April 7th, 2009
Linda’s flat was on the seventh floor. As usual the lift was broken. The health visitor, out of breath and struggling to be heard against the loud barking of the Alsatian that greeted her arrival, turned off the television herself. Linda was nursing the new baby born four weeks before. One-year-old Gavin tottered unsteadily among the debris of plastic toys holding a feeding bottle in his mouth by the teat. Three-year-old Tracey had opened the door; ‘Couldn’t get her to nursery,’ said Linda. Paul, Linda’s husband, appeared briefly in the doorway. ‘I’m off then.’ The health visitor groaned inwardly: so he was still here! Away from home for long periods doing ‘a bit of this and that’ she had assumed he was away for a while, long enough perhaps to get Linda down to the doctor’s for her postnatal check. She would have to raise the subject of contraception. Had Linda thought about it? Linda’s eyes glazed as she rocked the baby to and fro. ‘He likes kids, anyway they make you feel special don’t they?’ The health visitor understood how she felt. What was there to feel special about in Linda’s life except for having children; what choices did she have? Her stepfather had thrown her out when she found she was pregnant the first time, even though she had lost that baby. Getting pregnant again and marrying Paul was the only bit of security she knew, but Paul only seemed to care when there was a new baby around. But Linda could barely cope as things were. ‘Couldn’t you do with a break, Linda? Get to meet the other mums here, and make a bit of life for yourself?’ Linda looked doubtful. ‘I don’t want no injections, they make you sterile. I’ve seen the leaflet.’ ‘Not permanently,’ said the health visitor. ‘And I can’t take the Pill, never could remember anyhow, and he won’t use nothing.’ ‘What about a coil? If I took you down to the clinic you could have one put in straight away and then when you want another baby, have it taken out again.’ ‘You mean it doesn’t have to stay in five years? But I’m not sure I want something inside me all the time.’ ‘You had the baby inside. The coil’s just there until the next baby.’ Linda looked interested. Here was someone saying she could have another baby if she wanted to. ‘I wouldn’t mind for a bit . . . we could do with a bit of peace around here.’
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April 7th, 2009
The overwhelming attitude of men to this approach was that they wanted to ask whether their feelings were normal. They had clear preconceptions of ordinary male behaviour against which they considered their own feelings, identifying areas where they felt different. This sense of difference had over the years given rise to varying degrees of anxiety, and several of the men appeared to value the opportunity to talk in more depth.
In the present chapter this study has been used, as well as the glimpses of men’s attitudes to contraception seen during many years in general practice. Because of the strength of the stereotypes some of these common assumptions about male behaviour have been used as headings under which to consider the varied feelings of different individuals.
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April 7th, 2009
The psychological factors contributing to the chaotic lifestyle of some women have been discussed in Chapter 1. Included in this group are women who are psychiatrically ill, depressed, have drug and alcohol problems, or personality difficulties making it difficult for them to organize their lives. Sometimes women who normally manage their lives well may go through short-term difficulties, for example, a sick child or moving house, so that they are distracted and forgetful.
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April 7th, 2009
The boys come predominantly for condoms and may be provided with supplies without seeing the doctor. However, many doctors try to see them at least once, or make sure that they are offered an opportunity to come and talk, as a request for sheaths is often a calling card which they have used in the hope of getting help with some other anxiety or problem (Hutchinson, 1983). Insistence on making them see a doctor should be avoided as that could put them off, but if the clinic staff are sensitive to the unspoken needs of patients they may be able to offer help themselves, or smooth the young man’s passage to the doctor.
It is always useful to start by seeing people as they wish to be seen, as individuals, couples or even in more bizarre combinations.
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April 7th, 2009
The stability and quality of many relationships can determine whether contraception is used and which partner uses it. Where there is trust and openness in the relationship, contraception can be accepted more readily, though there may be resentment that it is needed and a dislike of the actual methods. When there is change in the relationship or when it is unstable, especially at the beginning or the end, contraception may not be used or, if it is, the use is often erratic.
The sexual relationship may be for mutual pleasure and joy, but it can be used to control, dominate or compensate for feelings of inadequacy. By not using contraception there may be an unconscious wish to control or limit the partner’s sexual activity. Resentment or envy of the other’s sexual enjoyment can also lead to a more overt expression of non-use of contraception exemplified by the phrase, ‘Well, why should I take the Pill (with all its dangers) when he is the one who gets the pleasure?’
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March 27th, 2009
Although it has its, fans the IUD is less satisfactory than the Pill, especially in young women who have not yet had a baby. The method probably works by dislodging an embryo which arrives in the uterus. Because of this it is really a type of early abortion – not a method of preventing conception.
Before an IUD is fitted the woman should have sufficient information about other methods in order to make an informed choice. She also needs to know the advantages and disadvantages of an IUD.
The advantages include the fact that nothing contraceptive needs to be done at the time of intercourse. Secondly, except at the time of insertion, it requires no motivation. Thirdly, if she is symptom-free and does not object to its presence, as some women do, it is an acceptable method; and finally, it does not disturb the hormones in the body as does the Pill.
The disadvantages are that the device is expelled in 2-10 per cent of women perhaps unknown to the woman herself. Although recent designs minimise this risk, the IUD has a failure rate which is about the same as the progestogen-only Pill. An IUD can produce menstrual disorders with resultant anaemia and also inflammation of the fallopian tubes, with the risk of subsequent infertility, if an infection with organisms such as chlamydia is present. This eventuality, and pregnancy, occur most commonly in the early months after the device is fitted but manufacturers recommend removal and the fitting of a new one every z or 3 years. If the woman is allergic to copper then devices containing copper should not be used and neither should the IUD be used in women with valvular heart disease or those on corticosteroid drugs. Furthermore, at the time of insertion or later, the device may pass into or through the wall of the uterus.
IUDs do not increase the chances of cancer of the cervix or uterus but deaths do occur from it at the rate of 3 to 5 per million users per year. Overall it is as safe from this point of view as other methods and safer than using no contraception.
With all this in mind the method is best used by older women who have completed their families and in whom sexual life style is fairly settled.
There used to be a variety of IUDs but choice is now more limited because of manufacturers withdrawing products from the market as a result of litigation, especially in the US. The Multiload Cu 375 gained a favourable report from the World Health Organisation. High hopes also exist for the Novagard/Nova-T which releases progesterone and can be left in position for 5 years. A failure rate of 1 per hundred woman years is claimed and it is associated with less menstrual pain and less blood loss.
For a variety of reasons the success of an IUD is associated with the fitting of the device by a doctor who has some enthusiasm, but not too much, for the method and who has a lot of experience in fitting them and caring for the patient afterwards. This factor appears to influence success more than the actual device fitted.
Chemical methods-Various substances kill sperms and, if put into the vagina before intercourse, reduce the chances of conception. Vaginal foams and pessaries are probably the most effective but any of the chemical methods can cause irritation. A possible advantage of these methods is that as well as killing sperms they may kill gonococci and cither organisms.
The effectiveness of such chemical methods is increased by using them along with a barrier method, such as a condom (sheath, rubber, protective) or a cervical cap (diaphragm) all of which are intended to prevent the sperms reaching the cervix.
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March 27th, 2009
As mentioned in the chapter on courtship, the sharing of fantasies is a sensible way to ensure compatibility. For those in an established relationship who have not done so previously it can present difficulties. Few people would seriously want to fulfil every fantasy even if they had the chance of doing so but talking about them communicates something of value. If the partners are self-confident and aren’t on the look-out for criticism in everything, then sharing fantasies is exciting, amusing and promotes love. The whole point of the sharing is to extend understanding and cooperation. It opens up new possibilities which can be jointly explored, if only in part or in a modified form. Since fantasies used in self-masturbation change, slowly maintaining this communication is an on-going way of keeping sexual boredom at bay. As mentioned later, personal masturbation in the relationship also has another value, that of keeping extra-marital affairs in check.
A degree of apprehension and nervousness is understandable at first when sharing fantasies and one way round this is to read sexy books in bed together, especially those with readers’ letters. Use the topics raised to see if they excite any response. Checking the genitals of your partner to see if they have become aroused also helps.
An interesting fact is that when partners in an established relationship eventually do reveal all they often discover that their fantasies match with, for example, the woman fantasising about a man doing to her just what her partner fantasises doing to a woman.
In clinical practice it is usually found that individuals in a good, satisfying relationship very commonly use fantasies involving members of the opposite sex other than their partner. These may be well-known figures such as film stars, friends, acquaintances or even strangers encountered in everyday life. Of course men and women also commonly have fantasies involving faceless, non-specific members of the opposite sex. This, along with occasional flirting, can be protective to the marital relationship because it is less threatening than actually having intercourse with others.
Other difficulties can arise from sharing fantasies. Some individuals, both men and women, have been brought up to be so inhibited about sex that they consciously restrict their fantasies or even abolish them from the consciousness altogether. In this way a woman may feel that prostitution, for example, is so revolting that even if a prostitution-type fantasy came into her mind she would banish it at once.
Some men’s fantasies are perpetually passive – the woman always takes charge of them. Women often fantasise that they are in a passive role because they have been brought up to believe that sex is something men do to them. Obviously if both partners fantasise passively they cannot really satisfy each other. The best solution in this situation is for them to agree to take it in turns to have their fantasy indulged.
A similar type of difficulty can arise when one partner, usually the man, always has fantasies of activities that do not culminate in intercourse. Some individuals are inhibited about intercourse and so encourage activities close to it, such as oral sex, which avoid the act of intercourse itself. Sometimes, although intercourse is what they would like, their most arousing fantasies are about, for example, dressing in women’s clothing, or the woman being tied up and/or beaten.
With these difficulties in mind, the sharing of fantasies allows the circumstances and types of intercourse to be so adjusted as to give maximal pleasure to both partners. It means that intercourse becomes unique to that couple and adds to their sense of private adventure. It also, perhaps, makes it less likely that either partner will seek adventure elsewhere, because they are both totally pleased and catered for within their sharing relationship.
Women frequently say that if they have to tell their man what to do it reduces their pleasure. This problem is solved if the man reserves some of her fantasies for occasional and unexpected use, especially if he adds a few variations of his own.
Good sex is neither exclusively of the mind nor of the body — it is a blend of both. As a result intercourse proceeds at least as much at the psychological level as at the physical level. The sharing of fantasies teaches partners about each other and this can be very important for men, who are frequently brought up to believe, usually unconsciously, that women are really sexless and have intercourse only to please a man or because they love him.
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March 27th, 2009
If inadequate studies such as intelligence and personality tests cannot convince us about the differences between men*and women, perhaps the truly scientific world has the answers.
Biologists differentiate between males and females in seven main ways: i the chromosomes; 2 the sex organs; 3 the sex hormones; 4 the internal reproductive organs; 5 the secondary characteristics; 6 the gender role; and 7 sexual identification.
Chromosomes-All living organisms are made up of cells, each of which has a nucleus which contains chromosomes. These carry the genes which contain the blueprint which defines every detail of each organism’s structures and function. These genes are inherited, thus explaining how it is that physical and psychological characteristics can be passed from generation to generation. Genes control the myriad of complex enzyme systems in the body, some of which are responsible for brain and hormone metabolism — both of which probably affect behaviour to some extent. Every cell in the human body contains twenty-three pairs of chromosomes, each of which in turn carries thousands of genes. The exception to this rule are the sex cells (sperms and eggs) each of which contains twenty-three single chromosomes. When an egg is fertilised by a sperm the two sets of twenty-three link to form a complex double set which is essential for the development of a new human being.
One pair of the twenty-three pairs of chromosomes is responsible for determining the sex of the individual. Generally each chromosome matches its partner in the pair, except for the sex chromosomes in males which are different. One is called the X chromosome and the other is very small and is called the Y chromosome. A woman has two X (normal-sized chromosomes) and a man an X and a Y. So women are XX and men are XY in sex-chromosome structure. Sperms carry either an X or a Y chromosome. The sex of the baby is decided by which reaches the egg first. If this is a Y-carrying sperm, the baby will be male. An absence of a Y chromosomes produces a female even if one of the chromosomes is missing (as sometimes occurs) with an XO pattern.
Because the Y chromosome is so small it is obvious that females have more genetic material than males right from the start. There is now evidence that one of these Xs is repressed and that only one is really operative. This would make sense in that both sexes would thus tend to have roughly equal amounts of chromosomal material.
But Nature plays some odd tricks from time to time and as a result teaches us some interesting things about males and females. Many of these lessons go to prove how difficult it is to be dogmatic even about something as seemingly straightforward as whether a person is male or female.
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March 27th, 2009
Psychosexual medicine is a fairly new branch of the medical profession in the UK and at the moment has attracted very few practitioners full time. The majority of ‘experts’ working in this field are consultant psychiatrists who, because of their understanding of psychological and emotional problems, tend to deal with sexual problems too. Many do not particularly want to deal with sexual problems and their patients share their reluctance. Few people with sexual or marital problems are mentally ill, and psychiatrists are doctors who deal mainly with mental illness. Going to a psychiatrist still has something of a stigma attached to it and there is always the suggestion (not from the doctor, of course) that one might actually have something ‘wrong’ with one’s personality. A few psychiatrists offer psychoanalysis for such problems but only a tiny fraction of 1 per cent of all marital problems need or receive true psychoanalysis.
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March 27th, 2009
Probably the need for romance and the search (or hope) for romantic love is best thought of as a stage in the development of the capacity to love in a mature, adult way. It emerges strongly in late adolescence when the love which used to be self-centred (in mid-adolescence) begins to be available for direction towards others. It would be extraordinary if people went from their
self-loving, mid-adolescent phase straight to an ‘other-centred’ type of love without some sort of intermediate learning phase. Romantic love is this phase in adolescence. Romantic love is a way in which we learn to bring together our sexual and loving feelings and to ‘aim’ them at the same person for the first time.
This phase of romantic love, which many young people experience more in fantasy than in fact and which others never grow out of, is still very much concerned with the self — it is almost entirely a preoccupation with one’s own feelings. This might seem strange at first sight because romantic love is, on the surface, very much concerned with the other person.
Both in literature and in fact, this phase of romantic love can also be associated with bouts of anxiety and depression. The loving feelings may even be experienced as a form of agony and yearning. Romantic writers very often talk of ‘the agony of being in love’ and in a sense suffering and tragedy are often an integral part of romance. Some women unfortunately never grow out of this phase and remain tragedy queens, as it were, all their lives. They have perfectly acceptable and enjoyable relationships yet spoil them by creating traumas and tragedies which they feel are necessary to their concept of romantic love.
So, it can be seen that the phase of romantic love is a learning one. Learning to love is much like learning any other skill; just as adolescents have to learn social skills, they have to learn the skill of love. Because it is immature love, it is often described as ‘calflove’ or ‘puppy love’ but this misses its importance. Unless one uses this stage as a foundation, one cannot build the love structure an adult needs. Parents should never make fun of or put down their teenagers in this stage of puppy love — the teenager needs to go through it.
Most people, however, progress to other relationships and, it is to be hoped, begin to get some idea as to what sort of partner would really suit them. Such a relationship once again releases romantic feelings, but now they are simply one component of the more complex emotional and sexual reactions of the chosen partner. Ideally the romantic portion of the relationship should be encouraged to emerge slowly so as to allow realistic assessments to be made. Romantic love then becomes increasingly added to the relationship rather than being its starting-point. In this way the objection that love is blind can be overcome.
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