The fear of dysfunction does indeed appear to be the most common phobic reaction in sexual dysfunction. Although it is easily identified, there often are many subtleties involved.
As sex usually involves two people, these fears occur within a social context. Sometimes a critical variable is not the patient’s fear of dysfunction but the partner’s fear of the patient’s dysfunction. One man, with sexual impotence, stated that the fear of dysfunction did not begin to appear until well after the impotence was established. Even at the time of consultation, that fear was not particularly strong. Further exploration revealed that his mate had had a series of experiences with sexually impotent men, that she was phobic to the thought that her current lover would become impotent, that because of this fear she was extremely anxious during sex. It was her anxiety, or rather his reaction to her anxiety, that brought about the dysfunction. Reduction of her fears relieved his impotence without any direct treatment of the man.
Sometimes the fear of dysfunction is combined with an assertive problem. The patient is usually an obsessive male who has great difficulty in saying “no” to a woman in a close relationship. This is especially true in the sexual area. Resentment builds up, and he begins to wish that he were impotent, as a means of gaining freedom. This wish is rapidly converted into a fear and then into an obsessive thought. Dysfunction follows. We have had only fair success in treating patients with this condition, several of whom also failed in couple sex therapy.
Finally, although not inclusive, is the fear of dysfunction as a mask for other fears. The core fear may be the partner’s reaction rather than the dysfunction itself, that the partner may become angry, frustrated, contemptuous, rejecting or even more common with women, pitying. In these conditions, even when reduction of the fear of the dysfunction is successful, there is a tendency for the dysfunction to return. Treatment cannot be considered complete until the fear of the partner’s reaction is removed.
Although the fear of dysfunction is the most common phobic reaction, many others do exist. Any part of the sex act or situation may become a phobic stimulus. Among phobic stimuli we have seen are parts of the partner’s body (especially the genitals), physiological sensations as
the person approaches climax such as change in breathing (in several patients with a history of childhood asthma) or rapid heartbeat, fear of performing specific sexual acts (which often include both the fear of being “perverted” and the so-called masturbation guilt), and the fear of not enjoying specific sexual acts (especially among young adults who are afraid of being “inhibited” or “uptight”).
Many of these fears are very subtle, and part of the art of behavior therapy is to identify them. One young woman could not have a climax in the presence of another person. The core fear turned out to be the fear of being ugly. She believed that during climax her face became contorted and that even in total darkness her partner might see it. One man had a history of losing all sexual interest in any long-term relationship. After a long investigation the problem turned out to be the fear of boredom. Reduction of this fear appeared to have changed the problem pattern.
Communication between the couple is especially important to attain a good sexual relationship. Hence, special note must be taken of those fears which inhibit such communication. However, regardless of what the specific fears are, usually the most effective method for reducing them is through the assertive training approaches rather than through phobic reduction methods.
Nonsexual phobic stimuli may also disrupt sexual functioning. Fear of darkness is but one example of the many that can be cited. As stated before, part of the art of behavior therapy is the identification of such specific phobias.
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Homosexualism is the same as homosexuality. Professional opinion is currently divided as to whether homosexuality should be considered a syndrome or simply a socially sanctioned erotic alternative analogous to left-handedness. In the American Psychiatric Association the majority opinion, as expressed in the referendum of early 1974, supported a change in official nomenclature, so that homosexuality per se is no longer classified as a mental disease or illness. In the religious law of former times, homosexuality was a crime synonymous with treason and heresy. In the civil law today, in many states, homosexuality is classified as a crime against nature, with penalties that are brutally severe. In other states, homosexuality is considered a matter of private morality, provided it takes place between consenting adults.
In current usage, there are those who define homosexuality mentalistically as a trait, state, or disposition emanating from the personality, and those who define it behaviorally as something that happens between two people with similar sex organs. The mentalist says that a person can be homosexual, even though his or her only sexual practices have been heterosexual, provided the erotic imagery is consistently homosexual. To the mentalist, a single homosexual act by itself does not make the person homosexual, because homosexuality is defined as a continuing state of mind or personality. The behaviorist says that a single homosexual act makes a person homosexual for the duration of that act, but from that one act alone it will not be possible to predict more of the same in the future, nor what the person will say or do to indicate a trait, status, or disposition toward homosexuality.
The only evidence that both a behaviorist and a mentalist have about homosexuality is behavioral, that is, what the ostensible homosexual says or does. Thus, it makes sense to define homosexuality in terms of two people each with a penis or two each with a vagina in an erotic partnership. Anything further about the fortuitousness of the event versus its replication, and anything about the imagery and thoughts of the partners, will need extra information. Only then can an inference be made about whether either partner is an obligative versus a facultative (situational) homosexual, the latter being in fact a bisexual. Homosexuality is extensively, though quite wrongly, used as a synonym for bisexuality in today’s literature.
Extra information, over and beyond that of erotic performance, also is needed before an inference can be made regarding the extent or pervasiveness of the gender transposition in homosexuality. There are some male homosexuals who manifest negligible femininity vocationally and recreationally. Even in erotic performance, they may be more masculine than feminine in what they do, except that it is usually considered a feminine trait to have a male copulatory partner. The same applies, vice versa, in the case of the female homosexual.
A male homosexual who manifests little gender transposition, except for entering into an erotic activity or partnership with a male, is often said to have a male gender identity, but to prefer a male partner. For the sake of precision, one should say more restrictively that his gender identity/role is predominantly male, though not completely so. Sexual practice and partnership are components of gender identity/role and must be included in its definition as masculine or feminine in any given case.
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Key statistics reveal that women still are not fully integrated into the mainstream of the American work force. Although they now comprise nearly half of all wage earners, they continue to be grossly under-represented in occupations associated with power or status. As recently as 1970, for example, only 5% of all lawyers and judges, 6% of all industrial managers, and 9% of all physicians were women (Council of Economic Advisors). Thus, despite federal legislation, consciousness-raising activities, and women’s caucuses, disparities persist.
Obstacles to women’s advancement in non-traditional areas derive both from forces within women themselves and from forces outside them. Women’s fear of success (Horner), limited self-confidence (Lenney), low achievement motivation (Veroff, Wilcox, and Atkinson) and role conflict (Hall) are some of the internal factors detrimentally affecting their own achievement. Discussion of these phenomena, although they act to support and maintain sex discriminatory practices, is not within the scope of this essay. It is designed to explore only the externally imposed barriers that thwart women in their quest for equality.
Because they are so central to the issues of women’s advancement, the focus of our concerns will be the experiences women encounter in the work world. When considering work-related discrimination it is necessary to distinguish between its two different forms (Levitan, Quinn, and Staines; Terborg and Ilgen). One is the non job-related limitations put on members of a subgroup influencing their attempts to enter an organization. This is called access discrimination. Funneling of women to some jobs and not others, failing to hire women applicants for certain positions, and offering a lower salary to women as compared to men all are examples of access discrimination on the basis of sex. The other form of discrimination, treatment discrimination, is the differential treatment of members of a subgroup once they have gained access to a position and are at work on the job. Promoting women more slowly than men, giving them fewer opportunities to learn new skills, or giving them lower or less frequent salary raises all are examples of treatment discrimination involving sex.
Because beliefs about women and how they compare to men are widely shared within our culture and are assumed to apply to nearly all men and women as members of their respective groups, these beliefs are called stereotypes. According to Terborg, sex stereotypes have two components. First, they specify the characteristics of each sex. Second, they dictate which behaviors are appropriate to men and women. Either of these can form the basis of sex discrimination, one based on faulty beliefs about what women are like and the other based on normative expectations about what women should be like.
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Anthropological reports document exaggerated emphases on sexuality in certain societies, primarily in Polynesia, Melanesia, and native South America. “Sex, in the modern Marquesas, is something of a national sport,” is one such statement (Suggs). Another ethnographer reports that Marquesans of both sexes name parts of the body, “honorably” naming the genitals (Linton). Marquesans have sacred songs with erotic lyrics believed to stimulate the sexual passions of the gods, thus promoting fertility (Suggs). On the Polynesian island of Mangaia it is said that “copulation is a principal concern of Mangaians of either sex” (Marshall). Adolescent boys will “race” with each other in a contest to see which age-mate can copulate with the most women, providing the most sexual pleasure for the females (Marshall). Inquisitive about the local Catholic priest, the islanders asked, “Are his privates sewn up?” Similarly, Mead reports that the concept of celibacy is “absolutely meaningless” to Samoans. Closer to home Dougherty finds that among rural black southerners, “sexual feelings are human nature and cannot be totally controlled”.
At the other end of the ethnographic spectrum one finds communities like Inis Beag (Messenger), an island of the Irish Gaeltacht. Messenger was amazed at the minimal attention to and knowledge about sexual matters: “Lack of sexual knowledge and misconceptions about sex among adults combine to brand Inis Beag as one of the most sexually naive of the world’s societies”. When Messenger asked one woman to compare the sexual proclivities of Inis Beag men and women, she responded, “Men can wait a long time for ‘it,’ but we can wait a lot longer”.
The extreme cases of Polynesian islanders and Irish peasants are difficult to explain. In an exceptionally provocative paper in this regard, Heider argues that the level of sexual energy is culturally determined, not innately fixed as the Freudians have it. The Dani of New Guinea invest an extraordinarily low amount of energy in sexual pursuits. In fact, Heider finds that the Dani do not invest much energy in anything. They engage in intercourse just frequently enough to maintain the population.
Coincident with this low interest in sexuality, Heider finds low intellectuality, impoverished art, and low levels of affect, for example, in their casual attitude towards death. Heider finds five lines of evidence:
1. Sexual abstinence four to six years postpartum. The Dani told Heider that parents should refrain from sex from the time of birth to the time the child is five years old (approximately, since the Dani do not reckon time in years). Whatever the actual period is, it contrasts notably with the period reported for couples in other societies, such as Tahitian parents who continue intercourse until two or three weeks before birth and commence again one or two months after birth (Levy).
2. The period of postpartum sexual abstinence is invariably observed. The Dani assert this (and Heider believes them) and furthermore, no Dani full siblings are less than five years apart in age.
3. The norm of long postpartum sexual abstinence is neither supported by powerful explanation nor enforced by strong sanctions. Heider understands the sanction as a somewhat casual, pro forma sanction. They do not abstain from sex for fear of death, ghosts, or any other moral imperative. Rather, sexual abstinence is easy; it is not an issue.
4. Most people have no other sexual outlets. Although one Dani man apparently had nine wives, only a minority had more than one (43 of 148 total males had more than one wife). Heider rejects the possibility of two wives bearing children for the same man within a few years of each other; wives tend to live in separate compounds, and men are likely to stay in the compound with the new infant for the first year or so of its life, effectively restrained from sexual visitations with other wives. Heider eliminates other possible sexual outlets for men: coitus interruptus with a wife, extramarital sexual intercourse, masturbation, homosexuality, and bestiality. According to Heider, none of these is practiced by Dani men, although they are not specifically prohibited by the regulations of postpartum sexual abstinence.
5. No one shows any signs of unhappiness or stress during the period of abstinence. Heider tried to get Dani men to talk about how they felt about celibacy. None of them reported much of a problem, and Heider could detect no anxiety or discomfort.
Considering all the data, Heider argues that Dani culture is in a steady state, lacking climax or motion, and is in a low-energy field. He contrasts it with the Balinese reported by Bateson, also in a steady state, this a high-energy one.
Heider found two possible causes for the low energy level of Dani cultural forms, including sexuality. One is ecological: Dani receive low stimulation from the environment (the Dani are rather isolated socially). The other is developmental: the infants are reared in low stress conditions. Recently Pontius has suggested a third hypothesis, this one medical. Dani subfertility, a subject Heider did not explore, may be caused by a combination of two factors: (1) tight scrotal strings which may rupture the epididymal ductus, and (2) a low protein diet.
The Ik are another group with a reportedly low interest in sexual activity. This small hunting group in East Africa is on the verge of starvation (Turnbull). In documenting the social decay of the Ik, Turnbull reports that although these “loveless people” do in fact engage in intercourse (which implies at least a degree of mutuality and cooperation), they do so somewhat as an extension of masturbatory practice, consistent with the Icean emphasis on “excessive individualism,” rather than as an interpersonal event. Turnbull suggests that sexual activity can occur without involvement; it does not need much cooperation nor much affection. Such is the sad case of the Ik, who apparently can engage in sexual intercourse without violating the “cardinal Icean maxim, which is not to love anyone”. Certainly the Ik orientation to sexual intercourse is radically divergent and lacks the considerations found in other societies, such as the Mangaian (Polynesian), in which men attempt “orgasmic timing” with their partners, having received explicit instruction in this regard (Marshall) In matters of Mangaian sexual performance it is believed that, “the man who only goes a short time does not love his wife” (Marshall).
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Anthropology has shared with the other social sciences a Victorian reticence to include investigation of sexual behavior among its interests in diverse cultural groups. Little more than a decade ago, an analysis (Marshall) of ten leading anthropology textbooks concluded that sexual behavior was accorded neither space nor attention in the basic formulations of anthropological knowledge. This lack of attention in the profession did not come from lack of either interest or knowledge; indeed, Suggs and Marshall noted that researchers might be interested in and know quite a bit about the sexual behavior of “their people,” without ever including such information in their scholarly books and articles. Scientists who violated the taboo on writing about sex risked their reputation, or at least the onus of being thought too interested in “pornography,” or too ready to violate the privacy of their subject groups. Stimulated by the work of Masters and Johnson, however, papers and monographs have begun to appear, and there is now a knowledge base sufficient to inform us of the diversity of sexual practices among earth’s people.
Patterns of sexual behavior among people do not arise independently or quixotically in some random fashion. Rather, they are part of society and culture, and reflect patterns of sex roles, beliefs about men and women, religious beliefs, notions of modesty and socialization practices, population and ecological factors, and other characteristics of a particular group. As Rostand said, in the joining of two human bodies, all society is the third presence.
An example of the interrelationship between sexual and nonsexual phenomena is an analysis by Friedl of sex roles in foraging and horticultural societies. She suggests that the universality of a degree of male dominance is the male monopoly on hunting game and their power to distribute it. If male hunting is minimal, and both sexes collect the plants which comprise most of the diet, women’s status is more equal to that of men. Women have the lowest status in groups whose main food is big game hunted entirely by the men. The importance of variations in patterns of male dominance is especially noted in marital sex relations. If woman has a more equal status, because of her role in providing a large share of the food, she has considerable autonomy in sexual matters. She may initiate sex and expect satisfaction. She may divorce, and her adultery is not more serious than is the husband’s. If her status is very low, the male being sole provider of all food, she may have no control over sexual relations in or out of marriage. Among the Eskimo, for example, who subsist on big game or sea mammals hunted by men only, the sexual services of women are considered a commodity that men can take at will, or give or exchange to another man. Pubertal girls are fair game for any man, and wives are freely exchanged among men who wish to make alliances with one another or to repay favors (Friedl).
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In general, treatment strategies fall into three main groups. The first of these is particularly aimed at supporting those who are looking after a person with dementia and in this chapter we will consider the role of support groups, and how to set one up from scratch if necessary. The other two strategies cover behavioural approaches and the use of medication.
Over the years there have been many behavioural approaches to treating people with dementia. The best known of these is probably reality orientation (RO), but there have been others such as reminiscence therapy and music therapy that are gaining popularity at the moment. It must be said that their main purpose is to try to maximize whatever intellectual ability remains, rather than improve the situation by resurrecting brain cells or preventing further decline. Many of the common-sense approaches that carers adopt to overcome difficulties are actually reality orientation techniques although not specifically called this. Reality orientation is the application of common sense to provide stimulation and exercise to the failing mental capabilities of a person with Alzheimer’s disease or a similar condition.
Reminiscence therapy, music therapy, and similar approaches are, in my opinion, effective methods of improving the quality of life for short periods for many people with dementia. Making the most of long-term memories can bring back pleasurable thoughts and associations, and may sometimes have a calming effect upon the sufferer. Music, particularly that relating to the past, can have a similar effect. When these activities are carried out in a group, it is sometimes possible to stimulate interaction between group members, even when the individuals appear to be quite severely demented. It is, however, often worth trying these or similar approaches in a one-to-one situation if attendance at a group session is not practical. Behavioural approaches to improving the quality of life of people with dementia are very important, but it often seems as if more is made of their scientific validity than is realistic and this can lead carers and relatives to expect to see an improvement in the intellectual ability of the person they are caring for, after the session or activity is over. This rarely happens; when it does it is usually short-lived and consists most commonly of an elevation of mood.
The therapeutic strategies involving the use of medicines fall into two groups. On the one hand there is the use of existing, well-tried, medical approaches to treatment of difficult behaviour in people with dementia. These involve drugs that are well-known to most of those looking after a person with dementia, especially professional carers. On the other hand new medicines are being developed and evaluated in the hope that they may slow down, or even reverse, a sufferer’s intellectual decline. Much of our hope for the future lies in the development of the latter group and there are many exciting new compounds on the way, although their effectiveness can only be tested in clinical trials, which may not be for a few years.
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The first requirement is the need to change regularly dirty or soiled clothes, and the second, washing and bathing. Some of the problems surrounding dressing have already been referred to, but the most difficult situation is a confused person who refuses to change his or her clothes. This usually happens when the suggestion is made after the person has already dressed and is most easily overcome by arranging for the provision of clean clothes and the removal of dirty ones either last thing at night or first thing in the morning.
Having a bath or a shower can also be a problem and if it provokes a catastrophic reaction it may be better to accept that there will be fewer baths if a daily routine can’t be established. Do remember to make sure that someone checks the temperature of the bath water. A bedbath, although sometimes successful, is often more problematic than an ordinary bath.
It is particularly important to ensure that the skin areas around the genitalia, the patient’s bottom, and the areas in skin folds, including under a woman’s breasts, are thoroughly attended to. If this is not scrupulously done, superficial skin infections will take a hold, with resulting discomfort and unpleasant odours. To prevent the skin becoming chafed and sore, ensure that it is completely dry after washing or bathing. Follow towelling with talcum powder, especially in areas under skin folds.
Safety in the bathroom is paramount. As well as non-slip mats and rails in the bath and shower, make sure that the floor will not become slippery if water is spilt on it, as is the case with linoleum. Modern bathroom carpeting is very effective, but expensive. An alternative, although second best, is a substantial bath-mat fixed firmly in place with Velcro pads, attached both to the linoleum and to the underneath of the mat.
Many people believe a shower to be more unsafe than the bath. This need not be so, as many baths have high sides and it is when negotiating these that accidents can happen. A shower cubicle with a chair or stool within it and a shower head attached to a flexible hose is often easier for a relative or other carer to manage.
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At some stage in their illness many people with dementia will show a tendency to wander. This can be a problem even if it is confined to the house, but some people will take to wandering, sometimes miles, away from home. Because this is potentially dangerous it usually causes a lot of anxiety and distress for the carers. It is, however, almost impossible to be absolutely certain that you could prevent a wanderer from ‘escaping’. Even in a hospital it isn’t feasible to watch someone for twenty-four hours a day.
There seem to be many different types of wandering and it is a form of abnormal behaviour that is only just beginning to be studied in detail. In some people with dementia it may result from boredom, in others perhaps it is a way of using up excess energy; on occasions it may be a reaction to pain or discomfort. In many cases it seems that sufferers are looking for somebody or something, for instance trying to find the house they lived in when they were a child under the mistaken impression that it is still their home. At a simpler level, some people wander when they have been moved into a new environment and once they become familiar with the layout of the accommodation and settle into a routine, the wandering will cease.
Another quite common cause of wandering is the mistaken impression sufferers can have that they have an appointment or that the time for an appointment has arrived when it may not in fact be for several hours, or may even be on an entirely different day.
There are various ways of trying to tackle wandering. If it is at all possible, it is worth making an effort to understand the reason behind it. This means that one has to be certain that there is no additional medical problem that is causing distress and medical advice may have to be sought. If, however, boredom seems to be at the root of the matter, then increased activity may well help. Very often all that one can do is to divert the person’s attention to some other activity that doesn’t involve wandering. When disturbed in the middle of the night, some carers suggest that the sufferer has a cup of tea before he or she leaves for wherever they imagine they are going. While the tea is made, it is often possible to divert attention away from leaving the house to something else and from there to the need to go to bed. If they insist on leaving the house, particularly if they appear to be becoming aggressive or violent, it is best to let them leave, to accompany them, and to try to divert their attention while walking so that they will eventually come round the block with you back to home.
Unfortunately a determined wanderer will sometimes escape. There is no reason why you can’t fit suitable locks and bolts to the doors, but do make sure that they are not difficult to open in case of an emergency, for example a fire. Give your relative an identity bracelet or some other means of identification, including your telephone number or that of a neighbour if you don’t have a telephone of your own. Make sure that local people, neighbours and shopkeepers for example, know of the problem so that they can alert you if necessary.
If, despite all precautions, the sufferer wanders off for some time, undetected and unseen by anybody, don’t panic. Accidents happen very rarely. I can think of hundreds of people with dementia who have wandered regularly, despite the best efforts of those caring for them, yet I only know of two or three who suffered in consequence. The greatest difficulty caused by wandering is the reluctance of day centres and nursing homes to take responsibility for a person who may disappear. This naturally increases the stress on those caring for them. Drugs are usually of little help, but may have to be tried as a last resort. It is essential though that they are only used for a short period and withdrawn very early if they don’t appear to be helping.
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As well as scanning techniques that examine the structure of the brain and the changes within it, there are also those that measure functional changes, such as the way in which the blood passes through the brain or the manner in which the brain cells use up some of the brain chemicals. One such approach is called PET scanning (positron emission tomography). This has revealed particular patterns of abnormality in the way in which the Alzheimer brain uses glucose for example, but this has been found to be the case only in younger people with the disease, not the older sufferers who make up the majority of people affected. One interesting finding, however, is the fact that the impairment of glucose metabolism in the cerebral cortex varies between individuals with Alzheimer’s disease, and that this difference appears to reflect the way in which the disease affects the sufferer — that is, which symptoms and signs he or she has developed.
PET scanning is extremely complicated and requires access to radioactive materials, albeit in minute quantities, that are difficult to make and use. It is therefore only available in a few centres.
These new scanning techniques, and also CT scans which have been available for quite a while now, have increased our understanding of the changes in the brain a little, but perhaps not as much as we had hoped. We are hoping that there may in a few years be some less expensive and more easily available scanning techniques that will prove useful in helping us to understand what is happening in the brain and improve our diagnostic accuracy.
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It used to be said that about a third of people with Parkinson’s disease would eventually develop dementia. This view would nowadays be considered controversial. Parkinson’s disease can affect the intellect, but in many instances this is insufficient to cause what we would consider to be dementia. It is particularly associated with a slowness of thinking and reacting, but often memory is relatively intact until the later stages in those whose intellect ultimately fails.
It is important not to forget that most people who develop Parkinson’s disease are relatively elderly and are therefore also likely to develop other conditions that occur more frequently in older people, illnesses that cause dementia among them. This has muddied the waters, and it is probable that some people whose dementia has been ascribed to their Parkinson’s disease were all the time suffering from some other unrelated condition, also causing dementia. Taking account of this possibility, a more accurate representation of the truth would probably be that only about one person in ten who has Parkinson’s disease is likely to develop dementia because of the Parkinson’s disease itself. The total number of people with Parkinson’s disease and dementia will be more than one in ten, as some of them may also have Alzheimer’s disease, multiple infarct dementia, or some other cause.
It should also be understood that some of the medicines that are given to people with Parkinson’s disease to treat their movement disorders, may themselves cause confusion. If a person with Parkinson’s is found to be confused, rather than immediately attributing this to dementia caused by the disease, it is important first to make sure that the confusion isn’t a side-effect of the sufferer’s drugs.
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