When the reported results are uniformly negative, and further psychodynamic exploration reveals significant intrapsychic pathology or interpersonal hostility, the couple is usually considered not ready for sexual therapy, and additional individual or dyadic therapy is needed. When the resistance to shower or relaxation exercises appears to be more a matter of fear of intimacy than hostility toward the partner, it is possible to proceed with sex therapy, bypassing the relaxation phase and proceeding to the intensive exercises.

In many cases, the results of the probe are not clear. Typically, the partners feel awkward, clumsy, and embarrassed, afraid of each other’s comments and fearful that they will do something wrong. Usually by the end of the second shower, the situation has eased considerably, but there still may be tension if not outright hostility. In these instances, although intimacy is desired, the tension is so great that intimacy seems threatening. Each has staked out a position in which one is “right” and the other is “wrong,” and intimacy can undermine these positions. Such dyads almost always can benefit by starting with the relaxation exercises.

When the therapy is terminated, the sex therapist reports the results to the referring therapist, and these reports, with the permission of the patients, will include discussions of any new material that may have arisen in the course of treatment. The holistic therapist, having incorporated dyadic and family therapy in the process of sex therapy, will reassess with the couple the direction in which they wish to proceed. Even unsuccessful sex therapy can help to clarify the underlying causes of the basic dyadic problem.

In the majority of referrals, treatment proceeds smoothly and there are no unusual complications. In some cases, special problems unrelated to sex therapy itself may arise. Because sex therapy per se encourages pleasure and enjoyment, positive transference to the therapist is sometimes very strong: a dyad still under treatment by a dyadic therapist may wish to leave and continue with the sex therapist; a member of the dyad undergoing individual intrapsychic treatment may wish to discontinue treatment or switch to the sex therapist. In both cases, the dyad or individual is advised to discuss his or her motives with the original therapist.

When does the sex therapist consult other therapists? The answer is, when it is in the best interests of the patient. This may occur when the sex therapist is only or primarily a sex therapist and the problem is not amenable to sex therapy, or if the dyad wishes to pursue another modality in which the sex therapist does not feel competent.

It may also occur when the patient and therapist have different priorities. Although dyadic therapists place a high priority on the stability of the dyadic relationship, they will not sacrifice the integrity or growth of the individual to the maintenance of the dyadic relationship, but they usually will try to ensure that this growth occurs within the boundaries of the relationship, if possible, and will devote considerable effort to this end. The dyad is indeed “the patient,” (as the family is “the patient” for family therapists), and the point of view of the dyadic therapist is that both partners are equally involved in the problem.

The sex therapist, on the other hand, often encounters situations in which only one member of the dyad has a dysfunction and the treatment, although pertaining to both partners, is aimed primarily at that one person. As progress is made and the dysfunction improves, the partner sometimes exhibits change in other areas (the individual ripple effect) that appears to threaten the dyad and may in fact destabilize the relationship. The sex therapist must be very sure whether he or she wishes to encourage the individual to change at the expense of the relational stability, to discourage such change, to work with the dyad on the relational problem, or to refer to another therapist. The sex therapist must be aware of his or her attitude toward extrasexual change if the therapy begins to go, as it often does, beyond the resolution of the sexual dysfunction.

*255/187/5*

At a minimum one must include the parameters of psychosocial development along with those of psychosexual development in understanding such personality potentialities. The development of the capacities for mature and mutually satisfying love relationships depends on the resolution of basic conflicts on many levels of psychological development. Kernberg has indicated the importance of such factors:

The capacity for sexual intercourse and orgasm does not by any means guarantee the capacity for being maturely in love; nor does the capacity for a total object-relation without the resolution of oedipal conflicts and the related freeing from sexual inhibition guarantee the capacity for being maturely in love and for stable relation. The capacity for falling in love indicates the achievement of important preconditions for the capacity for being in love; in the case of narcissistic personalities, falling in love marks the beginning of the capacity for concern and guilt, and some hope for overcoming deep, unconscious devaluation of the love object. In borderline patients, primitive idealization may be the first step toward a love relation different from the love-hate relation with their primary objects. This occurs if and when the splitting mechanisms responsible for this primitive idealization have been resolved and this love relation or a new one replacing it is able to tolerate and resolve the pregenital conflicts against which primitive idealization was a defense. In the case of neurotic patients and patients with relatively less severe character pathology, the capacity for falling in love should, if and when successful psychoanalytic treatment resolves the unconscious, predominantly oedipal, conflicts, mature into the capacity for a lasting love relation.

*219/187/5*

Most scientific studies have attempted to isolate specific types or instances of behavior and to relate them to exposure to erotica, or they have tried to assess the relative contribution of erotica, in concert with other factors, to predict categories of behavior.

The question of the relationship between erotica and antisocial behavior is an important one. It is, however, difficult to research because of the very high levels of exposure in the general public and the relatively low levels of antisocial behavior. Retrospective analysis is highly vulnerable to ascertainment bias, and prospective studies would require unacceptable levels of surveillance of unwieldly numbers over excessive lengths of time.

Despite the difficulties of defining a relationship between antisocial behavior and erotica, both laboratory and survey studies have provided interesting data.

Kutchinsky has made several careful survey studies of the effects of easy availability of pornography on the incidence of sex crimes in Denmark. Very substantial decreases in four specific categories of sex crimes—exhibitionism, peeping (voyeurism), physical indecency towards women, and physical indecency towards girls—were noted in Copenhagen after 1964. Some detractors of Kutchinsky’s data have stated erroneously that the number of crimes decreased because dissemination of pornography was no longer counted as a sex crime; others noted that sex crimes had been declining before 1964. The first objection is patently false, since only four specific categories of crimes were considered both before and after the change in availability of pornography. The second objection has more merit, but the decline before 1964 was irregular and gradual, and the decline afterwards was steady and substantial—the data clearly show two different slopes.

The decreases in exhibitionism and voyeurism found in Kutchinsky’s data could, in part, be attributed to changes in police attitudes or in the victims’ motivation to report such crimes. The change in public attitudes toward exhibitionism, as assessed in a representative sample survey of Copenhagen residents, was sufficient to account for any change in the reported incidence. Therefore, one cannot conclude that the reduction in this category was solely because of the availability of pornography. Changes in police attitudes could have accounted for the decreased incidence of reporting voyeurism.

The decline in reported incidence of physical indecency towards women also could be due to changes in attitudes toward “nonserious” incidents. No change in reported incidence of rape was found. One should keep in mind, however, that there are fewer rapes in Copenhagen in one year than there are in one weekend in New York City.

The category of crimes against children showed a fifty-six-percent decrease (from thirty-six to sixteen) in 1965, the first year in which hard-core pornographic picture magazines appeared in Denmark. This change could not be attributed to changes in public or police attitudes, to changes in methods of reporting nor to local changes since the figures for the country as a whole dropped from 220 crimes in 1965 to 87 by 1969.

Kutchinsky concluded that “the high availability of hard-core pornography in Denmark was most probably the very direct cause of a considerable decrease in . . . child molestation”. Perhaps more importantly, the number of recidivists for all sex crimes has decreased as much as the number of first offenders.

*181/187/5*

From Malinowski came a perspective which introduces into anthropology the notion that sexuality is equivalent to instinctual biological drive. Even though Malinowski ostensibly argued against a Freudian position which would give primacy to psychological over cultural systems, he accepted the Freudian view of sexuality. Consequently, Malinowski focused on cultural institutions which mediate between biological structure and sexual behavior; he did not consider sexuality as part of the symbolic structure of culture.

Similarly, Lowie’s theorizing allowed the popular anthropological alternative to which economic and political considerations take precedence over erotic considerations in understanding cultural systems. Lowie’s work emphasized these social elements of cultural form, without realizing that erotic considerations are inherently social and can, indeed must, contribute to investigations of cultural systems.

All together, Morgan’s transformation of sexuality, Malinowski’s institutionalization of sexuality, and Lowie’s analytic substitution for sexuality, have contributed to a trend in anthropology away from the study of ideas about sexuality as they operate in larger cultural systems.

Despite this trend, there is a growing body of ethnography which takes a cultural approach to sexuality. The ethnological goal becomes one of comparing entire cultural systems, rather than behavioral facts regarding sexuality. This requires more than documenting the richness of sexual life in certain societies (although such documentation was a necessary contribution to anthropology in its infancy); it requires analysis of cultural systems which alternatively do and do not delineate sexuality as an organizing construct of independent status. One hopes that anthropological accounts will be consulted in the future, by anthropologists and non-anthropologists alike, not only for their wealth in accurate and detailed accounts of sexual behavior, but also because they advance our knowledge of people, including ourselves, as cultural thinkers and actors.

*144/187/5*

In Kinsey’s samples, the accumulative incidence of sexual, same-sex contact among women was 28%, slightly more than half-as great as among men (50%). Thirty-seven percent of the single males compared with 13% of the single females reported homosexual contacts to orgasm.

Among single males, 25% of the total sexual outlet from the ages of twenty-one to twenty-five was in homosexual activity. The comparable figures for the late thirties and late forties were 42% and 54%, respectively. The active accumulative incidence among single males went from 25% in the teens to a maximum of 41% in the late thirties. Among males who were single until age thirty-five, 50% had had some homosexual experience.

Among women, the accumulative incidence rose gradually from age ten to age thirty. By age thirty, 17% of the Kinsey sample had had some homosexual experience and by age forty, 19% had had some sexual contact with another woman. By age forty, the accumulative incidence for single (never married) females was 24%, substantially greater than for married (3%) or previously married (9%) women.

As for extent of homosexuality, 2 to 6% of the females and 5 to 22% of the males were exclusively or primarily homosexual (5- or 6-point ratings on the Kinsey scale). In every age group, only one-half to one-third as many women as men were primarily or exclusively homosexual.

The Kinsey data on male incidence figures from ages eight to forty-five suggest a curvilinear relationship between age and incidence of homosexual behavior. These cross-sectional data for ages thirteen, twenty-four, thirty-six, and forty-five show the number of men engaging in homosexual activity at these ages to be 13%, 37%, 27%, and 23%, respectively. In the active sample, 22% of the single males in their late teens had had homosexual contact resulting in orgasm. The comparable figures for males in their late thirties was 40%.

Single-female incidence figures for contact to orgasm were 2 to 3% in the teens showing a gradual increase with age to a maximum of 10% at age forty.

Both single males and single females showed drops in incidence of contact to orgasm by the late forties, suggesting possible age-related declines in sexual activity. Females showed a 60% drop (to 4%) from the late thirties, but males showed a drop of only 10% (to 36% incidence) for the comparable age period.

In Kinsey’s active sample of single women, most (51%) had had one partner only. Twenty percent had had two partners, and only 4% had had more than ten partners. The single male experience was quite different, with 22% of the active sample males having had more than ten partners.

Frequencies of homosexual contact to orgasm were not higher than the frequencies of intercourse reported for heterosexual samples. Median frequency of contact to orgasm showed no decrement with age and was about .9 times per month for single women from ages twenty-one through forty. For the active sample of women, the mean frequency went from about once per week in the twenties to about twice per week in the thirties. No active sample data were available for women over forty.

Among single males, the mean frequencies to orgasm showed a slight age-related increment from 1 to 1.5 times per week in the twenties to about 2 times per week in the early thirties. The mean frequencies of homosexual contact rose from about one per week in the teens to almost two per week from the ages of thirty-one to thirty-five. They remained at more than once per week through age fifty.

The frequency of contact to orgasm for respondents did not decline in Kinsey’s data, and the percentages of respondents engaging in homosexual activity actually increased with age into the forties. Because Kinsey presented very little data on old-age subjects, there is no way to assess changes in activity after mid-life. The maximum frequencies within age groups among males suggest, however, a slowdown which is probably age-related. Kinsey reported maximum frequencies in the late twenties as high as fifteen times per week. By age fifty, the most active person was averaging only five times per week. The age-related increase in proportions of homosexually active respondents may be an artifact of the culture at the time of the Kinsey study. Societal pressures may have introduced a latency for resolving the homosexual orientation which would have resulted in submitting to homosexual inclination later in life.

*108/187/5*

Ralph went home and, taking his doctor’s advice, soaked in a hot tub. “Within an hour and a half the pain was gone. While soaking in the tub, I pumped it up.” Ralph—and his wife—were pleased. But he was initially surprised when his penis got wider and harder, not longer. Once his soreness disappeared, it took the couple about four weeks to get adjusted to the implant. Ralph had to learn to hit the release button in exactly the right way to deflate it.

Sometimes adjustment is a bit more of a problem. “I was in the hospital three days, and home for eight weeks recovering. It was eight weeks until I used it the first time. It takes a full year to adjust. It took me a year to learn how to pump it up and release it without pain. You need practice,” says Carl, a 54-year-old draftsman.

*164\184\8*

We are also aware that regular exercise positively affects brain wave activity, making you feel more energized. Body temperature is also raised, duplicating one of the main reactions associated with sexual arousal. Also, the more you exercise, the more muscular stamina you develop, which translates to the prevention or delay of fatigue during sex.

Physiologically, regular physical activity has an impact on vaso-congestion, raising blood supply to the penis and helping to achieve and maintain an erection. On a hormonal level, exercise raises testosterone levels, leading to increased libido. And it works psychologically as well. As the percentage of body fat begins to drop and you are able to exercise longer, self-image can soar. All these factors can positively alter personal attitudes about sex.

There are several types of activities that you can include in your daily regimen. They will restore and maintain suppleness of movement as well as overall flexibility. All are easy, don’t require special equipment, and don’t cost anything. They are: walking, stretching, and resistance exercises.

*127\138\8*

The chart presented here is designed to help you pinpoint whether a specific drug you’re taking is causing ED. It includes:

Name of the Medication

Under this heading, list every drug you are taking by brand and generic name. Include any over-the-counter drug as well.

The Prescribing Physician, Diagnosis, and Date Medication Was Started

This becomes especially important as you develop more ailments and consult with different doctors.

Dose and Frequency

In order for a drug to work effectively, you have to know the correct dosage, how often it should be taken, and when.

Adverse Side Effects

Have your doctor or pharmacist explain the major side effects of the drug to determine if ED is a possible outcome.

Sexual Difficulties

If you develop ED, or if it has worsened since beginning the medication, note it on your chart. Include any performance problems like lessened libido or delayed orgasm. Your symptoms may be related to the new drug. Ask your doctor if a different drug can be substituted, or if a lower dose could be used to eliminate, or at least reduce, the sexual dysfunction.

Drug Efficacy

This is the place to write down if you feel the drug is working and fully achieving the projected goal.

The following chart is that of a patient who received a new drug to help reduce his hypertension. As you will see, it didn’t work for him. After a month, his medication was changed, the side effects were significantly reduced, and his sexual problems disappeared.

Name of medication

(generic and brand names)
Doctor, diagnosis, date started
Dose and frequency
Adverse side effects
Sexual difficulties
Drug

efficacy
Diuretic
Lamm,
50 mg
electrolyte
erection
No
Chlorthali-
hyperten-
once a day
imbalance,
problem:

done
sion:

fever, chills,
6/19/97

175/105,

low back
6/30/97

6/3/97

pain,

possible ED

Note: Keep track of how much alcohol and/or tobacco you use on a daily basis as they too can contribute to, or produce, ED.

*98\183\8*

On a strictly physiological basis, anxiety can effectively prevent a man from becoming aroused and getting or maintaining an erection. It can also limit or even destroy spontaneity and curtail the partner’s exploration of new sexual territory.

Consider the case of Linda and Greg. His ED had been brought on by a combination of factors including obesity, insomnia, and stress. Sadly, all three of his conditions were a response to Linda’s precarious state of health. She was diagnosed with breast cancer at the age of thirty-eight. Greg, three years older and devoted to his wife, wasn’t all that surprised when his own problems began. When they came to see me two years later, their circumstances had, fortunately, changed. Linda had come through surgery and a course of radiation weak but determined. Her prognosis was excellent. Greg, however, still had his ED.

“It’s not that I don’t want to have erections again,” he began nervously. “It’s that I’m worried that after I take the medication and can function again, I’ll hurt Linda. She’s so thin and frail, I’m afraid to have sex with her.”

“You’ve been scared to touch me for two years,” she challenged him.

“That’s because I saw what was happening to you and it put a brake on me.”

Linda regarded him with a combination of sadness and anger. “I think you’re just put off by how I look. Be honest, Greg—isn’t it true?”

Smiling ruefully, he answered, “The truth is, I look a lot worse than you do.”

Throwing her hands up in the air, Linda exclaimed, “The competition never ends. Greg, I want you to know—in front of a witness— that I want you again, spare tire and all. If you want me, then it’s with my buzz cut and protruding ribs. But you have to stop being afraid of me. I’m not going to break—and you’re not going to hurt me any more than I’m going to hurt you.”

This situation is not an unusual one: sex is often a casualty of cancer. Please note that sex will not cause the disease to spread; nor are women who receive radiation dangerous to your health. (This is a particular concern for men whose partners have cervical cancer.)

*70\183\8*

Your emotions and your state of mind affect your physical ability to get an erection. Here’s where the nervous system plays such an important role. There are two parts to the unconscious (or autonomic) nervous system which control erections: the parasympathetic network, which relaxes you, and the sympathetic system, which puts your whole body on alert.

During erection, the parasympathetic nervous system is in full gear, sending messages to the arteries and sinuses to expand and let more blood into the penis. The parasympathetic nervous system also plays a crucial role in food digestion and in relaxation.

In contrast, the sympathetic nervous system is the uptight partner in this operation. These nerves tell the arteries and sinuses in the penis to constrict and decrease blood flow. They go into full gear when you are anxious or tense, shifting blood away from your penis and digestive system into your muscles. Therefore, a man who is tense and anxious might be physically unable to get an erection because the overactivity of his sympathetic nervous system is clamping down on the blood flow into his penis.

*31\184\8*