employment. A minimum of two or three weeks per trimester is required to be spent on campus, although experience has shown that for the majority of students the more time they spend in residence the better they progress. Reading, viewing videotape courses, writing papers, and similar work required during the trimester may be done in private study at home. Because sexology has emerged as a separate academic and professional field in the United States only in the last 20 years, students admitted to the Institute bring with them backgrounds that vary widely in experience and training. This requires that the process of acceptance into the program and the evaluation of work already completed be as comprehensive as possible, since the Institute tries to adjust the program to the individual and gives a limited amount of credit for previous academic work and professional experience in the field of human sexuality. Whenever a student has special training needs (e.g., statistics, research design, basic counseling skills) that cannot be provided at the Institute, efforts are made to have courses taken at cooperating educational institutions. The Institute restricts its programs to the field of sexology.

Students come from all over the world, as the Institute remains the only school in the world providing graduate degrees exclusively in sexology. The student body is a multilingual, multicultural mix, which in itself is a learning experience. Most students already have had graduate training when they enter the Institute, and many are involved professionally in the field of human sexuality or related helping professions. Current students include teachers, ministers, writers, physicians, social workers, nurses, psychologists, and others, and they range in age from the early 20s to the mid-60s. The Institute has always maintained an almost even number of male and female students. Average enrollment is 85 students.

A unique feature of the Institute has been the thorough documentation of its own activities.  All lectures and seminars of its faculty have been videotaped and remain available to its students in a media archive. This is also true of all classes, seminars and lectures given over the years by external lecturers. These were not only academics, but also others who knew something about some special aspects of human sexuality, such as publishers, writers, artists, journalists, politicians, health officials, police officers, businessmen, political activists etc. Among them are many well-known personalities, as even this partial list already makes clear: Gene Abel, Elizabeth Allgeier, Dennis Altman, Jack Annon, Bernard Apfelbaum, Lonnie Barbach, Frank Beach, Alan Bell, Sandra Bern, Edward Brecher, James Broughton, Vern L. Bullough, Mary Calderone, Deryck Calderwood, Michael Carrera, Eli Coleman, Alex Comfort, Theresa Crenshaw, Clive Davis, John DeCecco, Milton Diamond, Anke A. Ehrhardt, Albert Ellis, Marilyn Fithian, Robert Francoeur, John Gagnon, Allen Ginsberg, Bernard Goldstein, Sol Gordon, William Granzig, William Hartman, Jack Heidenry, Julia Heiman, Shere Hite, Evelyn Hooker, Laud Humphreys, Simon Karlinsky, Lester Kirkendall, Fritz Klein, Dorr Legg, Roger Libby, Del Martin, William Masters, Norma McCoy, Jack Morin, Donald Mosher, Lonny Myers, Anne Peplau, John D. Perry, Ronald J. Pion, James Prescott, Virginia Prince, James Ramey, John Rechy, Ira Reiss, Robert Rimmer, Howard Ruppel, Leah Schaefer, Pepper Schwartz, William Seabloom, Randy Shilts, Mervyn Silverman, William Simon, Margo St. James, William Stayton, Samuel Steward, Lyle Stuart, C.A. Tripp, Daniel Tsang, Gore Vidal, Paul Volberling, Paul Walker, Martin S. Weinberg, James Weinrich, Glenway Wescott, Beverly Whipple, Fred Whitham, Bernard Zilbergeld. All of their contributions have been preserved. Indeed, all in all, the Institute can be said to be the best-documented institution of higher learning in the world.

Graduates of the Institute are located throughout the world. They are teachers in high schools, colleges, and medical schools. Many are in private practice as therapists, while others combine therapy with teaching, writing, and workshops. Some graduates have continued in their previous professions as clergy, social workers, and so forth but now do specialized work in sexology. Others have found a place in the commercial world as writers, publishers, filmmakers, and media specialists.

Because San Francisco is a large metropolitan area containing two large universities and a number of smaller universities and colleges, access to other libraries and academic resources is easy for Institute students. The physical facilities of the Institute include a large classroom with the latest media and environmental accoutrements. The Institute further offers print, film, and videotape libraries, videotape viewing areas, physical therapy facilities, administrative and faculty offices, smaller classrooms, and a common room that serves as a socializing space for students, faculty, and staff. The facility has the latest videotape equipment, comparable to a commercial television studio. There are 11 specialty libraries composed of 85,000 books, 120,000 magazines and pamphlets, 12,000 videotapes, 125,000 films, and more than 500,000 photographs and slides. Together, the Institute's library system and erotological material make up one of the most, if not the most, comprehensive sexological resource in the world. Though students pay tuition, much of the work of the Institute is supported by three special tax-exempt funds that solicit contributions (which are tax-exempt) from the general public: the Exodus Trust General Support Fund, the Scholarship Fund, the Exodus Trust AIDS Project. The Institute is located at 1523 Franklin Street, San Francisco, California 94109.

Ted Mcllvenna (amended by Erwin J. Haeberle 2011)


Categories of intersex conditions
Some history of the management of intersexuality
Intersexuality among non-human species
Support groups for intersex and transsexual persons

The topic of intersexuality is not new either to the public or to scientists, but the discussion of all parameters and issues associated with the subject is relatively new. And much new material is constantly being added to or amending the old.


The general public has long been familiar with the common term hermaphrodite. Those so designated were often associated in the public mind with circus sideshow exhibits of so-called half-man and half-woman persons. In truth there are extremely few such people but there are, indeed, many individuals that are born naturally with characteristics of both typical males and females. And the conditions are, while not common, by no means rare (Blackless, Charuvastra et al. 2000).

While many animal species are known to be hermaphroditic, for humans the term hermaphrodite is no longer considered polite or politically correct. Those with these male-female combinations of characteristics prefer to be known as intersexed or persons with intersex conditions. Basically this refers to the fact that their bodies contain features that are usually seen separately in both men and women. These persons might, for instance have gonads consisting of one ovary and one testis or gonads that are combined ovatestes. Or they might have chromosome combinations that are atypical. Humans commonly have twenty-three sets of chromosomes (46 chromosomes). Twenty-two pairs (44) of chromosomes are called autosomes. The other pair of two chromosomes is called the sex chromosomes. Males usually have one X sex chromosome and one Y sex chromosome.  Typically females have two sex chromosomes that are both Xs. Occasionally, however, individuals are born with sex chromosomes that are of different combinations. This involves one type of individuals that are intersexed because of genetic variation. The most common different Intersex combination of sex chromosomes is XXY and is called a typical Klinefelter sybdrome. Other combinations, such as XXXY, XXXXY and XYY also exist. These are called Klinefelter variants. An individual might also be born with a chromosome missing and thus have 22 sets of autosomes and an XO combination of sex chromosomes where the O indicates a sex chromosome (originally either an X or Y) has been lost. These persons are said to have a Turner syndrome intersex condition.

In general society, when a baby is born, one of the first questions asked is this: “Is it a boy or a girl”, and the determination is made quickly and simply. If the genital appendage looks like a penis, the baby is considered a male and is to be raised as a boy. A baby born without a penis is considered a female and raised as a girl. But nature is not that simple. Babies are born that do not have a penis and yet are males based on other characteristics, and babies are born with genitals that look like a penis but are, in reality, females based on other factors. Individuals with a Y chromosome usually have a phallus that is penis shaped and so are dubbed as male when they are born. Those without a Y chromosome (such as those with XX chromosomes or an XO (Turner) set of sex chromosomes) do not have a penis-like phallus and are seen as female. To complicate matters further: Babies, perhaps as many as one in 2 to 4 thousand, are born with genitals that are not easily categorized as male or female. There is no clear penis or vaginal entrance. These genitals are considered ambiguous so a designation of male or female is not immediately apparent. These children are the most commonly known intersexed persons; at birth they have genitals that combine obvious features of male and female. There are other types of intersex persons, perhaps the majority, in which the designation is not known until puberty or later.

Obviously the definitions of male and female are at issue. Biologically there have been several ways to define these terms. These definitions have not always been consistent, and still not everyone agrees on which characteristics or features should be given prominence. The primary biological or medical sexual characteristic to distinguish male from female had been either the gonads (does the individual possess testicles or ovaries) or the chromosomes (are the sex chromosome combination XY or XX).  But, over the years, as exemplified above, it became clear that many different combinations existed. To further complicate the matter, persons with these different biological features might live as men or women regardless of whether they were assigned as boy or girl.  Here it becomes obvious that male and female are used as biological designations while boy and girl and man and woman are seen as social descriptions. Males could live as girls or women and females could live as boys or men.

This potential of how persons might live and identify has obvious social and sociopolitical ramifications. The general public wants and expects things to be simple and obvious and consistent. They expect males to live as men and have a visible penis and other masculine features. In a similar way they want females to have an obvious vagina and breasts and live as women.  With persons having intersex conditions this might or might not be so. This ability to mix and match biological and social features varies in different cultures; in some it is accepted and legal to do so and in some it is not accepted and considered illegal. Some religions feel strongly about this and others less so. And intersexed persons themselves often wish to have their own option on how to be addressed and considered; either as man or woman or intersex. Not all factions of society accept this.

In a well-meaning attempt to clarify this matter, a group of physicians and others met in 2006 and agreed to call intersex conditions Disorders of Sex Development or DSD
(Hughes, Houk et al. 2006) thus getting away from the term hermaphrodite and intersex altogether. Many physicians who have to deal with some of the aspects of intersexual conditions thought this a wise solution since the label Disorder put these conditions under the banner of medical issues with which they deal. However, this terminology did not please everyone.  Many intersex persons did not want to be labeled as having a disorder. I and other colleagues agree and think to consider persons with these conditions as disordered is not only stigmatizing but wrong since they are, in most cases, healthy, undistinguishable from their peers and not in need of medical attention (Beh and Diamond 2007; Tamar-Mattis and Diamond 2007; Diamond and Beh 2008). Indeed, I’ve not met any parents who are happy to learn that their child is disordered. The terminology that is used in this article is male or female depending upon the gonads or chromosomes the individual possesses; usually they are in concert. When I use the abbreviation DSD it refers to Differences of Sex Development. If a male prefers to see himself as a woman I use the female pronoun to refer to her. Likewise, if a female saw herself as a man I refer to him with male pronouns. It is the most courteous thing to do. This reflects on the issue of social sex - usually referred to as gender - as touched on above.

Most commonly males are considered to have two testicles as gonads and females are considered to have two ovaries. The gonads of the male produce sperm and those of the female produce ova (eggs). The sperm are released into bilateral ducts (Latin singular: ductus deferens) that take sperm and accompanying fluids to the urethra within the penis. The ova are released into bilateral oviducts (Fallopian tubes) that lead to the uterus. Males have an extended phallus called a penis while females have a phallus called a clitoris. These and other sex differences are shown in Table 1. For comparison examples are given where male and female intersex variations are merged. While this brief paragraph describes factors associated with reproduction, many intersex conditions involve infertility. It is a feature of the syndrome that is often most disturbing to the individual. Often the gonads do not function to produce viable ova or sperm.

The most common intersex condition is called Congenital Adrenal Hyperplasia (CAH). CAH can occur in otherwise typical males or females and is due to an overproduction of androgens by the fetus or mother’s adrenal glands. This can occur during pregnancy so the female infant is born with a slightly enlarged clitoris/phallus or her genitals might be masculinized enough to be ambiguous. Or she might look as if she has a penis and her labia might be fused to appear as a scrotum. In cases where the condition is such that the infant would lose needed body salts it is one of the few intersex conditions that require serious and immediate medical attention.
(See Nieman 2010 for more details about CAH.) CAH is one of the few Intersex conditions where the individual maintains reproductive capacity.

CAH is due to an enzymatic deficiency where, for more than 90 percent of cases, the normal conversion of hormones (17-hydroxyprogesterone to 11-deoxycortisol) does not occur and the body-needed cortisol is not produced and must be provided. This conversion of hormones is mediated by an enzyme (21-hydroxylase) that is deficient. But other hormones can block the normal formation of cortisol and lead to CAH. There are many other Intersex conditions caused by other enzyme deficiencies. Two common ones are simply called by an abbreviation of the enzyme involved, i.e., 5-alpha deficiency (Wilson 2009) and 17-beta dehydrogenase deficiency (Geissler, Davis et al. 1994). Both of these conditions give rise to male infants born looking like females; they appear without penises. In these conditions, the deficient enzymes develop with maturity and allow for increased masculinization. Usually, with puberty, the masculinization has proceeded to the extent that these persons, although raised as girls switch to live as boys and then men (Imperato-McGinley, Peterson et al. 1979; Imperato-McGinley, Peterson et al. 1979; Imperato-McGinley, Miller et al. 1991).

Table 1. Comparison of Male, Female and Intersex
 MaleFemaleIntersex Example1
DuctsDuctus DeferensOviducts 
BreastsFlat chestFatty w/mammary glandular tissueFlat, Full or Ambiguous
GametesSpermOvaGenerally Infertile
1) This is only one type of intersex combination. There may be many others.

Categories of intersex conditions

Intersex conditions can result from three main fundamental processes; genetic, enzymatic-hormonal and receptor based. As mentioned above the most typical genetic causes of intersex involve chromosomal variation. Usually this variation extends throughout the whole body. Each body cell contains a like chromosomal complement.  A less frequently seen variety is where there is variation that shows differences in separate areas of the body.  This is called mosaicism. In such cases there exists a mixture of cells so that one part of the body might be XX in character while XY in another. One part of such a body might contain a testis while another contains a uterus. In extremely rare cases a person might essentially be a male on one side of the body and a female on the other. This is called a chimeric condition.  (Imagine a potential set of eggs that might have gone on to produce twins instead combining to produce one person.)

Another set of etiological causes of intersex conditions result from varieties of enzymatic-hormonal interactions. These were mentioned above where CAH was the main example. Other examples were the 5-alpha and 17-beta variety.

A third variety of intersex conditions are caused by a normal receptor absence. Receptors are molecules on the surface of cells that combine with different biochemical factors to allow for their normal biochemical operation. In some cases the receptors needed for different hormonal activities are absent or do not function properly. Such a type of intersex condition is called the Androgen Insensitivity Syndrome (AIS) of which there are two types; a complete variety (cAIS) and a partial type (pAIS). Since androgens are needed for the development of maleness in structures as well as behavior the syndromes are considered among other androgen deficiency syndromes.  With complete AIS, since their body cannot respond to the hormones needed for male structural sexual differentiation, these persons develop looking as females despite having testes that produce adequate amounts of the androgen testosterone. At puberty breast development is common because much of the androgen is

converted to feminizing estrogens. With the partial variety of AIS many phenotypes occur.  Some persons with pAIS have a small penile phallus and develop breasts while others do not. Most persons with this condition live as women but others live as men. Many androgynous persons have occult and undiagnosed conditions of pAIS. A subset of such individuals will be raised as males but go on to live as women.

Some history of the management of intersexuality

Prior to the 1950s, intersexuality and its various manifestations were poorly understood and considered a condition of shame and to be hidden. Medical treatment was minimal and, when offered, based on obvious symptoms rather than a clear diagnosis of etiology.  Individuals, so affected, were generally assigned a gender based on the appearance of their genitals; if they looked more penis-like at birth the child was assigned as a boy and if the genitals appeared more like a girl’s the child was assigned as such.  Social and cultural conditions were such that persons unhappy with the assigned sex were usually forced to maintain the gender of assignment despite contradictions in feelings and other aspects of sexual life. Complications that might have developed such as being sexually attracted to those that might be socially considered inappropriate or discomfort in living according to social expectations considered distasteful were seen as aspects of life that were to be endured.

Since most persons with these identified intersex conditions stayed in their sex of birth assignment and did not switch their gender identity, it led the investigator John Money to mistakenly believe and propose that individuals are psychosexually neutral at birth and that it mattered not if they were raised as boys or girls (Money, Hampson et al. 1955; Money 1963). Despite the fact that this theory was extracted from cases of intersex it was proposed to hold as well for typical individuals (see Diamond 1999). Regardless of how they were biologically, it was believed that intersex children would accept the gender assigned to them at birth. Many of such children, noted at birth due to their ambiguous genitalia, were then often subjected to surgery to normalize their genitalia. This was in the belief that as adults they would thank the surgeons for relieving them of potential embarrassment. It is now known that such treatment was well meaning but wrong.

For the most part, when choosing surgical treatment, physicians opted for a believed optimum female form because it is easier to fashion female genitalia than male. This held true for males as well as females.  Males would be reassigned as girls and females would have any enlarged clitoris removed or reduced in size. And then, relying on a nurture-based theory of gender identity, physicians advised parents to accept their surgically altered infant and to raise the child in a manner consistent with the child’s surgically altered genitalia. This was to hold without regard to any gender identity that might have naturally developed (Kessler 1990; Kessler 1997). The same advice has been given when a male infant’s penis has been severely mutilated by trauma or is considered significantly small. Clinicians had assured parents that the surgical potential for normal-looking genitalia should dictate the child’s gender and that any innate gender propensity of the child can be changed by careful upbringing.

Despite a paucity of confirming evidence, medical literature since the 1970s, had promoted this treatment until the end of the twentieth century. The medical literature relied on a body of published reports which themselves were initially predicated on studies of intersex individuals and most significantly, one infant’s incredible case which was widely reported in medical, psychiatric and popular literature (Money, Hampson et al. 1955; Money 1963). In 1997, the medical community was reacquainted with that infant who had been reported as long lost to follow-up (Diamond and Sigmundson 1997a). Only then did the medical community discover that the outcome of this single case (now known as that of John/Joan) was not as first reported (Diamond and Sigmundson 1997a). The foundation on which the old treatment rested began to crumble.  It is now known that infants are not psychosexually neutral at birth but are, instead, biased as males or females (or intersexed) at birth and there is no way, until the child is old enough to express his or her own feelings, to know if the preference is to live as a boy or girl, man or woman, or in some manner of their own choosing (Diamond 2006; Diamond 2009 ). Until then it is best to do no surgery, encourage the parents to love the child as it is, and raise it as a boy or girl based on the best bio-medical information available.

Fortunately, at least in the USA (Diamond, Burns et al. 2005) and among the most enlightened areas of the world, practices for the management of intersex cases are changing and cases of cosmetic infant surgeries are becoming less common. Physicians and parents are becoming more accepting of this and are willing to wait and see how the child itself prefers to live. Decisions as to how to raise the child with ambiguous genitalia are based, not on whim or guesswork, but on the best diagnostic evaluation available. Parents are also increasingly aware that their children might make decisions as to gender and partner choices that were not predictable at birth. Fortunately there now exist many support groups both available to parents of intersexed children and support groups for persons of many different intersex varieties.

Intersexuality among non-human species

In plants and non-human animals intersexuality is quite common.  While there are plants that have only flowers with male or female parts there are many with flowers that have both male and female parts.  And adding to this are plants with flowers that have all three types of flowers; male, female and combined.  Plants that have flowers with both male and female gametes are called perfect because they can pollinate themselves requiring neither wind nor insects.  (Despite mythology and fantasy this cannot happen with humans.) Peppers and tomatoes are examples of plants with flowers considered perfect.

In animals, particularly fish, there are three types of intersexuality and in these cases the term hermaphrodite is still considered correct. In the first variety there are simultaneous hermaphrodites where individuals can copulate and reproduce both as males and females simultaneously. Hamlets are one such species type of reef fish where individuals can mate taking turns as either male or female.

The second and third varieties, also quite common among reef fishes, are protoandrous hermaphrodites and protogynous hermaphrodites. These are similar except that for those species that are protoandrous the organism starts off as male and changes to female. For those species that are protogynous the organism starts life as a female.  The stimulus for change might be visual, pheromonal or tactual.

Mammals, other than humans, are also known to exhibit intersexuality.  Perhaps the most commonly known examples are those in farm animals such as pigs and cattle (often called Freemartin) but non-domesticated animals also have been reported.


Many people make a clear and sometime very vocal distinction between intersexuality and transsexuality. Most opposition to linking these two concepts or categories come from those intersexed individuals who think their own situation in the public eye is somehow diminished by the association. This is regrettable. Both of these sexual minorities are stigmatized in society and I think they not only should rather be allies in their fight against discrimination, but also, actually think they have things in common. I maintain that transsexuality is a form of intersex. I conclude this derived from my own clinical experiences, my own experimental research, and knowledge of the research of others. I accept that my thoughts on this matter are a minority view among colleagues and fellow scientists.

I believe that transsexuals are intersexed in their brains as others are or might be more obviously so in their gonads, genitals, hormonal character, receptor, enzymatic or chromosomal constitution. And it is this brain intersexuality that biases the person to assert his or her gender identity.

As one can vary on a Kinsey scale from 0 to 6, and can fluctuate during one’s life so too can one vary from 0 to 6 on the Benjamin scale (Benjamin 1966) demonstrating different degrees of a trans identity. This can be manifested from occasional cross-dressing to a full-time transsexuality where a person desires to live full-time in a mode different from the way he or she was born and raised. And this gender identity can fluctuate from mild to intense during different times in one’s life and in reaction to a variety of life experiences. These reflect differences, not disorders, of identity. While some persons are seriously impaired by these conflicts of identity and societies views of propriety and might need and desire help in resolution, others have managed to come to terms with their inherent biases and the negative social demands they encounter and see no need for counseling or therapy. While some may be seriously psychically disturbed and require or desire counseling or medical assistance, I don’t see persons with trans variations as mentally ill based solely on their manifestation of a trans condition. And certainly there are examples enough where obviously intersexed persons reared in one gender have decided later in life to switch to the other.

There are of course, also persons with strong transsexual feelings that do not transition just as there are those obviously intersexed that elect not to change from existing conditions that they find distasteful or uncomfortable. They do so to solve other of their life problems with which they have to contend, for example: Will the change mean the loss of family, religion, job, children, etc.  Because persons are willing to confront the social conflicts and difficulties involved in living a trans or intersex existence, I see them as only different in expression and character from others that do so by expressing major open societal differences in sexual orientation, religion or other feature of their inherent physical or psychological biases. I think society should understand this characterization. I also think professional therapists, via the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association should reflect this possibility and potential.

Support groups for intersex and transsexual persons

There are many groups available to assist those with intersex and transsexual conditions. For a list of the most important of these groups, click here.
For a free online course on intersexuality, click here.


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Wilson, B. E. (2009) "5-Alpha-Reductase Deficiency." eMedicine from WebMD.
Milton Diamond


Sexual behavior between couples may be viewed on a continuum from total lack of emotion or feeling, and sex for sex's sake, to a deep emotional bond or commitment. This latter state is intimacy. The essence of intimacy encompasses the biblical concept of two persons becoming "one flesh" through complete pleasurable sharing of the body, personality, and feelings.

Couples in sex therapy often report discovering during an intensive daily treatment program that a shared, mutually enjoyable closeness was the missing ingredient in their relationship. The symptoms of erectile dysfunction or lack of orgasm were resolved—but they were only symptoms.

The importance of intimacy in sex therapy is that where true intimacy exists, there are no sexual problems. There may be some dysfunction, but when a couple is close and intimate, the expectation of performance and the fear of satisfying a partner or oneself ceases. Where there is intimacy, the warm feelings of loving and being loved for who and what you are eradicate fears that so often inhibit good sexual functioning. Differences in desire are often related to a lack of intimacy in a relationship.

Intimacy has only recently emerged as a key concept for consideration by marital and sexual therapists. Schnarch's study summarizes the development of this concept and its therapeutic application.


Alien, G., and C.G. Martin. Intimacy: Sensitivity, Sex, and the Art of Love. Chicago: Cowles, 1971.

Beavers, W.R. Successful Marriage. New York: W.W. Norton, 1985.

Clinebell, H.J., and C.H. Clinebell. The Intimate Marriage. New York: Harper & Row, 1970.

Malone, T.P., and P.T. Malone. The Art of Intimacy. Englewood Cliffs, N.J.: Prentice Hall, 1987.

Schnarch, D.M. Constructing the Sexual Crucible: An Integration of Sexual and Marital Therapy. New York: W.W. Norton, 1991.

William E. Hartman
Marilyn A. Fithian


Intrauterine devices (lUDs) have a long history that dates back to claims that Arab camel drivers put stones in the uterus of camels to prevent conception while on long trips. The IUD's modern history is most closely connected with the name of the German gynecologist Ernst Graefenberg. In 1922, Graefenberg used stars of silkworm gut held in shape by a silver wire as an intrauterine contraceptive. He soon abandoned this method in favor of a silver spiral ring, which gave better results and avoided the possibility of infection that arose from cutting off communication between the vagina and the intrauterine cavity. It was not until 1930 that Graefenberg reported on his experiments with silkworm-gut rings and silver rings, demonstrating that the silver ring was superior to the silkworm-gut device. He held that there was a 3.1 percent failure rate with the silkworm-gut insert and only a 1.6 percent failure rate with the silver ring. Norman Haire, who had contact with Graefenberg, also began using the silver ring in 1929 and at first was enthusiastic, but the danger of infection led him eventually to drop it, as did Graefenberg. In 1934, Tenrei Ota, of Japan, introduced gold and gold-plated silver rings into the uterus; these intrauterine rings were claimed to be even more effective than Graefenberg's devices. Again, the dangers of infection led Ota temporarily to stop using the device.

With the development of effective antibiotics, particularly in the 1940s, and the reduced dangers of infection, others began experimenting with lUDs. In 1958, Lazar C. Margulies, a member of the obstetrics department at Mount Sinai Hospital in New York City, approached the head of his department, Alan F. Guttmacher, a member of the medical advisory committee of the Council on Population, about the potential of IUDs. Margulies argued that some of the past dangers could be eliminated by making an IUD out of plastic and that infection could be controlled. Guttmacher allowed Margulies to try out the device. Other research on the lUDs serendipitously appeared at the same time, including an article by Willi Oppenheimer, a student of Graefenberg's, who had been using the IUD in Israel. Other Americans, such as Jack Lippes, were also experimenting with lUDs and found difficulties in the removal of both the Graefenberg ring and the Ota ring. Lippes's solution was to attach a filament to the end, which went down through the cervix. He also began to use a polyethylene loop.

These new developments led to an international conference on the IUD in New York in 1952, sponsored by the Population Council. The participants at the conference agreed that there were no serious problems associated with the method, and several devices were discussed, including the ones mentioned above. A Cooperative Statistical Program for the Evaluation of Contraceptive Devices (CSP) was set up, under the direction of Christopher Tietze.

Developments were rapid and a number of lUDs went on the market including the Lippes Loop, the Binberg Bow, and the Margulies Spiral. By 1974, some 20 different lUDs were being produced commercially, and some 15 million women were using them. Among the new devices appearing on the market were copper lUDs like the Tatum-T, the Y-shaped Gravigard, and a progesterone-releasing IUD. The copper devices appeared to be superior. One of the reasons for the use of copper was that in investigating Graefenberg's silver ring, researchers found that it was made not of sterling silver but of an alloy containing a large amount of copper; it was the inclusion of copper that had made it so effective.

In the United States, IUD usage dropped suddenly, not so much because of the growth in popularity of the oral contraceptive as because of the scandal associated with the Dalkon shield. One of the problems with the IUDs was the lack of official testing procedures for them, and not all went through a rigorous period of testing. As the use of IUDs increased, pharmaceutical firms rushed into the market with their own devices, and the A.H. Robbins Company purchased a poorly designed, relatively untested device from Dr. Hugh Davis in 1970. Apparently, most of the reports on testing compiled by Davis for his device were not particularly accurate, and there were also ethical issues involved, since Davis was doing both the testing and the marketing, a violation of professional ethics. Though questions were raised about the Dalkon shield almost as soon as it appeared on the market—insertion was exceptionally painful and there was a high rate of infection—complaints were ignored by Robbins, as were the growing number of deaths associated with use of the device. It was finally withdrawn from the market in 1980. That action was much too late, however, and the company was subjected to a large number of lawsuits, which ultimately led to bankruptcy. In the aftermath of this incident, other companies were also sued, and though the lawsuits were not particularly successful, liability-insurance rates rose so much that companies in the United States ceased to distribute the devices for a period. At the same time, regulation of lUDs came under the jurisdiction of the U.S. Food and Drug Administration, and rigid testing procedures had to be completed before the devices could be sold again in the United States. None of the older lUDs went back on the U.S. market, although the Lippes Loop continued to be used in Canada and in much of the rest of the world. Instead, new devices were allowed onto the market only after rigorous testing, and only two had gained approval by the early 1990s: the TCU-380A IUD, which needs replacing every five years, and the Progestasert IUD, which releases progestin and has to be replaced every year. No such replacement is necessary for the polyethylene devices like the Lippes Loop that have been kept in place as long as ten years without difficulty. Ultimately, however, even these lUDs should be removed periodically.


Graefenberg, E. An Intrauterine Contraceptive Method. Reprinted in L.L. Langley, ed., Contraception. Stroudsburg, Pa.: Dowden, Hutchinson & Ross, 1973.

Ishihama, A. Clinical Studies on Intrauterine Rings. Reprinted in L.L. Langley, ed., Contraception. Stroudsburg, Pa.: Dowden, Hutchinson & Ross, 1973.

Lehfeldt, H. Ernst Graefenberg and His Ring. Mount Sinai Hospital Journal of Medicine, Vol. 42 (1975) pp. 345-52.

Lippes, J. A Study of Intra-uterine Contraception: Development of a Plastic Loop. In L.L. Langley, ed., Contraception. Stroudsburg, Pa.: Dowden, Hutchinson & Ross, 1973.

Lippes, J., T. Malik, and H.J. Tatum. The Post Coital Copper-T Advances. Planned Parenthood, Vol. II (1976), pp. 24-29.

Mintz, M. At Any Cost: Corporate Creed, Women, and the Dalkon Shield. New York: Pantheon, 1985.

Oppenheimer, W. Prevention of Pregnancy by the Graefenberg Ring Method. Reprinted in L.L. Langley, ed., Contraception. Stroudsburg, Pa.: Dowden, Hutchinson & Ross, 1973.

Tietze, C. Intra Uterine Contraceptive Rings: Historical and Statistical Appraisal. In C. Tietze and S. Lewis, eds., Intra Uterine Contraceptive Devices: Proceedings of the Conference, April 30-May 1, 1962, New York City. Excerpta Medica, International Congress Series 54. Amsterdam, 1962.

World Health Organization. Mechanization of Action, Safety and Efficacy of Intrauterine Devices. Geneva: World Health Organization, 1987.

Hans Lehfeldt
Connie Christine Wheeler
Vern L. Bullough


Equality of the Sexes
The Muslim Family
Women in Islam

If delving into sex relations in general is risky and controversial, analyzing them in the Islamic context is like venturing into a mine field. It is not only the dearth of studies that makes it so but also the radical differences between those who believe in greater sexual freedom and those who adhere to traditional values. The inevitable result for the researcher is ostracism by both sides. His or her situation is like that of the man during the Civil War who, wanting to be safe, wore a blue jacket and gray trousers and was shot by both sides. What makes it particularly difficult to report on sexual behaviors and patterns in the Muslim world is that this subject is sensitive and makes many people feel uncomfortable, so much so that public discourse about it is more or less taboo. Privately and separately, both sexes may occasionally discuss it, but even here many areas exist beyond the realm of the permissible. This means that despite its powerful and compelling pressure, sex exists almost in the twilight zone, referred to only rarely and with the utmost caution and embarrassment.

This being true of sex in general, some sexual topics, such as homosexuality, are almost unmentionable. Homosexuality is often referred to casually, superficially, or in a derogatory manner but rarely in an analytical or objective way. This is why the Muslim researcher must be extremely cautious in exploring such sensitive and explosive areas. They involve emotional issues that touch many nerves.

At the same time, Muslims regard sexuality as part of being human, although an individual's behavior and sexuality are determined by basic precepts and concepts and guided by religious beliefs. Humans are created with certain needs and instincts that must be satisfied in order to enjoy a healthy, stable, and balanced life. Within this context, individuals should avoid extremes, which may lead to social and biological dysfunctions.

Islam does not deny or even try to suppress sexual desires. It merely tries to regulate them so they find a proper, healthy outlet within the framework of a sound, rational social system. As a general rule, Islam does not try to impose unrealistic, impractical, and purely idealistic demands, which can neither be met nor withstand the test of time and reality. But if it does not attempt to impose unreasonable prohibitions, it is also leery of permissiveness. Rather, it holds that a healthy balance should exist among one's conflicting desires and that the welfare of society as well as the individual should be considered. Islamic morality is not a mere set of principles, commands, and restrictions but a system that takes into account human nature with all its material and biological, as well as spiritual, imperatives. This is perhaps the centerpiece of sexuality in Islam. If such a delicate balance is shattered—when one desire dominates the others—both the individual and society inevitably suffer anxiety, uncertainty, and insecurity.

It would also be a great error to judge sexual relations in the Muslim world by Western standards and principles. Though no contemporary culture has been totally immune or insulated from the influence of the sexual revolution that has engulfed the West and is spreading to the rest of the globe, no cultural grouping is as concerned, troubled, and even frightened by this phenomenon as the Muslim people. They see it as a deadly threat that, if not checked, contained, and controlled, would eventually destroy their social institutions and perhaps society. They are convinced that neither the family nor the cohesion of society can survive the ruinous impact of Westernism.

For the Muslim believer, sexuality must find its expression within the family, where men and women are the shepherds, responsible for the well-being of the society. It is only within the bounds of the family that the reproductive process should take place. Though sexuality is pleasurable, it must be kept within the bounds of responsibility and morality. Here, one can clearly see the emphasis on collective obligation, as everyone is equally accountable for the stability and cohesion of the family and society. In this context, sexuality is never viewed as an end but merely as a means to achieve certain biological, familial, and societal objectives. At the same time, Islam recognizes the power of seduction, the temptation of the sexual urge, and the human desire for love and companionship. Men and women are naturally attracted to each other, but this affectionate relationship should be conducted within and through the acceptable channel of marriage. For this reason, Muslims are encouraged to marry at the earliest possible opportunity. The Prophet stated that "whoever gets married completes half of his (or her) faith." He also warned that "whoever can afford marriage and refrains from doing so is not one of us." If perchance one lacks the wherewithall to marry, that individual is to remain chaste until God has rewarded him with the ability to get married.

To ensure adherence to God's commands, punishment, in both this world and the next, forms an integral part of Islamic teaching. Muslims are constantly reminded that straying from the straight path effects penalties on the Day of Judgment. God may put off punishment, but He never overlooks the sinful deed. Muslims are particularly cautioned against adultery, which is regarded as ruinous and as a deviant way of releasing sexual energy that has serious repercussions. It may bring venereal diseases, cause destruction of the family, create uncertainty of parental lineage, and result in suspicion, tension, and animosity. It is the duty of the family and society to protect individuals from such actions by giving advice and even scolding. If these methods fail, then punishment is meted out according to strict limitations and considerations. Unless the individuals are caught in the act or for some reason confess to committing adultery, proving adultery in the Islamic world is almost impossible, since it requires four unimpeachable eyewitnesses to testify to the act.

False accusation is viewed with grave concern. The Qur'an report that "those who launch charges against chaste women and produce not four witness, flog them with eighty stripes and reject their testimony ever after, for such people are wicked transgressors." In addition, "Those who slander chaste women are cursed in this life and the hereafter, for them there is a grievous penalty," and on the Day of Judgment their tongues, hands, and feet will bear witness to their deeds (Holy Qur'an, XXIV, No. 4).


In Islam, homosexuality is believed to be the result of weak character, lack of religious teachings, sexual permissiveness, economic pressure, and circumstances. To most Muslims, it is a serious deviation from nature and an affront to human honor and dignity. The Qur'an, like the Christian and Jewish Scriptures, report the case of Sodom and Gomorrah and make it quite specific that the incident is one of males approaching males, deserting the women who had been specially created for them. Though Lût and his family were saved, He destroyed the rest of the people by showering them with brimstones (Holy Qur'an, XXVI, Nos. 165-173).

Adding to the effect of these verses are others emphasizing that "those men who have intercourse with other men or animals" are cursed. Note that the focus here is on male rather than female homosexuality. Lesbian relationships are seldom, if ever, discussed in Islamic writings, almost as if such relationships did not exist. Hence, if it is unlikely for gays to come out of the closet, it is virtually unthinkable for lesbians to do so.

Although homosexuality exists in the Islamic world, and the literature would indicate that it has always existed, no open, candid, or objective studies have been conducted. Instead it is a subject to which one refers casually or satirically. Some writers have held that Islam is more tolerant of homosexuality than Christianity traditionally has been, but it is extremely difficult to document this. It is true that people are not discriminated against in the job market on the basis of their sexual preference, but this is undoubtedly due to the fact that homosexuality is still practiced in almost complete secrecy and always in fear of exposure. Those publicly identified as homosexuals are often shunned, excluded, or ridiculed at social functions. To practice such unacceptable behavior privately is one thing, but to pronounce it publicly and defiantly would, under present conditions, certainly trigger a violent and perhaps catastrophic reaction.

Equality of the Sexes

Many people, inside and outside the Muslim world, have written extensively about women's equality, or the lack of it, in Islamic life. From its beginning, Islam made it clear that, in the eyes of God, faith, rather than race, color, or sex, would differentiate between people. All humans are viewed and treated with absolute equality, just like the teeth of a comb. Throughout the Qur'an, people are referred to as "men and women" who are endowed with equal, though not identical, rights and obligations, based on their emotional, biological, and functional capabilities. In practice, this means that each has significant rights and responsibilities. To Muslims, it is unnatural for men and women to insist on or believe in performing identical tasks. The Prophet pointedly stated that "cursed are those men who imitate women, and those women who imitate men. " This does not mean that either one should be denied equal pay for equal work, nor should they be deprived of equal opportunities in the job market, education, services, and politics. By stating that "seeking knowledge is the duty of every Muslim man and woman," Islam has always urged both men and women to seek education. It allows women to have their own businesses, as exemplified by the Prophet's first wife, and to occupy any position as long as it is within the framework of Islamic principles. Furthermore, not only does Islam establish and define a woman's right to inheritance, but it also prohibits other Muslims from taking a woman against her will or treating her with harshness except when she is guilty of open lewdness. Ideally, a man is supposed to live with women on a footing of kindness and equity (Holy Qur'an, IV, No. 19).

Equality of the sexes in Islam does not, however, entail the denial of natural, biological differences. Women, for example, are exempt from some of the basic rituals and obligations, such as prayer and fasting, during menstrual periods and pregnancy. With biological differences taken into account, it is important not to mix or confuse the functional duties of one sex with those of the other. "Wish not what God endowed the other with" is a standard saying in Islam. Marital relations should be compatible and complementary and not based simply on lust, beauty, wealth, or rivalry. To marry for the latter reasons is to invite humiliation, degradation, and eventual alienation.

In pre-Islamic times, though women were active in business and trade, female infanticide was widely practiced. Modern commentators have held that infanticide was done for economic reasons—for example, because girls were not as productive as boys and too many daughters would lead to the loss of a family's fortune through marriage. Others have argued that it was to prevent tainting the family's name and honor. Still, some think the practice was based on a primitive belief that women were the embodiment of the devil and therefore should be buried alive. It was Islam that put an end to this abhorrent behavior among the Arabs.

Muslims were sternly warned that they would be held accountable on the Day of Judgment for any acts of infanticide. In general, Islam prohibits killing or aborting children of any sex because of poverty or fear of lowering the family's standard of living. It is God who provides for parents as well as children. He is the Creator, Cherisher, and Provider. For this reason, Islam even encourages a good Muslim to marry the poor, for God will enrich the person who does so.

The Muslim Family

Throughout the Muslim world, the family, which is the centerpiece of society, is unmistakably patriarchal, and usually the oldest male is the head of the family. However, tradition, as well as social and financial status, may determine both headship and succession. Because Muslims like to keep their families close and intact, the preferred marriage is between first cousins, especially children of brothers. Although marriage is still generally arranged by parents, this practice has been breaking down because of increased mobility, modernization, and urbanization. Marriage is regarded not merely as a bond between a man and a woman but also as a union between families, clans, and tribes. The focus in Islam is on the family and not on the individual. Couples are matched on the basis of compatibility, family status, and economic position, although the consent of the prospective mates is regarded as essential before the matrimonial agreement is concluded. Still, individuals can be and sometimes are pressured into marriage against their wills, particularly in rural and tribal areas.

Among Muslims, great emphasis is placed on female chastity, purity, modesty, and even (in some areas) complete seclusion and veiling. A matter of constant and permanent concern to Muslim men is the conduct of women, since what they do affects and reflects the family's reputation. The whole family, or in some cases even a village, may be dishonored by the misconduct of a female member. Sometimes, friends assume the role of protectors or guardians of the community's honor. The focus is on the female and not the male because it is widely believed that she is primarily responsible for any relationship with the male. Because consent rather than coercion is the rule, it is her responsibility to ward off any unwanted advances. Men are chastised only for extramarital activities, although women are generally treated more harshly and strictly.

Islam allows men to marry as many as four wives. Whether a woman is in a polygamous or monogamous marriage, her rights and privileges are defined and protected by law and are not dependent on the charity, generosity, or conscience of a man. The allowance of multiple wives was never intended merely to satisfy desires, impulses, or whims. Its justification was to prevent delinquency and the fragmentation and destruction of the family due to immoral or adulterous behavior. Taking a second wife must be done with the full consultation of the first wife. While some believe this means consent, others argue that it entails only informing her of the pending action. Sometimes it is the first wife who urges her husband, due to her sterility or sexual dysfunction, to take a second wife.

There is a prohibitive clause in the Qur'an that sets standards for a husband taking additional wives by insisting that they be treated with equality and fairness although the Qur'an also recognizes also since it states as sort of an afterthought that "none of you will (or can)."

In other words, polygamy cannot be rationalized on the basis of emotions, finances, or social status. It is to be undertaken with great caution, care, and as an absolute necessity. Even then, justice and equality must be taken seriously into consideration. Whether a man has one or more wives, it is incumbent upon him to treat them with great tenderness and kindness before, during, and after sexual intercourse. In fact, men are encouraged to plan an emotional preparation to maximize mutual sexual enjoyment. They are not to behave selfishly or inconsiderately. The Prophet advised them "not to pounce on your wives like animals" and to make certain of mutual sexual gratification.

Islam urges those with marital difficulties to seek professional, medical, or familial assistance, with divorce as the very last resort. Although divorce is relatively easy to obtain, its rate is extremely low, as it is still viewed as a disgrace to both the divorcees and their families. Families and friends intervene, pressure, and arbitrate to solve marital problems. Each party's grievances, particularly the wives', are taken seriously, and reconciliation is tried by every possible means. Furthermore, "divorce, in the eyes of Allah, is the most hated permissible." Hence, for religious, social, familial, and practical reasons, divorce may be considered with great reluctance, for not only is it difficult for divorcees, especially women, to remarry, but also the dissolution of the family casts a permanent shadow over its members' lives. For these reasons, couples are frequently compelled to stay together even when their marriage has become meaningless, worthless, and even hellish. Due to the serious complications and ramifications of divorce, Muslims are urged to approach it with painstaking deliberation and consideration. They are reminded that "you may dislike something (marriage) through which God would effect bountiful good for you" (Holy Qur'an, IV, No. 19).

Women in Islam

In the eyes of Westerners, with feminism and women's liberation firmly established, women in the Muslim world may seem to be oppressed, deprived, and discriminated against. One should, however, be cautious with such a sweeping judgment. First, the concepts of equality and sexuality must be viewed within their cultural context. Second, one must differentiate between Islam's principles and a Muslim's behavior. Third, moral judgments should be rendered with great caution and reservations and in view of the social system. Life is a trade-off, as gains are usually balanced by losses. This means that what is regarded as progress invariably has its price, and as of this writing Muslim women have not challenged traditions in any significant way; where they appeared to do so for a time in Iran and even in Egypt, many of the changes have been overturned. Moreover, contrary to Western stereotypes, there is a case to be made for Islam as a liberating and egalitarian influence in opposition to rigidly sexist tradition. In fact, many of the customs and practices in the Muslim world are cultural and environmental rather than religious. For example, both opponents and proponents of the veil generally agree that no explicit reference to it can be found in Islam. In the Qur'an, men and women are urged to resist temptation, restrain their lust, and be modest. It is incumbent upon adherents "to lower your gaze and guard your modesty." Women should not display their beauty and ornaments, except that which is apparent, and are cautioned to draw their veils over their bosoms (Holy Qur'an, XXIV, Nos. 30-31).

Those who believe in the importance of veiling advance many arguments. Interestingly, none of them come from the scriptures. For example, proponents cite practical considerations by pointing out that the veil provides a degree of equality and peace of mind. Since not all women are endowed with beauty, the less fortunate would often be at a disadvantage. They would be less attractive and perhaps ignored or even mistreated. Yet behind the veil, all women are equal. In addition, the veiling of women existed in pre-Islamic times as a symbol of social status. Later, in the Ottoman Empire, the veil came to symbolize aristocracy and elitism. However, justice and equality are two of the fundamental principles of Islam. Perhaps the strongest point in behalf of the egalitarian interpretation of the Qur'an is the elimination of injustice and the protection of the weak from abuses by the strong. If one accepts this as the overriding message of Islam, even customs once considered to be Muslim might be superseded in the name of this ultimate Islamic principle.

It is advisable, therefore, in defining sex roles and the status of women to differentiate between Islamic and traditional norms that developed with many variations throughout the Muslim world. Undoubtedly, some conservatives tend to be antifeminist and often advocate female subordination. In so doing, they are convinced that they are correctly interpreting and defending Islam. Nevertheless, Muslims in general believe that female unchastity is the most potent threat to family honor and that woman's sexuality threatens the social order. To them, even today, perhaps nothing is more devastating to the family's social status and reputation than a female family member who is sexually promiscuous. Men are vilified, derided, scorned, and perhaps shunned if their women behave outside the bounds of tradition. This naturally affects male protective-ness and guardianship of females' behavior. Fear and concern often lead to confinement as a means of damage control. In many Islamic countries boys and girls are segregated in schools, except at the university level, and even university segregation occurs in some areas. Dating is forbidden and risky, although it is practiced secretly beyond the watchful eyes of families and friends. It is not uncommon for couples to delay courtship until they are actually married and the wife has moved to her new domicile. Premarital pregnancy or loss of chastity is regarded as a calamity with very serious consequences to those involved and their families.

Finally, one must explore briefly the complex areas of Westernization, modernization, feminism, and emancipation. It must be understood that these are not synonyms and are construed differently by various groups and cultures. Muslims, while rejecting Westernization, embrace modernization through education, but only within the framework of their faith and tradition. A few, mainly Westernized women feel that they need Western-style emancipation to achieve independence and equality. But, as has been noted, Islam has allowed women to be active in social and economic affairs as long as such activity does not conflict with or contravene their main responsibilities to the family and society. Most Muslims still hold that the main goal of women is and should continue to be marriage, motherhood, and family. Most Islamic spokesmen regard sexual freedom and permissiveness as the ultimate degradation of womanhood. They couple these practices with materialism and secularism and hold that they have cheapened women, who have become merely sex objects and commodities constantly displayed on the meat block. They resent and detest sex being flaunted and used to commercialize almost everything from toothpaste to cars and liquor. Consequently, to Westernize means to part with traditional values and to blur sex roles. It is significant that in Egypt many of the liberal, Western-oriented laws championed by the wife of the former president have been repealed under pressure, not from men but from educated, veiled women. These and other reversals are the results of social, historical, and political pressures. By rejecting Western modes of life and sexual behavior, Muslims are also protesting and rebelling against Western domination. Does this mean that "East is east and West is west, and the twain will never meet"? The answer depends on the areas of potential cooperation and confrontation. In education, science, and modernization, there are certainly mutual benefits. However, in the area of sexual behavior, it is hard to imagine any reconciliation or common ground. Here the two cultures not only do not but perhaps never should meet. As long as the West is obsessed with sexuality, Muslims would rather live within the confines of their faith and tradition. So, as they object to some aspects of Western culture, Muslims are particularly shocked by what they view as the tasteless, overexposed, public exploitation of women and femininity for hedonistic commercial purposes.

It is clear that Muslims' views and behavior are at variance with those of Westerners. This does not mean, however, that one outlook is better than or superior to the other. It is simply a matter of cultural suitability and compatibility. Every social system has its advantages and disadvantages, but ultimately it is the people who decide what is best suited for their cultural environment. To pass a sound judgment, one must take into consideration freedom and responsibility, enjoyment and consequences, individuals and society, and above all rights and obligations if there is to be a healthy, productive, and meaningful life, with the family always the main focus and concern.


Anderson, R., and R. Seibert, Politics and Change in the Middle East. Englewood Cliffs, N.J.: Prentice Hall, 1990.

Bullough, V.L. Sexual Variance in Society and History. Chicago: Univ. of Chicago Press, 1976.

Holy Qur'an. Technically this cannot be officially translated, but there are various Exploration translations in English.

Yaken, F. Islam and Sex. Al Rissalah Establishment, 1986.

Mohamed El-Behairy

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