A couple in their mid-twenties, both teachers, was referred to sex therapy as a last resort. Their referring therapist was seeing them individually and as a dyad, and yet could not help them break through the hostility and coldness they felt for each other. They were planning to divorce, but on the urging of their therapist they decided to try sex therapy.

The woman was orgasmic, the man impotent—but had not been before their marriage. At the initial evaluation session, their anger toward each other was expressed not only in words and intonations but also in posture; they never touched and sat half-turned away from each other. The distrust, indignation, and defensiveness were almost palpable.

With some trepidation, the therapist began with simple “pleasuring” exercises. Although everything else had failed these succeeded: within three sessions the man had an erection, he achieved full penetration, with thrusting, after nine sessions. At the twelfth and final session the couple sat together, holding hands and crying as they related how they had regained their original loving feelings. A later check with their referring therapist indicated that their remaining problems had been solved quickly, and the relationship was now secure and functioning well.

The third effect devolves from the first two, and that is the effect of sex therapy on the family.* With a change in the self-concept and ego-functioning of at least one of the parents, and with a further change in the behavior and attitudes of the parents toward each other and the children, it is hard indeed to imagine that changes will not occur in the children themselves. When the children are living with the dyad under treatment, these changes almost inevitably occur.

The problem for one couple was premature ejaculation of the husband. The initial interview revealed that the entire sexual relationship was hampered by their ten-year-old son. An angry and difficult child, the boy would burst into their bedroom at unexpected times; the resulting apprehension did nothing to help the already troubled sex life of the parents.

When the first sexual exercises were prescribed, the parents declared their fear that their son might interrupt them. They were advised simply to lock the door on those occasions and allow their son to lock his when he wanted privacy. After some reassurance that this would not harm their son psychologically, they agreed.

On first encountering the locked door the boy became very angry and kicked it. Subsequently he would stand outside and shout, “What are you guys doing in there—screwing?” But the couple persisted in keeping the door locked and in doing the exercises. In about ten weeks, the dysfunction was cured.

The experience of joining together to defend their own interests (locking the door) and to enhance their own satisfaction (improving their sexual functioning) pulled the couple closer together and eased communication with each other. The father was able to transfer this ease to dealing with his son, and for the first time they began to have long talks with each other. The boy was finally able to reconcile himself to the loss of his Oedipal fantasies. He became less angry and is no longer a serious problem. The couple returned to the referring family therapist with renewed enthusiasm.

Accompanying the removal of symptoms, then, are behavioral and attitudinal changes so profound and so pervasive as to justify a place for sex therapy (when appropriate, of course) in the holistic approach to patients. First, it is useful to explore the reasons for the strength and dependability of the ripple effect. But it must be emphasized that these effects do not occur in isolated cases but in almost all cases; they are not erratic but predictable, arising from the centrality of sex in human functioning.

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In the pregenital periods, the child’s relationships have been based primarily on one-to-one relationships with each of the parents, separately and individually. In these separate relationships, the child has had the opportunity to develop important aspects of interpersonal relationships, particularly elements of trust, dependency, autonomy, and initiative. His relationships to parental objects move to a new level of complexity in the oedipal situation, insofar as involvement with the parents is no longer one-to-one and separate, but now involves both of them simultaneously in a triadic relationship.

The move from a level of dyadic to a level of triadic involvement gives rise to other significant factors. It involves an increased capacity for differentiation between the internal and external reality, an increased capacity to tolerate the anxiety and uncertainty of oedipal involvement, and an increased capacity for tolerating ambivalence and a new level of complexity of social interaction. The oedipal situation and the Oedipus complex represent the climax of infantile sexual development. The transition from a level of oral erotic development through anal erotic modifications to a phase of genitality and the associated changes in the development of object relations, from simple one-to-one dependency to a more complex triadic oedipal involvement, culminate in the oedipal strivings. The working through of these strivings and their associated conflicts can be replaced later in adolescence by a more mature and adult sexuality. The working through of these conflicts is thus an important prerequisite for further normal sexual development. By the same token, psychoneuroses reflect a continuing and unresolved unconscious fixation in the phallic phase and an unconscious clinging to oedipal attachments.

The Oedipus complex emerges during the phallic period, but there is some discrepancy between the sexes in the pattern of its development. In Freud’s view, this discrepancy was the result of genital differences, although contemporary views would see the matter in terms of considerably more complex interactions with social and cultural parameters. Freud felt that the oedipal situation for boys was resolved by the castration complex, that is, because the little boy had to give up his libidinal attachment to his mother for fear of castration (castration anxiety). The situation for the little girl was somewhat different as Freud felt that in her case the Oedipus complex was the result of the castration complex. Thus, the little girl differs from the little boy in that she is already castrated. Consequently, she turns to the father, who has a penis, out of a sense of disappointment in her own lack of a penis and her disillusionment with the mother who also lacks this vital organ. Consequently, the little girl is more threatened by a loss of love, particularly from the father, than by actual castration anxiety.

It should be noted that this classical analytic view has been modified considerably by analytic thinkers since Freud’s early formulations, and in the current context represents one of the most vital and dynamic areas of psychoanalytic assessment and reformulation. It seems clear at this point that many of Freud’s conclusions about the implications of the oedipal period can no longer be sustained. Particularly in reference to female development, Freud’s implications regarding penis envy, feminine masochism, and the characteristic defects in feminine character development, like impediments in superego development, cannot be supported by the evolving contexts of evidence (Blum; Schafer). These matters still are disputed and will be for the foreseeable future.

*215/187/5*

1. the average person, applying contemporary community standards would find that the work taken as a whole appealed to the prurient interest, and

2. the object depicted or described in a patently offensive way sexual conduct specifically defined by the applicable state law as written or construed, and

3. that the object taken as a whole lacked serious artistic, literary, political, or scientific value.

The Court’s use of the term “prurient interest” seems to be based on the term used in the Fanny Hill, “Memoirs” decision. In a subsequent decision, prurient interest (from the Latin prurire, to itch) was defined as a sick or morbid interest in nudity, sex, or excreta. It is clearly distinguished from a normal erotic interest.

As currently stated, the first test of obscenity requires that the average person, applying contemporary community standards and considering the work as a whole, find that its predominant appeal is to the prurient interest. This test implies that the standards of what is sick or morbid in a community may change. Moreover, the work as a whole must appeal to the prurient interest. A single paragraph, photograph, or chapter presumably would be insufficient to cause a work to flunk the pruriency test.

What is not clear is to whose prurient interest the work must appeal. The Court seems to assume that within each normal average person there is a prurient maniac waiting to be released by an appropriate stimulus. There are scant data in psychology to support such a hypothesis, although some psychoanalysts might contend that some or most normal persons have a pathological interest in sex.

As a few plain examples of what a state statute could define for regulation under the second part of the standard announced in the Miller opinion, the Court suggested: (a) patently offensive representations or descriptions of ultimate sexual acts, normal or perverted, actual or simulated, (b) Patently offensive representations or descriptions of masturbation, excretory functions and lewd exhibitions of the genitals” (Fleishman). The reference to the ultimate sexual act is perhaps a bit confusing, and Mr. Justice Burger did not enlighten the plaintiffs regarding his definition of ultimate. It may generally be assumed, however, that he meant some sort of sexual intercourse. This essay will deal with the material that may be subsumed under the examples given in this paragraph.

The court’s definition of obscenity omits any relationship between exposure to an obscene work or object and behavior. The definition is solely for attitudes and opinions (prurient interest ), taste (patent offensiveness), and values (literary, artistic). For scientists concerned with the behavioral effects of social stimuli, this exclusive focus on the cognitive and value aspects of obscenity might seem peculiar. For the empirically testable question of a connection between obscenity and antisocial behavior, the Court, in the case of Paris Adult Theatre I v. Slat on, stated:

It is not for us to resolve empirical uncertainties underlying state legislation. . . . We do not demand of legislatures “scientifically certain criteria of legislation.” . . . Although there is no conclusive proof of a connection between antisocial behavior and obscene material, the . . . [state legislature] could reasonably determine that such a connection does or might exist. . . . Nothing in the Constitution prohibits a State from reaching such a conclusion and acting on it simply because there is no conclusive evidence or empirical data (Fleishman).

*177/187/5*

Levy concludes that the m?h? as a sexual partner is simply a “substitute woman” and “it is not a threat to the definition of a man’s masculinity if he utilizes the substitution”. Tahitian men will dance with men when there are no female partners, even getting unthreatening erections when they rub against one another. “We would laugh because our penises became stiff,” Levy is told.

Levy’s claim that Tahitians subscribe to a “doctrine of sexual equality” can certainly be substantiated, but other important conclusions emanate from this work as well. The Tahitian self is not contingent on sexual dimorphisms—that is, on the presence of distinct “species” of persons, one male and one female—when compared with the importance of gender in the construction of the American self. Because of this, homophobic reactions are reduced to almost nothing, and homoeroticism is non-threatening to the sense of self. The self is defined to be primarily erotic, with a healthy attraction to persons of the opposite sex but without the strong opposition to homosexual eroticism that Americans have.

Both American and Tahitian identities are largely sexual. However, American culture is motivated largely by an erotic field charged with an inherent and natural dimorphism, domination, and complementarity between two very different sexes. Tahitian culture may be thought to be eroticized by those elements believed to be shared by both sexes, though exclusive to neither. Both the American and Tahitian identities are responsive to the erotic elements in their cultures, but the former has an additional, countervailing, homoerotic force contributing to the shape of the self which is lacking in the latter.

There may be some confusion over Levy’s comment that homosexuality is the covert part of the m?h? role, which sounds as though there were some social force preventing its expression at a more public level. Although some Tahitians do indeed disapprove of the m?h? role, it does not follow that the sexual element of the role is covert because of community disapproval. Rather, it is important to realize that sexuality is the covert part of every role Tahitians engage in, with the possible exception of prostitution. Allowing that the m?h? has undergone a role reversal, there is no reason to postulate an additional inversion of the overt/covert which apparently has nothing to do with the dynamic.

The asymmetry of the m?h?-male relationship looms as something of a paradox, given the “doctrine of sexual equality” between the sexes. I think the passivity of the male engaged with a m?h? is a function of his utilitarian relationship to the individual. The goal for the non- m?h? is to achieve immediate sexual gratification, not to establish a relationship with the m?h?, who provides a service, rather than a person. For the m?h? the interaction has a different meaning, manifested primarily in performing fellatio. The m?h? is the performer; the non-m?h? is the erotically-stimulated audience. From this perspective the non- m?h?s passivity can be understood as a distancing mechanism, not from homosexuality but from “active” participation in an activity. Furthermore, it is possible that the passivity of the non- m?h? role is attractive to some non- m?h? males who are unable to interact with women with the same detachment.

An additional definition of homosexual activity comes from American prisons, in which Spradley finds even homosexual relationships are defined in the idiom of hustling—a man “peddles his ass” to someone in jail in order to receive food and cigarettes. Here the peddler is not a homosexual though his activity is. The peddler acts not for erotic experience in itself, but as a means to an end.

*140/187/5*

The Duke University data confirm Kinsey’s findings of lower sexual-activity levels in females than in males at every age and suggest that declines in female sexual activity occur somewhat earlier than those among males. Because female sexual capacity shows less age-related change, non-physiological variables must be examined to explain these differences in activity.

In a cross-sectional study of over 500 middle aged males and females* from forty-five to sixty-nine, Pfeiffer reported that the percentage of women at each age level who reported “no current intercourse” was considerably greater than the percentage of men. Fourteen percent of the women under fifty but no men of this age group said that they were currently not engaging in intercourse. In the late fifties and sixties, the proportions of men who were totally inactive were 7% and 24%, respectively; these figures for females of the same age groups were 42% and 73%. Sixty-two percent of the males and 39% of the females under fifty reported having intercourse once a week; in the late sixties, these figures were 26% and 11%. Very active subjects (those who engaged in intercourse more than three times a week) were rare in the middle-aged sample (under fifty) and nonexistent in the groups over fifty years of age.

An analysis of longitudinal data indicated a marked sex by marital status interaction, although there were no consistent age-related changes in the incidence of sexual activity among males. The sexual activity criterion did not include amount of activity but merely incidence—presence of absence of any activity at the time of interview. Subjects were interviewed at three different times; the average ages at the times of Studies I, II, and III were sixty-nine, seventy-three, and seventy-six (Verwoerdt). There were gradual declines in the proportions of active married men with increasing age. The proportions of active unmarried men were inconsistent over time. At the time of Study I, a higher proportion of married (57%) than unmarried males (35%) were sexually active. By the time of Study II, the incidences were 53% for married and 80% for unmarried men, and by Study III, 36% of the married men and 55% of the unmarried men were active. There was very little systematic change with age among females as a function of marital status. At the time of all studies, married women (42%) always were more active than unmarried women (5%). The proportions of active females stayed about the same across the three studies, although the active proportions of unmarried females increased slightly. By the time of Study III, there was a higher percentage of active married females than of active married males.

Verwoerdt also looked at the degree of sexual activity in this sample. A cross-sectional analysis indicated that the degree of activity (as indexed by a frequency of intercourse rating scale) decreased significantly with age. The average frequency of intercourse at the time of the first observation was no more than once a month. By the third observation six years later, the average frequency had dropped almost 50%.

*104/187/5*

It is virtually impossible to tell whether or not a man has an inflatable implant when he is not erect. That’s why men who often are naked around others prefer this type of device. The prosthesis has three basic components: the two cylinders which occupy the corpora cavernosa; a reservoir of fluid which is placed under the muscles in the lower abdomen just in front of the bladder; and a pump which is placed in the scrotum. The cylinders are fundamentally different from the semirigid variety, because they are simply shells (made of silicone or a type of plastic) into which fluid can be pumped. Think of an inner tube totally deflated and then pumped up, and you get the picture. When a man squeezes the pump located in the scrotum, fluid is transferred from the reservoir into the cylinders, traveling along small tubes that connect all the components. How many times a man has to pump to achieve an erection varies a little, but usually 10 or 20 pumps does the job.

When he wants to deflate the erection, he simply depresses a release valve under the skin and holds it down. The result: The fluid goes back into the reservoir, and the man has a flaccid penis. The release valve can be felt, but it is invisible to the eye, because like all other parts of the system, it is located under the skin.

*160\184\8*

Black tea isn’t the only variety to offer health benefits; green tea also has health properties. In a study of 1,300 men over the age of forty published in 1996 in the British Medical Journal, it was found that those who drank significant amounts of green tea—in this case ten cups a day—tended to have lowered LDL cholesterol levels. When compared to non-tea drinkers, these men also had an increased proportion of HDL cholesterol.

Give your body a health boost. Two cups a day of black or green tea will keep your arteries clearer, your blood flowing better, and your erectile capabilities enhanced.

*125\183\8*

Most antacids, such as Alka-Seltzer and Turns, contain a buffer that helps to quell stomach acid. They offer relief and don’t affect erection capability. However, the newer antacids, such as Tagamet HB, Pepcid AC, Axid AR, and Zantac 75—each a former prescription ulcer medication—can. They effectively short-circuit histamine signals that are sent out after an offending food is eaten. No stomach acid means no heartburn, gas, or belching. Unfortunately, while they block stomach acid these drugs also effectively hinder the effects of testosterone, leading to a lessening of libido as well as erection difficulties.

*96\183\8*

Without honesty and openness about what is making you uncomfortable or what you desire for more pleasure, you are both going to be stuck. Many times, ingrained embarrassment stemming from social or religious attitudes is the reason for silence. Most often, however, it’s due to a lack of self-awareness about what makes sex personally enjoyable.

A mediator with diplomatic skills would have been a welcome addition to my meeting with Monica and Charles. Married for twenty-two years, this couple, both in their late fifties, were tense and drawn when they strode into my office.

“Let’s get this charade out of the way as fast as we can,” Monica began as soon as she was seated. “He wants to get his erections back— but it has nothing to do with us.”

“Why should it?” Charles snapped back at her. “We’ve been living like brother and sister for the last six years—which predates my sex problems by four. Besides, why do you care? Sex was always a big bore to you anyway—no matter what I did to make it exciting.”

In an attempt to intercede, I asked them why they were still together.

Sighing, Monica presented her side in a singsong voice that sounded as if it had been repeated many times before. “We have two children; our families would be devastated if we split up; being married is good for both of our careers. Isn’t that enough?”

“Not anymore,” Charles interjected. “Now there’s a chance for me to have a full life again. I’m entitled to it—even if you don’t think so.”

Feeling his ED was in part related to his bad marriage, Charles and Monica separated. Charles took the time to discover what he really wanted, in or out of a relationship. When he did, the pills worked for him and his new partner.

This volatile situation contained several sexual problems:

• only one person wanted to make a change

• unequal interest in sex

• mutual dissatisfaction

*68\183\8*

Some testosterone, however, is essential to sexual desire. When there’s just a bare minimum of testosterone in his body, a man’s sexual interest is greatly reduced or disappears completely. Along with this discouraging change comes a decreased volume of ejaculate and persistent low energy. The transformation that can occur when low-testosterone men are treated properly is truly remarkable. Men with low testosterone levels who are listless, sexually uninterested and withdrawn can undergo a major personality change when they receive the correct care.

Take Mark, for example, who lost both testicles to cancer when he was 27. The surgery saved his life but left him without the ability to get or maintain an erection. Because he had no testicles, his body made no testosterone, exceptforthe insignificant amount produced by his adrenal glands. Mark was told to take testosterone pills to offset the loss. But unknown to Mark, the prescribed dosage was too low. He was left with no sexual desire and only token explanations.

For years, Mark accepted his doctor’s assurances that everything possible was being done to help him. Other doctors told him his impotence was psychologically caused, that he had not recovered mentally from the trauma of having his testicles removed. This went on for ten long years, until finally Mark heard about some new treatments for impotence. He made a decision that turned his sex life around: He sought another opinion. After evaluating Mark, the urologist injected him with a much larger dose of testosterone. Three weeks later,

Mark was a new man. He was energetic and enthusiastic, and happily reported that his sex drive was back—and very strong. Mark will always have to give himself testosterone shots on a regular basis. And he’ll have to come in for routine checkups. But thaf s a small price to pay for a normal life after a decade of bad advice and no sexual intercourse.

*27\184\8*