#54 Sex, Society and Science

Laura Brown, Teacher with the Toronto District School Board

February 13, 2019

Think back to your first sexual education experience. What did you learn? Who taught you? How has your understanding of sex, sexuality, and gender changed as you got older? In this episode of Raw Talk, we explored these questions and more. Toronto District School Board teacher, Laura Brown, shared her thoughts on changes to the Ontario Health and Physical Education Curriculum. AIDS Committee Toronto worker, Alex Urquhart discusses PrEP as a revolutionary medication in the gay community. We also had some fun with Dr. Jessica Maxwell chatting about her PhD and current postdoctoral work on relationships and how to boost sexual well-being and satisfaction. Finally, we brought back Dr. Gillian Einstein, who walks us through the biology and neuroscience behind sexual differentiation, and what science says about both sex and sexuality existing on spectrums.

Written by: Melissa Galati

Episode #31: Sex, Gender and the Brain
University of Toronto Sexual Education Centre
Walt Disney - The Story of Menstruation (1946)
Ontario's Health and Physical Education Curriculum (2015)
Ontario's Health and Physical Education Curriculum (1998)
Testosterone Rex by Cordelia Fine
Closer by Sarah Barmak
AIDS Committee Toronto
The Lived Experience of Female Genital Cutting (FGC) in Somali-Canadian Women's Daily Lives (article)
Sex Beyond the Genitalia: the human brain mosaic (article)
Male or Female? Brains are Intersex (article)

Mashup Clip 1 [0:00] Don't have sex, because you will get pregnant and die. Don't have sex in the missionary position. Don't have sex standing up. Just don't do it, promise? Okay, every take some rubbers. If you have sex outside of one, permanent, monogamous... and monogamy does not mean one at a time, that means one partner who has only been with you... you have sex outside of that context, and you will pay. So if I saw you undress you would look like a woman to me, totally? Yes? I'm not anti-sex. I'm not anti-gay. In many ways, I'm not even anti-intersex or transsexual. I barely understand those things, because that's not real life.

Melissa Galati [0:57] Let's face it, sex, sexual identity and gender are confusing and sometimes taboo topics. As a result, there's a lot of misinformation that pervades our society, and often our science. That becomes a problem when we're creating evidence based policies. Welcome to Episode 54 of Raw Talk, we've called today's episode "sex, society and science". On this episode, we went out of the lab and into the bedroom to discuss topics like sexual education, happy and healthy sex, and of course, science of sex. The research questions we ask and the way we design our studies are influenced by factors like sex and gender. In Canada, the Canadian Institute for Health Research mandates that all researchers applying for funding stipulate exactly how their study design consider sex and gender, it forces us to reflect on our biases, and consider how an individual's biology and lived experiences might affect health and disease. We started today's episode off by going into the community and asking people where and how they learned about sex, and what misconceptions they had about sex growing up.

Speaker 1 [2:05] I actually went to Catholic school up until I was 13. So we don't get too much of an in depth sexual education. We had this religious textbook, it was called "fully alive", and it literally just said, if two people are in love, and then they get married, then they make a family. No detail whatsoever into like safe sex or how it actually works. I kind of wish I knew, like just the very basic of how sex worked and how women got pregnant. Even when I went into high school, I got a really brief education. I remember there was a teacher who had told the class that you can only get pregnant during your fertile stage of your period cycle. I also didn't really know how periods worked either, because I never got proper education on that either. So I thought this meant you can only get pregnant when you have your period. Luckily, I wasn't having any sex when I was learning about sex in high school. So thankfully, I didn't get pregnant, but I just really like was misinformed about everything. Because no one had actually sat me down and given me a detailed education on safe sex and just how sex worked.

Speaker 2 [3:17] I think a common misconception that young boys and girls pick up, especially I think it's from porn, is they only see sex really from the perspective of men. So I think if you watch a lot of porn videos, you think that you know, the girl is expected to maybe go down on the guy. But the guy isn't really expected to do much, or it's not anything. I think we learned a bit more as we get older. But at a young age, I think that's really our first initial exposure to that, especially with the way the internet is in our lives, now.

Speaker 3 [3:48] I feel like I've had to spend most of my adult life, unlearning all the harmful wrong things that I was either taught, or were implicitly or explicitly told to me as a kid and teenager. So what were my main misconceptions? I think one of my biggest misconception was orgasms and the idea that they occur simultaneously, in a very dramatic movie quality way, equally, every time you have sex for a man and a woman, which is just not true. I did more digging on this and I actually found, just like there's a gender gap in pay inequality, there's actually an orgasm gap between the genders. The studies behind this are really crazy. There is one of like 800 college age students, and they found a 52% orgasm gap. So 37% of women said they always experienced orgasm from sex compared to 91% of men. The study didn't question "is this sex a random hookup or is this like with your long term boyfriend/girlfriend?" So there was another study by Armstrong et.al, in 2012, that surveyed 15,000 college student around America. They found that the orgasm gap was worse for hookup sex than for like committed relationship sex. But even when you're in a committed relationship, there's still a gap of 17%. Then, if you look outside of just college aged students, you might be like "Oh, they just don't know what to do, yet. They're not experienced." There was a survey of 3000 single people between 18 and 65 years old, and then they said when they were having sex with a familiar partner, women, orgasms about 63% of the time and men 85% of the time. So you're like "well, maybe it's just that women, biologically, it's harder for them to reach orgasm." You know, it's more complicated and takes longer, the equipment is more confusing. But lesbian women have significantly more orgasms than straight women, according to the same study by Garcia et. al in 2014, whereas there's not a difference between gay and straight men, and women who masturbate have aren't more orgasms than when they have sex with a partner. So 39% will always orgasm from masturbation versus like 6%, who will always orgasm from partnered sex. So the problem isn't that it's just harder for women to orgasm. The problem is that when you are having partnered sex, in this case, with a man, the priority for your orgasm isn't there. So that's something we need to address just like we need to address the pay gap.

Alex Urquhart [6:25] I think one of the biggest ones was that sex would probably occur in the context of a monogamous relationship only, which for me has just personally not been the case. But I think growing up, I think that's just how I always saw it portrayed. I thought that was really the only option. It really wasn't until I was older, that I sort of realized that I don't necessarily need to stick to that sort of blueprint. I could really do whatever it was that I wanted. Yeah. I think probably one of the other big things is that, sex is really not perfect and pretty as we sort of see in movies, TV, isn't that kind of stuff, right? I mean, it's awkward, and it's messy, and you can accidentally elbow someone in the face, those things happen.

Speaker 1 [7:09] I think my introduction to sex was definitely in school, when they were like, "okay, we're gonna have a health class on sex." But in terms of the details of how things actually worked, I would say my older cousins when they started talking to me about their sex life, which I was very surprised that they were sexually active because we just never talked about sex between our family members. They had just told me how it worked. I had actually told them, "Oh, I learned in class that you can only get pregnant when you have sex during a period." They were like, "What? no that's not true at all, do not do that if you don't want to get pregnant."

Speaker 2 [7:46] I think when you're young, it's in maybe mid to late elementary school just through hearing from other students on the playground, or whatever it may be. Then for me personally, I know when I was in high school, my gym teacher, who's actually this very intense German man who never even crack the smile. So unfortunately, me and the other 15 year old boys had the misfortune of learning what a uterus was from him. It was definitely uncomfortable.

Speaker 3 [8:12] So I went to Catholic school, elementary and high school, they taught us that abstinence was the best answer. They didn't have like condoms or birth control available at the school. In high school, if they did talk about sex is always in relation to horrible diseases that you could get, which is important to know about, but it wasn't anything about consent. It wasn't anything about trans identities, barely anything about being gay. At the time, they had evolved to the Catholic catechism being like, we accept people who are gay and love them, but they just can't act on their feelings. So it was a pretty scant education, and so I had to learn from it, literally from reading Greek mythology in school. Little did I know, you're reading stories about incest and people turning into a man and then a woman, and then back again, and hermaphrodite, so you're learning about all these like concepts in Greek mythology. I didn't learn what oral was for a woman until grade 10. I didn't know that was a thing until grade ten.

Alex Urquhart [9:22] As a queer guy, and people in general, we don't really get sex ed, it really was picking bits and pieces from pop culture, movies, books, and television. Just picking up on those little things. It's like trial and error, right? So I mean, it was a very messy experience, I guess. There was no book for me to read, to learn how to do it. Whereas, that was different from my peers. I think I learned a lot of it from, when I got older, my actual sexual partners, they taught me things. The first time I ever got tested was when, someone I had sex with, he took me there, and he showed me what to do, he made me feel better about it. I think a lot of this, it just comes down to, how lucky were you to be exposed to this sort of stuff. So once I dated this guy, and I dated him for a couple months, and I was like 21 at the time and so was he. We started talking one day about HIV, it came up, and then he actually said to me, "how do you get HIV?" I think at the time I was kind of angry to him, we actually got into a bit of a fight about him. How are you a 21 year old gay man and you don't know about HIV? I think now I realized that it was inappropriate for me to react that way to him. The only difference between me and him was that I was lucky enough to be exposed to these different ideas and things like that, that I was able to explore and learn about how to protect myself from stuff like that.

Melissa Galati [10:53] That last response came from Alex, the online outreach coordinator at Aids Committee Toronto. ACT for short. We'll come back to our discussion with him a little later, it's clear that our sexual education experiences are varied. In fact, as you heard at the beginning of the episode, there's a lack of consistency between provinces in Canada on what should be taught and when. In British Columbia, Alberta, Manitoba, and Quebec, children are taught the proper names for body parts in kindergarten. While children in New Brunswick aren't taught this until grade six. Sexual orientation is taught in Saskatchewan and Nova Scotia in grade three, but in Newfoundland and Labrador it's taught in grade nine. Ontario? Well, we recently had an overhaul of a sexual education curriculum that hadn't been changed since 1998. The 2015, Ontario sex ed curriculum sparked so much political controversy, our new administration has decided to dispense with it all together, and revert back to the old curriculum. Maria caught up with Laura Brown, a teacher in the Toronto District School Board to learn more about both curriculums, her experienced teaching sexual education, and her thoughts about how we're doing in Ontario.

Laura Brown [12:04] So as we know, there was a shift from the old sex ed curriculum, which was basically last updated in in the 90s to the 2015 curriculum, the new sex ed curriculum that got a lot of attention from the media. Now there's a shift back, with the new government, to the old curriculum again. So currently, we are still teaching the new curriculum in the Toronto District School Board. Starting next September, we will roll back to the old curriculum. Basically, the new curriculum places a larger emphasis on mental health, it places a larger emphasis on dispelling any sexual myths that the students may have, and just basically creating open lines of communication between parents and students, teachers and students, things that the old curriculum never touched upon. For example, the old curriculum focused more on abstinence, and kind of just a don't do it kind of mentality that the kids had to follow, but clearly weren't following. The new curriculum is kind of in a response to the old curriculum, because it's placing more of an emphasis on, "Okay, well, we know you're going to do it, but these are the ways that you can prevent pregnancy, or these are the ways to treat STI's, and these are the ways that you can protect yourself."

Melissa Galati [13:16] Okay, so this new curriculum places a huge emphasis on debunking quote unquote "sex myths" among students, so that they're equipped with sufficient knowledge to protect themselves. The curriculum also promotes building students mental health and general well being. Laura explains that in the 2015 curriculum, this is done by encouraging pathways of open communication.

Laura Brown [13:36] It places more of an emphasis on creating healthy communication pathways between you and a partner, you and your friends, you and your parents, you and a teacher. So it allows students to feel more comfortable in opening up to other people about anything they feel uncomfortable about, or maybe things that they're experiencing within a relationship that they're confused about, or that they're uncomfortable with, and they don't really know who else to go to. So it's kind of creating those pathways where they can feel more comfortable talking to people close to them, rather than just asking friends, or focusing on, "well I don't know who else to ask, so maybe I'll have to ask my partner."

Melissa Galati [14:13] Kids get information from a lot of sources, whether it's online on social media, porn, or from their peers. As we heard from our "word on the street" guests, sometimes that information leads to a lot of misconceptions.

Speaker 1 [14:26] You can only get pregnant when you have your period.

Melissa Galati [14:28] Laura explains that the 2015 Ontario curriculum mandates teachers to address misconceptions, whether it's by having a question jar where students can submit their questions anonymously, or having an open dialogue initiated by the teacher on topics they've heard students discussing. She's concerned for the next school year, though, come September 2019. Teachers are no longer required to engage in these types of discussions. In fact, they're not even allowed to teach from the 2015 curriculum.

Laura Brown [14:55] A lot of teachers that I know are super upset at that the fact that we're reverting. It feels like we took two steps forward and one step back. We have this great piece of curriculum that we are, having open discussions, and we're talking about things like mental health, and things that were never talked about in the old curriculum. Now all of a sudden, are we just supposed to pretend like we didn't have those conversations with our kids? Right? So perhaps we're having conversations with the grade six, and next year, they're in grade seven, and now we're not having any of those conversations and they're going to have questions. They're going to ask us, and what are we supposed to say? Are we supposed to answer honestly, are we supposed to answer in the way that's not going to help us lose our jobs and go back to the old curriculum? It's definitely a sticky situation to be a health teacher going into the 2019 year, because you want your kids to have the knowledge and the information that they need to make their own choices. But it's hard when your job is literally at stake, And I do know that there's a website that if parents find out that you're teaching the new curriculum, come September, they can submit the teacher's name. it goes right to Doug Ford. So it's like, do you continue to be honest and truthful to the children and the students about these questions that they have? Or do you want to protect your own job And you revert back to the old curriculum? It's very, very tricky. Definitely.

Melissa Galati [16:20] Well, Laura had a lot of great things to say about this new curriculum, we asked her what she thought could be improved in both curriculums.

Laura Brown [16:26] Personally, I think that there could be more emphasis on gay, lesbian, bisexual, asexual relationships, and what does that mean, and what kind of life and what kind of struggles those people may go through. It is talked about, the children and the students know what it means to be gay and what it means to be lesbian. But the conversation ends up stopping there, it doesn't continue forward, it doesn't continue on to what kind of struggles they may face in society in general, because it's still, for some people, they still can't tolerate it, they can't accept it. So I think having those kind of conversations can really start opening up, you know, young minds and thinking that we need to not only tolerate but also accept and show acceptance, because it's truly not enough to tolerate anymore. I think just having the conversation stop that this is what it means to be gay. It's just not enough for 2019.

Dr. Gillian Einstein [17:20] If you asked me to design a course for students, I probably would design a course that was a lot like the one I teach undergraduates. I think I would try to get them to know something about sexual differentiation, what's known about development, let them see that there's a spectrum. Potentially even show them a couple of experiments and try to get them to think about whether the paradigm for the experiment is a reasonable paradigm.

Melissa Galati [17:48] Recognize that voice? If not go back to episode number 31, sex, gender and the brain. It's a good one, we promise. We brought back neuroscientist Dr. Gillian Einstein to join in the discussion this episode.

Dr. Gillian Einstein [18:00] Pretty much anybody at any age can understand a scientific experiment and can be a judge. I would view it as an opportunity, to increase science literacy. So I think I put it in a bigger picture than just the anatomy... what it usually is about.

Melissa Galati [18:17] Do you happen to know what... do you remember what you were taught about sex ed when you were in school?

Dr. Gillian Einstein [18:21] Well, I mean, it's really laughable. I'm not sure I ever had sex ed. You know, you're talking to somebody who's went to school a long time ago. I remember a video about menstruation, which you can find on the web called very personally yours, which is made by the people who manufacture Tampax and Kotex, if they still exist, I don't know. Actually, it's a cartoon. It's wonderful. I mean, it's beautifully done, but it's hilarious.

Melissa Galati [18:50] It really is. The video Dr. Einstein is referring to was produced in 1946 by Disney and co presented with Kotex. It's called "the story of menstruation" and was circulated with a pamphlet called "very personally yours". We've linked it in the episode description in case you're interested, although I don't think they're still showing it in schools anymore.

Dr. Gillian Einstein [19:09] Yeah, I'm not sure I ever got any sex education. I know we never were taught anything other than heterosexuality. That was just the assumption. I mean, I go back and forth about this stuff. What gets downloaded, outsourced to the state to do, and what should be happening in people's homes? I think there are learning opportunities all the time in an open home. My biggest conflict is we shouldn't be outsourcing these things to the government. On the other hand, I can see the argument that there might be some families in which it's never discussed or there might be some families that discuss it in a way that might not lead to great citizenship, and citizenship is a really important thing as well.

Melissa Galati [19:52] It's that idea of good citizenship that Laura was getting at as well. She reflects on one teaching placement at a school where the children came from a high socio economic background, the parents were actively involved with the school. As a result, when sexual education was being taught, Laura found that certain topics became optional.

Laura Brown [20:10] The discussion was going to be about different types of families. So we were talking about lesbian families, and gay families, and nuclear families, and extended families. The school advised me that I had to send permission forms home to the parents to get written permission that the kids could be in the class to listen to the conversation we're about to have. I thought it was very odd because it's in the curriculum, and every student should know that there are different types of families in the world. Most of the parents agreed and said that their kids could listen and engage in the conversation. But I had a few parents who said, "No, I don't want my child there for that conversation." So about three children were removed from the class during that day, and they were sent to a different room while we had the conversation. I thought it was quite interesting because it was sending a message to the other children that the topic we were talking about was very taboo, and that it was an optional thing. Clearly, things like math or literacy are not optional. So I think it's interesting that health becomes now an optional conversation to have, especially in terms of anything other than a man and a woman family.

Melissa Galati [21:14] That's where opinions diverge, should health and related topics like sexual identity be considered just as important and mandatory as math and science? We'll come back to this idea a little later. In the meantime, let's switch gears. While sexual education curriculum can have many goals. One of them is arguably to emotionally prepare and equip young individuals to navigate relationships and manage their own sexual health. We shared some common misconceptions people had about sex earlier in the episode, we asked those same people what constitutes a happy sex life for them.

Speaker 1 [21:46] I feel like this is so cliche, and I feel like a lot of people are going to say this, but I honestly think communications and basically just vocalizing what you enjoy, what you don't enjoy, your likes and dislikes, setting limits and expectations on what you guys both would like.

Speaker 2 [21:51] I think it's a combination of two things. First of all, frequency, so I think maybe once or twice a week. Then secondly, it's more just equal desire on on both times, so not the same person initiating all the time.

Speaker 3 [22:16] I think, in all things, knowledge is power. So I think the more you know about yourself, and the more you know about your partner, if it's partnered sex, which you get through communicating and being not too embarrassed to talk about it or ask what you want. I think that's just, if you don't know better, you can do better. So the more you know, I think the the better you do.

Alex Urquhart [22:37] A good sex life is being able to be open about what it is that you want, and being empowered or feeling empowered enough that you're able to ask for those types of things.

Melissa Galati [22:48] So happy sex life means different things to different people. To find out what research says about having a happy sex life, we went to a literal expert. Bonnie chatted with Dr. Jessica Maxwell, who completed her PhD at the University of Toronto studying... well, the psychology of relationships and sex. Hands up if you didn't realize that was something you could actually study.

Bonnie Lewis [23:11] I'm curious about what the most surprising thing that you've learned about behavioral patterns surrounding sex from your research.

Dr. Jessica Maxwell [23:18] From my research? Yeah, that's a great thing, there's so many surprising findings, but one of these sort of overarching things that I would say is that people aren't having as wild sex as we think. Or as some people might think. I think as a society, we sort of have this perception that the grass is greener, that everybody is having tons of really hot sex. But that's not always what we find in research. So again, there's some cool research that came out of UTM, U of T Mississauga, that found that most couples, on average, have sex about once a week. So that is kind of surprising to some people. What's more surprising is that having sex once a week for people in relationships, is the rate that maximizes your happiness or life satisfaction. So it's not that the frequency of sex has like a linear effect on your happiness, it's not like more is always better. It's like meeting just a once a week threshold is enough to keep you quite satisfied in your life. So I think that does sort of surprise people sometimes, because I think some people think, well, more sex must be better, right? But it doesn't necessarily need to be the case. So I always like to tell people that finding becauseit sometimes reassures them that you don't need to be having sex multiple times a week in order to to be happy.

Bonnie Lewis [24:41] Right. I guess, if you're having sex once a week with your partner, would you consider that, from a scientific standpoint, a happy sex life?

Dr. Jessica Maxwell [24:52] Yeah. I mean, that seems to be what's bearing out in the research that most people... of course there's going to be individual differences, I'm sure for some people they would be unsatisfied with once a week... But by and large, the people who are having sex once a week tend to be quite relationally satisfied and satisfied with their life overall.

Bonnie Lewis [25:09] What sort of factors stand out to you from couples that have a happy sex life? Like, what are they doing that makes it so great.

Dr. Jessica Maxwell [25:17] So there's some really cool research out of the University of Ottawa that talks about optimal sexuality. They've actually looked at people who sent self identify as having really great sex and sort of interviewed them about what makes for great sex and why are these people special. One of the things, I forget all of the exact things that come out of it, but one of the main themes is feeling authentic, and feeling safe. So just I think having a secure relationship is a main factor for having a happy sex life, and just feeling free to express yourself. But there's a lot of other research too about little things that can make your sex life happier. So my dissertation that I did at U of T, what I found was that your beliefs about sex can actually have a huge implication for how happy your sex life ultimately is. So what I found is that, if you believe that sex takes effort and work, you're more likely to have a happy sex life than, for example, if you believe this idea that it's all about having a soulmate or having natural sexual chemistry with someone. So having maybe more of this pragmatic view about sex, it kind of sounds unsexy to say that your sex life takes effort and work, but I found that that's one of the factors that can actually help you have a happy sex life. Even if you are a new parent and aren't sleeping and things like that, your beliefs about sex can really matter. Another thing that's sort of related is that there's some research that suggests that being a responsive sexual partner is really important to have a happy sex life for both couple members. So what I mean by that is, if you think that your partner is willing to meet your sexual needs, that makes you feel happy. So if you feel like, they'll make compromises with you, maybe they'll do things like have sex at the time of day that you prefer, or little things like that, to show you that they're listening to your sexual needs. That's really important for couples to have a happy sex life and to have a happy relationship. Overall, I think one of the the main things is just trying to be as open as honest as you possibly can, which I know is very, very hard, because sex makes us feel so vulnerable. But I think it's really important that we have these types of conversations with our partners. If we think about it, I just said how it's important that our partner responds to our sexual needs, but how can her partner respond to our sexual needs, if we're not actually going to tell them what we want or what we need?

Bonnie Lewis [27:49] Kind of like, I don't know how to read your mind, how am I supposed to know?

Dr. Jessica Maxwell [27:53] Exactly. I even did a study at U of T about that. What I did was have undergrad couples rate, how much they enjoyed a wide variety of sexual activities, and then had their partner rate how much they thought they enjoyed them. So I kind of compared like how accurate our partner is about knowing each other's sexual likes and dislikes. They found that people were pretty good at knowing which is a positive thing. But what I thought was really interesting was that people overestimated how much their partner wanted to do adventurous type activities, like acting out fantasies or like 50 Shades of Grey type ideas. So that I thought that was kind of interesting, because to me, what that suggests is, again, maybe we think people are wilder than they truly are. Also it means that we might be sort of imbuing cultural stereotypes on our partner instead of actually asking them what they like and dislike.

Bonnie Lewis [28:51] Now, I want to get an idea of how you define sexual health. What types of things encompass sexual health that people wouldn't necessarily think about? So straying away from just STI, and contraception, what are your thoughts?

Dr. Jessica Maxwell [29:08] Well, what I think is actually interesting, I'm so glad you brought that up, because when we talk about sexual health people automatically have visions back to probably high school, the school nurse, and STI's. But what's really interesting is that there's been a movement towards thinking about it more comprehensively, and more in a positive, pleasure based way. So the World Health Organization actually defines sexual health as physical, mental, and social well being regarding sexuality. I think that's so great because it's focusing also on that mental and social aspect. So it's not just feeling safe and secure and free of disease. It's also about feeling good about your sex life and feeling supported. So I think for me, when I think of sexual health, I think of just sort of being comfortable and happy expressing one sexuality. I think that can look very different for different people. So I think getting back to this idea of authenticity, I think if you're being authentic and feel free to be open about your sexual interests, I think that's one important aspect of sexual health as well.

Bonnie Lewis [30:17] Right. For people who maybe, either themselves or their partner, are expressing sort of unhealthy behaviors in regards to sexual health, how would you recommend mediating that?

Dr. Jessica Maxwell [30:31] Yeah, it's such a tricky question too because I think we struggle in relationships, generally with communication. Then I think anytime we're talking about sex, it's just compounded by social taboos, and people feeling super vulnerable. So I think with sexuality, we do need to tread lightly in our conversations, be a bit more cautious. So I think if someone's expressing unhealthy sexual behaviors, I think it sort of depends on what that looks like. But I think it's just really important to call them out on it, talk openly about why you feel uncomfortable with that.

Bonnie Lewis [31:08] I think some people are really scared to do that, and they're scared to express their own needs. But I think that's extremely important.

Dr. Jessica Maxwell [31:15] Exactly, and I think that gets especially important... You know, there's a lot of great literature from the public health perspective as well on condom negotiation, and how that's really important in relationships. I think one of the things that some of this does boil down to as well is having a sense of what we call like sexual self esteem, or sexual assertiveness. So you need to be really confident in yourself in order for you to be able to tell a partner that you insist on condom use. So I think it's always really important to try to boost people's self esteem and just remind them too that they don't have to be in any sort of unhealthy or unsafe situation. I think there's a lot of people who are worried about their well being, there's lots of research on this too, if you're worried about your partner rejecting you, you're not going to feel comfortable asserting your own needs. I think it's really important for sexuality, that if they're not going to listen to your needs, like it's not worth having that sexual experience, because it's not going to be positive or not be sexually healthy, like we talked about. You have to feel authentic and safe and supported.

Melissa Galati [32:23] Okay, so Jessica and Bonnie spent a lot of time talking about sexual health in the context of relationships. But we didn't forget about those of you flying solo. In fact, much of Jessica's current work focuses on the well being and satisfaction of those having sex outside of relationships, her results? Well, it turns out, it doesn't really matter whether you're in a relationship or not, sexual experiences can be positive, as long as you're being authentic and having sex for the right reasons.

Dr. Jessica Maxwell [32:50] The reason I was fascinated by this is that the research on casual sex is the most mixed that you could imagine, right? Like there's studies showing casual sex is awful for your mental and physical health, and there's other studies showing casual sex is great for your health and well being. So what researchers are now sort of delving into more is, for whom is casual sex good and bad, and what makes for positive casual sex experiences. It's exactly what you're saying, like a lot of it boils down to the same kind of thing, just feeling safe and supported, and authentic. So if you're having casual sex, because you really want to do it, and you want to feel good, and you're really aroused, and that's something you want to do, then then it tends to be a positive experience. But if you're having casual sex, because you feel pressured to or because you think it'll maybe make you feel sexier or something like that, then you're sometimes at risk of feeling a bit more regret afterwards. So I think really, the reasons why you're having casual sex and the type of relationship you have with your partner are really important. So in some of my research, I've been finding that friends with benefits relationships, or sort of sex buddy relationships, where you're having sexual encounters with the same person repeatedly, that those can be satisfying. Especially if you're someone who's more secure in yourself in your relationships. So I think what's really going on there is that those type of relationships sort of do provide a degree of familiarity and sometimes can provide intimacy. I think that that can help those experiences be satisfying for people.

Melissa Galati [34:28] Looks like the same types of benefits can be derived from casual sex and relationship sex, as long as the deed is done for those positive reasons. Jessica did have a couple of words of caution though, and they mostly boil down to protect yourself.

Dr. Jessica Maxwell [34:42] I think with anything when we're talking about sexual health in not relationship context, again, it's extra important to be careful about safe sex practices. So one of the things that really gets interesting about friends with benefits relationships is, as much as they can be positive experiences, people sometimes forget that even though this persons your friend, they're often not being monogamous with you. So it's really important to be having those safe sex conversation.

Bonnie Lewis [35:09] Yeah, that's an extremely important conversation to have, and I think you kind of do just get caught up in the moment and forget to ask.

Dr. Jessica Maxwell [35:16] Exactly, and because you're feeling familiar with this person, maybe you know them, maybe they're your acquaintance, or they're actually your friend, you're kind of less on guard than I think you would be if you were having a hookup with a random. So I think those are really important situations where it's important to remember that, yes, friends with benefits can have lots of great benefits, but you do have to be mindful of the fact that they're often not monogamous. Then I think in terms of your overall well being with these casual sex experiences, one thing that we are finding as well, it's important that your expectations are calibrated. So you know, I don't think you're going to have a positive experience if you're going into these experiences thinking that they can turn into relationships, because although that happens, sometimes that's not always the case.

Melissa Galati [36:02] So for those of you exploring friends with benefits, be sure to be crystal clear on expectations. If you're wondering what the research says about people transitioning from friends with benefits to a full on relationship, don't worry, we asked Jessica.

Dr. Jessica Maxwell [36:16] The research on that, it's probably about five years old now, but they did find that in their sample, about 20% of friends with benefits turned into romantic relationships. So about one in five. If your relationship started as a friends with benefits, your relationship was just the same as any other relationship. There wasn't any... it's not like relationships that came from friends with benefits were worse off in terms of relationship quality, or communication or anything like that. So it's definitely possible that friends with benefits will turn into relationships, but I guess the flip side is saying 80% of them do not turn into relationships. The reason I think it's important to bring that up is that when you ask people what they're looking for in a friends with benefits, you do find people endorsing that it might be a way... they're viewing it as potentially a gateway to relationships. That's when I think it's potentially not so good for you. So I think if you go into a friends with benefits and are aware that it's probably just a casual thing, then you can experience a lot of benefits. But if you're sort of hoping that might be a gateway to a relationship, you might be let down and ultimately have like a less positive experience.

Melissa Galati [37:27] Jessica's reminders to protect yourself while having casual sex are especially true in the gay community. Since men having sex with men are more likely to contract HIV than those having heterosexual sex. It's part of the reason why sexually active gay men are recommended to be tested for HIV every three months. But times are changing, and a lot of that has to do with the advent of a small pill called PrEP. PrEP, or pre-exposure prophylaxis is an antiretroviral cocktail that disrupts the virus's ability to replicate and lowers the likelihood of HIV infection. In addition to his role as online outreach coordinator at asked, Alex is also the PrEP access coordinator, we asked him to talk about why PrEP is so revolutionary.

Alex Urquhart [38:11] So I definitely think revolutionary is the correct word for that. So that is a pill, and basically, you take this pill every single day. As long as you take it every single day, it reduces your chances of getting HIV by 99%. So at its most basic, that's what it is. I think culturally, in gay culture, we're sort of having a moment right now because it's really changed how guys are feeling about their sex lives. So a lot of people, myself included, we grew up with the shadow of HIV, over our lives. I think, for a lot of people, that AIDS panic was kind of a defining queer experience. I think, basically, prep has allowed that to not be the case anymore. I think people are having the kinds of sex that they want to be having. So, at ACT, we created this website called HIV now, which was basically to help connect people to PrEP. For that website, I interviewed several guys, and included a series of videos, and why every single person chose to go on PrEP was different, but the one thing that they all had in common was the fact that PrEP gave them peace of mind. It allowed them... it was like their insurance policy. It was like, if a condom broke no matter what happened, they knew that they were protected and it allowed them to take their health into their own hands basically.

Melissa Galati [39:39] The concept of PrEP and the notion of casual sex relationships, maybe more common in today's hookup culture with apps like Tinder and Grindr, but such an open attitude to sex is a fairly recent phenomenon. The sexual revolution of the 20th century is one of the most profound examples of social change in recent history. Although the subject of sex is often still taboo, or at the very least uncomfortable to talk about, how sex is perceived in our society and the impact of this on our sexual behaviors has come a long way. Research like Jessica's could not have taken place until social attitudes towards sex, sexuality and gender shifted. As a society, we have evolved to become more open minded when it comes to sexuality. In Western culture, for example, acceptance of same sex relationships and marriage equality has increased from around 50 to 70% since the mid 1990s, which is great because research shows that there are considerable health benefits for the LGBTQ community when same sex marriage is legalized. Social attitudes about sex clearly have and will continue to change, and we are starting to see this social shift reflected in how we do science. Both sex and gender influence the development of human health and disease. It's been increasingly clear that studying both men and women is both an ethical and scientific imperative. However, a 2010 study published in Nature found that eight out of ten research disciplines were biased towards using male animal models. In some fields like neuroscience, there were nearly six times more studies that used only male animals rather than only female ones. Why is this the case? Well, including sex and gender as a research variables introduces an additional layer of complexity to research study designs, researchers may fear that including females in their experiments will increase variability that is hard to account for, like fluctuations in hormone levels, making it difficult to standardize research methods. This sex factor can also inflate the cost and timelines of running experiments. When it comes to taking gender into research considerations, while we don't even have a consensus on how to define and measure it, but governmental and funding agencies are finally taking note of this and other examples of gender and sex disparities in research. The World Health Organization urges the incorporation of gender into health care policy worldwide. In 2010, the Canadian Institutes of Health Research established policies that require health and medical researchers to include both sex and gender as critical variables in any plans, studies, or clinical trials. The European Commission did the same in 2013, and since 2016, grant proposals to the National Institutes of Health in the United States must include information on how sex will be incorporated as a biological variable in research studies. But it's more than just incorporating sex and gender into scientific research. In fact, scientists are still refining our definitions of sex and gender, and we're increasingly finding that our X and Y chromosomes aren't always sufficient to determine our biological identity or sex, or social identity or gender. While non binary definitions of gender have already been embraced in the social sciences, think LGBT plus vernacular. In the biological sciences, we're beginning to get hints certainly of a gender continuum and potentially even a sex continuum. People with disorders of sex development or intersex individuals, as they're referred to, are probably the clearest indication that some sort of male female continuum exists. In these individuals, there's some disruption of the incredibly complicated sexual differentiation pathway. As a result, some aspect of their biology, like their reproductive anatomy, for example, doesn't fit the typical male or female mold. Remember this clip we played at the beginning of the episode?

Mashup Clip 2 [43:31] I'm not anti sex. I'm not anti gay. In many ways, I'm not even anti intersex or transsexual. I barely understand those things, because that's not real life.

Melissa Galati [43:43] It was taken from a YouTube video critiquing Ontario's 2015 sexual education curriculum. The host selected a couple of passages of choice from the curriculum proposal and attempted to argue that the curriculum was not evidence based, as the government at the time would have you believe, but rather part of a political agenda to sexualize children. While I won't spend time trying to refute his logic, it's maybe an indication that we need to do a better job as scientists to translate our findings and their implications for the general public. Scientifically, we know that intersex is in fact, quote, unquote, real life. Dr. Einstein explained this a little better.

Dr. Gillian Einstein [44:21] So it's interesting because I am teaching this course called "Sex and the Brain" to undergraduate semester, and we've just finished sexual differentiation.

Melissa Galati [44:27] Okay, good, so you're fresh on it already.

Dr. Gillian Einstein [44:29] Yeah, one of the things that's interesting about sexual differentiation is that in the embryo, the reproductive tissues start, in both males and females, both xx, xy, x not x, yy, every version they all start with, something called the indifferent gonad, which can go in either direction. I always tell students is kind of like, well, it doesn't care, it's indifferent. In the story about sexual differentiation that most people learn is that there's something that turns on testes determining factor, called SRY gene. The SRY gene turns on the development of the testes in the in different gonads, and it starts going toward male. The secretion of androgens by the testes then leads to further differentiation of the male pathway. So that ultimately, you get retraction of the Mullerian duct system and you get the expansion of the Wolffian ducts, you got increase in phallus size, and you get the production of dihydrotestosterone, which is a end stage testosterone that leads to the full elaboration of the testes and the penis, etc...

Melissa Galati [45:45] ...and women?

Dr. Gillian Einstein [45:47] ...on the XX side, the story is still is pretty much that it's the absence of testosterone, and the lack of development of the testes, because they don't have SRY, that leads to the female phenotype and the female reproductive system. The pictures that you see are always very binary, that you've got the xy pathway with the Xx pathway. There's no crossover. But in fact, we know that there are like about one and 1000 births of human beings that have indeterminant genitalia. That might be because of a gene mutation, it might be because of an extra chromosome, it might be because SRY somehow got switched over during meiosis to an X chromosome. So an xx person ends up looking male, and they're just a bunch of these...

Melissa Galati [46:45] ...these people would be referred to as intersex?

Dr. Gillian Einstein [46:47] They would be referred to as intersex. Yeah. So the gradual realization that there are these variations, to not have them depends on everything going exactly right along these pathways. With the probability of that being very low, makes me think of both these pathways being a kind of rheostat, where different stages can be accentuated or changed, but also setting up ultimately a continuum of overlapping morphologies, that I think, even if they're relatively rare, speak to the diversity of both phenotype, and ultimately, gender identification, and sexual identification that we see in the population. Phenotype, genotype, and hormones are not necessarily all going to go according to plan, and so it's the mixing of these, that that really lead to a continuum. Now I have a colleague, Daphna Joelle, who has published a number of papers, showing that the brain is actually a mosaic. So rather than a continuum of sex differences in the brain, it's actually a tiling of male and female patterns. But she sets up this argument by saying the genitalia are dimorphic, but the brain isn't. I actually think that genitalia aren't, I mean, I kind of say to my students, anybody who spends any time in a gym knows about the sort of variation of type across people. So to think that the genitalia are dimorphic, to me is... yeah, there are versions at either end of a continuum, that are part of the story that we tell. Then I think of gender as pushing something that is not really binary to being binary. Somehow, I think people have this deep seated need to know who's male and who's female, like we are so upset about when we don't know. There used to be this whole routine on Saturday Night Live... again, really dating me... but there was some character on Saturday Night Live that you could never tell whether they were male or female, and that was the unsettling and funny thing about it.

Melissa Galati [49:16] Dr. Einstein believes that sex and sexuality both exists on a continuum, but we as a society imposed binary views on them. When we looked at historical perspectives on sex and gender in both society and science, we see that they seem to have evolved together. The way we ask questions, design studies, and interpret results are all influenced by the biases we have from our experiences within society. As a result, there's not much neurobiological research supporting Dr. Einstein's hypothesis.

Dr. Gillian Einstein [49:46] It's mostly been focused on showing dimorphisms, they call them dimorphisms, but in the end, they're not as strong as dimorphisms they're called differences. So that's done in the realm of gay and straight, it's done in the realm of trans. It's using this idea that male and female brains, the circuits are sexually differentiated, circuits are set in place at the time of sexual differentiation, just like the genitalia are differentiated. That's called organization, and most of the research is done trying to determine if they're organizational differences that would make in the brain, for example, the idea is that a gay brain might be more like a female brain. I think that says volumes, about what we think being gay is about, actually, which may not be accurate. The research looking at trans feminine brains, trying to see if they're more like female brains than male brains, etc, etc. That's really what the focus has been on.

Melissa Galati [50:55] In neuroscience, researchers like to point out the differences between male and female brains, they don't talk about the huge overlap that exists between them.

Dr. Gillian Einstein [51:04] So this is in the neuroscience realm. So I could imagine that there would be lots and lots of studies in the social science realm or the humanities realm, where they might actually be showing a continuum of expression, or feelings, or stories. But just in the neuroscience domain, I'm afraid people, with the exception of my colleague Daphna Joelle and maybe me, really focused on using the paradigm of organization and activation and the binary that is implied in that paradigm. I think we'll get to a better world, I think we'll get to the point where science is questioning the paradigm a little bit better. But I think what it's going to take is actually questioning the whole paradigm of organization and activation, and thinking about gender as shaping the very questions that we ask.

Melissa Galati [52:01] One study initiated by a transgender student in Dr. Einsteins lab look to see whether the organization and activation paradigm held up in the context of transgender brains. His thinking was that if sexual differentiation in the brain occurs simultaneously with sexual differentiation of the genitalia, and trans individuals identify as the sex that is not the sex they were born as, then those trans individuals should have some brain characteristics similar to the gender to which they identify. So trans men should have brains similar to cis men, even before hormone replacement therapy, and likewise, for trans women and sis women.

Dr. Gillian Einstein [52:38] There are a couple of tasks that are cognitive tasks that females are better at them than males. Males are better at...the big one is mental rotation. So being able to rotate these figures that are drawn in three dimensions on a piece of paper, and you know, seeing it one way, and then matching up three others with it, when they're rotated slightly different...find the one that matches when it's rotated slightly differently. So we gave that task and then we gave a verbal task. It's not that this task, the verbal task is better in females than males. But in females, the ability changes with the menstrual cycle and also... the big deal is that it's affected by estrogen depletion. So we gave these two tasks to trans men, before hormone therapy, trans men after, cis men, and cis women, and the cis women and the trans men before hormone therapy. We tested in the mid luteal stage and the follicular stage of the menstrual cycle. What we found, most surprisingly, actually, was that it's not that women don't do as well on the mental rotation task as men, it's that, at least in our hands, anybody with a menstrual cycle does worse when estrogens are high and better, and perform like cis men, when estrogens are low. So the studies just hadn't taken the hormonal component into account.

Melissa Galati [54:15] So they would have examined all women at whatever time in their menstrual cycle.

Dr. Gillian Einstein [54:20] They just put them all in a study.

Melissa Galati [54:21] Yeah, yeah. So some would have been significant outliers?

Dr. Gillian Einstein [54:25] Right, and they put all the... even if they studied trans men before hormone replacement, they didn't separate them by menstrual cycle phase. I mean, to me, the most important thing about that is not that trans mens brains are, at least on this task, are more like sis men's brains, but that the whole paradigm of organization and inactivation may not be a great paradigm.

Melissa Galati [54:51] Okay, so the idea that trans men before hormone replacement therapy might have similar brain organization to cis men didn't hold up in Dr. Einstein's study. Her main point here is that while it may be convenient, we can't just lump brains into male and female bins. The circuit for doing that mental rotation task exists in both males and females. It's just whether or not it's activated. Dr. Einstein works with another group that helps to shed light on the direct impact societal norms have on our biology. It's a group of Somali Canadian women who have undergone a process called female genital cutting. While a large part of her work is focused on chronic pain in these women, Dr. Einstein is also interested in their lived experiences, for other reasons.

Dr. Gillian Einstein [55:35] The tradition of female genital cutting comes out of a gender norm, that women must look different than men, and that if you don't cut the clitoris in women, then the clitoris will keep growing and or look like a penis, and there won't be any difference between males and females. The circumcision of men is supposed to take away from the men what is female, which is the foreskin. So the men get off a lot lighter on this one, but the drive is the same thing, which is to differentiate male from female. The anthropological literature suggests that the view is that males and females are born the same, they look equivalent when they're born. So you have to do this to make sex. Just like we "have to" do stuff.... I mean, have to, I say that in quotation.

Melissa Galati [56:27] Society expects us to.

Dr. Gillian Einstein [56:29] We have to do gender surgery in order to make sex in kids of indeterminant sex. I mean, that's being changed now, but that used to be the thinking. So I'm interested in female genital cutting from that perspective. But I'm also really interested... you know, and also, I really care about the women actually... but I'm also interested in it from the perspective of women's sexualities, because a lot of the women who've had their external portion of their clitoris removed, and their labia cut and sewn together, they still say they have orgasm, and there's pretty good indication that they do.

Melissa Galati [57:09] Wow.

Dr. Gillian Einstein [57:10] So we in the West are very focused on the external portion of the clitoris as the site of orgasm, and I think that's a good thing...I don't think that's bad. But I do think we do that because we're too focused on drawing a parallel between male sexuality and female sexuality. I think there's going to be a continuum again, and that female sexuality may be a lot more complicated. You have, if you don't mind my saying so, you have women reporting orgasm from touching their breasts or touching other parts of their body. You don't usually hear males reporting orgasm from touching any part of their body. Now, maybe males can be trained that way. You know, maybe that's a limitation.

Melissa Galati [57:55] Maybe we had to get more inventive.

Dr. Gillian Einstein [57:57] Yeah. But anyway, I just think actually, that they can teach us something. Yeah, that we don't have opportunities to know.

Melissa Galati [58:05] It's clear that we still have a lot to learn about sex, sexuality and gender. Dr. Einstein, who also chairs the Board of the Institute of Gender and Health, says that one of the emerging goals of the Institute is to encourage a whole new science that brings the social together with the biological. We hope that whether or not you're a scientist, you've taken something away from this episode. Whether it's a deeper understanding of biological identity and the impact social identity has on us, or maybe just some good old fashioned dating tips. Thank you to our guests, Laura Brown, Jessica Maxwell, Gillian Einstein, Alex Urquhart, and all our friends who contributed their knowledge, thoughts and experiences. Content development and interviews were conducted by Maria, Bonnie, Anton, and Kat who also did our audio engineering. We'd love to hear what you learned from or thought of this episode. Send us a voice note or tweet us at Raw Talk Podcast.

Melissa Galati [58:58] Raw Talk Podcast is a student presentation of the Institute of Medical Science and the Faculty of Medicine at the University of Toronto. The opinions expressed on the show are not necessarily those of the IMS, the faculty of medicine or the university. To learn more about the show, visit our website rawtalk podcast.com and stay up to date by following us on Twitter, Instagram and Facebook at Raw Talk Podcast. support the show by using the affiliate link on our website when you shop on Amazon. Also, don't forget to subscribe on iTunes, Spotify or wherever else you listen to podcasts and rate us five stars. Until next time, keep it raw.