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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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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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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?’

*21/197/1*

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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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.

*98\164\2*

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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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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Elderly homosexual people have particular difficulties in this area. Retirement villages and nursing homes are just not geared for people who prefer same-sex partners, and so aging will make the prospect of social isolation even more likely. The problem is probably greater for men than for women because society has less trouble accepting close and loving relationships between women than between men. In either case it is clear that this group of people have special needs as they age that are not being met by the current system. Part of the reason for this is that this group in the community has been virtually invisible until this generation. So what are the solutions?

The first is to somehow integrate the needs of elderly homosexual people into the existing structures. Now this may sound simple enough on the surface, but when you consider the potential barriers it is not as easy as it sounds. To overcome those barriers there would need to be special training or selective employment of nursing and domestic staff. The heads of various government departments and administrators of the nursing homes or retirement villages would need to be supportive of the idea and willing to spend the money to put the changes in place, and the relevant politicians would need to see some political gain for themselves.

The other option is to develop special purpose retirement and nursing home facilities to cater specifically for the needs of the aging gay population. This concept is already in practice for some ethnic and religious groups. Some might say that this approach is separatist, far removed from the cosier notion of everyone accepting the individuality of others. But we are trying to deal with realities here. No single solution is going to be the right one, so what we are talking about is choice, freedom and right to privacy.

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Some men think they are ‘impotent’ because they lose their erections before or soon after penetration. However if the erection disappears because he has already ejaculated, that’s an entirely different matter. We call that premature ejaculation. It’s a bit hard to come up with a definition for premature ejaculation because, like many sexual problems, it’s largely a matter of perception. Many women who orgasm quite quickly (often during foreplay) are not rapt in the concept of being pumped for ages.

Over the years they’ve tried to define premature ejaculation by a variety of methods — not being able to last two minutes after penetration, or a certain number of thrusts and so on. The definition I like is that a man or his partner wishes he could last longer.

One of the myths about the best way to deal with premature ejaculation involved the man distracting himself by reciting some list, like the American presidents. ‘George Washington, John Adams … oops! What is it about Thomas Jefferson?’ or ‘That was great darling … at least a Woodrow Wilson!’ Sports fans could try lists like the batting averages of the cricket Tests since 1912 … ‘What do you mean “You’re out”? Don’t you think there is a certain irony about trying to enhance a mutually erotic experience by pretending you aren’t doing it?

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Even the most adaptable relationships can take some adjusting and many people just don’t expect the degree of change, including the differences in their sexual needs. One mother told me, ‘We were very sexual before the baby arrived and it came as a great shock to me that I wasn’t the slightest bit interested for ages afterwards. My breasts were always a really important part of stimulation for me and it just wasn’t the same going to bed wearing a nursing bra. My libido didn’t come back until I’d stopped breastfeeding. Actually, I found feeding was almost a sexual experience in itself. It’s not like an orgasm you’d get with your partner, but it’s certainly incredibly sensual.’

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When there are children involved it can get very complicated. One of the main problems for a new relationship is that there never seems enough time to be alone and that will be intensely frustrating. The system of jealousies can be incredibly complex. The reactions of children will depend a lot on their age but seeing your parent relating physically or sleeping with a person who is not your other parent can create confusion, resentment and even anger at any age. If your parents’ relationship was strained for some time you may never have seen the adults around you engaged in any sort of intimate behavior before and that can be particularly confronting. Children can be very protective of their parents and new partners may find themselves competing for attention, physical affection and personal space with their partner’s child. Stepparents may feel inhibited about showing affection in front of each other’s children for fear of setting off a reaction. So establishing a blended family raises a multiplicity of sexual issues that will take time, patience, understanding and a big dose of common sense to unravel.

The main answer to dealing with relationship problems and breakdowns is early preparation. Obviously the example set by your own parents is a vital element, but in any relationship the backgrounds of the two people will be different in some respects. Just because one of you knows how to communicate emotions, it takes two to tango. It would be like sending a message over the radio when your intended audience is tuned to another station. The missing link is relationship education by specially trained teachers in schools. In fact, understanding relationships is so integral to our emotional survival that it needs to be a cornerstone in the education system. To survive in the modern world we need the ‘four Rs’ … Reading, wRiting, aRithmetic and Relationships.

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But it’s not enough to silently hope that your partner, no matter how committed they may be to the relationship, will never have a sexual encounter with another person. If you look at the statistics, the truth of the matter is that the majority of married men and women will have an extramarital liaison at some time. Denying this reality or just refusing to acknowledge it or talk about it leaves far too much to chance. Some therapists argue that it is not necessarily the affair itself, but the exposure of the affair or the fear of what it might do to the relationship that actually does the damage. The feeling of betrayal and loss of trust that follow can tear a relationship apart. Catching an STD and then having to tell your primary partner is a sure way of exposing an extracurricular relationship, and it can be devastating.

However, the discovery of an STD may have nothing to do with infidelity, so it’s essential to have your facts right before you pick up the phone to call your lawyer. (For that matter call a counsellor before you call a lawyer.) Find out all you can about the infection. Take chlamydia for example. By the 1980s it had become the most common sexually transmitted bacterial infection in North America, Europe and Australia, so its impact has been widespread. Chlamydia is one infection that can lay dormant for years before it is detected, so even though it may be found on a test today it may have been the result of a sexual contact some years before. It can go on causing damage for all that time with no symptoms at all, until it ultimately leads to infertility in both men and women.

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