Psychological and Medical Perspectives on Fertility Care and Sexual Health

By Kim Bergman

Psychological and Medical Perspectives on Fertility Care and Sexual Health provides the necessary specialized training of sexual dysfunction and sex therapy to those in reproductive medicine. Understanding and knowledge about these sexual dysfunctions is needed for reproductive specialists to identify sexual problems, provide treatment if they are able or make appropriate referrals, and coordinate care for more specialized and specific needs as part of the patients overall reproductive medical management. This must-have reference explores the intimate interface of sexuality and fertility, male and female sexual function, cultural influences on women, Eastern medicine, and more!

• Provides the first-of-its-kind book for clinicians that summarizes literature and interventions and brings together the current researchers and thinkers on this topic
• Explores diverse populations typically left out, including lesbian, gay, bisexual, transgender individuals, women and people of color
• Presents a treatment dilemma for many health care providers: should one condition be treated before the other or should concurrent services be offered?
• Identifies common sexual problems/dysfunctions presented by infertility patients
• Describes interventions for these problems and identifies resources for appropriate treatment of sexual dysfunction

• Language: English
• Publisher: Elsevier Science
• Release date: Oct 21, 2021
• ISBN: 9780128232750

Book preview

Part I

Reproductive health

Outline

Chapter 1 The acquisition of sexual and reproductive health knowledge

Chapter 1

The acquisition of sexual and reproductive health knowledge

William D. Petok¹, ² and Arik V. Marcell³,    ¹Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States,    ²Independent Practice, Baltimore, MD, United States,    ³Departments of Pediatrics and Population, Family & Reproductive Health, The Johns Hopkins University, Baltimore, MD, United States

Abstract

Humanity’s struggle to understand conception is unending. While the biology of human reproduction is well known today, it was not always so. Humankind speculated for millennia on the acts and actors that create life, each discovery part of a slowly unfolding drama. Even with the advanced state of our knowledge, significant numbers of men and women struggle to build families. Some have difficulty with the biological components of conception. Others have problems with the sexual side of the equation. A lack of success with either can lead to great emotional distress and interpersonal challenges. This chapter reviews the history of our comprehension of sex and fertility and explores the current status of how that knowledge is acquired, setting the stage for the remainder of this volume.

Keywords

Sex; infertility; sex education; fertility awareness; history

Introduction

Humanity continues to struggle to understand basic concepts related to conception. While the biology of human reproduction is well known today, it was not always so. Humankind speculated for millennia on the acts and actors that create life, each discovery part of a slowly unfolding drama. Now, with the play almost complete, it has become clear that sexual and reproductive health (SRH) is important and related to overall health [1] as well as quality of life [2].

Even with the advanced state of our knowledge, significant numbers of men and women struggle to build families. Some have difficulty with the biological components of conception whereas others have problems with the sexual side of the equation. A lack of success with either can lead to great emotional distress and interpersonal challenges. When the two collide, it can create difficulties that are more than additive. If knowledge is power, then a good understanding of SRH can lead to substantial improvements in personal and interpersonal wellbeing.

This chapter will review the history of our comprehension of sex and fertility and explore the current status of how that knowledge is acquired.

Prehistory of sexual and reproductive knowledge

Two critical evolutionary changes are important in our understanding part of the connection between sex and fertility. The first point, for the purposes of this discussion, is the prehuman development of Ramapethicus, and bipedal locomotion, walking on two feet. From Ramapethicus came Homo Erectus, the oldest known early humans with modern human-like body proportions. This evolutionary milestone changed the mating position of our ancestors to face to face. Quite different from rear entry mating of many primates, the possibility of a different sensual experience exists that most nonhuman primates do not have. Some have theorized that this evolutionary change led to the female orgasm [3]. Sex, which other animal species instinctively have for procreation, now becomes something that provides pleasure as well [4] (p. 16). As Komisaruk et al. state, …women and men derive pleasure from orgasm and it is the pleasure of orgasm that helps reinforce the performance of sexual intercourse, thereby promoting procreation [5] (p. 12).

The other significant human development is that of menstruation. The vast majority of sexually reproducing animals have an estrous cycle. For these species, pheromones, behavioral or visual cues indicate to males that a female is in a fertile state. Males, in return, become interested in mating. These species generally copulate for reproductive purposes alone. Sex for pleasure is not part of their scheme. Humans and a small number of other mammals have a menstrual cycle in which the lining of the uterus is shed on a regular basis. The mechanism by which human females may provide pheromonal information to potential male partners indicating they are in a fertile state is only recently being understood [6,7]. However, it has been demonstrated that human female subjective arousal levels are stable across the phases of the menstrual cycle [5], suggesting that pleasure is a significant reason for sexual activity. And so, sexual intercourse is possible at all times, rather than during a specific hormonally determined period. Sex for pleasure and relationship enhancement become additional reasons for humans to engage in the acts and setting us apart from other animals [8]. We aren’t in it just for the babies!

Humans are not just like other animals as some would opine. One way we are different is that we know where babies come from. While all animals have a powerful sex drive, otherwise they become extinct, humans have a baby drive. During the course of history, we have created veneration of virgins, marriage, castration, assisted reproductive technologies (ARTs), and genetic manipulation. All allow humans to experience sex differently than any other animal and imbue it with cultural and emotional meaning. We have reproductive consciousness [9].

The anthropologist, Holly Dunsworth, asks the questions do animals know where babies come from? After evaluating the data, she concludes:

No matter how passionate or nurturing it is, nothing about the sexual, social and parental behavior of animals requires knowledge of reproduction. In contrast, much about Homo sapiens behavior does. Somewhere along the line, our species developed cultures rich in beliefs about procreation, family and connectedness—beliefs that in many ways set us apart from our ape cousins and indeed every other creature on the planet [10] (p. 69).

Dunsworth, in discussing reproductive consciousness, says that sex is not something that just happens with humans. Rather, we know what can happen when we have it. We understand that the act can create relatedness and kinship. And this knowledge—sex equals babies, and babies equals kinship—marks one of the turning points of the history of life. She dates reproductive consciousness to approximately 100,000 years ago with the development of abstract thinking in Homo sapiens [9].

Humans moved from hunter–gatherers to farmers about 10,000–12,000 years ago at the end of the last Ice Age. Breeding of plants and animals for specific traits, such as better crop yields or more milk, was only possible if the farmers knew about events like pollination or mating. They knew about sex and reproduction and this allowed for the transition to agricultural societies which require improved output. With this evolution these cultures developed stories and myths about fertility [9]. A glimpse into these societies and their view of sex and fertility is contained in the archeological record.

Early historical evidence

Rene’ Neuville, a French prehistorian, published an article in 1933 describing what has become known as the Ain Sakhri Figurine or sometimes, the Lovers of Ain Sakhri [11]. It is the oldest known representation of two humans copulating and is dated at approximately 9000 BCE. It currently resides in the British Museum (https://www.bmimages.com/preview.asp?image=M0000000028&itemw=0&itemf=0002&itemstep=1&itemx=8). Believed to be associated with fertility rites, it strongly suggests that the peoples of the Natufian period were concerned with fertility and knew something about where babies come from.

The archaeologic record reveals earlier symbols redolent of sex. The best known are the Venus figures, the most notable being the Venus of Willendorf, dating to the time period 30,000–25,000 BCE. Historians often describe her as a fertility goddess because she has pendulous breasts, a rounded belly, and a prominent mons pubis. Approximately 60 similar artifacts have been discovered, primarily in Central Europe [4]. Whether she was a human fertility goddess is questionable and the assignment of her as such is speculative at best. Regardless, contemporary authors see her as symbolic of female sexuality [12] (Fig. 1.1).

Figure 1.1 Venus von Willendorf, Naturhistorisches Museum Wien, Public Domain.

Symbols of male sexuality from a similar time period are available as well. A 28,000-year-old phallus with an obvious glans penis was found in the Hohle Fels cave in southwest Germany [12]. It was likely used as a tool for working with flint blades and is clearly an erect penis. Once again, a definitive understanding of the object’s meaning with regard to sex or fertility is unknown. Other European Paleolithic art contains images of erections, circumcision, and tattooed penises [13,14] (Fig. 1.2).

Figure 1.2 Hohle Fels phallus. Reproduced with permission of Senckenberg Centre for Human Evolution and Palaeoenvironment (HEP), University of Tübingen.

Fertility images from the early Chalcolithic or Copper Age (5000 BCE), most famously the Lemba Lady from Cyprus, are similar to the older Venuses in that they have emphasized breast, hips, and pubic regions [15]. There is debate about this categorization, with some suggesting that just because she has breasts and genitalia fertility is not the only interpretation of her meaning. In other words, Lemba Lady could be sexy and therefore a goddess of sexuality not associated with fertility [16] (Fig. 1.3).

Figure 1.3 Lemba Lady. Reproduced with permission of Department of Antiquities, Republic of Cyprus.

Recorded history

Human fertility was important to most ancient cultures. Fertility gods and goddesses are present in story and myth, presumably to help understand fertility and cope with infertility via offerings and ritual observances. Female fertility and pregnancy was better understood, while male infertility was an afterthought at best. The Egyptian Kahun papyrus (c.1825 BCE) offers gynecologic advice that deals with female infertility. The Egyptians understood the relationship between sexual intercourse and pregnancy. Man planted his seed into the fertile ground of the uterus where it grew into a fetus. Osiris was the god of fertility [17]. According to the myth, the birth of new crops each year signified his resurrection after his dismemberment (Figs. 1.4 and 1.5).

Figure 1.4 Papyrus Kahun VI. 1, pages 1 and 2; medical papyrus 12th Dynasty. Public domain.

Figure 1.5 Papyrus Kahun VI. 1, pages 2 and 3; medical papyrus 12th Dynasty. Public domain.

Sumerian texts and seals describe the sexual act and relate it to fertility. Simple drawings of male and female sexual organs showed a marriage bond by juxtaposing them. A translation of several Sumerian literary texts dated 1900–1600 BCE describe intercourse consummated by a priest and priestess as a means of gaining fertility for the community. These texts also describe seduction and lovemaking. From them we see that the purpose of marriage was procreation and not necessarily a pair bond for life. Pictorial representations exist from the same time period of couples having intercourse. Other scholars have suggested that the depiction of nude female forms in Mesopotamian art from the second and third millennia BCE are more linked to sexuality than fertility [18]. Some of these artifacts display sexual acts between two men, indicative of homosexual intercourse [19] (p. 22).

Male fertility and virility have been associated with Min, the son of Isis and Osiris, an ancient Egyptian god. Worship of Min dates to the fourth millennium BCE. Men who sought fertility and virility would offer sacrifices to Min and eat a type of lettuce, Lactua serriola, probably because of its phallic shape and the semen-like substance it releases when rubbed. Priapus, the Greek god with an oversized permanent erection, was considered the protector of fertility, sexuality, male genitalia as well as agriculture. The Lingam, linked to Shiva the Hindu destroyer god, is sometimes represented phallically and considered a symbol of Shiva’s creative power. Representations of Kokopelli, the fertility god worshiped by some southwestern Native American communities date to CE 200. Once again, an erect phallus represents fertility and virility. In these and other representations of fertility/virility gods an erect penis capable of ejaculation indicates the communities that worshiped them knew that semen was crucial to reproduction [20].

Similar art, artifacts, and writings occur in ancient cultures around the world. They visualize sexual and fertility gods and goddesses as well as rituals and speak to the interest humankind has in reproduction since reproductive consciousness could be recorded in a lasting form.

Modern religious writings, beginning with the Hebrew Bible, are aware of fertility and sexuality. They begin to address the psychological impact of infertility, most notably on women, and will be discussed more thoroughly in a subsequent chapter. With the advent of these monotheistic religions, sexuality is reserved for matrimonial bonds. These writings, which include the Christian Bible and Islamic Fiqh [21], have a decided view on sexual intercourse and its role in human relations and seek to bring it under control for procreation within marriage only.

Science and fertility

Aristotle was among the first to give a scientific explanation to conception. For those animals who were observed to mate, he thought each brought specific matter to the process. The female, her menstrual blood, and the male his semen. Those two combined, blood given form by semen, with the outcome being a baby. Following Hippocrates’ opinion, Galen, the Roman physician, thought there were two semens, male and female, but the female semen could not be seen. Aristotle’s view prevailed before the turn of the millennium [22].

Monotheistic religious thinkers believed semen was the primary component of conception. Chinese thinkers talked about the generative capacity of the energy created in organ networks in both sexes, referred to as generative vitality. World science views, such as they were then, were decidedly not in agreement [22].

These early views predominated for 1500 years. In 1651 William Harvey became convinced that the egg had something to do with conception, but his animal dissections failed to reveal the it or how of this process. He decided that new life was produced in the uterus following intercourse similar to how imagination and appetite are produced in the brain. The female’s testicles, as he termed the ovaries, played no role at all [23]. Within 25 years scientific thinking had changed and egg theory was being embraced for the female contribution to all animal reproduction, including humans [24].

The work of Swammerdam, Stenson, Van Horne, and eventually de Graaf confirmed that female eggs, from ovarian follicles, were the elusive other side of the equation. The observation, by de Graaf, that ruptured rabbit follicles released spheres into the fallopian tubes and the number of spheres was most often the same as the number of ruptured follicles was decisive. However, his notion of a seminal vapor reaching the egg and fertilizing it missed the mark. But the specific female contribution to conception had been proven [22]. In 1679 the French Journal des Sçavans wrote: The view that man, as well as all other animals, are formed from eggs is something that is now so widespread that there are hardly any new philosophers who do not now accept it [22] (p. 4). How the egg’s contribution took place was as yet unclear. In fact, it was not until the human egg was first seen by Karl Ernst von Baer in 1827 that its existence was proven [25] (Fig. 1.6).