Medicine:Hypersexuality

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Short description: Excessive arousal and interest in sex
Hypersexuality
SpecialtyPsychiatry

Hypersexuality is extremely frequent or suddenly increased libido. It is currently controversial whether it should be included as a clinical diagnosis[1] used by mental healthcare professionals. Nymphomania and satyriasis were terms previously used for the condition in women and men, respectively.

Hypersexuality may be a primary condition, or the symptom of another medical disease or condition; for example, Klüver-Bucy syndrome or bipolar disorder. Hypersexuality may also present as a side effect of medication such as drugs used to treat Parkinson's disease. Clinicians have yet to reach a consensus over how best to describe hypersexuality as a primary condition,[2][3][4] or to determine the appropriateness of describing such behaviors and impulses as a separate pathology.

Hypersexual behaviours are viewed variously by clinicians and therapists as a type of obsessive-compulsive disorder (OCD) or "OCD-spectrum disorder", an addiction,[5][6][7] or a disorder of impulsivity. A number of authors do not acknowledge such a pathology[8] and instead assert that the condition merely reflects a cultural dislike of exceptional sexual behavior.[9][10]

Consistent with there not being any consensus over what causes hypersexuality,[11] authors have used many different labels to refer to it, sometimes interchangeably, but often depending on which theory they favor or which specific behavior they were studying. Contemporary names include compulsive masturbation, compulsive sexual behavior,[12][13] cybersex addiction, erotomania, "excessive sexual drive",[14] hyperphilia,[15] hypersexuality,[16][17] hypersexual disorder,[18] problematic hypersexuality,[19] sexual addiction, sexual compulsivity,[20] sexual dependency,[10] sexual impulsivity,[21] "out of control sexual behavior",[22] and paraphilia-related disorder.[23][24][25]

Causes

There is little consensus among experts as to the causes of hypersexuality. Some research suggests that some cases can be linked to biochemical or physiological changes that accompany dementia. Psychological needs also complicate the biological explanation, which identifies the temporal/frontal lobe of the brain as the area for regulating libido. Persons suffering from injuries to this part of the brain are at increased risk for aggressive behavior and other behavioral problems including personality changes and socially inappropriate sexual behavior such as hypersexuality.[26] The same symptom can occur after unilateral temporal lobotomy.[27] There are other biological factors that are associated with hypersexuality such as premenstrual changes, and the exposure to virilising hormones in childhood or in utero.[28]

In research involving the use of antiandrogens to reduce undesirable sexual behaviour such as hypersexuality, testosterone has been found to be necessary, but not sufficient, for sexual drive.[28] Other proposed factors include a lack of physical closeness and forgetfulness of the recent past.[29]

Pathogenic overactivity of the dopaminergic mesolimbic pathway in the brain—forming either psychiatrically, during mania,[30] or pharmacologically, as a side effect of dopamine agonists, specifically D3-preferring agonists[31][32]—is associated with various addictions[33][34] and has been shown to result among some in overindulgent, sometimes hypersexual, behavior.[30][31][32] HPA axis dysregulation has been associated with hypersexual disorder.[35]

The American Association for Sex Addiction Therapy acknowledges biological factors as contributing causes of sex addiction. Other associated factors include psychological components (which affect mood and motivation as well as psychomotor and cognitive functions[36]), spiritual control, mood disorders, sexual trauma, and intimacy anorexia as causes or type of sex addiction.[37]

As a symptom

Hypersexuality is known to present itself as a symptom in connection to a number of mental and neurological disorders. Some people with borderline personality disorder (sometimes referred to as BPD) can be markedly impulsive, seductive, and extremely sexual. Sexual promiscuity, sexual obsessions, and hypersexuality are very common symptoms for both men and women with BPD. On occasion for some there can be extreme forms of paraphilic drives and desires. "Borderline" patients, due in the opinion of some to the use of splitting, experience love and sexuality in unstable ways.[38]

People with bipolar disorder may often display tremendous swings in sex drive depending on their mood. As defined in the DSM-IV-TR, hypersexuality can be a symptom of hypomania or mania in bipolar disorder or schizoaffective disorder. Pick's disease causes damage to the temporal/frontal lobe of the brain; people with Pick's disease show a range of socially inappropriate behaviors.[39]

Several neurological conditions such as Alzheimer's disease, autism, ADHD,[40][41] various types of brain injury,[42] Klüver–Bucy syndrome,[43] Kleine–Levin syndrome,[44] and many more neurodegenerative diseases can cause hypersexual behavior. Sexually inappropriate behavior has been shown to occur in 7–8% of Alzheimer's patients living at home, at a care facility or in a hospital setting. Hypersexuality has also been reported to result as a side-effect of some medications used to treat Parkinson's disease.[45][46] Some recreationally used drugs, such as methamphetamine, may also contribute to hypersexual behavior.[47]

A positive link between the severity of dementia and occurrence of inappropriate behavior has also been found.[48] Hypersexuality can be caused by dementia in a number of ways, including disinhibition due to organic disease, misreading of social cues, understimulation, the persistence of learned sexual behaviour after other behaviours have been lost, and the side-effects of the drugs used to treat dementia.[49] Other possible causes of dementia-related hypersexuality include an inappropriately expressed psychological need for intimacy and forgetfulness of the recent past.[50] As this illness progresses, increasing hypersexuality has been theorized to sometimes compensate for declining self-esteem and cognitive function.[29]

Symptoms of hypersexuality are also similar to those of sexual addiction in that they embody similar traits. These symptoms include the inability to be intimate (intimacy anorexia), depression and bipolar disorders.[51] The resulting hypersexuality may have an impact in the person's social and occupational domains if the underlying symptoms have a large enough systemic influence.[52][53]

As a disorder

(As of 2010), a proposal to add Sexual Addiction to the Diagnostic and Statistical Manual of Mental Disorders (DSM) system has failed to get support of the American Psychiatric Association (APA).[54][55][56] The DSM does include an entry called Sexual Disorder Not Otherwise Specified (Sexual Disorder NOS) to apply to, among other conditions, "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used".[57]

The International Statistical Classification of Diseases and Related Health Problems (ICD-10) of the World Health Organization (WHO), includes two relevant entries. One is "Excessive Sexual Drive" (coded F52.7),[58] which is divided into satyriasis for males and nymphomania for females. The other is "Excessive Masturbation" or "Onanism (excessive)" (coded F98.8).[59]

In 1988, Levine and Troiden questioned whether it makes sense to discuss hypersexuality at all, arguing that labeling sexual urges "extreme" merely stigmatizes people who do not conform to the norms of their culture or peer group, and that sexual compulsivity be a myth.[9] However, and in contrast to this view, 30 years later in 2018, the ICD-11 created a new condition classification, compulsive sexual behavior, to cover "a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour". It classifies this "failure to control" as an abnormal mental health condition.[60][61]

Treatment

Hypersexuality may negatively impact an individual. The concept of hypersexuality as an addiction was started in the 1970s by former members of Alcoholics Anonymous who felt they experienced a similar lack of control and compulsivity with sexual behaviors as with alcohol.[9][62] Multiple 12-step style self-help groups now exist for people who identify as sex addicts, including Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, and Sexual Compulsives Anonymous. Some hypersexual men may treat their condition with the usage of medication (such as Cyproterone acetate) or consuming foods considered to be anaphrodisiacs.[63] Other hypersexuals may choose a route of consultation, such as psychotherapy, self-help groups or counselling.[64]

Terminology

The Merriam-Webster Dictionary defines hypersexual as "exhibiting unusual or excessive concern with or indulgence in sexual activity".[65] Sexologists have been using the term hypersexuality since the late 1800s, when Krafft-Ebing described several cases of extreme sexual behaviours in his seminal 1886 book, Psychopathia Sexualis.[66][11] The author used the term "hypersexuality" to describe conditions that would now be termed premature ejaculation. Terms to describe males with the condition include donjuanist,[67] satyromaniac,[68] satyriac[69] and satyriasist,[70] for women clitoromaniac,[71] nympho and nymphomaniac,[72] for teleiophilic (attracted to adults) heterosexual women andromaniac,[73] while hypersexualist, sexaholic,[74] onanist, hyperphiliac and erotomaniac[75] are gender neutral terms.[76]

Other, mostly historical, names include Don Juanism, the Messalina complex,[77] sexaholism,[78] hyperlibido[79] and furor uterinus.[80]

See also

References

  1. ↑ "hypersexuality". https://www.psychologytoday.com/ca/conditions/hypersexuality-sex-addiction. 
  2. ↑ Stein, D. J. (2008). Classifying hypersexual disorders: Compulsive, impulsive, and addictive models. Psychiatric Clinics of North America, 31, 587–592.
  3. ↑ Bancroft, J., & Vukadinovic, Z. (2004). Sexual addiction, sexual compulsivity, sexual impulsivity or what? Toward a theoretical model . Journal of Sex Research, 41, 225–234.
  4. ↑ Coleman, E. (July 1986). "Sexual Compulsion vs. Sexual Addiction: The Debate Continues". SIECUS Report 14 (6): 7–11. https://ahcaf.com/wp-content/uploads/2019/05/14-6.pdf. Retrieved 2012-10-15. 
  5. ↑ Orford, J. (1985). Excessive appetites: A psychological view of the addictions. Chichester, England: John Wiley & Sons.
  6. ↑ Douglas, Weiss (1998). The Final Freedom : Pioneering Sexual Addiction Recovery. Fort Worth, Tex.: Discovery Press. pp. 13–14. ISBN 978-1881292371. OCLC 38983487. 
  7. ↑ Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: CompCare.
  8. ↑ Levine, S. B. (2010). What is sexual addiction? Journal of Sex & Marital Therapy, 36, 261–275.
  9. ↑ 9.0 9.1 9.2 Levine, M. P.; Troiden, R. R. (1988). "The Myth of Sexual Compulsivity". Journal of Sex Research 25 (3): 347–363. doi:10.1080/00224498809551467. https://www.scribd.com/doc/24115543/The-Myth-of-Sexual-Compulsivity. 
  10. ↑ 10.0 10.1 Rinehart, N. J., & McCabe, M. P. (1997). Hypersexuality: Psychopathology or normal variant of sexuality? Sexual and Marital Therapy, 12, 45–60.
  11. ↑ 11.0 11.1 Kafka, M. P. (2010). Hypersexual Disorder: A proposed diagnosis for DSM-V. Archives of Sexual Behavior, 39, 377–400.
  12. ↑ Quadland, M. C. (1985). Compulsive sexual behavior: Definition of a problem and an approach to treatment. Journal of Sex and Marital Therapy, 11, 121–132.
  13. ↑ Coleman, E. (1990). The obsessive–compulsive model for describing compulsive sexual behavior. American Journal of Preventive Psychiatry & Neurology, 2, 9–14.
  14. ↑ "ICD-10 entry for "Excessive sexual drive".". Apps.who.int. http://apps.who.int/classifications/icd10/browse/2010/en#/F52.7. 
  15. ↑ Money, J. (1980). Love and love sickness. The science of sex, gender difference, and pair bonding. Baltimore, MD: Johns Hopkins University Press.
  16. ↑ Miller, B. L., Cummings, J. L., & McIntyre, H. (1986). Hypersexuality or altered sexual preferences following brain injury. Journal of Neurology, Neurosurgery, and Psychiatry, 49, 867–873.
  17. ↑ Orford, J. (1978). Hypersexuality: Implications for a theory of dependence. British Journal of Addiction, 73, 299–310.
  18. ↑ Krueger, R. B., & Kaplan, M. S. (2001). The paraphilic and hypersexual disorders. Journal of Psychiatric Practice, 7, 391–403.
  19. ↑ Kingston, D. A., & Firestone, P. (2008). Problematic hypersexuality: Review of conceptualization and diagnosis. Sexual Addiction and Compulsivity, 15, 284–310.
  20. ↑ Dodge, B., Reece, M., Cole, S. L., & Sandfort, T. G. M. (2004). Sexual compulsivity among heterosexual college students. Journal of Sex Research, 41, 343–350.
  21. ↑ Kafka, M. P. (1995b). Sexual impulsivity. In E. Hollander & D. J. Stein (Eds.), Impulsivity and aggression (pp. 201–228). Chichester, England: John Wiley.
  22. ↑ Bancroft, J. (2008). Sexual behavior that is "out of control": A theoretical conceptual approach. Psychiatric Clinics of North America, 31, 593-601.
  23. ↑ Kafka, M. P. (1994). Paraphilia-related disorders: Common, neglected, and misunderstood. Harvard Review of Psychiatry, 2, 39–40.
  24. ↑ Kafka, M. P. (2000). The paraphilia-related disorders: Nonparaphilic hypersexuality and sexual compulsivity/addiction. In S. R. Leiblum & R. C. Rosen (Eds.), Principles and practice of sex therapy (3rd ed., pp. 471–503). New York: Guilford Press.
  25. ↑ Kafka, M. P. (2001). The paraphilia-related disorders: A proposal for a unified classification of nonparaphilic hypersexuality disorders. Sexual Addiction & Compulsivity, 8, 227–239.
  26. ↑ Robinson, Karen M. DNS, RN, CS, FAAN (January 2003). "Understanding Hypersexuality: A Behavioral Disorder of Dementia". Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional 21 (1): 43–7. doi:10.1097/00004045-200301000-00010. PMID 12544463. 
  27. ↑ Devinsky, Julie; Devinsk, Oliver; Sacks, Orrin (18 Nov 2009). "Neurocase: The Neural Basis of Cognition". Klüver–Bucy Syndrome, Hypersexuality, and the Law 16 (2): 140–145. doi:10.1080/13554790903329182. PMID 19927260. 
  28. ↑ 28.0 28.1 Catalan, Jose; Singh, Ashok (1995). "Hypersexuality revisited". The Journal of Forensic Psychiatry 6 (2): 255–258. doi:10.1080/09585189508409891. 
  29. ↑ 29.0 29.1 Robinson, K. M. (2003). Understanding Hypersexuality: A Behavioral Disorder of Dementia. Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional, 43-47.
  30. ↑ 30.0 30.1 Silverstone T, T (1985). "Dopamine in manic depressive illness. A pharmacological synthesis". Journal of Affective Disorders 8 (3): 225–31. doi:10.1016/0165-0327(85)90020-5. PMID 2862169. 
  31. ↑ 31.0 31.1 "MedlinePlus Drug Information: Pramipexole (Systemic)". United States National Library of Medicine. https://www.nlm.nih.gov/medlineplus/druginfo/uspdi/203739.html. 
  32. ↑ 32.0 32.1 Boyd, Alan (1995). "Bromocriptine and psychosis: A literature review". Psychiatric Quarterly 66 (1): 87–95. doi:10.1007/BF02238717. PMID 7701022. 
  33. ↑ "Dopamine, learning and reward-seeking behavior". Acta Neurobiol Exp 67 (4): 481–488. 2007. 
  34. ↑ Nestler, Eric J. (2005). "Is There A Common Molecular Pathway For Addiction?". Nature Neuroscience 8 (11): 1445–1449. doi:10.1038/nn1578. PMID 16251986. http://dept.wofford.edu/neuroscience/NeuroSeminar/pdfSpring2006/a7.pdf. 
  35. ↑ Chatzittofis, A.; Arver, S.; Öberg, K.; Hallberg, J.; Nordström, P.; Jokinen, J. (2016). "HPA axis dysregulation in men with hypersexual disorder". Psychoneuroendocrinology 63: 247–53. doi:10.1016/j.psyneuen.2015.10.002. PMID 26519779. 
  36. ↑ "Psychological components - Mobility and transport - European Commission" (in en). 2016-10-17. https://ec.europa.eu/transport/road_safety/specialist/knowledge/fatique/introduction/psychological_components_en. 
  37. ↑ "American Association For Sex Addiction Therapy" (in en-US). https://aasat.org/. 
  38. ↑ Mitchell, Stephen (1995). Freud and Beyond: A History of Modern Psychoanalytic Thought. New York: Basic Books. ISBN 978-0-465-01405-7. https://archive.org/details/freudbeyondhisto00mitc. 
  39. ↑ Cummings, J. L.. Dementia: A clinical approach (2nd ed). Boston: Butterworth-Heinemann. 
  40. ↑ Jones, M. C.; Okere, K. (2008). "Treatment of Hypersexual Behavior with Oral Estrogen in an Autistic Male". Southern Medical Journal 101 (9): 959–960. doi:10.1097/SMJ.0b013e318180b3de. PMID 18708975. 
  41. ↑ "Grossly disinhibited sexual behavior in dementia of Alzheimer's type". Arch Sex Behav 36 (2): 133–4. April 2007. doi:10.1007/s10508-006-9144-1. PMID 17308974. 
  42. ↑ "Hypersexuality or altered sexual preference following brain injury". J. Neurol. Neurosurg. Psychiatry 49 (8): 867–73. August 1986. doi:10.1136/jnnp.49.8.867. PMID 3746322. 
  43. ↑ National Institute of Neurological Disorders and Stroke. "NINDS Klüver-Bucy Syndrome Information Page". https://www.ninds.nih.gov/Disorders/All-Disorders/Kl%C3%BCver-Bucy-Syndrome-Information-Page. 
  44. ↑ "Kleine-Levin syndrome: a systematic review of 186 cases in the literature". Brain 128 (Pt 12): 2763–76. December 2005. doi:10.1093/brain/awh620. PMID 16230322. 
  45. ↑ Vogel, H. P.; Schiffter, R. (1983). "Hypersexuality: A complication of dopaminergic therapy in Parkinson's disease". Pharmacopsychiatria 16 (4): 107–110. doi:10.1055/s-2007-1017459. PMID 6685318. 
  46. ↑ Uitti, Ryan J.; Tanner, C. M.; Rajput, A. H.; Goetz, C. G.; Klawans, H. L.; Thiessen, B. (1989). "Hypersexuality with antiparkinsonian therapy". Clinical Neuropharmacology 12 (5): 375–383. doi:10.1097/00002826-198910000-00002. PMID 2575449. 
  47. ↑ Mansergh, G., Purcell, D. W., Stall, R., McFarlane, M., Semaan, S., Valentine, J., et al. (2006). CDC consultation on methamphetamine use and sexual risk behavior for HIV/STD infection: Summary and suggestions. Public Health Reports, 121, 127-132.
  48. ↑ Burns, A.; Jacoby, R.; Levy, R. (1990). "Psychiatric phenomena in Alzheimer's disease. IV: Disorders of behavior.". British Journal of Psychiatry 157: 86–94. doi:10.1192/bjp.157.1.86. PMID 2397368. 
  49. ↑ Series, H.; Dégano, P. (2005). "Hypersexuality in dementia". Advances in Psychiatric Treatment 11 (6): 424. doi:10.1192/apt.11.6.424. 
  50. ↑ Karen M. Robinson, DNS, RN, DS, FAAN. (Jan 2003). Understanding Hyper sexuality, A Behavioral Disorder of Dementia. Home Healthcare Nurse. Vol.21, no.1.
  51. ↑ Douglas., Weiss (1998). The Final Freedom: Pioneering Sexual Addiction Recovery. Fort Worth, Tex.: Discovery Press. pp. 31–34. ISBN 978-1881292371. OCLC 38983487. 
  52. ↑ Douglas., Weiss (1998). The Final Freedom: Pioneering Sexual Addiction Recovery. Fort Worth, Tex.: Discovery Press. pp. 87–88, 92–93. ISBN 978-1881292371. OCLC 38983487. 
  53. ↑ Weiss, Douglas (2007). Sex Addiction: 6 Types and Treatment. Fort Worth, Texas: Discovery Press. pp. 33. ISBN 978-1-881292-36-4. 
  54. ↑ Rubin, Rita (2010-02-09). "Psychiatry's bible: Autism, binge-eating updates proposed for 'DSM'". USA Today. https://www.usatoday.com/news/health/2010-02-10-dsm10_ST_N.htm. 
  55. ↑ "Black Friday deals for Target, H&M, Forever21, Old Navy, Radio Shack and more". Daily News (New York). 2010-02-10. http://articles.nydailynews.com/2010-02-10/entertainment/27055937_1_autism-mental-disorders-mental-illness. 
  56. ↑ "New Diagnostic Guidelines for Mental Illnesses Proposed". Health.usnews.com. 2010-02-10. http://health.usnews.com/health-news/family-health/brain-and-behavior/articles/2010/02/10/new-diagnostic-guidelines-for-mental-illnesses-proposed. 
  57. ↑ American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text revision). Washington, DC: Author.
  58. ↑ "2012 ICD-10 Diagnosis Code F52.7 : Excessive sexual drive". http://thcc.or.th/ICD-10TM/gf50.htm. 
  59. ↑ "2012 ICD-10-CM Diagnosis Code F98.8 : Other specified behavioral and emotional disorders with onset usually occurring in childhood and adolescence". Icd10data.com. http://www.icd10data.com/ICD10CM/Codes/F01-F99/F90-F98/F98-/F98.8. 
  60. ↑ Christensen, Jen. "WHO classifies compulsive sexual behavior as mental health condition". CNN. https://edition.cnn.com/2018/07/10/health/compulsive-sexual-behavior-mental-health-condition/index.html. 
  61. ↑ "ICD-11 - Mortality and Morbidity Statistics" (in en). https://icd.who.int/browse11/l-m/en#/http://id.who.int/icd/entity/1630268048. 
  62. ↑ Goleman, Daniel (October 16, 1984). "Some Sexual Behavior Viewed as an Addiction". New York Times: Cl, C9. https://www.nytimes.com/1984/10/16/science/some-sexual-behavior-viewed-as-an-addiction.html?scp=2&sq=sex. Retrieved 2012-10-15. 
  63. ↑ Bitomsky, Jane. "Aphrodisiacs, Fertility and Medicine in Early Modern England by Jennifer Evans." Parergon 32.2 (2015): 293-294.
  64. ↑ Griffiths, Mark D., and Manpreet K. Dhuffar. "Treatment of sexual addiction within the British National Health Service." International Journal of Mental Health and Addiction 12.5 (2014): 561-571.
  65. ↑ "Hypersexual – Definition of hypersexual by Merriam-Webster". merriam-webster.com. http://www.merriam-webster.com/dictionary/hypersexual. 
  66. ↑ Krafft-Ebing, R. von (1886/1965). Psychopathia sexualis: A medico–forensic study (H. E. Wedeck, Trans.). New York: Putnam.
  67. ↑ Sifuentes-Jáuregui, B (2002). Transvestism, Masculinity, and Latin American Literature: Genders Share Flesh. p. 207. ISBN 9780230107281. https://books.google.com/books?id=oBt-DAAAQBAJ. 
  68. ↑ Scruton, Roger (2015). Sexual Desire: A Philosophical Investigation. p. 168. ISBN 9781472927842. https://books.google.com/books?id=4ckfCgAAQBAJ. 
  69. ↑ Eghigian, Greg. "Hypersexual disorder: an encounter with Don Juan in the archives." Psychiatric Times 29.8 (2012): 18-18.
  70. ↑ Spooner, Henry (1918). American Journal of Urology and Sexology. p. 565. 
  71. ↑ Plummer, Ken. "A sociological perspective." Sexualities: Difference and the diversity of sexualities 3 (2002): 43.
  72. ↑ Nemerof, Charles (2004). The Concise Corsini Encyclopedia of Psychology and Behavioral Science. p. 630. 
  73. ↑ Trout, Steven. "Decadence & Modernism." English Literature in Transition, 1880-1920 40.2 (1997): 210-214.
  74. ↑ Gozzi Jr, Raymond. "Confessions of a metaphoraholic." ETC.: A Review of General Semantics 52.1 (1995): 51-55.
  75. ↑ Coleman, Eli. "Compulsive sexual behavior: New concepts and treatments." Journal of Psychology & Human Sexuality 4.2 (1991): 37-52.
  76. ↑ "Jen Gerson: Feel free to opt for the epidural sans guilt, new moms". 8 April 2016. http://news.nationalpost.com/full-comment/jen-gerson-feel-free-to-opt-for-the-epidural-sans-guilt-new-moms. 
  77. ↑ Orford, J. (1978). Hypersexuality: Implications for a theory of dependence. British Journal of Addiction, 73, 299-320.
  78. ↑ Longo-Disse, Samadhi Carol. "Sexaholism: A perspective." Sexual Addiction & Compulsivity 13.1 (2006): 69-94.
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  80. ↑ Groneman, Carol. "Nymphomania: The historical construction of female sexuality." Signs: Journal of Women in Culture and Society 19.2 (1994): 337-367.

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