Treatment begins with a thorough evaluation, which has two purposes: to determine whether the patients are suitable candidates for sex therapy and to formulate the erotic sexual tasks appropriate to that couple. The evaluation interview includes a medical and psychiatric history of the patients and a thorough sexual history. The initial aim of the therapist is to obtain as clear a picture as possible of the “target” sexual dysfunction or dysfunctions and of the current sexual relationship of the couple. The patients are asked to describe their latest sexual experience together “as a video picture”; only when the therapist understands both the symptom and the context in which it appears will the next area be explored. An attempt is made to formulate both the immediate and the remote causes of the patient’s problem. To this end the experiential description of the sexual interaction, the “video picture,” is supplemented with a description of the history of the dysfunction, including the patient’s childhood experiences. The relationships among parents and siblings are explored, and the sexual functioning of each partner in childhood, adolescence, and premarital adulthood is ascertained. The etiology is completed with a discussion of the couple’s marital history.

During the initial evaluation interview, if profound intrapsychic or interpersonal difficulties are revealed which might preclude successful sexual therapy, the patients are referred to the appropriate individual or to conjoint therapy and are not accepted at that time for sex therapy. They are, however, encouraged to return, should they still need sex therapy after the resolution of their other conflicts. Contraindications to sex therapy lie in the intrapsychic and interpersonal domains. According to Kaplan, “Sex therapy is indicated only if . . . earlier problems are not insuperable nor screens for psychotic processes. With severely disturbed individuals or couples, sex therapy is usually not indicated”. Contraindications include significant medical illness, use of narcotics, or alcoholism, and major active psycho-pathologies (“florid schizoid reactions, blatant paranoia, and significant depression in either partner”). However, if these are remedied, successful treatment is still possible, “providing the therapist is sensitive to and careful not to tamper with the crucial defense against the emergence of open illness”. Interpersonal contraindications are a lack of caring and cooperation necessary to perform the sexual tasks together.

For patients who are marginally suited for sex therapy, the next few sessions are devoted to exploratory exercises intended to clarify their status. The “sensate-focus” exercise (Masters and Johnson) is frequently used as a “probe”; sometimes the couple is merely instructed to shower together, washing and drying each other (Witkin). Usually within three sessions, but sometimes requiring as many as four or five sessions, the prognosis is much clearer, and the patients will either continue in sex therapy or be referred to another treatment modality.

Once therapy proper begins, the average course of treatment lasts between six and sixteen weeks. In almost every case, persistence of the symptom beyond twenty weeks is considered an indication that this particular problem is not amenable to rapid sex therapy and calls for other forms of therapy.

*246/187/5*

The stages of psychosexual development constituted the basic theory of psychoanalysis, particularly the primary theory of development within psychoanalysis, for most of the early period of Freud’s thinking. It was not until the emergence of a structural theory in The Ego and the Id and the subsequent emergence of a more developed ego psychology at the hands of Anna Freud, Heinz Hartmann, David Rapaport, Erik Erikson, and others, that the basic developmental schema provided by the stages of psychosexual development came to be modified to any great extent. The stages of psychosexual development even today remain one of the best understood and most firmly established dimensions of psychoanalytic theory. Although the schema has been considerably modified since Freud’s early thinking about it, it nonetheless has remained a fundamental dimension in the psychoanalytic assessment of personality and the pathology of disturbed states of functioning.

In discussing the role of psychosexual development in disorders of sexuality, it is of particular importance to keep clearly in mind the distinction between developmental characteristics derived from the respective psychosexual stages, and the levels of regressive fixation that may characterize one or other form of psycho-pathological expression. Thus, many aspects of reasonably well-integrated and well-functioning individuals may originate in the respective psychosexual stages, but this does not mean nor can it be used to infer that the behavior in question is an expression of that level of psychological functioning and psychosexual integration, nor that it necessarily reflects a fixation at that particular developmental stage. It is quite a different matter to say that a given individual manifests oral characteristics in his behavior and to say that the organization of his personality reflects fixation at the oral stage of psycho-sexual development. There has often been a basic confusion in the use of such terms and a failure to distinguish between regressive fixations and developmental attainments.

With these cautions in mind we can turn at this point to a brief description of the psycho-sexual stages and to a brief specification of some aspects of their implications, both for pathological functioning and for personality development. The following description of the psychosexual stages is based on Freud’s early formulations but reflects the contributions of later psychoanalytic thought to the understanding of psychosexual development. Of particular importance in these later contributions are the deepening of the developmental implications of the pre-genital stages, the mutual interaction of psychosexual dynamics with object relations, and finally the interplay of psychosexual and psychosocial developmental processes.

*210/187/5*

Rosen and Jerdee found that women were thought to be out-of-role when they took a threatening approach in filing a job grievance. These same authors (Rosen and Jerdee) found that employees’ requests for released time from work because of family problems were perceived to be more acceptable coming from a woman than a man. There also is some evidence that the sex of a manager influences how descriptions of different managerial styles are evaluated (Bartol and Butterfield; Rosen and Jerdee). Generally, these studies suggest that both women and men are evaluated more favorably when their leadership activities consist of sex-appropriate behaviors, e.g., a female manager showing consideration and a male manager initiating structure. Evidently, conformity to traditional sex role standards is regarded favorably in work as well as in other settings.

Most jobs that carry with them authority and responsibility are thought to require behavior that is explicitly male. What are the consequences for women who take such jobs? How do others react to them and how might their performance be affected by these reactions? What are the implications of these reactions for their careers?

Costrich, Feinstein, Kidder, Maracek, and Pascale investigated the reactions to women’s out-of-role behavior in a series of laboratory studies utilizing three different experimental procedures. The results indicated that women who violate norms of feminine passive-dependency were penalized by the undergraduates serving as subjects. They were rated both as less popular and as more poorly adjusted than women who abided by the behaviors appropriate to their sex. These findings’ suggest that, paradoxically, women in nontraditional fields may be evaluated negatively if they do their jobs well.

Such reactions, if they occur in work settings, can impair the advancement opportunities of women. There have been a number of field studies that examined the reactions to females in previously male-dominated roles; however, they have focused on the reactions of subordinates to female and male supervisors. Although the reactions of subordinates clearly are not as critical for our purposes as are the reactions of those who have the power to take personnel actions, these studies are nonetheless instructive in understanding the by-products of incongruence between sex and job in actual organizational settings.

Two separate research investigations (Petty and Lee; Petty and Miles), investigated the correlations between subordinate perceptions of leader behavior and subordinate satisfaction. Both in the nonacademic divisions of a university and in a social service organization, the correlation between consideration behaviors and satisfaction with supervisors was greater for female supervisors than for male, In the social service organization study the correlation between initiating structure behaviors and satisfaction also was greater for male supervisors than for female. In fact, men with women supervisors had negatively correlated satisfaction scores and ratings of initiating structure. Satisfaction was thus found to be linked with perceptions of sex-role-consistent behavior.

Rousell conducted a field study in which, as Terborg has pointed out, greater care was taken to control adequately for factors in addition to sex, thus allowing for a more precise statement about supervisor sex and subordinate reactions than in the Petty studies. The effects of department-head sex on teacher ratings of department climate in ten high schools were investigated. The teachers were randomly selected from the four largest departments in each school. The twenty-five men and fifteen women department heads had few differences in background and virtually no differences in teacher ratings of professional knowledge, aggressiveness, or power—all potentially confounding variables. Results indicated that departments headed by men were rated as having a far more favorable climate than those headed by women.

The data from these studies have several pertinent implications. First, they suggest that women in supervisory positions are limited in the extent to which they can adapt a variety of supervisory styles to do their jobs effectively. Their flexibility is constrained and their ultimate performance may suffer. Second, they suggest that negative reactions to women in non-traditional roles are confined not only to the woman herself but influence the perceptions (and perhaps the realities) of the climate of the work setting. Each of these can have costly consequences for the woman striving to move up in the organizational ranks.

An additional and not unimportant point is the fact that the anticipation of negative reactions by organization members can prevent decision makers from placing women in nontraditional positions. Results of a 1965 Harvard Business Review survey of 1,000 men and 900 women executives indicated that over two-thirds of the men and almost 20% of the women said they would not feel comfortable working for a woman. Very few of either sex (less than 10% of the men and approximately 15% of the women) felt that men employees feel comfortable working for a woman. Beliefs of this sort make the prospect of placing women in high-level jobs seem risky. Surely this must enter into decisions about who to put in what position and who to put in charge of whom.

In reviewing the literature pertinent to on-the-job sex discrimination, it again is apparent that sex stereotypes are the basis for the differential treatment of men and women. There is indication that if a woman were to perform well on the job her success might not be acknowledged or even if it were, it might be interpreted as a result of temporary conditions. There also is indication that a woman, simply by her presence in an out-of-role position, can create low morale and dissatisfaction among others at the work place, thereby limiting her effectiveness and others’ perceptions of her potential. It seems clear that when competing with men in the work world, women face a tremendous disadvantage.

*172/187/5*

In American culture, according to Schneider, sexual intercourse is “exclusive to and distinctive of the husband-wife relationship”. Schneider knows full well that sexual intercourse as behavior occurs outside of marriage, but his point is that it never occurs outside of the marital context. In an important footnote Schneider supports his contention and demonstrates the broad scope of husband-wife sexuality in defining the impropriety, illegitimacy, and immorality of other forms of sexual activity:

Sexual intercourse between persons who are not married is fornication and improper; between persons who are married but not to each other is adultery and wrong; between blood relatives is incest and prohibited; between persons of the same sex is homosexuality and wrong; with animals is sodomy and prohibited; with one’s self is masturbation and wrong; and with parts of the body other than the genitalia themselves is wrong. All of these are defined as “unnatural sex acts” and are morally, and in some cases, legally, wrong in American culture.

With this reasoning Schneider could define the symbolic system of American kinship, consisting of and in terms of the central symbol of sexual intercourse. In later publications Schneider widened his study to additional cultural domains grounded in the same symbolic process.

Schneider’s argument allows a cultural approach to such topics as adultery. If we expand upon Schneider’s argument, we learn that adultery is wrong because it extends to outsiders the order of law, which unites individuals through marriage. Americans also reckon relatives through tracing “blood” ties. The conjugal love of marriage is opposed in the cultural system by the cognatic love between persons related “by blood.” Schneider points out that the product of conjugal love provides the actors who partake of the “blood” relationship. Sexual intercourse, therefore, is instrumental and symbolic in both conjugal and cognatic love.

Adultery, in this analysis, breaks the symmetry and threatens the entire system. Because it is a pivotal symbol, sexual intercourse outside of marriage not only threatens that marriage but threatens personal relationships defined by the “blood” with which it is dynamically associated. Note that the epithet “homewrecker” used to disparage the proverbial “other woman” refers to the total damage done to relations defined both by blood and by law.

Of particular interest to anthropologists are the arrangements of polygamous marriages. Herskovits was somewhat surprised to find that Dahomean polygynyous marriages were not necessarily tense or jealousy-arousing. Cooperative co-wives make adjustments among themselves, should a husband’s four-day cohabitational visit coincide with a wife’s menstrual cycle. She will exchange places in the rotation with a co-wife and not be deprived. Herskovits concludes: “In essence, the great mass of Dahomean matings, either because of complacency, or of human ability to make the best of a situation, are permanent ventures which in terms of human adjustment cannot be called failures”.

Schapera, reporting on the Kgatla, is not as impressed with the way the system works for them, finding jealousy, suspicion and unhappiness among a Kgatla’s many wives. His conclusion differs from Herskovits’s: “Many women grow reconciled and manage to lead a tolerable existence with husbands who are not unduly inconsiderate, others find some sort of relief by being unfaithful themselves, and some are acutely miserable”.

We have a similarly indefinite perspective from the literature on polyandry. Linton reports that jealousy among co-husbands in the polyandrous Marquesas was considered “very bad manners”. This report is contradicted, however, by Suggs, who reports that “sexual jealousy is, and was, pronounced in the Marquesas”.

Little light will be shed on the topic of jealousy in marriage, plural or otherwise, unless some consideration is given to the larger context provided by native conceptions and explanations. One start in this direction is offered by Firth who finds that among the Tikopia, jealousy is something engendered by marriage and is a natural extension of the marital relationship:

Jealousy is a definitely recognized type of behavior in Tikopia, characterized by a special linguistic expression, masaro. It is particularly evident in newly-married people, the natives say, and they regard it as a kind of accompaniment to the recently-wedded state. One of the young pair excites jealousy of the other . . . [Firth asks, "Over what?"] We don’t know; there it is, the co-habitation of a newly-married pair. They dwell together, they become jealous.

For the Tikopians, jealousy is an expectable part of marriage, especially in its earlier stages. It stems from the marriage and not from the predispositions of either mate, either to incite jealousy by behaving in certain ways or to become jealous easily because of personality.

As might be expected, people in various societies seek evidence to substantiate their suspicions of infidelity about a marital partner. Evidence may be as highly conspicuous as the love scars Trukese inflict upon one another (Gladwin and Sarason), or as subtle as a change in eating habits, as among the Tapirape (Wagley). Tapirape men are known to get ill if they eat soon after an adulterous tryst, so a woman would know if her husband had been adulterous if he should eat sparingly on mornings. A recognizable footprint or buttock-print left in the forest surrounding a Mehinaku village can spell trouble for an adulterous couple (Gregor). Suspicious Dobuan men will time their wives when they leave the compound to urinate or defecate. Extremely suspicious husbands will insist on accompanying their wives to the bush just to make certain (Fortune). Tapirape husbands carefully watch the fathers of newborn infants, for these men are liable to consort with other men’s wives, owing to the postpartum sexual prohibition which denies them access to their own (Wagley).

*135/187/5*

Both morning erections and nocturnal emissions occur less frequently with age. Kinsey reported the median frequencies of morning erections at two per week in the thirties, one per week by age sixty-five and two per month in the late sixties. In a Sexology study reported by Rubin, 57% of a sample of sixty-five to sixty-nine-year-old males who were being treated for impotence claimed to have some morning erections. Rubin used these data to suggest that in many of these men the etiology of impotence was psychological. Kinsey reported that 71% of single males in their early twenties had nocturnal emissions. For both married and single men, emissions declined in frequency after age thirty. By fifty, about 30% of males interviewed had emissions but less frequently than in earlier years. Maximum frequencies per week recorded by Kinsey were twelve in the teens, three in the thirties, and less than one (.5) in the fifties. Only 14% of the men over sixty were still having any nocturnal emissions.

Scrotal elevation which occurs for younger males in the late excitement or early plateau phase of the sexual response cycle is attenuated for men over fifty-five. Full scrotal elevation prior to ejaculation is not always observed, and testicular descent following ejaculation may be extremely rapid. Past age fifty-five, the testicles often do not show the usual 50% increase in size due to vasocongestion. Penile detumescence during the resolution phase often occurs extremely rapidly following ejaculation rather than in the two stages typical of younger men (Masters and Johnson).

Erectile impotence is quite rare in males under age thirty-five. In Kinsey’s sample less than .005% under twenty-five and 1% under thirty-five suffered from erectile failure. For these young men, the condition frequently was transitory. However, Kinsey observed an increasing proportion of erectilly impotent males at ages above fifty. These proportions at fifty, seventy, and seventy-five years were 8%, 27%, and 55%, respectively. The degree to which generally poor health and other physical factors contribute to the rising proportions of impotence is unknown.

A number of behavioral changes in sexual activity (increased latency to ejaculate, increased reaction time for penile erection, decreases in precoital mucus) suggest that aging males lose sensitivity to stimulation or that their thresholds for erotic stimulation increase with age. Alterations in collagen and elastic tissues of the skin may contribute to increases in the threshold of cutaneous sensitivity (Magladery). The loss of accessory structures’ ability to maintain recurring penile contractions probably contributes to a diminished sense of satisfaction at ejaculation. Kinsey’s erotic responsiveness ratings by age showed that with advancing years responsiveness (or sensitivity) decreased. The average indexed responsiveness figure for males thirty to thirty-five was about fourteen; this figure fell to six by the mid-fifties, to four by the late sixties, and went to zero for persons over seventy.

*99/187/5*

You may have already suffered some deformity from brittle or porous bones, have lost some height and be stooped. Unfortunately, there is no way to repair crushed vertebrae, expand a spine already compressed, or straighten a ‘dowager’s hump’ (although researchers are experimenting at the University of North Carolina, Chapel Hill, with a new ‘artificial bone’ that is a blend of plaster of Paris and fired ceramic particles of hydroxyapatite, the primary calcium compound in bone).

Repairs of hip fractures can be made: broken sections of bone can be pinned or screwed, and severe fractures may dictate that part of the femur (thigh bone) be replaced. Having had an osteoporotic fracture in one part of your body, you are more likely to suffer another fracture in another area, osteoporosis being progressive and capable of inflicting several disabilities.

*57\114\2*

With the frightening statistics now emerging, all women have to ask themselves if they could become victims of osteoporosis. What are your chances of having bone thinning and fracturing? With roughly 1 in 4 women being affected, we are on the verge of an epidemic. The disorder is far more common in women than in men for many reasons. For instance:

Women have smaller bones, with less bone mass at maturity.

They get less exercise, so their muscles are smaller.

They are inclined to go on slimming diets that frequently are

not nutritionally balanced.

•    Extra demands are made on their total calcium level during

pregnancy and breast-feeding – an especially critical situation when teenage girls become pregnant before their bodies have reached their peak mass.

Women are taking up smoking in ever-increasing numbers.

Alcoholism among women is on the increase.

Many women are heavy users of laxatives.

Many women take diuretics to flush water from their

systems.

•    More women are in stressful occupations in difficult jobs or

have conditions at home that cause strain.

•    More women are using antacids to overcome stomach

problems.

•    Hysterectomy, with removal of ovaries, is a common type of

operation for women.

•    After menopause, women no longer have the oestrogen

hormones that have been giving bone protection.

• Women live longer than men, with an extension of life expectancy twenty-five or thirty years after menopause.

How much are you at risk? With many factors involved, it is not easy to predict who will suffer. Some factors you can change, and others such as gender and genes you obviously cannot. While a certain amount of bone loss is normal, some factors play their part in maintaining your bone mass, other factors have a bearing on how quickly you lose it, and it also depends on how long you live.

*9\114\2*

Although increasing your intake of calcium from foods and supplements is generally considered safe for most people in amounts up to 2000mg per day, consult your doctor before making any radical changes in your diet, as you may be one of the few people prone to forming kidney stones. If you have multiple kidney stones, you have a very real need to cut down calcium intake.

The mechanism of stone formation in adults is a complex phenomenon. Scientists are not always sure why kidney stones form, or why one person has them and another does not, but heredity appears to play an important role in the tendency to form stones. A high level of calcium in the urine often leads to kidney stones. While certain foods may promote stone formation in susceptible people, scientists do not think that eating any specific food causes stones to form in healthy people. Evidence suggests that stones can form because of drinking too little fluid, they may be part of other metabolic disturbances, urinary tract infections, the misuse of certain medications, or lack of exercise of a person subject to stones. Stone formation may also be linked to overactivity of the parathyroid glands or excessive consumption of vitamin D and vitamin C.

According to D.H.S.S. estimates in England in 1983, over 4600 people had hospital treatment for kidney stones; more than a million Americans are hospitalized every year with the problem. Stones seem to occur more often in whites than in black people, in three males for every female; they are also more likely in tropical climates.

What is a kidney stone? Stones, or calculi, may consist entirely of one compound, but most are a combination of various salt or mineral crystals, building up gradually on the lining of the kidneys or urinary tract, possibly causing bleeding of the tissues there and often creating much pain as the stone breaks loose and moves down the urinary tract. When stones grow so large that they cannot be passed out of the body easily, they can obstruct urine, causing acute pain and possible kidney infection or damage.

A doctor’s attention is immediately needed to assess the seriousness of the situation. Although in many cases the calculi are passed harmlessly from the body by taking an increased amount of fluids, surgery is often necessary; recent medical advances have increased the possibility that many cases can be cured or controlled with non-surgical techniques such as ultrasonic probes and high-energy shock waves.

*45\114\2*

Regular exercise is essential for maintaining muscle tone and putting stress on bones – necessary not only for halting bone loss but stimulating the formation of new stronger bone tissues.

Astronauts in space flights lost considerable amounts of bone tissue, at a rate of 0.5 per cent per month, after a short time in a weightless state. More recent missions have included exercise to try to prevent bone depletion; unfortunately, this exercise has proved ineffective without the stress and pull of gravity on bone and muscle.

Similar problems occur in hospital patients or those confined to wheelchairs – a condition called disuse osteoporosis. Bones weaken and shrink when not used, in a sedentary lifestyle, just as muscles do; bones respond by becoming stronger and larger when stress is placed on them with exercise. Exercise increases blood flow to bones, bringing in nutrients for new formation. Exercise can change the levels of the body’s hormones that form bones, creating a better environment for new bone formation, increasing oestrogen and decreasing harmful adrenal hormones. When athletes build up muscles, the strenuous training also builds bone mass.

A study has been carried out at the University of North Carolina, Chapel Hill, USA, under the direction of orthopaedist Peter Jacobson: 400 sedentary women aged between thirty-five and sixty-five were compared with 80 women of the same age range who played tennis regularly each week. Of those under fifty-five, there were no special differences in bone structure. But women over fifty-five in the study had much stronger bones among the tennis-playing group. Research suggests that tennis, jogging and other ‘weight-bearing’ exercises may help to strengthen older bones.

Other studies of menopausal women have them square dancing, jazz dancing and performing isometrics to determine the changes in their bone mass. Bone loss may not be inevitable in later years, but proportional to a slowdown in exercise and physical activities.

Although many people think of themselves as being fairly active, very often their hectic lives mean they are mentally and socially active but not physically. Exercise is a Do-It-Yourself venture; no one else can do it for you. Make it a part of your lifestyle for the rest of your life!

At the same time you’ve got to strike the right balance: if you exercise as vigorously as some athletes that you stop menstruating, you can place yourself in danger of having bone loss as a result of lower oestrogen levels. Loss of menstruation, called amenorrhoea, occurs in up to 50 per cent of competitive runners and ballet dancers but affects only 3 to 5 per cent of women in general. If a woman does not menstruate for a year, she should have her bone density checked.

In recent research, Robert Marcus, M.D., of Stanford University School of Medicine, Christopher E. Cann, Ph.D., of University of California, San Francisco, and others, studied bone-mass variations in a group of white long-distance runners (running up to 160 kilometres a week). Of the seventeen women, six had regular menstrual periods and eleven had none. Four of the women without periods had started intense training before the onset of menses. The non-menstruating athletes had 17 per cent lower spine density than the menstruating women. Cortical bone mass was not apparently affected by lack of menstruation, but trabecular bone density was lower. The study supported the idea that intense physical training at an early age may delay menarche, and women would be better not to train to such an extent that they don’t menstruate regularly.

Although athletes may be under pressure from coaches and peers to keep weight down, they still need to consume sufficient calories, calcium and protein, and avoid vitamin overdoses. Most importantly, non-menstruating athletes may need a greater intake of calcium daily, similar to postmenopausal women.

Women should not be frightened off exercise, however, as few have such tough multi-mile running programmes, as in the previously mentioned study, or do other aerobics so strenuously. The effect of regular exercise on bone density is positive, providing calcium intake is maintained; the benefits of exercise still far outweigh the hazards.

*32\114\2*

The Pill is associated with risks of high blood pressure, blood dotting (thrombosis), and cardiovascular disease; but evidence suggests stronger bones for women who have used the Pill for extensive periods of time. The positive effect on bones is related to the amounts of oestrogen and progestogen in the oral contraceptives, with these hormones also probably stimulating the release of calcitonin to inhibit bone reduction. The Pill may maintain or strengthen your bone mass.

But even the new oral contraceptives are not risk-free, and they can interact with other drugs you may be taking, altering their effectiveness – certain antibiotics, epilepsy drugs, antiinflammatory or anti-arthritic drugs and barbiturates, for instance. Your doctor will probably only prescribe them if you -

are under the age of thirty-five,

do not smoke,

have normal or low blood pressure and normal cholesterol

level,

are no more than 30 per cent overweight,

have never had diabetes, liver or gallbladder disease; cancer

of the liver, breast or reproductive tract (uterus, ovaries or cervix); epilepsy, migraine headaches, or exposure to DES (Diethylstilbesterol) before you were born.

Read the ‘patient leaflet’ that usually comes with oral contraceptives. They tend to change your body chemistry and the use your body makes of food nutrients. Consequently you may have a deficiency in vitamin B6, vitamin C and folic acid that you will need to make up with generous servings of orange juice, wholegrain breads and green vegetables daily.

*21\114\2*