Fortunately the female, unlike the male, does not have to produce an erection for sexual intercourse. However, any lack of hormones, particularly testosterone, lessens her sexual desire and interferes with her enjoyment of sex. It is strange but true that the male sex hormone is responsible for arousal in the female, and the female sex hormones in the male. The female sex hormones, oestrogen and progesterone, are responsible for a woman’s feminity and the normal changes in her sexual apparatus during menstruation, sex and pregnancy. Similarly, testosterone in the male is responsible for his manliness and for the development of his sexual organs including the penis. The hormones keep their respective sexual machinery in trim to respond to a stimulus from the arousal centre. Hence both sexes need male and female hormones for effective sexual responsiveness. The same three reflex mechanisms as in men, Arousal (AM), Copulatory (CM), and Regulating Mechanism (RM), are involved in female sexual behaviour.

So many people have said to me, “Show me a happy marriage. I’ve never seen one. I don’t even know of any—do you?” They are convinced that happy marriages are a fantasy conjured up by television producers. My reply invariably is, “Yes—in fact I know of several.” The following case histories are based on couples I have treated, known, and/or interviewed. They are among the several.

Todd and Charlotte are entertainers who, unlike most such people, have managed to keep their marriage together for over thirty years. They have separate careers and live apart for months at a time. However, they keep in touch almost daily by phone, discussing their careers, their children, their homes, and whatever else comes to mind. Their communication is constant and constructive, and they have a great deal of mutual respect. Even though his career has been more visible than hers, they value each other equally. “Today my career may shoot up; next year hers may,” he says. “What appeals to the public at any particular moment is unpredictable and has nothing to do with my value as a human being or Charlotte’s.



Players: Husband, wife, and “stranger.”

Activists: Interested spouse and friend. Setting: Hotel.

Aim: To provoke jealousy and other unconscious feelings that are blocking sexual interest.

Game Plan: It must be stressed that this game is a radical one and should be played only if everything else has failed. Basically, in this game the activist spouse gets a friend of the opposite sex to help him or her make the uninterested spouse jealous. The game should be played warily, and the two activists of the game must be prepared to abandon it if it appears too upsetting to the uninterested spouse.

The activist spouse (presented in this scenario as the woman) approaches the sexually uninterested spouse some evening and asks, “Do you remember that movie, Indecent Proposal?”

“Yes. What of it?”

“Well, a few days ago I received an indecent proposal of sorts, and I thought I’d better tell you about it.” “I’m listening.”

“You remember Martin, the man we met at the club?” “Yes.”

“Well, he’s made an indecent proposal.” “What is it?”

“He’s offered to pay me—us—$1,000 if he could sleep with me.”


“You’re not jealous?”

“Not at all. Anyway, we could use the money.”



“Well, being that you are the last person on earth, maybe I ought to just give you a tussle.”

“Yes, being that this is the last day in the world, we might as well get our money’s worth.”

“Even though you’re disgusting, I’ll try to get through it.”

“Even though you’re ugly, I’ll do my best.”

They begin intercourse and continue the dialogue: “This is disgusting, but I’ll press on.” “This is awful, but I’ll get through it.” “Your beard scratches me, but it’s all right.” “Your breasts are flabby, but I’ll hang with it.” “You smell, but I’ll live.” “You’re too loud, but I’ll deal with it.” “After all, you’re the last person on earth—so I might as well enjoy it.”

“And this may be our last day on earth—so we might as well take advantage of it. One never knows.”



Players: Husband and wife. ActivistIs: One or both.

Setting: Home or hotel.

Aim: By going against the grain of the perverse couple’s fantasies this game arouses the feelings that are being acted out.

Game Plan: The last thing that a perverse couple wants is to have sweet, wholesome sex. They do not at all feel sweet or wholesome, and in fact are generally cynical. They are most likely to think that sweet, wholesome sex is for nerds and birds. They try to avoid straightforward sex because they need to ward off the feelings that such intimacy would create. This game is a paradoxical approach that “kills them with kindness” and brings up those feelings that are warded off by their perverse sexuality.

One evening, the activist spouse (with or without the cooperation of the other) sallies up to the more perverse spouse and says, “I have an idea. Let’s go to bed and make love.”



The crusader and the alcoholic go through a ritual in which the alcoholic goes on a binge and the crusader chastises and condemns it. Then the alcoholic confesses his or her “sins” and begs for forgiveness, promising never to do it again, and the crusader forgives “one more time.” Then the alcoholic goes on another binge (and so on). This ritual can be virtually endless, since from it each derives a secondary gratification from his or her role in the ritual. The alcoholic gets to relieve shame through frequent confessions and to act out rage through defiantly going on binges. The crusader gets to be morally superior and to prove that he or she is beyond such impulsive behavior. They both defend against and defeat a part of themselves that they wish to disown.

Impulsives use sex the way they use drugs—to avoid pain. Long-term relationships of commitment and responsibility do not appeal to them. Falling in love again and again, or constantly having new and different sexual experiences, does. It is no wonder, then, that Dennis and Diane had become bored with one another after a few months. They tried new sexual positions, having sex in novel places, swapping with other couples, and—finally—having separate affairs. Eventually they began discussing divorce. That is when they finally sought treatment.



Most people who have a scabies infection develop the rash on the hands and wrists, and this is usually the first place where symptoms are seen. The itching is usually worse at night and after a shower. There is also a variant of the infection called “Norwegian scabies,” which consists of a similar distribution of the rash but with much more scaling over the rash.

Children often have less characteristic rashes, making scabies in them more difficult to diagnose. They can have rashes on the scalp, palms, and soles, and they often also have secondary bacterial infection, which may make some of the bumps look like tiny pimples.

If a person is either taking oral steroids for a medical condition such as asthma or using a topical steroid cream on the rash, then the lesions may be harder to diagnose. Steroids suppress the immune systern, and since the symptoms of scabies result primarily from the body’s immune response to the infection, they may be somewhat lessened.



The Western blot assay for herpes is very accurate in distinguishing type 1 from type 2 herpes. It is expensive, however, and only a few laboratories in the country perform the test. However, it is probably a good idea to ask your provider for this test if you want the most accurate result and a culture cannot be performed, or if the culture result is negative.

This test can take three weeks to six months after infection to show up as positive and in rare cases may take even longer. Performing the test on someone at the first onset of symptoms will indicate that person’s herpes status three weeks to six months ago, but the test will not give a positive result for herpes if a person just acquired the infection.

The Western blot herpes assay detects about 95 percent of cases of culture-proven HSV-1 and nearly 100 percent of cases of culture-proven HSV-2. The test does not tell where a person has the infection, however. For example, a person with type 1 herpes in the mouth will show the same result as someone who has type 1 herpes

in the genital area.



Condom use may not help much in preventing transmission of the virus, because it is present in the entire genital area, not just the part that a condom covers. Although the effectiveness of both male and female condoms in preventing HPV transmission is not known, using them with new partners is recommended because they may decrease the risk of transmission. For couples in long-term relationships in which there is a good chance that the virus has already been transmitted, using condoms to prevent HPV transmission is of questionable value. Anyone with a history of genital warts should talk with prospective partners about HPV and other STDs. It is up to each couple to make decisions about condom use together.

Given that most sexually active people have the virus and that most are completely symptom free (though they can still transmit the virus), the most worrisome outcome from an infection with HPV is the increased risk for skin cancer in men and women and for cervical cancer in women. The number of people who develop these complications is relatively small, and appropriate routine screening, such as Pap smears for women, can detect cancer in its earliest stages, when it can be successfully treated. One focus of current research is the development of an effective vaccine to prevent people from becoming infected with HPV In the future, such a vaccine may prevent infection and thereby help prevent cervical cancer and other genital cancers that have been linked to HPV Other vaccines are being developed to treat existing HPV infection.



One of the cause of poor decision making is alcohol or drug use. Like Antoine, some people only feel comfortable in social situations if they are using alcohol or drugs. Others may go to a social event not expecting to have a sexual encounter, but then cloud their judgment by drinking or using drugs and end up doing things they wouldn’t have done if they were sober. These contacts can be very risky for STD transmission. If a person engages in casual, unprotected sex with you, there is a good chance that he or she has engaged in casual, unprotected sex with others. Some people engage in such behavior over and over again, realizing they are putting themselves at risk but not feeling they can do anything about it. If you are in this situation, it is important to realize that you must get help for your drug or alcohol problem, and that only through overcoming your problem will you be able to have control over all your sexual encounters.

If you use injection drugs, get help for your addiction in a drug treatment program and absolutely never share your equipment with others. In some areas of the country, needle exchange programs are available. If you must share, disinfecting your equipment first with bleach may help decrease the risk of acquiring infection, but this is not a guarantee.

Finally, some people have a sexual addiction. They put themselves in dangerous situations over and over again—for example, choosing high-risk partners or engaging in risky anonymous sexual encounters with partners—despite recognizing the hazards involved. People who are putting themselves and possibly their partners at risk by such behavior may benefit from counseling to break this cycle and regain control over their lives.

Before moving on, it’s important to emphasize that people can leave behind high-risk lifestyles for safer ones. If a partner has a high-risk background but is not currently engaging in high-risk activity, and has had a full screen for STDs and been found free of infection, and if you and that partner are mutually monogamous, then you may feel more at ease with this partner.


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