Psychological Perspectives on Human Sexuality.

Edited by Lenore T. Szuchman and Frank Muscarella. New York: John Wiley & Sons, 2000, 682 pages. Cloth, $69.95.

This is a long and dense book--the kind that can cause carpel tunnel syndrome in book reviewers who attempt to lift and read it. It is the kind of book that editors fear will not be reviewed because the reviewer will never finish reading it. I was tempted to read selective chapters of the book and write the review based on a representative sampling of the content. However, I soon found myself caught up in each chapter I read, unable to decide which chapters to read. I tried several strategies--random selection, picking those chapters I knew the most about--always unhappy about giving up reading the chapters that were cut out by any particular strategy. I finally recognized that I wanted to read this book, all 682 pages, and so I did. This fact, more than anything else I will say during the rest of this review, speaks to the quality of this compendium.

Psychological Perspectives on Human Sexuality is an ambitious book, an edited overview of the field of human sexuality. The danger with edited volumes is that the quality of the volume can vary dramatically, all depending on the contributor of each chapter. This volume showed a consistently high level of quality, largely due to the seemingly judicious selection of authors who were experts in their assigned areas.

The first chapter, an overview of research in human sexuality by Wagstaff, Abramson, and Pinkerton, starts out this volume auspiciously. It covers the general ballpark that is sexuality research, bringing in some of the newer perspectives garnered from HIV-related research. The chapter does a nice job of reviewing the extensive literature on the pros and cons of various data collection instruments, including well-known problems with the external validity of laboratory data, as well as how face-to-face interviews exacerbate socially desirable responding. Other important topics covered included a review of national surveys and data bases about human sexuality currently collected in the U.S., a review of the professional organizations and journals in the area of human sexuality, and some of the newer research showing that maintaining an active sex life is related to greater life expectancy, at least in men.

Chapter 3 on female sexuality by Everaerd, Laan, Both, and Van Der Velde is the arguably the most exciting chapter in this compendium. It is written by both female and male researchers doing cutting edge research in this area. The authors set out and succeed in focusing on the subjective meaning of sex for women, integrating meaning with the most current physiological research in female sexuality. They do an excellent job of summarizing historical perspectives on the denial of women's sexuality and new perspectives on sexual anatomy and physiology. For example, the renewed discussion about the clitoris and connected erectile tissue (two stripes of erectile tissue which diverge into the crura inside the labia majora) is reviewed. Recognition of the importance of this connected erectile tissue is reflected in proposals to rename this tissue "clitoral bulbs."

The most exciting part of this chapter is the authors' cogent review of new (their and others') research on female sexuality integrating cognitive theory and physiological findings. In particular, this research attempts to explain (not denigrate) the enigmatic discrepancy between genital and subjective sexual arousal and sexual behavior and subjective sexual arousal. In their thoughtful and respectful discussion, the authors attempt to explain the consistent finding that, in contrast to studies of men, women show far less agreement between reported genital sensations and changes in vasocongestion. However, rather than pointing this out as a deficiency in women, they use a cognitive arousal theory of emotions to validate this perspective and conclude

   "... a given situation will not be experienced as sexual, despite the
   presence of genital arousal, without the occurrence of appropriate
   emotional attribution. Thus, a situation (a stimulus) is not intrinsically
   sexual; it becomes sexual by its transformation."(p. 113)

Thus, they predict that in women the appraisal of the situation will account for more of the variance in subjective experience of sexual arousal than feedback from genital sensations. They then go on to propose that both genital and subjective indices are important and necessary to reliably assess sexual arousal and conclude that genital arousal appears to be a less important factor in subjective sexual arousal for women than it appears to be for men.

Their affirming and scientific discussion of gender differences in arousal for women and men helps explain some crucial differences in sexual response that women with sexual problems or dysfunction need to be informed about. Tiefer argues that focusing only on the physiological aspects of sexuality, as the DSM does, favors men's sexual style over women's. In my clinical practice, I have seen many sexual dysfunctions that are diagnosed in women come about as a result of women's erroneous internalization of a male view of sexuality. Since these women think they should be responding sexually just like their male partners, they discount and thus turn off their own natural desire and arousal, oftentimes creating a sexual dysfunction where none would exist or, at the very least, exacerbating any sexual dysfunction they do have.

Chapter 10, "HIV/AIDS and Sexuality" by Ross and Schonnesson, two acknowledged experts in the field of HIV prevention and coping with AIDS, is an ambitious attempt to summarize the voluminous literature in this prolific field, as well as an attempt to blend quantitative and qualitative perspectives. These authors are commendable for taking on such an extremely difficult task. Ross and Schonnesson are at their best when making some broad observations about HIV research based on their considerable experience. Paradoxically, they note some of the positive impacts of the HIV pandemic on sexuality research. This includes new research funding for basic and applied research in human sexuality and research in cross-cultural sexuality, since the epidemic affects all cultures worldwide, especially sexual minorities and poorer cultures and cultural groups.

Ross and Schonnesson do a particularly good job of summarizing HIV-prevention research in men who have sex with men, a group that has been well researched. They focus on research examining "contexts of risk," correctly (I think) noting that risk should not be conceptualized as only an individual-level variable. They review literature showing how affects such as being in love and/or being highly aroused may override rational thought. Ross and Schonnesson review research on important intervening variables related to risk such as attitudes toward condom use, alcohol and drugs, and sensation seeking.

Their review highlights the complexity of this research. Predictors of risk behavior are rarely simple and there are numerous interactions and intervening variables. For example, general social assertiveness was negatively associated with condom use in heterosexual men, but positively associated in homosexual men. In another study examining the mood states of gay men engaging in an unsafe sexual encounter, the older men had been in a better mood at the start of the evening and the younger men in a more negative mood at the start of the evening. Research results may be slow in accumulating as researchers struggle to tease out these complex interactions.

The last half of Ross and Schonnesson's chapter is a descriptive discussion of how HIV disease affects the psychological functioning (i.e., psychological survival, social threats, sexual threats) of those diagnosed. The concept of psychological landscape is defined in an attempt to appreciate the existential meaning, adaptation processes, and self-context as one struggles to cope with the meaning of the disease on one's life. It is very different in tone from the first half of the chapter and needed, I thought, to be anchored in some quantitative research. For example, what percentages of those with HIV disease internalize negative societal attitudes toward HIV and become their own "internal persecutors" as described? It is likely that there is no research operationalizing and quantifying much of this discussion, but the authors needed to note that and should call for such research.

Similarly, this chapter would have been strengthened if the authors had explicitly acknowledged their focus and what they were leaving out of their discussion: Research on minority communities, women, and heterosexual relationships, where the epidemic is now growing, was minimally acknowledged. There was no mention of the fact that condom use tends to decrease in longer-term relationships and the huge implications of this for HIV prevention. The inherent conflict between current strategies for HIV prevention and the desire of women to bear children was not discussed nor was the huge cross-cultural literature mentioned.

Other excellent contributions include Chapters 2 ("Male Sexuality"), 5 ("Sexual Orientation"), 14 ("Sexuality and the Internet: The Next Sexual Revolution"), 16 ("Rape and Sexual Aggression"), and 17 ("Therapists' Sexual Feelings and Behaviors: Research Trends and Quandaries"). In my opinion, Chapters 8 ("Disabled Sexual Partners") and 12 ("Genital Surgery on Children below the Age of Consent") were the weakest chapters: The former because there is probably very little new research to discuss on this topic and the latter because it was more of an editorial diatribe against early reconstructive surgery for intersex children and male circumcision than a scientific review and discussion. The remaining chapters on "Love Relationships," "Sexual Fantasy and Erotica/Pornography," "Older Adult Sexuality," "Adolescent Sexuality, Paraphilias," and "Aftermath of Child Sexual Abuse" were competent and scholarly. Chapter 4, "Issues of Transgender," was, for the most part, accurate and informative, with an occasional lapse into unsubstantiated assertions or editorializing against the Harry Benjamin International Gender Dysphoria Association's Standards of Care.

In sum, this volume is a consistently excellent research-based overview of major topics in human sexuality. I would recommend it to college professors teaching upper-level undergraduate or graduate-level courses, as well as to clinicians and researchers seeking an overview of the current state of the field of human sexuality. This volume represents an ambitious undertaking from which readers are sure to benefit.

Reviewed by Beatrice "Bean" E. Robinson, Ph.D., Program in Human Sexuality, University of Minnesota Medical School, 1300 South 2nd Street, Suite 180, Minneapolis, MN 55454; e-mail: [e-mail].