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If psychotherapy in general is evolving toward a holistic approach, where does sex therapy fit in? The immediate answer is that it is a subspecialty within dyadic therapy, since it deals with a special class of dyadic problems. This classifies sex therapy by the symptoms treated and not by the effects of the therapy— a classification with which most sex therapists would probably agree. However, to narrow sex therapy to symptom removal alone is to ignore the significant role of sex in human functioning. Poor sexual functioning wrenches individual, dyadic, and family functioning into distorted, painful shapes; good sexual functioning can restore inner and outer harmony.

Successful sex therapy has a very strong “ripple effect”; the resolution of sexual problems usually resolves or moderates other problems, interpersonal and intrapsychic. Indeed, the ripple effect is really threefold—a triple ripple, so to speak.

The first ripple is the effect on the formerly dysfunctional patient. In helping a woman achieve orgasm or a man overcome impotence or premature ejaculation, the therapist has usually helped that person gain a whole new self-concept.

One woman, about thirty years old, visited her physician complaining of severe headaches and menstrual cramps which had started many years before and persisted ever since. The physician, a highly sensitive man with a superb ear for unexpressed problems, inquired about her sex life. It turned out that she was anorgastic and her husband was “all right,” but “very fast.” (This bilateral dysfunction, failure to reach orgasm in the woman and premature ejaculation in the man, is very common.) The physician referred the couple to sex therapy.

They were highly motivated people, and it was decided to address both dysfunctions together. (Usually, the orgasmic difficulties are treated first, then the premature ejaculation.) Results were surprising even for the experienced therapist: the woman had several orgasms after only the second therapeutic session, and the man achieved substantial ejaculatory control after the fourth session. This couple was seen a total of six times; by the end, the woman’s headaches had disappeared, and she had had one menstrual period with no cramps at all!

The relief of physical symptoms is not the only effect of sex therapy on individual functioning and usually is not the most important effect. An extremely gratifying case had no physical effects at all, in a sense.

A man in his early fifties, an important executive in a major corporation, appeared for sex therapy with one wish: to have at least one firm erection, one penetration, and one thrusting experience before he died. Describing himself as impotent, he had been examined by a “famous doctor” when he was twenty years old and was told that he would never have an erection as long as he lived. Although the man later married and had two children, he never had a firm erection and of late, having an erection and full-scale intercourse had become an obsession with him.

Although successful at his job, this man almost always had lunch by himself, never went out after work “with the boys” for a drink and some “man talk,” and never told— and could barely listen to – risqu?, off-color jokes: they reminded him of his problems and aroused the fear that his reactions would reveal that he was less than a man. Socially, he and his wife merely fulfilled their obligations, entertaining others and going out as a matter of duty rather than of pleasure.

The first step in therapy was to send this man to an endocrinologist, who found nothing physiologically wrong with him; in fact, his testosterone level was slightly above normal. The man received this information, from the therapist, with complete neutrality; it took, in fact, several weeks for him to internalize and accept its implications. During this time initial sex exercises were prescribed. When the man, by his comments, indicated a readiness for more intensive work, exercises were given aimed at helping him achieve firm erections. He was told, however, not to attempt intercourse with his wife until he did have a firm erection and then to avoid using their bed, since that had been the scene of many disastrous attempts at intercourse and had depressing associations. In the course of the exercises the man for the first time in his life had a firm erection; he and his wife of twenty-seven years piled blankets on the floor and had successful, thrusting intercourse for the first time in their marriage. During the weekend, this was repeated several times.

The couple now enjoys sexual intercourse regularly. At his work the man now goes out with his colleagues, tells and listens to any kind of sexual joke, and has become, as he reports, not only more liked but also more respected. On that first weekend he and his wife went to a party at which, as they gleefully reported, they astonished everybody by dancing every dance and generally leading the festivities. Since then their social life has been much richer and more enjoyable.

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The next stage in the progression of psychosexual development is the phallic stage beginning some time during the third year of life and extending until approximately the end of the fifth year. The phallic phase is characterized by the focusing of sexual interest, sexual stimulation, and sexual arousal on the genital area. The penis in this stage becomes the organ of principal interest and concern to children of both sexes. In the classic theory, the lack of a penis in the female is thought to be the basis for feminine castration concerns and penis envy. The phallic phase is associated with an increase in genital masturbation in both sexes, usually more predominant in male children in view of the greater availability and utility of the penis, but occurring in females as well. Such genital activity is accompanied by predominantly unconscious fantasies of sexual involvements with the opposite-sex parent. The threat of castration and the related castration anxiety is connected to guilt over masturbation and to such oedipal wishes. It is during this phase that the oedipal involvements and the oedipal conflict are established and consolidated.

During the phallic stage, one of the most significant psychosexual developments takes place, namely, the integration of pregenital instinctual derivatives under the primacy of the genital area. In this way, erotic interest becomes focused on the genitals and their functioning. This lays the foundation for a more specific sense of gender identity and serves to integrate the residues of previous psychosexual stages into a predominantly genital sexual orientation. The establishing of the oedipal situation and its conflicts is essential to the organization and integration of these functions and to laying the basis for subsequent identifications, which not only will consolidate sexual identity but also will serve as the basis for extremely important and enduring dimensions of character organization and functioning.

When the oedipal conflicts fail to be adequately generated and formed or to be adequately resolved, either because of excessive contamination from pregenital determinants or because of failures in the dynamics of the oedipal situation itself, pathological character traits can arise. The derivation of such pathological traits from the failures of phallic-oedipal involvement is extremely complex and is subject to such a wide variety of modifications and influences that it covers the entire range of neurotic and normal development. Neurotic personality development, in fact, is defined in terms of the genesis and resolution of phallic oedipal conflicts. The primary issues are those of castration in males and penis envy in females. The influence of castration anxiety and penis envy, the defenses against both of these, and the patterns of identifications emerging from the phallic phase become the primary determinants of the development of human character.

The phallic phase is also the stage in which the residues of previous psychosexual stages are integrated so that any fixations or conflicts that may be left over from these previous stages can play a continuing role in the modification and resolution of the oedipal situation. The persistance of preoedipal conflict can contaminate the child’s experience of the oedipal situation and thus contribute to the manner in which the child’s pattern of sexual identification and integration takes place. The male child, for example, who remains excessively close and dependent on the preoedipal mother, cannot sufficiently take her as a love object and cannot adequately separate from her in order to begin to identify with the father as an appropriate object of masculine identification. The pull in the masculine direction, that is in the direction of separation from the mother, assertiveness, and masculine aggressiveness, will prove to be too conflicting and too threatening and drive the child back to a more defensive position of dependent clinging to the preoedipal mother.

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Although orientations toward women have roots in socialization processes, and sex stereotypes are often firmly decided at a very early age, some of the unjust consequences of these stereotypes can be limited without actually changing them. Here the issue is not the elimination of the stereotypic belief system but the control of its consequences. Such control requires an understanding of environmental factors facilitating or hindering the pertinence of sex stereotypes and thus the degree to which they are used. Two such factors will be considered here. Both can regulate the extent to which stereotypic attributes are assumed to characterize one specific woman.

Information. It already has been mentioned that stereotypes about women in general are most likely to be employed when ambiguity exists. Specific information about the woman in question often is more compelling than beliefs about sex-stereotypic attributes. This suggests that consideration be given to revising current personnel decision-making procedures. If resumes could be supplemented by extensive background information, if performance appraisals were to specify the reasons behind performance, and if concrete evidence of success could be supplied whenever possible, stereotypical assumptions could be prevented from dominating decision processes. Drawing from Kelley, it would seem that information about consistency of successful performance and degree of consensus among evaluators would be particularly important. If, for example, it is known that Ms. X has repeatedly succeeded in the past, has succeeded admirably in various tasks, or has been judged to be greatly talented by many evaluators using many measures, her potential and ability would be very difficult to discount. Structuring both the richness and the specificity of the information given to decision makers conceivably could preclude the ill effects of sex stereotypes without actually altering stereotypical beliefs.

Sex composition. In her recent book, Men and Women of the Corporation, Kanter claims that the proportional representation of women in work settings not only influences their feelings and attitudes but also influences the way in which they are treated by others, When there is a great disproportion in the size of the minority and majority groups, she believes there is cause for concern. When tokens (the members of that piddling minority) are isolated from informal social networks, they are viewed as alien and different, and their characteristics are distorted to fit stereotyped conceptions. According to Kanter, tokenism is deadly, fostering reliance on stereotypes no matter what the personal characteristics of the individuals are.

The implications of this point of view are simple. Whenever possible, group-hiring and not individual hiring of women for male-dominated positions should be the rule. When a number of women are to be brought into positions held by few other women, clustering, not dispersing is suggested. Women should be bunched in numbers large enough so that they are not tokens even if it means that some units have no women at all. Simply by avoiding numerical scarcity, and providing evidence of the variety and differences among women, reacting to them all as if they were the same becomes unjustifiable.

These are only two examples of contextual factors which can regulate the degree to which sex-stereotypic attitudes affect decisions made about any one woman. Discovering others is of paramount importance. The capacity to control discriminatory behavior may be, at the moment, the only option we have.

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The anthropological material on homosexuality is uneven and deficient by most disciplinary standards. We find ethnography to report homosexuality to be “common throughout Polynesia” (Suggs), which contradicts Marshall’s inability to find a trace of homosexuality on the Polynesian island of Mangaia. Gladwin and Sarason inquired about homosexuality on Truk and were met, first by puzzlement, then denial. Such findings can only weakly encourage cultural inquiry.

Many reports which discuss homosexuality at all treat it as an alternative to heterosexual intercourse, a second-best option used when women are scarce (e.g., Suggs; Herskovits; Evans-Pritchard and Levy). There are similar explanations of lesbianism as a “stopgap” when men are not around (e.g., Schapera and Evans-Pritchard). With regard to male homosexuality, one male Azande told Evans-Pritchard: “What man would prefer a boy to a woman? A man would be a fool to do so. The love of boys arose from lack of women”.

Evans-Pritchard speculates that the custom of taking boy-wives arose from a combination of factors, especially a shortage of marriageable women, who were monopolized by rich noblemen able to maintain large harems through extravagant bridewealth payments. Kinsmen of boys who were taken as boy-wives were compensated with bridewealth. They assumed women’s roles and did women’s work in camp while their husbands were out fighting. Evans-Pritchard finds in all respects, “They were like wives. Their lovers did not approve of their laughing loud like men, they desired them to speak softly, as women speak”.

Levy provides us with a comprehensive analysis of the mahu, the Tahitian male who assumes a female role. He may or may not engage in homosexual behavior (although Levy was unable to determine a definitive answer for this). The mdhu in Levy’s district (apparently each district has its mahu) generally wore standard male dress, although Levy came across a picture of him, prominently displayed in the mdhus foster-mother’s house, dressed in a girl’s dancing costume. As a youngster he performed girl’s duties, such as cleaning house, braiding palm leaves, and babysitting. His primary associations were with girls, with whom he would share gossip and walk arm-in-arm, something seen otherwise only among same-sexed adolescents.

When mdhus are engaged in homosexual acts, they are cast in the active role. Similarly, males emphasize their passive participation in their contact with mdhus. Levy’s informants were well aware of the asymmetry in the relationship: “You just take it easy while he [the mdhu] does it to you,” and “you just don’t take it seriously”. Tahitian men who have been “done” by mdhus report rather matter-of-factly to others that they have been fellated, much as they would recount any other sexual escapade. The standard story Levy heard was of a young man who had been drinking, and unable to find female companionship, settled for service by a mdhu.

In his discussion of sexual identity Levy develops the importance of the mdhu role. In Tahiti there is relatively less sexual differentiation than the Westerner might expect. Gauguin observed this, describing Tahitian man as “androgynous,” and remarking that “there is something virile in the women and something feminine in the men” (cited in Levy).

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Marital Coitus (MC)

The Kinsey data indicated that the proportions of males and females engaging in MC decreased gradually as they aged. Comparable proportions of men under forty and females in this age group (98%) reported some outlet from MC. By age sixty, 94% of the males and 84% of the females were still active.

Among young married males, 85% of the average 4.8 per week outlet was accounted for by MC. Although each successive five-year period reflected a drop in average frequency, MC accounted for roughly the same percentage of total outlet over the years.

Females from sixteen to twenty reported a mean frequency of MC of about 4 per week. This average dropped to 2 per week at age forty and to 1.5 per week at age fifty. By age sixty, the average frequency was nearly 1 per week. The percentage of women with maximum frequencies of MC of 7 or more per week declined steadily from 5% at age thirty to 0% at age fifty-five. Within each age group, the average frequencies of orgasm closely paralleled frequencies of MC.

Bell and Bell looked at average frequencies of MC among a sample of nearly 2,400 women who had been married on the average for thirteen years. The frequencies reported were extremely close to those reported by Kinsey. In another study, Pearlman reported data from 2,600 married males on the frequency of intercourse. Among subjects in their twenties, 45% had engaged in MC from three to four times per week. For subjects in their forties, only 14% reported these frequencies. By the fifties, the incidence was 5% and past age sixty, less than 1%. By ages sixty to seventy, 25% of the men were engaging in MC one or fewer times per month, and 33% were not having MC at all. By age seventy, 20% were having MC with a frequency of two or more times per month.

Extramarital Coitus (EMC)

From 23 to 37% of married males within each age group surveyed by Kinsey had engaged in EMC. Twenty-six percent of the married women in his sample also reported having had EMC by the age of forty. Active incidence in males tended to remain about the same across all age groups, whereas the active incidence in females was low in the teens, increased through the thirties and decreased thereafter. Only 6% of women in their fifties were active. Again, the average male frequencies were higher than the average female frequencies at all ages sampled. For men under twenty-five, the average frequency in the active sample was 1.3 per week and decreased to 1 per month by age sixty. For active females, these frequencies increased from .5 per week in the teens to .8 per week in the forties. After age thirty, EMC accounted for a relatively constant proportion of total outlet among males. For females, EMC as a percentage of total increased steadily from 3% in the teens to 13% in the late forties.

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Two very new designs of implants, the Flexi-Flate and the Hydroflex, represent something of a cross between the inflatable and the semirigid types. Like the semirigid implant, these consist of two cylinders placed in the corpora cavernosa. But like the inflatable type, these cylinders actually inflate and the penis can be flaccid or rigid. To inflate the implant, a man pushes on the part of the prosthesis near the head of the penis. This transfers all the fluid from one chamber into another, causing an erection. The beauty of this design is that the reservoir is actually contained inside the cylinders themselves.

On the plus side, this type of inflatable implant is easier to put in than the other kinds of inflatables, requires less extensive surgery and is still very concealable. For a man who runs a greater-than-average risk from general anesthesia but who prefers the inflatable implant, these newer models present a viable compromise, because often a local anesthetic is all that’s required.

The drawbacks to this crossbreed are that the penis never reaches a completely relaxed state, and it doesn’t increase in girth as much as the more traditional type of inflatable implant. That’s s because the reservoir has to be smaller since it is located inside the corpora cavernosa. And it may be two to three months after surgery before you can operate the implant fully.

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After taking your history, the doctor will probably give you a complete physical examination. This is an essential part of the medical detective work involved in diagnosing and treating erection problems. Your doctor is looking for signs of unsuspected diseases which could cause or contribute to your difficulty.

The physician should pay special attention to your pulses and arteries to check for signs of arterial disease which could make blood flow to the penis difficult or impossible. He’ll feel the arteries in your groin, behind your knee and in your feet. This may seem strange, but a sign of blockage in these arteries can be a tip-off that you have similar problems in the arteries to the penis. While your doctor may also try to feel arteries in the penis, they are very small and often escape detection. So, the state of your other arteries may be the best clue to the state of your blood-flow system.

The nervous system also deserves special attention. Testing the “knee jerk” reflex in your legs and ankles is one indicator of the health of your nervous system. And the doctor may pinch your penis near the tip. He’s looking to see if your anal sphincter contracts, and checking the same response in the bulbocavernosus muscle, the one that encircles the urethra and propels semen. When these reflexes are present, it indicates that the nerves from the penis to the spinal cord and back to the penis are healthy. The absence of this reflex does not necessarily indicate a problem, but it may steer the doctor to further tests.

The doctor may test for a similar reflex by pricking (lightly!) the anal sphincter with a pin. The sphincter should contract. If it doesn’t, you may have nerve damage. The same type of pinpricks can be used to test sensations around the penis and the rectum. Brushing with a soft cotton ball also works—and feels better. The doctor may also test your ability to feel vibrations by putting a tuning fork or a special instrument on your penis. The whole point is to see if nerves in these crucial areas are functioning properly.

And, of course, a close inspection of the penis is in order. The doctor should feel your penis carefully. He’s checking for hard, lumpy scars that can be a symptom of Peyronie’s disease, which can cause impotence.

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Sometimes, the desire for a “quick fix” to an erection problem backfires because the woman’s needs, and the whole structure of the relationship, are ignored. It’s important that both partners agree on the therapy.

Martin’s experience illustrates just how crucial the involvement of the partner can be. This quiet man had been married for some 30 years and was nearing the age of retirement. He’d suffered from erection problems for the last 10 years, but didn’t think anything could change that. While in the hospital for a minor surgical procedure, however, Martin began talking with the nurses and doctors, and found out about penile implants. Martin decided this was the solution he was looking for.

A few weeks later, Martin showed up at the clinic. He was very direct about the problem and the solution. Tests showed that blood-flow problems were the culprit in his inability to get an erection, and a penile implant was suggested as a solution. First, however, the doctor wanted to explain the procedure to Martin’s wife. “My wife thinks the implant is the greatest thing since sliced bread,” Martin declared, and explained that she had been called out of town on pressing business. He assured the doctor, however, that he had explained the entire procedure to her, that she had no questions and that she was totally in favor of the operation.

The urologist, taking Martin at his word, performed the surgery without talking to or meeting Martin’s wife. Everything went without a hitch, and, after several days in the hospital, a happy Martin was sent home to recover, with instructions not to use the implant until the doctor said it was all right (usually, several weeks after surgery).

Martin had done extremely well in the hospital, with few complaints of pain. But after he returned home, he was very uncomfortable. Several office visits failed to establish any cause for the unusual amount of pain, and in fact Martin was healing very well. No one could find anything wrong with him, but he was clearly unhappy.

Finally, just three weeks after the surgery, Martin returned once again to the clinic, this time demanding that the implant be removed. “Take it out or I’ll cut it out myself,” he yelled.

Martin refused to discuss the matter in any detail. He was adamant that the “thing” be removed, and would not answer any questions about his wife’s feelings about his operation.

Faced with this situation, the clinic doctors decided they had no choice but to schedule surgery to remove the implant. But the staff was troubled by Martin’s dramatic change in attitude. Finally, a staff member, attempting to reach Martin at home, found himself talking with Martin’s heretofore elusive, always out-of-town-on-business wife. She was extremely angry. “How dare you put this thing in my husband? It was those young nurses in the hospital who convinced him to have this done! I won’t let him back in the house until you remove it,” she said.

Martin’s wife said further that she had told him from the very beginning that she did not want him to have the surgery. She was through with sex, and she wanted things to remain as they had been.

As it turned out, Martin had never consulted his wife about having his potency problem treated. Like many couples, Martin and his wife had lived with the erection problem for ten years, and in many respects had adjusted to that situation. To change it suddenly without the clear and informed involvement of both partners was a disaster.

The surgeon, resolving to never again put an implant in a married man without first interviewing the wife, removed the prosthesis from Martin. He recovered without difficulty, and returned home.

Cases like this just reinforce the fact that the woman should be involved in treatment to boost potency.

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Severe kidney disease can destroy a man’s potency as it destroys his health. There are lots of reasons for this, Kidney disease can lower testosterone production and raise the level of another hormone, prolactin, which can cause erection problems. And patients with kidney disease may suffer damage to nerves that are essential for erection. And even dialysis, the mechanical blood-cleaning process that can save patients with kidney disease, can cause impotence. Some doctors have found that dialysis may remove zinc from the body, and too little zinc can cause erection problems. Giving patients extra zinc to make up for this loss may help with potency. But the results are not clear; different researchers have come up with different results, some finding that zinc supplementation doesn’t help.

(We hasten to point out that in healthy individuals in the U.S., zinc deficiency is quite rare. Extra zinc is not a cure for impotence.)

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Ifs important to examine your testicles regularly for cancer, even though testicular cancer is relatively rare. Men 18 to 32 years old and over 60 run a higher than average risk of getting testicular cancer. But anyone can be vulnerable.

If left untreated, this cancer can lead to death. Fortunately, removal of the diseased testicle often halts the cancer. Removal of one testicle will not affect potency. If both testicles are removed (a very rare occurrence), potency problems can result. While potency can be restored with testosterone shots, ifs best to catch the cancer early. That’ s why self-examination is so important. Here’s how to do it.

Hold the testicle with both hands, so it doesn’t slip around. (It’s important in doing this exam that you know the location of your epididymis, since you could mistake it for trouble. The epididymis is normally a soft, sausage-shaped organ, running up and down the back of the testicle. It feels like a bump when you touch it. There’s a slight groove between the testicle and the epididymis.) Lightly massage the whole surface of each testicle, using both hands. You should not feel any hard lumps. If you do feel one, see your family physician or a urologist immediately. If found early, testicular cancer is virtually 100 percent curable.

Play it safe and give yourself an exam once a month. It only takes a couple of minutes, but it can save your life.

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