Health news blog

Vasectomy

The cutting and tying of the two sperm-carrying ducts that lead from the testes to the penis.

Advantages

•     Almost 100 per cent effective.

•     Sex drive is not affected in most men.

•     Once done it needs no further thought.

•     The man can be sure that he cannot father children he doesn’t want.

•     There is no chance of his partner ‘making a mistake’.

Disadvantages

•     It is permanent and virtually irreversible-a major disadvantage in a world of unstable marriages because the man might want children in a new relationship.

•     In men who are psychosexually unstable, or when the relationship is not good, there is a danger of sexual problems afterwards.

•     It is not immediately effective and other methods have to be used for the first four months after the operation or until tests show that there are no live sperms in the semen.

Coitus interruptus (withdrawal, ‘being careful’)

With this method the man withdraws his penis just before he is about to ejaculate so that no sperms enter the vagina. The failure rate is undoubtedly very high. It is a good idea to keep some spermicidal foam handy in case of an accident.

Advantages

•     It doesn’t cost anything.

•     It has no medical side-effects.

Disadvantages

•     It is very unsafe because many men find it difficult to withdraw when it comes to it, especially if they are ‘carried away’ with the sex act.

•     It restricts positions of love-making to those in which the penis can be withdrawn instantaneously.

•     If the woman is worried that the man will not withdraw in time she may not relax and so will not enjoy sex much.

•     The man may need to withdraw his penis before his partner has had an orgasm because his is about to occur. This can leave the woman ‘high and dry’. Obviously she can be brought to orgasm in other ways but many couples find this unsatisfactory.

•     It is not a good method for the inexperienced couple, mainly because the man probably has not learned to recognize when his ejaculation is imminent.

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Sex therapy as a field can be considered in many ways. It is a therapeutic discipline, usually requiring rather extensive training for proficiency. It is a rapidly growing body of knowledge, techniques, and modalities within the general realm of psychotherapy. It is a speciality within the broad area of dyadic and family therapy, with significant implications for both.

Since sex, dyadic, and much of family therapy center on the treatment of dyads, it is logical that there should be relationships among the three. Theoretically, the resemblances are clear, but in practice the three areas of therapy have only recently begun to move together. The reason is that each arose and developed not only at different times but also in different ways.

Dyadic therapy (usually called couples or marital therapy) was preceded by pastoral counseling and became recognized as a field of therapy in the 1930s (Bowen). Early counselors, in addition to the clergy, were social workers who had to improvise techniques for dealing with the dyadic problems. Later, psychiatrists and psychologists entered the field, with a variety of theoretical and dynamic formulations explaining what they observed. There is no central figure in dyadic therapy that occupies the place dominated by Sigmund Freud in individual therapy. This also applies to family therapy. More recent than dyadic therapy, family therapy arose in the 1950s among psychiatrists, particularly those treating patients with highly disturbed, neurotic family backgrounds, or patients institutionalized for schizophrenia. With the former, progress or insights in the office seemed to dissipate. With the latter, cures in the hospital could be effected, but in most cases once the patients returned home, the schizophrenic symptoms reappeared. To obtain more lasting cures and to help dysfunctional family constellations, the psychiatrist began to try to modify the family environment, and family therapy was born. Ackerman was one of the first to publish in the field; he was followed by many others, including Whitaker, Wynne et al, and Weakland.

Sex therapy can be traced largely to the work of four people. The first was Dr. Alfred C. Kinsey. Though never addressing the relief of sexual dysfunctions, Dr. Kinsey’s dispassionate, scientific inquiry into sexual practices made the entire subject intellectually and socially reputable. Dr. William H. Masters and Mrs. Virginia Johnson initiated sex therapy per se in 1970 with the publication of Human Sexual Inadequacy. Their approach was and remains rather stringently behavioral. In 1974 Dr. Helen S. Kaplan extended the therapy of Masters and Johnson by adding psychodynamic and interpersonal modalities to the behavioral techniques, describing her approach in The New Sex Therapy. This is the approach generally followed by the author in referring to sex therapy. Unlike sex therapy, family and dyadic therapy does not have major nucleal figures. As Hogan states, “The way in which the family system is approached differs markedly from one therapist to another. Some family therapists . . . think primarily in terms of the family structure. . . . Others emphasize the interplay between . . . individual dynamics and the larger family system. Still others emphasize the communication aspects”. Similar words could be written about dyadic therapy.

In considering the relationship between sex therapy and dyadic and family therapy, it might be asked, to which of the many types of dyadic and family therapy is sex therapy related? The answer is, to all of them and to individual therapy as well.

The reasons lie in the centrality of sex (discussed later) and in current trends in psychotherapy. Psychotherapy as a whole may be looked at in two ways, in terms of techniques or schools—psychoanalytic, gestalt, behavioral, Rogerian, existential—and in terms of fields or areas of application—individual, dyadic, family, sex, children, geriatric, drugs. What seems to be happening is that distinctions among schools and distinctions among areas of applications are blurring, as the practice of therapists and the fields in which they practice begin to merge into each other. In the words of Martin, “It is clear that the fields of individual, marital, and family therapy have overlapping boundaries and that distinguishing one from the other is, to some extent, an artificial process”. There are similar amalgams in psychotherapeutic techniques. But a mere union of techniques and/or fields does not necessarily equal a holistic approach, for even with these amalgams it is possible to view the patient partially, to split the patient into sections treatable by one’s specialty. That is, the person practicing individual psychotherapy tends to split the patient from his or her family, but the dyadic or family therapist tends to split the family member from his or her unique intrapsychic problems. Holism insists on the integrity of the patient: the patient is seen as a whole, as part of a dyad or family (or even, as Auerswald says, as part of a neighborhood, community, or country), and as an individual. Holism also implies that the therapist can vary his or her approach depending on the needs of the patient, dyad, or family. “Man is autonomous,” says Bowen, “yet not separated from family and multigenerational past”.

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The transition to the anal stage is marked by the maturation of neuromuscular control over the functioning of sphincters, particularly the anal sphincters, which thus permits a higher degree of voluntary control over the retention or expulsion of feces. This period extends roughly from about the first to the third year of life and is characterized by a recognizable intensification of aggressive drives mixed with the libidinal compounds in anal-sadistic impulses. The acquisition of sphincter control is also connected with an increased shift from a posture of passivity to one of increasing activity and assertiveness. The classical contexts in which these issues are joined are the struggle with the parent over the retaining or expelling of feces in toilet training. The ultimate issue is one of control: who has the final say as to when and how things will be done. These conflicts over anal control and the struggles with the parent over the retaining or expelling of feces increase the degree of ambivalence. The parent in this period becomes the object of both intensely loving and hating impulses, since the child wishes both to comply with the parent’s wishes and thus continue to receive love and affection from the parent as well as to rebel against the parent and withhold the precious fecal gift.

This is also the period of separation and individuation, in which the questions of the extent to which the child can function on his own without continual reliance and support from the nurturing parent are joined. Here again the anal drives are characterized as erotic, referring to the sexual pleasure in anal functioning, both in retaining the precious feces and in presenting them as a precious gift to the parent, and as sadistic, referring to the increased expression of aggressive impulses connected with the discharging of feces as though these were powerful and destructive weapons. These wishes may often be displayed in children’s drawings or in play activity in the form of fantasies of bombing and explosion.

The major issue in the anal period is that it is essentially a period of striving for independence and for the child’s separation from the continuing support of the parents and from his dependence on them. The issue of control is particularly important here, since in one direction the excess of parental control deprives the child of the opportunity to separate adequately and to gain some foothold for his own stirring autonomy, while the opposite extreme, a failure of parental control, would leave the infant too much at risk of failure and too threatened by the anxieties of separation and the intensification of his still powerful dependency wishes. In this arena, then, the objectives of sphincter control without an excessive degree of overcontrol (fecal retention) or the loss of control (messing) can be matched with the child’s attempts to establish and achieve autonomy and independence without an excessive degree of shame or self-doubt arising from the loss of control. Erikson has characterized this developmental crisis as the tension of autonomy versus shame and doubt.

Certain maladaptive character traits, which often seem inconsistent, arise from the failure to resolve these basic developmental issues and reflect the tensions over anal erotism and sadism and the defenses against it. Thus, one often sees such characteristics as orderliness, obstinacy, stubbornness, willfulness, frugality, and parsimony as characteristics of anal personalities. These characteristics derive from the fixation on anal functions and often assume a highly rigid and controlling quality. When the defenses against anal traits are less effective, either because they have been weakened or have undergone some degree of regression, the anal character then often reveals traits of heightened ambivalence, messiness, defiance, rage, and severe degrees of sadomasochistic behavior. Such anal characteristics and their correlative defenses may often be seen most typically in the obsessive compulsive neuroses and obsessive compulsive character structures.

But the conflict and struggle over anal issues and the difficulties of separation and individuation may also have their successful outcome. The successful resolution of the anal phase and its difficulties is a basis for the development of an increasing sense of personal autonomy, the capacity for independence, and for the exercise of personal initiatives without an abiding sense of guilt. There can result a capacity for self-determination without a sense of shame or self-doubt. In such personalities a healthy degree of independence and the exercise of personal initiative and self-determination can be accomplished without any significant degree of ambivalence. Such individuals, having a firmly established and reasonable degree of personal autonomy, can engage in various levels of willing cooperation with others and even submission of themselves in willing ways to the objectives and purposes of others without a sense of excessive willfulness or rebelliousness on the one hand, and without a sense of self-diminution, defeat, or humiliation on the other.

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Direct evidence of the relationship between stereotypes and discriminatory behavior is rare; most often it simply is inferred from “post-hoc” explanations of research results. In unequivocally establishing that stereotypes mediate discriminatory behavior, one problem has been the development of a reliable instrument to measure stereotypical attitudes toward women at work. In the Attitudes Toward Women Scale developed by Spence and Helmreich only a few of the fifty-five items deal directly with attitudes toward women at work. An instrument developed by Bass, Krusell, and Alexander, designed specifically to measure attitudes about women managers, is faulty in its construction, e.g., items are double-barreled and all item stems are unfavorable in valence. In 1974, however, Peters, Terborg, and Taynor developed the twenty-one-item, Likert-type Women as Managers Scale (WAMS). Although it has its critics, it since has been validated (Terborg, Peters, Ilgen, and Smith) and used in a number of investigations.

Garland and Price demonstrated that favorable attitudes toward women in management (as measured on the WAMS) were positively correlated with personal causal explanations and negatively correlated with situational-causal explanations of a woman’s work success. These results, together with those of the previously discussed Heilman and Guzzo study suggest that stereotypical attitudes about women at work can result in the discriminatory allocation of their organizational rewards. Also, Terborg and Ilgen found that the higher the score on the WAMS, the higher their subjects rated the desirability of hiring a female. Selection processes also indicate that stereotypes about women are related to how fairly they are treated in work settings.

Additional support for this idea can be found in a study by Mischel. She demonstrated that in Israel, a far less sex-typed society than our own, the biases so often shown here in the United States were not apparent. Israel is a country with a policy of sexual equality in many more areas than ours (e.g., women are required to serve in the military). With this equality one might expect sex stereotypes to be less prevalent. Using Israeli students in an experiment fashioned after Goldberg, Mischel in fact found little evidence of evaluation discrimination. Therefore it appears that the lack of traditional stereotypes facilitated the more equal treatment of men and women.

There are findings that verify the relationship between sex stereotypes and sex discrimination. But how does one go about changing such stereotypes? Two very different types of change are conceivable. One is cultural change, the changing of the forces that produce biased conceptions of women. The other is individual change, the changing of the current stereotypical attitudes and beliefs held by a specific man or woman.

Most investigators have found little evidence that in recent years sex stereotypes have changed within the culture. Even today’s college students seem no different than their predecessors in their attitudes and beliefs about women. This lack of change was particularly evident when researchers took precautions to limit the pressures on subjects to give socially appropriate responses. However, there is some evidence suggesting that current societal changes ultimately may alter views of women. If a person’s mother has worked, for instance, that individual has been shown to have a less stereotyped view of women than one whose mother has not (Vogel, Broverman, Broverman, Clark-son, and Rosenkrantz). Exposure to a woman in a nontraditional role (a working mother) can influence one’s general view of women. Extrapolating from this finding, one might expect that changes in the way women are portrayed by the media, in the way they are depicted by our educational institutions, and in their visibility and importance in the work force will contribute slowly to an evolved view of women in the coming generations. There is therefore some room for optimism about the future.

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Several anthropological reports indicate an important difference in the quality of sexual activity inside and outside of marriage. Gladwin’s and Sarason’s male Trukese informants say that “love for your wife is not the same as love for your sweetheart”. “Coitus with a mistress is said to be considerably more pleasurable than with a wife,” is a similar report on the Mehinaku. In fact, Mehinaku men report to Gregor that they have intercourse with their mistresses four to five times more often than with their spouses.

Following in the tradition of Oscar Lewis, Rainwater compares marital sexuality in four “cultures of poverty,” and finds a general axiom for each: “Sex is man’s pleasure and woman’s duty”. From the four lower-class systems studied (Puerto Rico, England, United States, Mexico), Rainwater concludes that the low value placed on compatibility and harmony in sexual relations is a function of the more general distance between men and women in the marital relationship.

Victor Turner and Paul Riesman have approached the marital/extramarital sexual distinction in symbolic terms. In Africa, Turner finds a symbolic congruence between the color black and (female) sexual attractiveness: “Women with very black skins are said by Ndembu men to be very desirable as mistresses, though not as wives”. Riesman details the importance of place as well as of partner in the Fulani symbolic system:

adultery always takes place in the bush and that only the sexual act of a married couple occurs in the wuro in the suudu of the woman. As a result, to the extent that women in their huts symbolize legitimate sexuality, hence the right to progeny, they are in fact a necessary cause of the dispersal of men.

Fulani symbolism would have to differ from peoples like the Baktaman of New Guinea (Barth) for whom marital sexual intercourse takes place in the forest near gardens, because of enforced sexual segregation at night. Yet in all these cases there is an unmistakable separation of marital sexuality from passionate sexuality.

What might account for the fact that men in so many societies find extramarital sex more attractive than marital sex? In Trukese marriage the joint interests of husband and wife are subordinate to the lineal (“kinship”) commitment each spouse has to his or her own people. If a dispute should develop, a wife must side with her brothers, even if it means she must oppose her husband. Goodenough contrasts this with the basically exclusive and dyadic relationship between sweethearts. One of the ways that sweethearts are able to express their attraction for each other is through their willingness to run great risks in order to be together. In support of this, Mead offers a convincing example of the danger and risk in love-making in her description of moetotolo, “sleep crawling:” “As perhaps a dozen or more people and several dogs are sleeping in the house, a due regard for silence is sufficient precaution”.

Schieffelin explains the political nature of marital sexuality in his ethnography of the Kaluli of Papua/New Guinea. Only after a husband has begun having sexual relations with his new wife does he initiate presentations—in this case giving meat to his wife’s relatives. Schieffelin reports that this might not commence for as long as a month or two after marriage. The concurrence of (marital) sexuality and presentation suggests that wifely sexuality is part of what the husband is reciprocating. We are not told what, if any, effect this has on sexual performance in marriage, but we do know that it is certainly missing in sexual relations outside of marriage. This feature of apolitical sexual expression, coupled with the contingent opportunity to engage in a veiled but rebellious gesture against the marriage (or its politics), places extramarital sexual activity in the realm of an “intriguing lascivious achievement,” rather than the merely foolish, to paraphrase the Dobuans (Fortune).

Ideological issues are also important to our understanding of “alligatoring,” a Mehinaku courtship technique in which a male suitor hides behind a female’s house, waiting for her to appear so he can solicit sex (Gregor). As Gregor explains, “The term is a reference both to Mehinaku mythology, in which the alligator … is highly sexual, and to the animal’s famous ability to lie motionless in wait for its quarry”. A Mehinaku male will have a set of “alligator spots” from which he can surreptitiously view a girlfriend’s house and await her appearance. Upon making visual contact, sometimes with the aid of a lip-pursing call, the male will lead his friend down an “alligator path” which in turn leads to “alligator areas,” where the couple hastily has sexual intercourse, usually in a standing position. The Mehinaku, it turns out, are strongly segregated by gender during the day. They work apart; they even have separate ceremonies, all of which enables “alligatoring” to work relatively smoothly.

If one assigns primacy to the social organizational component, the analysis goes something like this: the social organizational fact of segregation during the day allows, or contributes to, the phenomenon of “alligatoring” observed by Gregor. On the other hand, the approach through ideology recognizes the cultural structure underlying an individual Mehinaku’s relationships to persons of the same and opposite sex, both in everyday and in “alligatoring” contexts. One is not social organization, the other “custom.” Both are contexts in which ideology comes into play. This ideology, in turn, is predicated on cultural premises.

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The Kinsey self-report survey data are still considered to be the most comprehensive picture of sexuality across the life span. Although Kinsey did not adequately represent older people in his sample (he had only 126 males and 56 females over sixty) and although he drew some of his conclusions by extrapolating patterns in younger subjects, most of his conclusions have stood up remarkably well in view of later research (for example, Masters and Johnson on sexual capacity,; Pfeiffer and Verwoerdt on activity and interest).

The Kinsey data indicate that males are most sexually active in their teens. It is at this age that frequency of sexual behavior (all types) and number of sexual outlets are greatest. Sexual activity in males diminishes gradually with age, but changes across age groups do not represent differential rates of decline (Kinsey). Average corrected U.S. population frequencies of sexual activity (total outlet) were 3.3/week at age twenty with relatively little change to age thirty. By age forty-five, this average was 2/week and declined to .8/ week at age sixty and .2/week by age seventy-five. Married and single males showed differences in maximum average frequencies in their teens—4.8/week and 3.2/week, respectively. The differences in average frequencies by marital status, however, leveled and were comparable by age fifty. Age-related declines in sexual activity can be observed by referring to the maximum reported frequencies per week of various types of sexual activities across representative age groups. Masturbatory frequencies per week in single males declined from 15 in the late teens to 7 in the late thirties to .5 in the late fifties. The maximum frequencies per week for marital intercourse at these age groups were 25, 20, and 5, respectively. Extramarital intercourse frequencies per week were 18 in the late teens, 4 in the thirties, and 2 in the fifties. Kinsey’s data on female sexual activity showed that women on the average were less sexually active than males. In frequency of total outlet, single women (active incidence) had a median frequency of orgasm per week which did not significantly decline with age. At twenty, this frequency was about .3; at forty and at fifty, frequencies were .5 and at age fifty-five, it was .35. The active median frequency for married women showed some age-related decline, going from 2 per week at twenty to 1.5 per week at 35 to .8 at age fifty. By age fifty-five, this average frequency was .6 per week. Variability in frequency of female behavior was much greater than in males. For example, although females on the average have much lower frequencies per unit time in total outlet, 1% of the single females from sixteen to thirty reported having from seven to twenty-nine orgasms per week. Slightly less than 1% of single females from forty-six to fifty reported frequencies in the range of seven to eighteen per week. There were slightly higher percentages of married females reporting these frequencies in their respective age groups.

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There’s a lot to consider when choosing an implant, and you should discuss your options in detail with your physician and your partner. Remember, no one model is right for everyone. The best one for you depends on your particular health needs, physical condition, personal preferences and lifestyle.

Once you’ve been evaluated by a physician and it’s been determined that your best treatment would be an implant, it’s time to consider the different types. In most cases your physician will make specific recommendations. If s important to weigh all the factors, to involve your partner and to actually see and touch the different models, if possible.

You may find it helpful to talk to men who’ve had the different types of implants (and your wife may benefit from talking with their partners). Support groups (see chapter 6) can be helpful, and your doctor may be able to put you in touch with patients who have had the surgery, and their partners. But remember, your needs are uniquely yours. What’s right for one man won’t necessarily be right for you.

The importance of personal preference was emphasized to us when we talked with two different patients on the same day. In the morning, a man with a semirigid implant said he “couldn’t imagine” why anyone would want an inflatable prosthesis. Just a few hours later, another gentleman, happy with his inflatable, declared he would never even consider the semirigid type. Each was sure he had made the right decision— and each was correct.

Take all the time you need to make a decision. Some couples decide rather quickly. Robert and Greta, for example, married for almost 50 years, didn’t take months to choose. “Both of us went to the doctor and both of us decided,” Robert explains. This 74-year-old gentleman wanted the inflatable, and that’s what he got.

Gabe, a 52-year-old office manager, found the choices more difficult than Robert. Gabe’s potency problem was due to a case of Peyronie’s disease. He was fortunate, however, because the scarring from the disease was moderate, and the inflatable prosthesis was an option for him. Gabe took a year to make up his mind, and during that time the newest type of inflatable implant with the reservoir in the penis became available. He calls the results “fantastic. I’m like a young man, and my wife can attest to that.”

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A report from the sex therapy clinic of Masters and Johnson illustrates how physical problems can mimic psychological ones. Eight out of 136 male patients at the clinic were found to have blood levels of the hormone prolactin that were high enough to cause erection problems. The 8 men were found to have pituitary tumors, a common cause of high prolactin levels. Usually, surgically removing the tumors or giving medications can restore potency to men with this condition.

What’s significant is that the abnormal hormone levels were not discovered until after the patients went through two weeks of intensive sex therapy, which, according to the authors, resulted in “some degree of improvement of sexual function.” However, “full restoration” of their sex drive didn’t occur until the hormone imbalance was treated.

Once the physical problems were corrected, the men’s erections were firmer and occurred more quickly. And the men’s sex drive and sexual activity increased.

The lesson to be learned from all this is that these men were at the clinic to be treated for psychological impotence. None of their previous doctors had diagnosed hormonal problems. While sex therapy can help some patients with physically caused impotence get back in the swing of things, it’s no substitute for proper diagnosis and treatment of underlying medical problems.

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Many women have told us that although they took pains to make sure they remained involved in their husband’s diagnosis and treatment, they felt ignored by the doctor. One woman said the doctor treated her like a piece of furniture. “I was there the whole time. None of the doctors ever talked to me. Nobody asked me what I was going through, how I felt. I would have found that helpful, yes,” says Andrea, who’s been married to her husband for ten years.

Andrea learned the hard way that some doctors must be pushed to involve the woman in therapy. One way to guarantee the woman’s participation is to make it plain that you and your wife function as a team. If your doctor doesn’t agree, and you aren’t satisfied with the explanation, consider seeing someone else. After all, you’re paying for the service, and you have a right to have your needs met.

The physician may want to interview and examine you alone, but you can explain that you want your wife included at the end of each visit, to hear for herself what’s happened and what the next step is. The idea is to make sure that you and your wife have ample opportunity to voice any concerns and questions.

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Researchers believe that only a small number of men are actually born with leaky veins. But they theorize that there’s another, more widespread cause of vein problems—arterial disease. It works—or rather doesn’t work—like this. Normally, when a man becomes erect, the veins are squeezed shut as the sinuses in the penis fill with blood. Consequently, the veins become narrower and the blood flow through the veins out of the penis decreases. But if the blood flow into the penis is significantly reduced due to blockage of the diseased arteries, there’s less pressure on the veins. This type of blood-flow problem develops gradually and can be caused or aggravated by smoking, a high-fat diet and diseases such as diabetes.

One sign of mild vein problems is that erections improve when the man stands up. Why? Because when even the most well endowed man stands, his heart is higher than his erect penis. Consequently, the blood has to flow uphill to get back to the heart. The result is that the penis stays full of blood longer.

Very sophisticated tests like cavernosography help detect vein problems. Once correctly diagnosed, vein problems can be treated, either by tying off the offending veins, or, if arterial disease is also severe, with a penile prosthesis.

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