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Masturbation is an inexhaustible subject of increasing public interest. The reason for this is that it is, in one form or another, universal, but because of centuries of religious opposition it came to be regarded as sinful, shameful, harmful, and secret. The removal of the veil of secrecy has led to the altogether healthy increase in interest.

It is widely agreed that almost all men masturbate, but statistics gained from surveys purport to show that masturbation is less common in women. This is because female masturbation is very difficult to define. It is infinitely more variable than in men and all that can be said with reasonable confidence is that it consists of some recurrent psychological and/or physical activity, undertaken consciously or unconsciously, resulting in signs of sexual arousal (signs which in themselves might not be recognised by the woman) and perhaps resulting in an indefinable orgasm. This highlights another area of difficulty. Male sexual arousal is easy to recognise but female arousal is not obvious to an observer except on close inspection. This is probably why boys are said to masturbate more than girls in childhood.

The next problem when considering the subject is to account for the diversity of female masturbation and its relative inefficiency in some women. The answers can be found by considering three related, phenomena. The first is the greater parental suppression of genital activity in girls than boys. Parents of both sexes are more tolerant of genital handling in boys than in girls. Because they are more affection-dependent, girls may also be more willing to try to conform. They may, as a result, find ways of masturbating that do not lead to easy detection. Instead of lying on their backs, opening their legs and touching their vulvas, many routinely adopt other postures such as lying face down, lying on their side, sitting, or even standing. Muscular contractions or rubbing the vulva against an object (including the heel) may be substituted for direct touch methods. If genital stimulation is not abandoned altogether, as it is in some girls, it can occur through clothing, or a whole variety of objects may be used as a substitute for the girl’s hand.

Alternatively masturbation may become attached to ‘legitimate’ pursuits such as washing the vulva or even urination. Although many women claim to be able to masturbate by more than one method, women who carry into adulthood, as most seem to, any of the less obvious methods mentioned above can find themselves unable to reach orgasm except in that position or by that method. As a result they claim they never masturbate.

The second explanation of the diversity of female masturbation lies in the fact that the female body can respond sexually to stimulation in almost any anatomical area. This also happens in pre-adolescent boys. Movements such as rotating the pelvis, rhythmically contracting the vaginal muscles or making thrusting movements with the pelvis can bring on an orgasm in some women. Being rocked about on buses, bicycles, motorcycles and trains, for example, can lead to orgasms in others. Even movements of the vulva against underclothing is reported as being arousing to the point of orgasm by some women.

The third reason is that female orgasms are very variable in intensity. One factor here is the number of throbbing muscular contractions which occur during an orgasm. If there are only a few of these contractions it is experienced as only a mild sensation and if the woman has been taught that sexual pleasure is rude, naughty or sinful, the anxiety associated with the act may stop the contractions entirely. Something similar can happen in anxious men. Similar muscular contractions to those which women enjoy at orgasm eject semen in men and under some circumstances ejaculation can be reduced to a few little dribbles. Since most definitions of masturbation refer to orgasm as the end-point, a woman who when masturbating only can achieve a minor sensation may think of herself as not masturbating at all.

The point here is that the anxiety earlier instilled into her gives her an unconscious incentive to play down her responses so as to avoid too much guilt. Similarly, the women mentioned earlier who use somewhat obscure masturbation methods are using less than the best method (direct stimulation of the genitals) to get an orgasm and as a result are inefficient. Unfortunately, for these women, direct methods would arouse anxiety to a point where it would be impossible to have an orgasm at all.

Men, of course, or some of them, have the same difficulties. Men who have been strictly reared with regard to masturbation (parents sometimes even make them promise never to do it) masturbate the way many other men do yet can block off the consciousness of orgasm and although they ejaculate they still claim not to masturbate. Although older men often rub their erect penis with no intention of reaching orgasm (which according to most definitions would not amount to masturbation, though it clearly is), some guilty young men do so too and later have a nocturnal emission (wet dream). These men also deny that they masturbate.

Guilty women will, in a similar way, confine their masturbation to the twilight state between sleeping and waking (or vice versa) and so deny masturbation on the grounds that it does not occur when they are fully conscious. Some women who deny masturbation do so on the basis that they do not fantasise while doing it. However, they often have a rich fantasy life which simply does not coincide with when they stimulate the vulva.

A substantial minority of women claim never to have masturbated, as do a tiny percentage of men. When the factors outlined are taken into account, however, it can be seen that the denial does not necessarily amount to a deliberate lie. In clinical experience, at least, and regarding those people in whom it is important that the subject of masturbation be clarified, it is true to say that virtually everyone masturbates in some way or another.

The less direct the method used, the more the individual shows that a difficulty exists about sexual expression. It could be argued that the less direct methods have been learned by chance and have then become fixed in preference to more usual methods. Such an argument does not fit in with clinical experience which shows that unusual masturbation methods are almost always associated with a difficulty. This is serious because learning to masturbate bears the same relation to intercourse as does learning to speak to conversation.

As well as being a form of sexual training, masturbation, or rather its associated fantasies, helps to bring images of the bodies of the opposite sex and of intercourse with them to mind, especially in the young. This is a learning process and is a kind of sexual rehearsal for the adolescent. Some males of all ages, but especially younger ones, rely on girlie magazines to get clear images for their fantasies. Learning to masturbate is simply a part of what a growing man has to learn. Girls and women may also be aroused by girlie magazines because they identify with the girls in the pictures but they commonly find the stories more of a turn-on.

Amongst adults today, married men are often found to be more reluctant to talk about their masturbation than are their wives. Less well-educated men are particularly likely to regard it as an abnormal and juvenile habit. However, it has a real place in married life because it allows differing sex drives to be accommodated without looking outside the partnership. This may be the reason why, on average, surveys report that women who masturbate do so more frequently than men. Also, a man can either have intercourse or masturbate, but not both in a short space of time, unlike a woman. In fact, women are perhaps, other things being equal, more likely to want intercourse after masturbation because sex is in their minds. This is useful clinically in women who have lost their sex drive. Encouraging them to masturbate can rejuvenate their sex lives.

Clinical experience with large numbers of couples who are happily married and enjoy sex with each other shows that on average the wives masturbate about as often as they have intercourse, whereas only every fourth orgasm in the husband is produced by self-masturbation. One value of masturbation in marriage may be that material from the accompanying fantasy may then be available for incorporation into marital sex. Even the fantasy itself may be used during intercourse because many women and particularly older men need to use fantasy to sustain their arousal and have an orgasm. Some people with deviant sexual needs can function satisfactorily in intercourse only by using an appropriate fantasy.

Women say they masturbate to relieve emotional tensions and some boys and men use masturbation to blot out anxieties in the same way that alcoholics and drug-takers do. This is really a misuse of masturbation. Other men find masturbation more gratifying than intercourse – this is a sign of the presence of an inhibiting anxiety. Women, especially young ones, tend to get more satisfaction from masturbation than they do from intercourse and frequently display greater physiological body changes during orgasm induced by masturbation. This may come about because they can stimulate themselves in their favourite way during masturbation whilst fantasising a scene that arouses them. This does not necessarily mean that such women prefer masturbation to intercourse – they like both.

Some men, on the other hand, routinely masturbate and never attempt to have intercourse with a woman. Due to reasons already discussed women make them so anxious that it spoils the pleasure.

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All persons diagnosed with HIV infection should have a skin test and chest X-ray to check for tuberculosis. Those determined to be positive must have treatment to prevent a reactivation of the disease, to which they will be more susceptible once infected with a virus that suppresses the immune system. A test for syphilis (the Venereal Disease Research Laboratory [VDRL] test or rapid plasma reagin [RPR] test) must also be done for the same reason.

Testing for toxoplasmosis should also be carried out after the initial diagnosis. As will be discussed later, people who have toxoplasma antibody have a history of infection, even though they may not remember being infected, since infection is frequently symptom free. This puts them at risk for reactivation of the infection as their medical condition worsens. Immunization against pneumococcal pneumonia, influenza (yearly, in the fall), and hepatitis B for sexually active persons is also recommended.

The health care provider of an infected person will use the CD4 or T-helper-cell count and monitor the person’s physical condition to decide on the best time to start the various medications available to treat HIV infection. Then again, a person may decide that he or she does not ever want to start these medications.

There can be significant variation in an individual’s CD4 count, even on a daily basis. A “normal” CD4 count is greater than 500; however, if a person without HIV infection experiences a serious illness or stress, this number can temporarily drop below 500. Similarly, most HIV-infected people will have CD4 counts greater than 500 during the early part of their infection. This daily variation can sometimes be up to 150 points in HIV-positive individuals, and even more in those who are HIV negative. A CD4 count that is significantly different from the previous count should be rechecked, ideally at the same time of day that the first count was obtained, to determine if the variation is real. This is a situation in which the newer viral load test can be useful.

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Sexual Contact. Hepatitis B can be passed through anal, vaginal, and oral sex, and possibly even through kissing. The risk of infection with hepatitis B increases with the number of sexual partners a person has. The fastest-growing group of infected people is heterosexuals. In one study, 21 percent of heterosexuals with more than five sexual partners in the past four months had hepatitis B, whereas those with fewer than five partners had a lifetime risk of infection of 6 percent. Sexual partners of people who are infected have a high risk of becoming infected themselves. People who know their partners are infected should be immunized. In fact, it could be argued that any sexually active adult should be immunized.

Mother-to-Child Transmission. If a woman is infected during her pregnancy, particularly during the last trimester of pregnancy, or if she is a carrier for hepatitis B infection, she has a high risk of infecting her child. Infection can occur while the child is in the womb, but it most often occurs during delivery, possibly from mixing of maternal and fetal blood. Children who are infected at birth more often than not become carriers themselves. A baby born to a mother who is infected with hepatitis B may show some evidence of infection in the blood at birth, but the baby may not be truly infected, because it may be the mother’s antibody that is being seen in the blood. However, a baby who persists in showing evidence of infection in the blood about four months after delivery can be assumed to be truly infected. Immunizing at-risk babies at delivery offers a good possibility of preventing these babies from becoming infected.

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incidence: very rare

cause: bacteria (Hemophilus ducreyi)

symptoms: genital ulcers, lymph node swelling

treatment: antibiotics

WHAT IS IT?

Chancroid is a sexually transmitted infection of the genital area caused by the bacteria Hemophilus ducreyi. The primary symptom of chancroid is painful genital ulcers. Having any sexually transmitted disease that causes genital ulcers makes a person more susceptible to acquiring human immunodeficiency virus (HIV) infection, because breaks in the skin make it easier for HIV to be transmitted.

HOW IS CHANCROID TRANSMITTED? Chancroid is transmitted through genital, oral, or anal sexual contact with an infected person. Chancroid is usually transmitted by a person who has a sore or sores, but the disease can be transmitted by someone who has no sores.

Condom use decreases the risk of transmission but may not eliminate it if a person has sores outside the area that a condom protects.

There is no evidence that the disease can be transmitted from one person to another by nonsexual contact, but an infected person can rarely spread the infection to other areas of his or her body by touching infected genital skin and then touching the other areas.

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We know PSA can signal the presence of cancer. But can PSA be more specific—can it tell a doctor the stage of a man’s tumor? Yes, it can. However, as always, PSA is tricky, and the PSA level alone doesn’t tell the whole story.

As a tumor gets bigger, the PSA level generally goes up. And, as the tumor grows, it tends to be overrun by the more malignant, poorly differentiated cancer cells. These poorly differentiated cancer cells elevate PSA less per gram of tissue than well-differentiated cancer cells. Therefore, the PSA level doesn’t go up in a directly corresponding way.

That’s why PSA can be normal even when cancer has spread to the seminal vesicles or pelvic lymph nodes, or it can be higher than expected in men with cancer that’s confined to the prostate. So, the true meaning of PSA can’t be interpreted without knowing the Gleason score.

Scientists at Johns Hopkins have found a more accurate way to estimate the exact extent of prostate cancer, using a special table that correlates clinical stage, Gleason score, and PSA (see table 3.3).

Even though prostate cancer may appear to be confined to the prostate on examination, surgery may reveal a different story – often, the cancer turns out to be more extensive than it seemed at first. That’s because insidious, microscopic bits of cancer can sneak past the prostate wall, and these can’t always be found with the digital rectal exam, biopsy, transrectal ultrasound or other diagnostic methods.

Because surgery is only indicated for the cancers that truly are localized to the prostate, it would be better for everyone to know before the operation how extensive the cancer is.

So, how to predict which cancers may have spread beyond the prostate wall? Tables 3.3a—3.3d were developed by Johns Hopkins researchers after a study of the course of prostate cancer in 1,186 men who had radical prostatectomy.

The tables are designed to help you and your doctor predict your definitive pathological stage and best course of treatment. For example, if you have stage T2a disease, with a Gleason score of 5 and a PSA less than 4, there is an 81 percent chance that the cancer will be completely confined to your prostate. On the other hand, if your Gleason score is 8 and your PSA is is, the likelihood drops to 29 percent. With this information and an estimation of your overall health and longevity, you and your doctor can decide whether or not it’s reasonable to select curative forms of therapy, or simply to adopt a policy of watchful waiting, in which the tumor is treated only after it produces symptoms.

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Anatomically, the prostate is divided into five zones: anterior, which occupies 30 percent of the space and consists mainly of smooth muscle; peripheral, the largest segment, which contains three-fourths of the glands in the prostate; central, which holds most of the remaining glands; preprostatic tissue, which plays a key role during ejaculation (muscles here prevent semen from flowing back into the bladder); and transition, which surrounds the urethra and is the sole site of benign prostatic hyperplasia (BPH). Most prostate cancer occurs in the peripheral zone. Also, this is the region most likely to be tapped in a needle biopsy of the prostate.

The prostate is not the sole basis for a man’s fertility or potency. Some animals that have had their prostate (or, in fact, their seminal vesicles—but not both) removed remain fertile. But growth of the prostate clearly is linked to sexual development: Starting at puberty, the prostate enlarges five times in size— from a weight of about 4 grams to 20 grams—by about age 20. For the next several decades, prostatitis is the most common form of prostate trouble; then, after about age 50, BPH and prostate cancer take over as the problems to worry about.

Most animals have a prostate. But only humans and dogs are prone to prostate trouble, and nobody knows why. What makes bulls, for instance, immune to prostate cancer? Why don’t cats get BPH? Again, a mystery.

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Women and men who have completed their families, or who know they do not want any children, may want a permanent method of birth control.

Permanent methods may be appropriate for mature women and men who find that:

• their partners agree that their families are complete, and no more children are wanted

• they want to enjoy having sex without causing pregnancy

• they don’t want to have a child in the future

• they and their partners have concerns about the side effects of other methods

• other methods are unacceptable

• the woman’s health would be threatened by a future pregnancy

• they don’t want to pass on a hereditary illness or disability

• they are men who choose vasectomy to spare their partners the surgery and expense of tubal sterilization. (Sterilization for women is more complicated and costly.)

Permanent methods are not appropriate for women or men if:

• they want to have a child in the future

• they are being pressured by their partners, friends, or family

• they have marriage or sexual problems, short-term mental or physical illnesses, or financial worries, or are out of work. Permanent methods are not good solutions for temporary problems

• they have not considered possible changes in their lives such as divorce, remarriage, or the death of their children.

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In our sexually repressive culture, we have little concern for the well-being of women and men who have sex less often than mo people. But we have grave concerns about women and men who have sex more often than most people. Having sex very infrequently, or not at all, is called hypophilia. Having sex more often than most people is called hyperphilia. The desire for women to have sex very frequently with many different partners is called nymphomania. A similar desire in men is called satyriasis or Don Juanism.

Some mental health professionals consider nymphomania and satyriasis sexual compulsions, or sexual addictions, if the search for sex partners:

• results from an obsession that is like being in a trance and involves the development of rituals

to intensify sexual arousal

• interferes with important responsibilities and commitments, such as getting to work, home, or

school, maintaining good health, and forming nonsexual social relationships

• seems utterly hopeless to control

Recovery groups, such as Sexual Compulsives Anonymous, can be very helpful for women and men who want to control what they believe to be sexual addiction. However, accurate diagnosis and treatment for sexual addiction through psychosexual counseling may also be very important for people who are concerned that they may be addicted to sex.

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On the basis of clinical experience, surprisingly little of which has been systematically documented, testosterone has long been the treatment of choice to induce or restore sexual functioning and drive in hypo-gonadal or castrated men. Estrogens and certain progestogens which suppress testicular testosterone production and/ or compete with testosterone at the target-organ level, typically interfere with male libido and sexual functioning. The clinical data on the effects of other androgens on sexual behavior are too scanty to permit any reasonable conclusion. There is an increasing number of clinical studies, that show a beneficial effect of LH-RH administration on libido and potency in impotent, hypogonadal, and normal men. Although the data are suggestive, one has to reserve judgment at this point because the sample sizes are usually small, the methodology sometimes inadequate and the results inconsistent.

High-dose androgen treatment as it is used in estrogen-dependent cancer in women is known to have a strong, positive impact on sexual drive in many such patients. Analogously, female patients with abnormally high androgen levels due to adrenal tumors or other abnormalities, also show an increased sexual drive. A new report on endocrinologically normal women presented sizable correlations between their plasma testosterone levels, averaged over the menstrual cycle, and their “self-gratification scores” (a more appropriate label might be “self-rated sexual arousal”). Testosterone has been used successfully in the treatment of sexually unresponsive women. It has been shown—although without replication – that adrenalectomy, not ovarectomy, will decrease female sexual drive. Therefore, Money has called adrenal androgen the female “libido hormone.” It appears likely, however, that it is not the weak adrenal androgens, but the much more potent testosterone itself (which, in the female, is largely a conversion product of adrenal androstenedione) that is responsible for such effects. The role of female ovarian hormones, estrogens and progesterone, on female sexuality is even less clear, and menstrual-cycle studies of female sexual activity and desire have not produced a consistent body of data (McCauley and Ehrhardt). Estrogens clearly affect female attractivity to males via their effects on the secondary sex characteristics and facilitate female receptivity, at least indirectly, through their effect on the vaginal mucosa. However, Persky and others failed to show any relationship of plasma estradiol level to sexual behavior in young women. Data on the role of progesterone in female sexual behavior are not yet conclusive (McCauley and Ehrhardt), and data on behavioral LH-RH effects are not available.

In conclusion, the evidence described above names testosterone as the major hormone for sexual motivation and behavior in human males and possibly in females, while hardly anything is known in humans about a facilitory or contributing role of adrenal androgens, and there is only inconsistent but suggestive evidence for such a role of LH-RH in males. Estrogens and progestogens inhibit male sexual behavior, at least when used in pharmacologic dosage. Their role in female sexual motivation is not well established; it is probably much less prominent than in the case of lower mammals, but the available studies on women are not sufficient for ruling out facilitory effects of estrogens or inhibiting effects of progestogens as they have been observed in nonhuman primates.

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During the first several years of life, the infant’s relationship to others centers mostly on relationships with the mother (or a mother substitute) and having physiological needs met, especially the need for food. Feeding is necessary for survival, but it is also an occasion for intimate contact with other persons as a part of the infant’s exploration of the environment. Objects are experienced by putting them in the mouth, by sucking, touching, eating, and biting. This basically autoerotic stage lasts for the first five or six months of life. From as early as two months of age onward and increasingly through the first year of life, infants are not so much passive and receptive as active in seeking interaction. Most infants show the need for the proximity of others sometime during the first quarter of the first year.

Attachment is a two-way process. Attachment behavior between mother and infant consolidates the affectional relationship. In studying the interaction of twenty-eight babies with their mothers, Ainsworth catalogued thirteen patterns of attachment besides those associated with feeding—the rooting response, sucking, and search for the breast. On the infant’s side, the thirteen include differential crying, smiling and vocalizing, visual-motor orientation, crying when the mother left, following, scrambling, burying the face, exploring from a secure base, clinging, lifting the arms and clapping the hands in greeting, and approaching through locomotion.

Preference for the mother is not present at birth; it must develop out of the feeding and caring experience. The infant’s earliest posture is one of undiscriminating responsiveness. In the first few weeks of life it can be assumed that the infant experiences the mother, and particularly her breast, as part of itself. The first few weeks of life can be characterized as an around-the-clock time of sleep alternating with waking periods in which the infant’s contact with the mother is directed by hunger rather than by any other drive or appetite. But the mother and the infant are two independent psycho-physiological systems. They interact through specific mechanisms of stimulation and pacification. In the process, circular social interaction becomes more discriminating, and the relations between the two become numberless and infinitely varied.

Most mothers in the nuclear family do not share the intimate care of their offspring with another adult (although more and more fathers are becoming involved) and are in a position to develop an unusually close relationship with their babies. Caldwell and Hersher found that such mothers, in contrast to mothers who shared care of the infant with others, were less intellectualized in their relationships with the baby, were more sensuous in their touching and handling, were more likely to vocalize, were more active and more playful with their six-month-old babies. At one year of age they were rated as more dependent upon their babies for the achievement of their own need gratifications. In general, the data suggests a comfortable relationship between infant and mother in the cases in which the mother had exclusive responsibility for the child.

Infants show differing personality traits, strengths in their aggressive instincts, for example. Some are placid. Some are quiet. Some are noisy and active. These temperaments stay with them as they grow. There are also male-female behavioral differences present at birth, though research findings are still sparse. The male infant has greater muscular strength at birth, but the female is in no way less active or expressive. The female infant from birth shows more oral sensitivity, engages in more frequent mouth-dominated approaches, and is a more frequent and more persistent thumb-sucker. Newborn females also exhibit greater cutaneous sensitivity than do males.

Parents treat male and female infants differently right from the start, hence there is constant parental reinforcement, not only of innate differences but also of differences in what society regards as gender-appropriate behavior. In other words, the infant’s unique male or female characteristics, as well as cultural expectations, may affect the nature of parent-infant interaction from the day of birth and onward. Moss found, for instance, that mothers had significantly more contact with infant boys than with girls on such variables as “attends” and “stimulates-arouses.”

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