In both inner instinctual drives and external societal expectations, few aspects of the human personality are as strong as sex or as pervasive in all three areas. The sexually dysfunctional man or woman has a damaged ego-concept and impaired awareness, has (usually) over-compensated relationships in one way or another, and cannot assimilate the past. With the sexual dysfunction resolved a central rupture has been healed; the improvement is not on the periphery, to trickle down, but at the core, to affect everything else. The power of the ripple effect derives from both the strength of sex among the determinants of human behavior and its omnipresence in the functioning of the individual or dyad.

One final “ripple” should be noted: successful sex therapy facilitates other therapies. It helps the dyad or individual to accept more easily other therapeutic modalities, being less rigid and more aware of the necessity for change. The improvement in sexual functioning (which is usually accompanied by increased self-confidence and decreased anxiety) helps to create a belief in the therapeutic process and the expectation of a successful outcome. With successful sex therapy as described, in usually not more than sixteen weeks the therapy is terminated, and the dyad feels—in the word most frequently used – marvelous. Dyads in this state of mind approach other problems with zest and determination and a readiness to try anything. Linked with the better ego-concept and dyadic relationship resulting from improved sexual functioning, this attitude immeasurably eases the task of the next stage of the therapy.

*253/187/5*

Generally at this age there is a general impression of the quieting of the instinctually driven behaviors and the muting of other instinctual derivatives. Certainly the formation of superego at the close of the oedipal period and the further maturation of ego functions during the emerging latency phase allows for much more control of instinctual impulses. Usually sexual interest during this period is thought to be quiescent. In both latency-age boys and girls, one sees the development of primarily homosexual affiliations and the tendency to sublimate libidinal and aggressive energies into learning, playing, exploring the environment, and proficiency in developing skills and techniques which allow the growing child to deal with the world of things and persons.

This is a period for the development of the important skills and capacities that will serve the child during the journey through life. There is often a shift in libidinal organization and a relative predominance of regulatory capacities which produces patterns of behavior that seem obsessive or overly controlled. Such a heightening of defenses and regulatory mechanisms allows more room for the exercise of relatively non-conflicted functions and for the typical latency age expansion in learning and the development of skills. Needless to say, such tendencies to structure and control can easily reach pathological proportions and can lay the foundations for emerging obsessive-compulsive personality organization.

The latency stage is primarily for the further integration of oedipal identifications and a consolidation of sex-role identity and sex roles. The relative muting, quiescence, and control of instinctual impulses encourages development of ego apparatuses and the skills of mastery. There are further identifications which may take place and may be added to the basic oedipal identifications-broadening the organization of the personality through increased contacts with other significant adult figures outside the family, e.g., teachers, coaches, and others.

The latency period also has its risks and dangers. As we have suggested, the inner controls can be excessive and when they are, it may lead to a premature closure of personality development and to the precocious elaboration of highly structured and rigidly organized personality, often found in obsessive character traits. Inner controls may not develop or may fail to consolidate. In such circumstances the child may fail to develop a capacity sufficient to sublimate energies in the interest of learning and the development of skills. This often may be expressed in latency-age children by difficulties in learning or by conflicts over school activities and other involvements with age-mates.

If there has been a tendency to underestimate the importance of the latency period within the developmental schema, more recent efforts have paid greater attention to the latency period and have shown greater interest in the complexities of latency development. There are important consolidations of the basic post-oedipal identifications during this period. The previous psychosexual attainments must be integrated and consolidated so that decisive patterns of effective personality functioning and adaptive activity can be established.

It is in this phase that the child can develop a sense of industry and a capacity for mastery of objects and concepts that allows him to function effectively and autonomously with a sense of initiative and competence and without running the risk of failure or defeat or without incurring a sense of inferiority. Erikson has described the psychosocial crisis of the latency stage as one of industry versus inferiority. The latency period is an important stage for the determining and consolidating important dimensions of the organization of personality, particularly those pertaining to organization of ego capacities and skills. When this has been done, the child is then ready psychologically for the regressive upsurge of instinctual drives and conflicts marking the onset of puberty. The more effective the latency consolidation has been, the better able is the developing personality capable of sustaining the regressive pulls of adolescent development and of resolving them successfully in a more effective and mature direction.

*217/187/5*

Since that time, a number of researchers have attempted to find a reliable, specific, and relatively noninvasive technique for measuring sexual arousal and physiologic response to erotica. The logical first choice for such an indicator might be changes in sex hormone levels. From a group of male volunteers Lincoln (1974) sampled venous blood from a catheter every ten to forty minutes and attempted to correlate changes in testosterone and luteinizing hormone levels with exposure to an erotic film. Levels were obtained for several hours before and after film viewing. He concluded that “There were no changes in blood levels of LH or testosterone which could be definitely related to the films. … it seems possible that a single skin puncture has a greater impact on the hypo-thalamic/pituitary axis than a 30 minute sexually stimulating film”.

Contrary to Lincoln’s findings, Pirke and others demonstrated different results. In their study, plasma testosterone was measured before, after, and during the showing of an explicit sexual movie. Relative to the control group who saw a nonsexual movie, the experimental group showed an average increase of 35% in testosterone levels peaking sixty to ninety minutes after the film.

A resolution of these conflicting results is not immediately apparent. It would seem that at the present time the best that can be said is that plasma testosterone levels are not reliable indicators of response to erotica.

The correlation of arousal and hormone levels in women is even more difficult to demonstrate than in men. Money and Ehrhardt have theorized that it may not be a “female” hormone which is responsible for arousal in women—it may be an androgen or “male” hormone.

Abramson and others collected self-reports from 133 women of sexual arousal to an erotic story. The independent factors were hormone levels controlled by birth control pills versus no pills, and phase of menstrual cycle. They found that the greatest degree of sexual arousal and genital sensations were experienced by women on the pill while they were in their menstrual phase. The least arousal was shown by women on the pill during their premenstrual phase. There were no significant differences in response to erotic stimuli between menstrual phases for women who were not taking the pill. These data are not wholly consistent with other studies (Money and Ehrhardt) which have found that sexual interest and arousability in women peaked during the secretory and luteal phase of their cycle.

In females as with males, the exact nature of the connections among arousal, hormone levels, and erotic stimuli is not yet known.

Ray and Thompson have demonstrated an interaction between personality traits and physiologic responses to erotica. They found that although all subjects responded with increased GSR to scenes of coitus, low sex-guilt subjects exhibited significant cardiac deceleration during viewing. High sex-guilt subjects failed to show significant deceleration.

Cardiac deceleration is not thought to be a measure of sexual arousal but rather, a correlate of attention. Fixing one’s attention on some thing usually will cause a slowing of the heart beat. Ray and Thompson have probably demonstrated that low sex-guilt subjects pay more attention to sexual stimuli, and high sex-guilt subjects, even though aroused, may not pay such close attention to sexual scenes.

This finding is intuitively consistent with the data collected by the COP, which show that conporns generally have seen less erotica than have proporns. One might question whether they see less because they are conporns or whether they are conporns because they see less erotica. The Ray and Thompson study may suggest that they see less because they are conporns.

*179/187/5*

Dahomean girls are incompletely prepared for marriage; they need to be groomed, developed, and fulfilled in marriage by coupling with a male. Boys, on the other hand, are naturally designed and prepared for marriage, so it is thought. This leads to yet another question Herskovits might have asked of his data. If the girl has been educated, then will the responsibility for marriage failure be assigned to her, since, after all, she is the “educated” party?

The emphases on sexual technique found in Samoa and Dahomey, and the subordination of females to males in Dahomey and in so many other places, have analogues in American culture. Kemnitzer’s analysis of American culture focuses on the development of the “new sexuality,” a recent move toward liberalization and popularization of sexuality, primarily among young professionals and white-collar workers. Kemnitzer finds that persons who subscribe to the “new sexuality” regard sex as a domain unto itself; sexual performance is emphasized at the expense of other matters. By contrast, in mainstream American culture, the sex act is part of an essentially exploitative institution, marriage. Kemnitzer argues that the “new sexuality” maintains the old forms of social relations in a new guise, even though sexuality is no longer submerged in and encapsulated by broader social relations (e.g., husband-wife, boyfriend-girlfriend).

The argument follows Polyani, finding it necessary in capitalist societies to develop standards by which work can be valued. Sexual intercourse, for these people, is work, which can be judged on a performance scale, rating the degree of competence with which the actors execute their assigned duties. The uniqueness of the action is lost to the extent that the person is lost to the action. Sexual activity becomes, if you will, a labor of love; the world of work has invaded the world of home. As Kemnitzer points out, the technical expertise of the work place is a sorry substitute for the sensitivity and intersubjectivity associated with ideas of the home.

Kemnitzer represents his approach to the “problem” of modern sexuality as a contradiction in culture. This he contrasts with Rollo May’s analysis which attributes “normal anxiety” to a confrontation between the cultural order and human psychic nature.

The paradigm through which May understands sexuality is a modified version of the standard popularization of the Freudian model of hostile opposition between instinctual needs and the repressive forces of culture (Freud). Freud could trace the development of the anal erotic child into an anal retentive adult, an adult whose loss of happiness is commensurate with his or her heightened sense of guilt. If, as Freud asserts, it is the aim of civilization to bring individuals together in social units, it is at an unfortunate and often unhappy cost; the individual’s aggressive and sexual impulses become frustrated in the process. Thus the struggle is on; primary, self-serving, egotistical drives are thwarted by culture, which is both an extension of the basic psychodynamic as well as its natural opposition.

*142/187/5*

Pfeiffer asked subjects to relate the strength of their current sexual feelings; their responses were categorized as absent, weak, moderate, or strong. Only 6% of the male sample stated that they had no current sexual feelings; 26% reported mild, 56% moderately strong, and 12% reported strong feelings. A much higher percentage of women (33%) reported no current sexual interest, 27% reported mild, and 37% reported moderately strong feelings. Only 3% of the women said that they had strong feelings. When male and female samples were broken down into five, five-year age groups, there was an age-related decline in interest, except for the very oldest age group (sixty-six to seventy-one). There was a similar finding for the activity data. The lack of decline in the very oldest group led the Duke researchers to speculate that the individuals who had survived so long may have represented a biological elite. This hypothesis was supported in a special piece of research which will be discussed later (Pfeiffer).

Overall, there was a significant decline in sexual interest with age. The proportion of males with strong sexual feelings was greater at every age than the corresponding proportion of females. The percent of females reporting no sexual interest was always greater than the respective proportions of males. As age increased, there was a tendency for the proportion of males reporting moderate sexual interest to be greater than the proportion of females.

In a more complete and older sample of subjects (ages sixty to seventy-eight and older), Verwoerdt specifically asked respondents about their interest in sexual intercourse (not sexual feelings) in each of three observations. Responses were put on a four-point rating-scale going from 0 (none) to 3 (strong). Sixty-five subjects participated in all three studies. A significant negative correlation between age and interest was observed in all three studies. The mean interest scores for the studies were 1.08, 0.83, and 0.91—low for each sample. “Strong” interest in intercourse was “exceptional after the age of seventy and was practically nonexistent after 75,” (Verwoerdt et al.). However, moderate and mild interest was not unusual at any age. There was a slight rise in the interest score in the very oldest age group (Study III).

Subjects then were classified not in terms of degree of interest but simply in terms of presence or absence of this attribute. In Study I (ages sixty to seventy-eight and above), 47% of the subjects (69% of the males and 29% of the females) reported some interest. In Study II, the incidence of interest was 56%. Age-related declines within each sample were observed and decline in incidence was seen as greater for females than for males. By the time of Study III (age range from sixty-six to seventy-eight and above), the total sample incidence figure was 53%. In all three studies, incidence of interest was higher among unmarried than married men. In the first two studies, unmarried women had a lower incidence than married women did but in Study III, the frequency was slightly higher than among married females.

*106/187/5*

You have to figure in the cost of the hospital stay, medications, time spent in the operating room, surgeon’s fees, anesthesiologist’s fees and the markup the hospital charges on the prosthesis.

A man who has a semirigid prosthesis put in on an outpatient basis, with no complications, may end up with a bill under $5,000. On the other hand, a man who gets an inflatable prosthesis and stays in the hospital several days may find himself owing $10,000 or more.

Many patients are fortunate to have all or a large part of their health insurance cover the cost of the operation. Be sure to check with your insurance company first. In 1986, Medicare paid 80 percent of the cost of implant surgery, if the patient’s potency problem was caused by a physical condition (see chapter 7 for additional insurance tips).

*162\184\8*

Steady drinking can inhibit both erection and orgasm. It does so by affecting the production of nitric oxide, which, in turn, makes it difficult for the tissue of the corpora cavernosa to relax enough to allow blood to flow in the penis. If drinking continues over time and alcoholism develops, there is even more damage. The peripheral nervous system is often injured, permanently affecting the ability to have an erection.

Excessive alcohol also has a negative effect on blood pressure levels as well. Estimates suggest that in about 7 percent of those with blood pressures of 150/95 or higher, the elevated hypertension is related to the consumption of three or more alcoholic drinks a day. A bottle of 4.5 percent beer, a 4 ounce glass of 12 percent alcohol wine, and 1.5 ounces of 80 proof spirits are each considered one drink. Studies have shown that a reduction in alcohol intake significantly lowers systolic and diastolic pressures in both hypertensive and normotensive men.

If you do drink, do so in moderation.

Many men who drink also smoke. You probably already know the ill effects of this habit, to which ED is another entry on a long list of health-sapping conditions. Smoking causes blood vessels throughout the body to be clogged. And once blood flow is restricted, the ability to have an erection is impaired. A 1994 study of 4,400 Vietnam veterans found that smokers were more likely to admit to ED than nonsmokers and men who had quit the habit. This translated to a whopping 68 percent higher overall risk of ED for smokers. Even ruling out the associated ED risks such as alcoholism, depression, and the use of a number of medications, the smokers still had 50 percent higher chance of developing ED than the others in the study.

The good news is this: if you give up smoking, erections can return within a few months. Your blood pressure will be lower, your blood flow will be better, your heart and lungs will function better, and you will have given yourself more years to actively enjoy a fulfilling sex life.

*126\183\8*

It was painful heartburn and the overdosing of Tagamet that brought George to my office. Wanting instant relief from his discomfort, and finding no help with the recommended dosage, the fifty-two-year-old man doubled the number of tablets. And although he felt better, he was now experiencing another problem. Suddenly, he could no longer sustain an erection. He thought he was going through “andro-pause,” the so-called male menopause.

It didn’t take long to determine what was causing George’s ED. It was the massive dosages of Tagamet. However, we also needed to find out what was giving him such intense gastric problems. A simple blood test revealed the presence of an alarmingly high amount of Helicobacter pylori (H. pylori) bacteria. Typically acquired in childhood, H. pylori has been implicated in ulcers, cancer of the stomach and upper intestine, as well as a host of gastrointestinal ailments. George’s stomach distress was being caused by a previously undiagnosed and therefore untreated peptic ulcer—not heartburn. While the Tagamet helped to reduce some of the harsher and more uncomfortable symptoms of his ulcer, it also gave him ED.

I switched George to Prilosec, a powerful acid reducer not known to be associated with ED in combination with an effective antibiotic to knock out the H. pylori. After thirty days, George was symptom and medication-free. His ulcer, as well as his erection problem, were gone.

*97\183\8*

“Ever since he’s gotten his erections back, it’s like living in a porno movie,” Katherine began. “He wants to try things that make me uneasy —to say the least. And he wants to have sex a lot more frequently than we ever did before his illness. I understand—I really do—that he’s overjoyed at getting back what he thought he lost forever. But still, I have to adjust to it, too, and he’s not giving me the time to do it.”

“Who has time?” George erupted. “We have to take what we want, when we want it. If you’d been hurt like I was, you’d really understand.”

“Look,” she told him. “I feel guilty when I tell you I don’t feel like having sex. And then I feel angry when you give me grief about it.”

In this situation, I referred Katherine and George to a psychotherapist. His anger and her guilt were a volatile combination, and they required professional guidance to help sort out their dilemma. In time, they were able to do so, drawing on the strong elements that had kept them together.

The sexual problems that touched them included:

• anger at a partner who refuses sex

• different ideas of appealing sexual behavior

Think about your own feelings concerning:

• any deficiency in your sex life

• your preferred sexual activities and those of your partner

• whether you perceive that you give your partner more than she gives you

• a sexual act that you would like to engage in

• any guilt felt about those acts, or ones you already perform

• your reaction when or if your partner doesn’t want to have sex

Where sexual problems are present, a couple often needs outside help. If you are committed to each other, you owe yourselves the time and effort needed to pass those roadblocks in your relationship.

*69\183\8*