Questions in psychiatry (QuiP): Contextualizing sexual behaviours and practices

This article is the third in our series on sexual wellbeing, which aims to highlight this vital aspect of patient's lives that is both poorly understood and seldom assessed. To assist with exploring this area with patients, and building on previous articles in this series, this QuiP provides a brief overview of typical^* sexual behaviours and practices (SPBs) and the extent to which individuals engage in them.

1. SEXUAL PRACTICES

Sexual behaviour is universal, but at the same time, immensely diverse. Defining what is typical sexual behaviour requires discussion of complex issues such as cultural beliefs, societal norms, legal constraints and some consideration of human desires. Naturally, an in‐depth discussion is beyond the scope of a brief piece such as this. Therefore we have made a number of assumptions that need to be borne in mind when considering what we define as 'typical' sexual behaviour.

For example, we do not discuss paraphilias and a whole range of sexual behaviours that are relatively uncommon and are generally not regarded as mainstream^† (for further information, see footnote^‡). For instance, BDSM,^§ whilst not rare, is generally regarded by most people as a ‘fringe’ sexual activity. Similarly, exhibitionism and behaviours including interaction with online pornography, fall outside the scope of this QuiP. In addition, this QuiP does not discuss disorders of sexual functioning (e.g., erectile disorder, female orgasmic disorder), however, these will be considered in the future.

Another reason for focusing on mainstream behaviours is that links between mental health and sexual behaviour have been examined mostly in relation to those practices that are most common. Surprisingly, many forms of sexual practices are seldom considered in academic literature and therefore, sourcing statistics and gaining an accurate picture of these activities is difficult.

The figure below (Figure 1) illustrates some statistics of sexual experiences across ages, between men and women and the frequency of some particular SPBs. In combination with the schema outlined in the previous QuiP for working through each of these behaviours with a patient, these additional statistics should serve as a useful foundation for making inquiries in a clinical context and formulating specific questions. Specifically, when appraising the sexual behaviour of a patient, information on frequency, age and other parameters, provides some useful context as to the kind of SPBs likely to be encountered (or reported) in the population.

FIGURE 1.

Schematic of sexual practices and behaviours

1.1. Frequency

Inquiring about the frequency of SPBs is important because not engaging in these practices for a prolonged period of time is likely to reflect some degree of dysfunction. This may be a consequence of an underlying physical or mental cause. However, it is important to note that the frequency with which an individual engages in sexual practices depends on many factors, several of which are not necessarily indicative of dysfunction per se. For example, people often experience a decrease in sexual activity during pregnancy and post‐partum, periods of physical illness/injury and during periods where couples are physically distanced—for instance because of work. Sexual activity may also decline with age because of decreased energy and mobility. On the other hand, various factors may contribute to an increase in frequency of sexual behaviours, for example soon after commencing a new relationship, or when trying to conceive. Note, the data shown in Figure 1 do not capture the frequency of sexual practices in all populations (e.g., LGBTQI+ individuals or those with disabilities) and therefore some additional facts and figures are discussed below.

Masturbation is a common, safe sexual practice that may be practiced solo or in the presence of a sexual partner.^¶ It often entails the viewing of pornography,^** and on average, men tend to masturbate more frequently than women. ¹

Sex as a practice, or ‘having sex’, means different things to different people. In regular heterosexual relationships, sex most commonly refers to vaginal intercourse, and this is practiced by couples on average 1–2 times per week. ² , ³ This frequency can vary depending on the age of participants and the duration of their relationship. It is also impacted by other factors mentioned above ‐ pregnancy and physical injury.

Like sexual intercourse, oral sex, which can include both giving or receiving, is also a common practice. Men tend to report higher levels of receiving oral sex than women, and the frequency of receiving oral sex decreases with age in both men and women.

Much less frequent than oral sex, but not uncommon, the lifetime experience rates for anal sex in relatively young people (age 25–29) are above 40% for both men and women. Like oral sex, anal sex involves both giving and receiving. ²

Finally, a broad range of sexual practices entail the use of sex toys such as vibrators and dildos. And this occurs in both solo or partnered masturbation, during intercourse and other sexual practices. On average, approximately 10% of men and 20% of women report having used a sex toy within the past month.

1.2. Age

As mentioned already, sexual practices vary by age both in terms of frequency and type of sexual practice. Generally, older adults engage in sexual practices less frequently than younger adults (approximately 2–3 times per month). However, many people remain sexually active throughout their life, and a significant proportion of older adults have active sexual lives. For example, in one study, between 60%–90% of adults aged 60–75 reported being ‘sexually active^††’ in the past year. ⁴

It is important to note that differences in rates of sexual activity between older men and women is not necessarily due to differences in libido. For example, older women are more often widowed than older men, and thus simply not having a partner may be the critical limiting factor that contributes to the difference in sexual engagement. Therefore, it is important not to assume that sex no longer plays a part in a person's life simply because of their age, just as mental illness should not preclude questioning about sexual practices.

1.3. Satisfaction

Sex is a complex, multi‐faceted construct and therefore, there are many ways of measuring sexual satisfaction. One important and reasonably discrete measure is whether a sexual practice achieves orgasm. As a consequence, many studies use rates of orgasm as an indicator of whether an individual is experiencing satisfaction in their sexual practices with their partner. Typically, heterosexual men report that they usually, or always, orgasm when sexually intimate^‡‡ (95%), whereas heterosexual women report generally lower rates (65%). ⁵ Interestingly, more lesbian women (than heterosexual women) report that they usually, or always, orgasm (86%). This is thought to be because lesbian women are perhaps more likely to engage in a wider variety of sexual practices (e.g., oral sex, partnered masturbation) and sustain foreplay (sexual activity preceding intercourse) for longer when intimate than women in heterosexual relationships. Thus, it may be useful to consider engaging in more varied sexual practices and using sex toys when discussing poor sexual satisfaction.

2. CONCLUSION

Sexual practices and behaviours form a key component of sexual wellbeing and sexual satisfaction is important for an individual's overall functioning and sense of self. Therefore, it is critical that sexual practices and behaviours are assessed routinely, and in sufficient detail to determine whether there is any impairment and identify means of addressing this. This is particularly important in those with a mental illness, in whom there is likely to be some degree of impairment, either because of their illness or because of the side‐effects of treatment. This QuiP has provided a brief introduction to a complex issue. It has shown that sexual practices and behaviours vary considerably according to very many factors, and that this knowledge should serve as a foundation for further enquiry.

FUNDING INFORMATION

The author(s) received no financial support for the research, authorship and/or publication of this article.

CONFLICT OF INTEREST

G.S.M. has received grant or research support from National Health and Medical Research Council, Australian Rotary Health, NSW Health, American Foundation for Suicide Prevention, Ramsay Research and Teaching Fund, Elsevier, AstraZeneca, Janssen‐Cilag, Lundbeck, Otsuka and Servier; and has been a consultant for AstraZeneca, Janssen‐Cilag, Lundbeck, Otsuka and Servier. The author E.B. declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

DATA AVAILABILITY STATEMENT

Data sharing is not applicable to this article as no new data were created or analyzed in this study.