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For women, the sexual situation can be complicated by the menopause. This is another area in which physical and psychological factors interact. Some women welcome the menopause because it liberates them from the fear of pregnancy but its approach is viewed by many as the end of their sex life. Those who really believe that sex is only for babies often suffer badly, as do self-centred women who measure their personal worth by their sexual attractiveness.
Because the menopause often coincides with the departure of children from the home, a woman who has invested all her energies in loving and caring for her children loses her role at the same time as her sex life (in her view). As her husband, who on average is three or four years older than she is, may be becoming sexually uninterested or seeking new partners, additional stresses are added. If her husband is successful in his career, he may be even more involved in his work than in previous years and will be less available just when she needs him most. Understandably some women become anxious, critical and unhappy, which tends to alienate their partners and perhaps discourage them from sex.
Any social, personality and temperamental differences between the couple become more pronounced and some such couples divorce once their children have left home. Unless a woman takes steps to counteract it even her circle of women friends diminishes as they lose the common experience of rearing children. In such a state of mind her preoccupations are more likely to turn inwards and menopausal symptoms assume an importance greater than would otherwise have been the case.
A woman’s ovaries begin to ‘shut down’ from her mid- to late thirties. The supply of available eggs gradually becomes exhausted and their quality declines. The pituitary gland increases its secretion of sex hormones in an effort to stimulate the ovaries but, when egg production finally stops supplies of oestrogen and progesterone fall.
Some women report a loss of sex drive after the menopause. In some this can be explained by the modest fall, of around 25 per cent, in testosterone (the sex-drive hormone of both sexes) but in others depression, a deteriorating relationship with her partner, sex-avoidance by him, or the belief that her sex life should have ended, may also be involved. There may be pain on intercourse, resulting from vaginal dryness and thinning of its lining, and this too can put a woman off sex.
As the menopause approaches, some women experience an increase in sexual interest and pubescent fantasies of the rape and prostitution type may occur. Extra-marital intercourse is not at all uncommon at this stage if a woman sees it as her last chance. Many women say that they have less intercourse than they want at this period of their lives. Masturbation rates often peak as the inhibitions taught in early life recede but in general, as with men, women tend to continue the habits of earlier years. However, although the intensity of sexual arousal may decrease around the time of the menopause orgasmic capacity in intercourse certainly does not. In fact, some women first experience orgasms in intercourse at this time of life.
Around the time of the menopause and afterwards women may be more likely to suffer from heart attacks. This is probably due, in the main to the reduction in oestrogen levels which previously protected them. But there are certainly other factors too. In a survey comparing 100 women who had suffered a heart attack (and survived – those who died were obviously not available for questioning) between the ages of forty and sixty with a similar group of women who had not, it was revealed that 60 per cent of the heart-attack group had either not been able to have orgasms during intercourse or no longer had intercourse because of their husband’s incapacity, compared with only 24 per cent of the second group.
Similar evidence is available from studies of men suffering from heart attacks. Around
two-thirds have been found to have had significant sexual problems before the onset of the attack.
From this and other research it seems reasonable to conclude that to the established practices for the avoidance of heart attacks – such as not smoking – we should add, for both sexes, the establishment of a successful sex life. Some investigators have also concluded that a good sex life in later years wards off mental deterioration.
Some older people with arthritis, which is increasingly common with age, find that their condition improves after intercourse. There is now some evidence to suggest that people who continue to practice and enjoy sex tend to live longer, but it is not possible to claim that sex itself makes for a longer life because it is equally possible that whatever factors promote a full sex life also promote a longer life.
The average age for the menopause is now around fifty. Those who start menstruating late tend to finish early: around 4-per cent do so in their early forties. Women of fifty-two and
fifty-three have given birth to live babies – sometimes after a year or two without periods. Because of this, it is advisable to use some form of contraception for a year after the periods stop. The menopause lasts for between six months and three years.
Although all manner of symptoms are attributed to the menopause they fall into three groups, vasomotor leading to perspiration, hot flushes and night sweats; metabolic due to falling levels of oestrogen and resulting in thinning of the vaginal wall, a dry vagina and skin changes; and psychological including the loss of sex interest already mentioned, depression, lassitude, insomnia, loss of concentration, and irritability. Two more hidden consequences are the effects on the heart, mentioned above, and on the bones. Not all women experience a difficult menopause but it tends to be worse in smokers. For example, around a quarter of women are troubled by vasomotor symptoms.
The adverse effects on the vagina can be offset by oestrogen preparations used in the vagina and by using the vagina more in intercourse and/or masturbation. One small difficulty is that the partner can absorb oestrogen through the penis and in rare cases this can be sufficient to make his breasts enlarge. However, a side benefit of vaginal oestrogen is that the urinary problems which are common in older women are often relieved.
However, all the troubles can usually be controlled by hormone replacement therapy (HRT) which, as the name suggests, aims to make up for the reduction in production of female hormones. The topic is controversial but medical opinion is now turning towards the more extensive use of HRT. Tablets, usually, are taken by mouth and the oestrogen in them relieves the symptoms. However, there is a risk of cancer of the endometrium (lining of the womb) and to control this progesterone is added for 10 or more days each month. The progesterone also has a mild sedative effect and relaxes muscles. Women who cannot take oestrogen for one reason or another may be given progesterone only. Problems are that withdrawal bleeding usually occurs and appears to be like a normal period but does not indicate a return of fertility. Fluid retention and breast discomfort may also occur. Regular medical checks are necessary.
The psychological problems of the menopause are often alleviated as a result of increased self-esteem and happiness as the physical symptoms recede.
Most doctors believe that HRT, if used at all, should be restricted to the year or two after the menopause but some now believe the benefits to be so great that it should be continued to 65 or even older.
One benefit is the reduction in bone loss (osteoporosis) which occurs rapidly in the years immediately after the menopause. It afflicts a quarter of women between 55 and 65 and half of those between 65 and 75. The problem is to know which women will be affected. Women of short stature, with small bones, who had an early menopause, who are lean, or who have a family history of osteoporosis may be especially vulnerable.
Apart from causing the bend in the upper spine known as a dowager’s hump, osteoporosis leads to bones being fractured easily and this is serious. Hip fractures (45,000 a year in the UK) are the most serious. They are increasing in frequency and a fifth of women suffering them are dead within six months. Oestrogen stops or reverses bone loss. For Women not on HRT, increasing calcium intake, for example, by drinking more milk, does not help but those on HRT do benefit from extra calcium. Exercise is beneficial and post-menopausal women, whether on HRT or not, should make considerable efforts to keep fit and not fall into the trap of becoming inactive. Exposing the skin to sunlight also helps.
Women on HRT are a third less likely to die than women of their age not on HRT, but other factors may affect this statistic. Their chances of heart disease are reduced by two-thirds and of cancer of the endometrium by half. Cancers of the breast and ovaries may also be reduced. Women, after years of being on the Pill, might not want to face a fresh bout of pill taking at the menopause and at the moment their GP is unlikely to raise the topic. The benefits, though, are so great that more women than at present are likely to be asked to consider HRT in the future. Oestrogen has the added effect of maintaining pre-menopausal skin and body characteristics.
Although the topic is the subject of considerable debate and controversy, it is now widely agreed that men can also have a menopause. It is thought to affect around 15 per cent of men. A few even have not flushes. Psychological factors can also afflict men in their fifties and sixties as they realise they are not going to live for ever, that they have not fulfilled their earlier ambitions and dreams and that younger men can beat them in many ways. Obviously if both partners are suffering from bruised egos at this stage of their lives they can either mutually support each other or blame each other.
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There are many other perversions. For example, there are some people who get their best sexual pleasure from masturbation and prefer it to other activities. Rapists sometimes claim in their defence that pornography led to their condition, but as erotic and pornographic material is widespread and rapists are not, other factors must be involved, even if the original statement is true as far as it goes. The use of alcohol is probably a much more common precipitant factor in a rather inadequate individual who is basically afraid of women but hostile towards them. Some rapists find that the struggle and the power they feel enhance their sexual drive, so perhaps they should really be considered perverted. Others can scarcely perform at all. Certain types of rapist are deterred if the woman fails to struggle or if she gives in. Psychopathic men may displace anger with one woman on to another and generally manage to convince themselves that the woman deserved what she received.
In general the conclusion which emerges from studying perversions is that there are components of them in most of us, but in most people they are integrated into the overall pattern of their sexuality and certainly do not dominate it. If they are to be at all useful, theories as to what causes them have to be sufficiently precise to allow parents to prevent their formation in the first place. Insufficient research has been carried out on this subject. The main dilemma such research would try to explain is why some individuals exposed to fairly similar situations in childhood and beyond as those experienced by deviants and perverts should develop normally or fairly normally. Some individuals are able to control their tendency towards a perversion, but may become neurotic and produce other physical and psychological symptoms.
On the whole psychiatry has been woefully inadequate in investigating perversions and has very little to say about their prevention. Another body open to criticism is the Home Office. If the Home Office made clinical histories of sex offenders available for study, together with the prisoners themselves, if they were willing, much light could be shed on the subject. Whilst prisoners should not be deprived of any rights, many would be willing to involve themselves in serious research aimed at uncovering the real causes of their plight, as opposed to the ones offered publicly in court, especially if it led to the establishment of preventive programmes.
A more immediate solution may be to establish walk-in clinics on the same lines as VD clinics, where even the names of those attending need not be taken. In such clinics help, advice and treatment could be offered to those who suffer from, or think they might have, a problem. Many know something is wrong before they commit an offence and some would be sufficiently motivated to seek help if it were available.
Looking at the problem more generally, anything which promotes happy and fruitful
man-woman relationships, better marriage and healthier, more rational attitudes towards sex would help. Parents and teachers need to be better informed about normal sexual development and, with increased knowledge about what is normal and what is not, should be able to get professional help for their children before things go too far.
Although many readers may be put off by the subject matter of this chapter, feeling that most of it is totally foreign to them, it must be seen as a part of human experience. Though we have tended to present the many facets of unusual sexual expression as simply as we can and in somewhat ‘barn-door’ ways, it should be realised that they also exist in lesser and less easily recognisable forms in most of us.
Rather than condemning the individuals whom this chapter describes, it perhaps behoves all parents to think critically about the impact of cultural restraints and excitations upon their children and to reflect on the long-term harm that can result from thoughtless actions.
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As we have pointed out, the actual first infection causes no immediate symptoms. As the antibodies begin to appear some people have a short glandular-fever type illness with such symptoms as sore throat, enlarged glands, muscle pains, diarrhoea and vomiting. Many
conditions can cause such symptoms so the fact it is due to HIV infection is not likely to be realised unless, perhaps, the patient is in a high-risk group. Many sufferers might not even see their doctor.
It is thought that most people who have the virus – who are HIV-positive – are highly infectious about this time but thereafter that infectivity declines until they develop the signs and symptoms of AIDS. In the meantime they may appear fit and well. Some, however, continue to be infectious and may be troubled by persistent enlarged glands. In others symptoms occur intermittently and these include feeling unwell, fevers, night sweats, arthritis, weight loss, Candida infections of the mouth (thrush), and diarrhoea. Such people are referred to as suffering from AIDS related complex (ARC).
Currently available evidence suggests that around 75 per cent of people infected with HIV will eventually develop AIDS. The disease can present itself in many different ways including heart disease or mental symptoms (such as an inability to concentrate; a loss of memory; or even schizophrenia). Most commonly the first symptoms are a special form of pneumonia and purplish patches on the skin known as Kaposi’s sarcoma. Once AIDS has started death is
inevitable but progress to AIDS and AIDS itself can be slowed down by treatment with a drug called Zidovudine. Many other drugs are being researched but it is thought that it will be a long time before a drug cure is found.
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As was pointed out earlier, it is perfectly normal for young people to go through a homosexual phase during their sexual development. This should not be seen as a prelude to a lifetime’s homosexuality but as a safe way of discovering about one’s own sex.
The stages differ in boys and girls, so let us look at them both briefly. Girls go through this stage in their pre-pubertal stage (thirteen to sixteen). Girls will play dressing-up games, which include undressing and perhaps smacking each other’s bottoms; kissing ‘like a boy’; putting a finger in a friend’s vagina; or playing with each other’s breasts. Rarely though, do girls teach others to masturbate.
Boys talk a lot about sex; have competitions as to who can ejaculate first; have mutual masturbation sessions, compare penis sizes; count hairs and so on. Boys of this age usually do all these things with boys of their own age and as long as this happens all is well. When older boys or men are involved there are legal and personal problems and such contacts should be vigorously discouraged.
Many girls at this stage, and later, have a crush on older girls or school teachers. Such homosexual crushes are rarely overtly sexual in content (except perhaps in the girl’s fantasies). They usually fulfil an unconscious need the girl has to identify with a woman she sees as likeable or successful in a quite non-sexual way.
All this means that it would be harmful and pointless to punish a child found enjoying homosexual experiments within these age bounds. Two girls aged sixteen found mutually masturbating for example, should be a cause for concern though because, unless it is a one-off game, it could well mean that one or both will have problems in relating to men.
The problem often starts when teenagers declare to their parents that they think they are homosexual. Over 80 per cent of parents are upset and understandably find it difficult to know what to say other than to be negative. The best way to handle this problem is for the parents and the child to discuss it fully and then to get professional help if there is still concern. The best place to start off is probably with the family doctor or Relate Marriage Guidance counsellor locally. Either of these will hopefully provide a relatively unbiased approach to the subject. By going straight to the many homosexual organisations a young person runs the risk of being welcomed with open arms and their homosexuality confirmed and celebrated. We feel this is bad for the young person, who might well just be going through a temporary phase in his or her development and because it might preclude or hinder heterosexual development in the future. Only if it is clear that the young person seems convinced of and is happy with his sexual orientation does it makes sense to contact a homosexual group so that he or she can start off his or her sexual life prepared for the problems and able to meet like-minded people.
Until homosexuality becomes totally acceptable (which is still a long way off), this sort of situation will always be a terrible dilemma for the average parent.
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Don’t say too little. This is a common mistake. The child then becomes even more confused but will probably never be able to verbalise his confusion, especially if you have been dismissive or made it all sound so simple that he or she feels they should have understood what you were talking about. On the other hand:
Don’t take the opportunity to deliver a lecture on the subject. Most children are simply looking for a straightforward, uncomplicated answer to what seems to them to be a very simple question. By going on at too much length you will confuse them, especially young ones. Gauge your replies according to what you know the child can cope with intellectually and emotionally.
Try very hard not to colour every answer with your personal views and hang-ups. We all have some negative or downbeat views about sexual subjects and it takes a real effort to try to counteract them for the sake of our children.
Ask the child a question in return and use the answer to teach on.
When a child asks where babies come from you could, for example, ask, ‘Where do you think they come from?’ The child might say, ‘from the tummy button’ and you can use this to teach the true facts and to dispel false beliefs and notion, so killing two birds with one stone.
Always answer sex questions at the time and do so spontaneously.
Never put off the answer or the child will imagine there is something strange going on and that you cannot answer straight away.
Bear in mind that a sex question from a young child simply does not have the same overtones and connotations it would have coming from an adult. If an adult were to ask you, ‘What’s a homosexual?’ your answer would be very different from the one you would give to a six year old, yet the question is exactly the same.
If you don’t know – say so. This raises the general question of honesty. We feel parents should never lie to their children about sexual matters. Children look to us as sources of trustworthy
information on most things in life and we owe it to them not to lie or mislead them with
half-truths.
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In most clinical settings, testing for HIV involves a test called the ELISA, or enzyme-linked immunosorbent assay, as a first step. This is a test for antibody, or the body’s immune response to infection. It can be performed on blood or saliva in a medical setting as well as on blood through a home testing kit (available in most pharmacies and drug stores). The testing procedure for samples collected in the home test is the same as that for samples taken in a clinic.
This test is very sensitive. Most infected people (about 90 percent) will show a positive ELISA test about three months after the time of possible infection. Everyone who is positive should show a positive test six months after infection, although very rarely a positive result may take longer to show up. The risk of a false negative test after six months from infection is 0.001-0.3 percent, depending on the number of people infected in a particular geographic area.
People who do not form antibody may have a rare deficiency in antibody formation, called agammaglobulinemia.
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Thorough washing of the hands after using the restroom and avoiding anal-oral contact with an infected person generally prevent transmission of hepatitis A. In addition, in 1995 a breakthrough in the prevention of hepatitis A became available: a vaccine that offers protection against acquiring the infection. This vaccine is composed of whole hepatitis A virus that has been inactivated and therefore cannot cause infection. It is given in two doses as a shot in the deltoid muscle of the arm, waiting six to twelve months between doses. Adults older than age seventeen are given a higher dose than children two to seventeen years of age.
The first vaccine becomes effective about two weeks after it is given and offers about a 94 percent protection rate against acquiring hepatitis A. The second vaccine provides protection greater than 99 percent and is thought to last more than twenty years. A person who does contract hepatitis A after receiving the vaccine will experience milder symptoms than someone who has not been vaccinated. Children younger than two years of age should not receive the vaccine, nor should pregnant or nursing mothers. Most people tolerate the vaccine well, with allergic reactions rare and mild discomfort where the vaccine was given being the most common side effect.
Elderly people and any person older than forty who grew up in an area presenting a high risk of infection probably should be tested for the presence of immunity before receiving the vaccine. Giving the vaccine to someone who has already had the infection (and thus cleared it, providing lifelong immunity to reinfection) would not be harmful, but it would be unnecessary.
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incidence: very common
cause: bacteria such as Gardnerella, Bacteroides, and Mycoplasma
symptoms: vaginal discharge, fishy odor
treatment: antibiotics
The vagina normally contains a combination of several kinds of bacteria, including the most common vaginal bacterium, Lactobacillus. Bacterial vaginosis (BV) is a bacterial syndrome that occurs when other bacteria that also occur normally in the vagina—such as Gardnerella vaginalis, Bacteroides species, and Mycoplasma hominis—begin to reproduce rapidly and replace the normal bacteria. BV then, is a syndrome caused by an overgrowth of bacteria in the vagina that disturbs the normal balance of bacteria there. It is sometimes referred to women, it is the most common vaginal disorder.
In the past BV was called Gardnerella (referring only to one of the bacteria that can cause this infection) or nonspecific vaginosis (a term that has gone out of use since the causes of BV have been determined).
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One man had a biopsy that was considered negative by one pathologist. His urologist sent it to this pathologist for a second opinion. “There were about four glands of cancer. We called it cancer, he had his prostate out, and there was tumor all over.” But for every such patient, there’s another man who turns out to have very little cancer.
Which brings us to one very tough question: Do all men who have cancer on needle biopsies need aggressive therapy? Again, the problem lies in our ability to differentiate between harmless and malevolent cancer. “If it were my family member,” the pathologist confesses, “I wouldn’t want to take the chance.”
But eventually, the goal is not to treat all prostate cancers, but to predict which cancers are going to turn serious, and treat these tumors aggressively. And predict which cancers will remain indolent, and monitor them closely.
Until very recently, the technology that made early biopsy possible also made these judgment calls much tougher—pathologists had trouble correlating the amount of cancer on the needle with the amount of cancer in the entire prostate. But now, research from Johns Hopkins promises to shed fresh light— to make needle biopsy findings much more helpful in determining a man’s course of treatment.
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The seminal vesicles, each about two inches long, sit behind the bladder, next to the rectum, arching over the prostate like two wings or, perhaps, like two clusters of grapes; they appear more clumped than streamlined. Arching still higher over them, on either side, are the vasa deferentia, which meet the seminal vesicles at V-shaped angles; these form the ejaculatory ducts, slitlike openings that feed into the prostatic urethra.
The seminal vesicles are composed of alveoli, little cul-de-sacs that bear viscous secretions—critical in ensuring the consistency of semen. (They got their name from the belief once held that the vesicles stored semen and sperm; they don’t.)
Like the prostate and related tissues known as “sex accessory glands,” the seminal vesicles depend on hormones for their development and growth, and for their ability to produce secretions. The seminal vesicles are highly variable among species: They’re large in humans, rats, hamsters and some rabbits, but are missing altogether in dogs, cats and bears. One unusual point: The seminal vesicles, so similar to the prostate in many ways, are almost always free of abnormal growth—benign (as in BPH) as well as malignant. No one knows why.
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