A couple in their early forties was referred to sex therapy by a psychiatrist treating the woman. The presenting symptom was occasional impotence on the part of the man; the woman was orgasmic. The woman was a compulsive cleaner, vacuuming the house several times a day. She also suffered from severe constipation. They had two daughters, sixteen and twelve years old. It was the psychiatrist’s opinion that her constipation was the result of poor sexual function, even though she experienced orgasm every time she and her husband had intercourse.

This couple practiced the very common “Sunday morning sex” ritual, common because that is when couples with children usually have the time for sex, or when excuses for not having sex no longer hold. It was an ordeal for them both, a duty repeated weekly. Even when he was potent the husband found the entire experience unsatisfying; his wife was even more inhibited than he. Neither disrobed in front of the other, nudity was strictly under the cover. Intercourse was quick—and they both felt that sex was supposed to be better than it was for them.

Both partners were virgins when they married, and neither had had any other partner. The woman never initiated the Sunday ritual, a fact that also irritated the husband.

It was clear that this couple was eager to improve their sexual functioning but was in a state of high anxiety. Rather than prescribing even the mild relaxation exercises, it was suggested that they begin by sleeping in the nude (a form of desensitization) together. At the same time, the therapy sessions began to explore the wife’s inhibitions and the husband’s anxieties, using various extrasexual modalities.

Initially, it appeared that the husband was indeed justified in his irritation with his wife’s inhibitions, since she refused to undress in front of him. However, as time went on she was able to remove her outer garments in his presence, to complete disrobing in bed, and finally to undress completely while he watched. At that time the relaxation exercises were prescribed, and the husband’s inhibitions appeared in full force.

Extrasexual exploration revealed that he had been hiding behind the Sunday ritual as a protection against his own anxieties about his performance in spontaneous intercourse. Further, while complaining about his wife’s failure to initiate sex, he in fact had been discouraging her every time she did initiate, claiming that he needed extra sleep, was tired, and so on.

As the therapy and the relaxation exercises (of the non-demand type) proceeded, the couple gradually grew more at ease with their own needs and desires and bodies. Finally, intercourse was prescribed—for any day except Sunday. The husband was potent; both found the experience the best they could remember. Their sexual functioning continued to improve, the wife’s constipation improved, and her compulsive cleaning was markedly reduced.

Many inhibitions and problems remained, however, so the couple elected to continue therapy. Soon they brought up the subject of their daughter. Almost seventeen years old, she had been seeing a boy for a year, and while they suspected that the daughter and her boy friend were having intercourse together, they were not sure. By now they had only two concerns about her: that she use a birth control device and that she have a positive experience; the last thing they wanted, both husband and wife declared, was for their daughter to be as “hung-up” about sex as they were, and for so long a time. They recommended to the daughter that she contact the therapist, which she did.

It turned out that the parents were correct: the daughter was having intercourse with her boyfriend, was not practicing birth control, and was not enjoying sex at all. She was also very fearful of sharing this information with her parents. And she volunteered that most of her friends were in exactly the same predicament.

After several counseling sessions (no real therapy was required), the girl, without telling her parents that she was sexually active, did notify them that she was going to be fitted for a diaphragm and that she wanted to visit the physician by herself. This opened the way to a whole new level of communication between the parents and the girl, who still, however, did not reveal her sexual activity. But the family grew much closer as a family, and the twelve-year-old daughter began to wonder when she could go into therapy—she had no apparent problems. In her last session with the therapist, the girl reported that she was using the diaphragm, that sex was becoming very enjoyable, and that many of her friends were trying to find the courage to do the same.

A few months later the girl left town to go to college and from the safety of that distance, phoned her parents and mentioned that she had been having sex. She was astonished at their concern for her own welfare and pleasure, and the family has never been closer in an emotional sense. In addition, she altered her original intention of studying education, because “teaching is easy for women to do,” to taking pre-law courses, because she had always wanted to be a lawyer but never felt capable until recently. The mother, meantime, was preparing for the absence of both her children by resuming a career in real estate and insurance that she had abandoned eighteen years earlier. The entire household was more relaxed, and the parents report that the younger daughter’s friends, who formerly resented the restrictions against messiness, now love to come over.

It should be clear that the holistic therapist can begin as a sex, dyadic, family, or individual therapist. Initial theoretical orientation is not crucial. But any expansion of the scope of practice requires new skills, and it is expected that the therapist entering a new field will obtain them. This granted, the advantages of combining individual, dyadic, sexual, and family therapy in a single therapist are clear and will surely be realized more and more in the future.

*256/187/5*

Thus, if we look at fetishism for a moment, the fetishist tends to cathect libidinally an inanimate object that has come to symbolize a part of the body of an ambivalently loved person. Fetishism is consequently a mental state that leads the person to worship or love such a material object which he takes as possessing a magical power or as having a special neurotic interest. This is the fixation of neurotic investment on an object or body part that is inappropriate to normal sexual purposes but is required by the person for the attainment of sexual gratification. Parts of the body such as hair, hands or feet, or even a shoe or handkerchief or other object of personal apparel can serve such purposes. The fetish itself usually is taken to symbolize the female phallus, and its use represents the denial of the danger of castration that might be suggested by the anatomical differences between the sexes. The mind of the fetishist therefore is split; part of his mind is able to assess and accept the absence of the penis in the female, but another part unconsciously adheres to and insists on the idea that the female does, in fact, possess a phallus. Fetishism can be viewed as one deviant resolution of the problem of castration anxiety.

Similarly, the transvestite finds pleasure in dressing in the garments of the opposite sex. For the male this may represent an identification with the phallic mother, and for the female it may serve her wish to deny the lack of a penis. Similarly, the often compulsive exposure of sex organs in exhibitionism may be a defense against castration anxiety because of the shock or fright in the female object at the sight of a penis. Conversely, voyeurism may serve similar defense needs. Sadomasochism early in Freud’s thinking was regarded as a partial instinct representing a tendency to seek or inflict physical or mental suffering as a way of achieving sexual arousal or gratification. In masochistic perversion, sexual gratification, even orgasm, is felt as a result of inflicted pain by such practices as beatings, threats, humiliations, or subjugations at the hand of a sexual partner. Similarly, sadistic gratification is derived from inflicting such torment on the sexual partner.

The organization of the perversions may come about either through arrested or fixated development or through a regression from more developed forms of sexual expression. The perversions that come from regression are not typical and tend to substitute aspects of sexual forepleasure for the mature sexual act. Such individuals generally tend to have a more infantile caste to their personality organization in general. The major part of the sexual energies of individuals with perversions is concentrated on one particular partial instinct, so that the dominant role of this partial instinct competes with the individual’s genital primacy. These individuals are capable of orgastic release, but the orgasm is usually stimulated by the perverse act rather than by normal heterosexual outlet. The capacity for genital orgasm is inhibited by an obstacle that is overcome or circumvented in the perverse act. Such perverse behavior and sexual expression does not lack organization as is often seen in the sexuality of “polymorphous perverse” children or regressed infantile personalities; rather, it is organized under the primacy of a component instinct whose gratification makes genital orgasm possible in a way that could not otherwise be achieved.

A critical question, then, is what factors inhibit the normal developmental progression to genital primacy. The psychoanalytic answer leans heavily toward the genesis of anxiety and guilt feelings related to the child’s oedipal involvement with his parents. The beginnings of genital primacy are established in the phallic phase (in about the third year when genital drives begin to emerge and the differences between the sexes, especially genital differences, become significant) in which the oedipal complex arises. The oedipal complex or situation refers to the complex emotional involvement in relation to both parents as a result of normal sexual development. In his earlier pre-oedipal years, the child is involved with each parent, mother and father, in separate and different ways. By the third year, he attained a new and more complex level of involvement with the parents. The child must relate to them together as a pair, no longer separately and singly in one-to-one interactions, but now as a member of a triad in which the child is the third, the smallest and most dependent member. This step is important because it is the child’s first experience of social interaction, and it sets a decisive pattern for later interactions. This particularly pertains to the experience of himself as a sexual being.

*220/187/5*

Davis and Braucht found that the amount of exposure to pornography correlated negatively with the overall index of character for subjects first exposed to pornography after the age of seventeen years. The amount of exposure was positively correlated with sexual deviance and with early heterosexual experience, homosexual, and deviant sexual practices. Exposure was also correlated with social—peer, neighborhood, and family—deviance. This latter finding suggests that exposure to pornography may not be a causal variable but rather an extraneous one which tags along with the deviant peer/deviant behavior relationship. When deviant family and deviant peer circumstances are statistically eliminated from the correlation, the relationship between age of viewing and character is not different from zero at the ninety-five-percent level of confidence. Similarly, when one calculates the partial correlation between exposure to pornography and sexual deviance, eliminating the effect of peer pressures, the result is not different from zero.

Their own analysis, plus that of the reader, suggests that Davis and Braucht have found exposure to pornography to be an extraneous variable in the relationship between individual sexual deviance and social environment. As Davis and Braucht acknowledged, there is “the possibility that exposure (to pornography) is merely part of or a product of adopting a sexually deviant life style”.

Goldstein reported a retrospective study in which samples of rapists, pedophiles, homosexuals, transsexuals, heavy users of pornography, and a control group sample from the community at large were interviewed regarding their experiences with erotic material. The striking finding consistent across types of exposure (photos, movies, books) and samples was that:

Adolescent exposure to erotica was significantly less for all non-heterosexual and offender groups compared to the controls. During adulthood, the sex offenders and transsexuals continued to report less exposure to erotic stimuli than controls, [emphasis added] . . . The control groups sampled had significantly greater exposure to erotic materials during adolescence than the deviants, convicted sex offenders, or heavy . . . users of pornography.

These data are in rather sharp distinction to those of Davis and Braucht, since they suggest that sexual deviance significant enough to result in criminal conviction or psychiatric treatment is associated with a low degree of exposure to erotica. Moreover, the relatively high levels of exposure in the community at large were not related to significant sexual deviance.

Both male- and female-object pedophiles reported less exposure to erotica than controls did. When one considers the sharp drop in attacks against children, related to the easy availability of pornography as reported by Kutchinsky, one wonders whether pornography might have a therapeutic and/or prophylactic effect if used for the treatment of American sex offenders.

Rapists and pedophiles reported very little or no discussion of sex in their homes during childhood. Both groups held very conservative, uptight attitudes toward sex and were uncomfortable talking about it. Pedophiles had very low levels of adult sexual experience, but rapists reported high frequencies of intercourse. Both groups reported very little satisfaction with sex. Although Goldstein reports other significant differences between rapists and pedophiles and between male-versus female-object pedophiles, the repressive and inhibited character of sexual emotions is common to both groups and is consistent with low exposure to and low interest in pornography.

Homosexuals and heavy users of pornography in the sample were reported by Goldstein to have liberal and tolerant sexual attitudes, low levels of adolescent sexual activity and high levels of adult activity. The author suggests that for the “user” group, interest in pornography may be a symbolic way to make up for lost time or an augmentation of infantile fantasy life which has persisted into adulthood. Other studies have found relationships among data for both groups which are somewhat supportive of both these hypotheses.

Laboratory studies of the effects of erotica on behavior are more limited in the ranges of behavior monitored but more exact in the manipulation and measurement of dependent and independent variables.

*182/187/5*

Power thus became the symbol of masculinity, and prophets and poets praised the virtues of being a male. The Latin word virtus (virtue) is derived from vir meaning man. The Hebrew gibbor (hero) and g’vurah (courage) are derivatives of gever (male). In practically all languages homo (human being) is synonymous with an adult male. Wisdom, courage, leadership, and responsibility have been ascribed to men, despite the obvious fact that such a generalization flies in the face of evidence. Rationalization (distortion of reality in defense of self-esteem) is probably older than rational thinking, and cowardly, sheepish, submissive, and stupid men by far outnumber the brave, leading, self-assured, and wise men.

The innumerable cases of heroic women have been understated, partly silenced and often totally denied by male-dominated historiography. The very same virtues praised in men were discouraged and ridiculed in women: brave, aggressive, and wise women were branded as being pushy, arrogant, competitive, and therefore unfeminine. Cowardly men have been ridiculed as being “feminine,” and brave women have been ostrasized for being “masculine.” The owners of slaves have always preferred submissive, subservient, and dull slaves (Wolman).

*146/187/5*

In frequency of sexual contact, younger respondents (under age twenty-six) and older respondents (over age forty-five) were more similar to one another than to those in intermediate age groups. The proportions of respondents who reported a high frequency of homosexual sex were 46%, 59%, 55%, and 41% for the age groups under twenty-six, twenty-six to thirty-five, thirty-six to forty-five, and over forty-five, respectively.

Weinberg’s and Williams’s study did not support the common view that, because the homosexual subculture values youth, older male homosexuals generally are poorly adjusted psychologically. On a number of psychological measures, older homosexuals compared with younger ones showed no differences in self-acceptance, degree of anxiety, depression, or loneliness. In fact, older respondents tended to have better self-concepts and were more stable. Weinberg) has suggested that the belief may have been perpetuated in part by “falsely attributing to the older homosexual the perspectives and expectations of the persons who hold these beliefs.” Younger people observing the sociosexual situations of the elderly view it from a perspective of their own needs and desires, and fail to realize that expectations change with age. Weinberg goes on to say that “the relatively good adjustment of our older subjects is not peculiar to the homosexual but is probably associated with characteristics of the aging process in general.”

Research reported by Francher and Henkin indicates that the “role change” experienced by male homosexuals is qualitatively different from that experienced by most heterosexual males. Generally relatively early in life, homosexuals go through a crisis which heterosexuals do not—the recognition and management of a socially unconventional and largely unaccepted sexual orientation and lifestyle. Once this has been faced, usually in early or mid-life, the response to a later life crisis— aging—differs. Absence of family responsibilities characterizes the homosexual lifestyle at every age; changes in family involvement (often representing a role crisis for heterosexual) do not occur. Further, these authors suggest that homosexual narcissism may help in coping with the role changes and declining sexuality associated with aging. There is a hint that some characteristics of the homosexual subculture may provide support for aging later on in life.

Saghir and Robins in an in-depth study of eighty-nine male and fifty-seven female homosexuals found that 28% of males were anxious about growing old. Thirty-eight percent said that when they grew old they would probably pay for sex, but over 25% were hoping for a stable homosexual relationship or several prolonged relationships. Only 12% of the female homosexuals expressed strong fears of growing old alone. More women (40%) than men (28%) hoped for a stable relationship in old age. A large percentage of both men and women in this sample indicated that they would participate more and more in nonsexual activities and relationships as they grew older.

These data suggest that homosexuals experience the same general age-related changes in behavior as heterosexuals do. In the homosexual samples reported, females were less sexually active than males, not in frequency of behavior but in incidence, and seemed to be more interested in long-term relationships. Interestingly, female homosexuals were less anxious than males were about growing old. This may reflect a juxtaposition of heterosexual male and female concerns about changes with age and may reflect basic male/female differences in perceiving the importance of human attributes in interacting with a social-sexual partner.

Homosexuals are as aware as heterosexuals are of changes occurring with aging. For the homosexual and particularly for the homosexual male these changes may require an altered life style. But the heterosexual also must change life style. There are different kinds of changes, but there is no evidence that the ability to adjust to them varies dramatically because of sexual orientation.

*109/187/5*

A woman who has gone without intercourse for a while may find sex a little uncomfortable at first, because her vagina may have tightened. But taking intercourse very slowly can really help. Enough lubrication is a must, and a water-soluble lubricant can be helpful. If pain persists, a woman should see her gynecologist.

Part of the adjustment process is becoming so comfortable that you forget about the implant. Just because you are always able to get an erection doesn’t mean you will always want to have intercourse. In fact, for some men, body image is a major factor in their satisfaction with the implant. For example, Gilbert recovered from the surgery, but later developed health problems which prevented him from having intercourse. However, “just the look and size of the penis helps our morale,” he says, referring to the satisfaction he and his wife feel. “We think this is an important point even though we are not using it for actual intercourse.” This elderly man also reports that his wife makes him feel good. “She praises the way look. She enjoys touching and holding me.”

What is important is that you feel comfortable and secure using the implant, and feel that it is a part of your body. If you and your partner have trouble adjusting, ask your physician to recommend a sex therapist, preferably one who is experienced in dealing with implant patients and their partners.

*165\184\8*

Some experts consider the laboratory NPT the best test to measure a man’s physical ability to get an erection, because if you don’t get good erections at night and you’re sleeping normally, chances are that you have a physical problem.

A laboratory NPT means you’ll probably spend two or three consecutive nights sleeping in the lab. Your only companions will be the machinery you’re hooked up to and the technician. Your wife or lover stays home. Sleep erections are a product of dreams, not the result of lying next to a woman.

Before you go to bed, you’ll be hooked up to electrodes that tell the researchers when, and if, you go into the rapid eye movement (REM) stage of sleep. It’s during the REM stage that erections occur. Tubes that look a little like rubber bands are placed around your penis to measure the erections. If you do have an erection in the night, the technician will measure its rigidity. Although it can feel strange to be hooked up to all this gear, you’ll feel no pain.

Not everyone needs to sleep in the lab for several nights. But often patients have trouble going to sleep in such unfamiliar and unusual circumstances, so more nights are necessary to get an accurate reading. If you have a good sleep and normal erections the first test night, you probably won’t need to repeat the experience.

The NPT test is very reliable, but it is not 100 percent foolproof. Even in a well-equipped sleep laboratory operated by trained personnel, the NPT test can give misleading results on occasion. For example, a man with the pelvic steal syndrome or damaged nerves may register normal on the NPT test but still have a physical cause for his potency problem.

And it’s important to recognize that when doctors use the NPT test, they’re assuming that a sleeping man isn’t affected by psychological factors. Well, that’ s generally true, but not always. Researchers at Columbia University studied two severely depressed men who had abnormal NPTs. After they were successfully treated for their depression, the NPTs were normal— and both men were able to have intercourse with their partners. This finding isn’t surprising, since depression can cause sleep disturbances, which can affect sleep erections.

*127\184\8*

1. Changing the medication to one that has the same capabilities but is less likely to trigger ED.

2. Lowering the dosage of the medication and observing whether the health condition is still controlled and ED either diminishes or disappears.

3. Decreasing the medication’s dosage and adding another low-dose drug to help control the underlying primary medical condition.

4. Taking a drug “holiday,” if suitable to the case.

5. Constantly being alert to newer treatment options.

6. Timing a patient’s sexual activity to the medication’s lowest strength during a twenty-four-hour period.

To illustrate these methods, here are examples of how each one worked for six different patients.

*99\183\8*

How do you know if you have low testosterone? Your body has warning signals: low energy, listlessness, a lack of sex drive and erection problems. But the only sure way to know if testosterone is lacking is to get a blood test. However, because a man’s testosterone level is not constant, but spurts, pooling of several samples to get an accurate measure may be necessary for accurate results.

The effect of hormones on erections is still something of a mystery. Some men with low testosterone experience dramatic improvement when they get extra amounts to bring them up to normal. What’s confusing is that not all men with low testosterone suffer from the effects of it—some are able to get normal erections without difficulty. A man with normal levels of testosterone will not get better erections if he takes unneeded supplements of the hormone, but his desire may increase—and he may endanger his health. The fact that we can’t say absolutely what is normal for any particular man makes the treatment of men with borderline low testosterone somewhat of a judgment call.

*70\184\8*

How much time does all this action take? A teenaged boy may go from no erection to complete erection so fast it appears to be almost instantaneous, while a man in his 60′s may find five to ten minutes is required. Generally, as a man ages, it takes longer for him to get an erection. This is normal, so don’t worry. As we’ve explained, it is not the first sign of impotence. Just use the extra time to enjoy your partner.

A man cannot will an erection to happen, although he can “set the stage” by being receptive to the sensations he is feeling. But a man can prevent an erection from happening by being too concerned about making love. In the same way that a man can give himself indigestion by worrying about business problems while eating a sumptuous meal, a man who’s worried (perhaps about his ability to satisfy his partner), upset, distracted or otherwise “not in the mood” may find his body uncooperative if he tries to have intercourse. Instead of allowing his body to respond naturally to the pleasurable sensations of lovemaking, he is trying to force an erection. Such efforts will often fail.

This does not mean the man will develop a persistent problem with erections. His body may just be reacting normally to stress, fatigue or other distractions. Sex should not be, and often cannot be, just another task or chore to perform. Sex isn’t a duty or an obligation. For men as well as women, it’s okay to say no. (Erection difficulties caused by trying to force an erection are unfortunately all too common.. But they are also, thankfully, preventable much of the time.)

*33\184\8*