• What the Partner Experiences.
• Some Characteristics of a Sex Addict's Partner
• What Usually Happens Without Help.
• Roots of the Partner's Behavior.
• A Typical Story.
• The Partner Has a Debilitating Condition Too.
• What to Do If You Need and Want Help.

What the Partner Experiences

For the relationship partner of a sexual addict, it can be a painful process experiencing the powerlessness of the addict's out-of-control behavior. Whether the partner is male or female or the relationship is heterosexual, gay or lesbian, the dynamics are the same. That is, the partner may not know what the addict is involved in, but she does know something is amiss. (For simplicity, "he" will be used in referring to the sexual addict and "she" when referring to the partner.) If the partner tries to discuss her feelings of uncertainty and confusion with the addict, he will probably steadfastly deny that anything is happening. Often the addict will tell his partner that she's imagining things, that everything's all right. The primary dynamic here is a denial of her feelings.

If, on the other hand, she has through one means or another found out that the addict is acting out sexually and confronts him, the addict may attack his partner, telling her that if she was not so (demanding, withholding, out of touch with the times, etc.) there would be no problem. The primary dynamic here is that she's somehow to blame for his behavior. Either way, nothing changes. Most partners describe these processes as "making me feel crazy."

Some Characteristics of a Sex Addict's Partner

A phrase that is used to describe a woman or a man in relationship with a sexual addict is a codependent of a sex addict, or co-addict for short. In her book, Back From Betrayal: Recovery for Women Involved With Sex Addicted Men, Jennifer Schneider presents a cohesive description of a co-addict. Schneider points out that the co-addict's self-esteem comes from her success as a people-pleaser. Her main goal in life is to try to figure out what her partner wants and then give it to him. To assure success at pleasing, she may become extremely sensitive to the momentary mood of her partner. She may constantly worry about what he thinks about her and try extremely hard not to make a mistake.

Because of these self-defeating characteristics, the co-addict usually is much more in tune with what someone else wants than with her own wants and needs. The underlying reason for such a belief is the co-addict's conviction that no one could love her for herself, just as she is, that she must earn love and devotion. The energy expended on such an endeavor can take a heavy toll on the co-addict as she tries repeatedly and unsuccessfully to " keep her man happy." She may engage in a variety of behaviors that range from the smallest violation of her value system to the truly dangerous and destructive. The co-addict, in an effort to please the addict, may do the following things. She may change her hair color, lose/gain weight, quit her job/go to work, or wear sexy underwear. Or she may perform sex acts that are unpleasant or repulsive to her, or attend events that shock and confuse her, swing with others, or expose herself to sexually transmitted diseases. Or, most importantly for a co-addict with children, she may use them and/or ignore them in her efforts to focus on the addict-partner.

To "please and keep her man" the co-addict will often attempt to become indispensable to the addict. Not surprisingly, with the need to be indispensable, the co-addict's most constant emotional state is one of fear. In their book, Women Who Love Sex Addicts: Help For Healing from the Effects of a Relationship With A Sex Addict, Douglas Weiss and Dianne DeBusk list some of the common fears a co-addict may experience. The list includes such beliefs as I was afraid I wasn't woman enough for him; I was afraid I could never please him sexually; I was afraid there was something wrong with me; I was afraid I was a pervert; I was afraid that I wouldn't protect my kids if they were being hurt by him; I was afraid of his anger; I was afraid he would give me a disease. Living with such fears inevitably leads the co-addict to attempt to control the addict's behavior.

Her (unconscious) rationale for this is that if she can keep him within certain parameters of behavior, she won't have to experience her fears of inadequacy and of being abandoned. In reality, such attempts are about as effective as trying to keep the dam from bursting by running around and sticking a finger in the many holes that keep appearing. Nevertheless, the co-addict repeatedly attempts to control the addict with such behaviors as calling or beeping him several times a day in order to find out where he is; checking his wallet for tell-tale evidence; going through credit card bills; checking his shirts for lipstick smudges or his dirty underwear for signs of semen; throwing away pornographic material. She may also attempt to manipulate his behavior with a variety of behaviors of her own, including acting overly understanding and/or becoming a screamer-yeller. Neither works; nor does anything else she tries.

What Usually Happens Without Help

Since the disease of sexual addiction is, like any addiction, progressive, that is, it gets more time-consuming and costly as time goes by, eventually the secret life of the sexual addict is discovered or uncovered and the couple experiences a tremendous crisis. Often, the sexual addict will then enter a period of extreme remorse, beg for forgiveness, and promise never to act out again. His promises at the time are probably sincere and most co-addicts want to believe the words. A honeymoon period may follow, including intense sexual activity between the two people. Since, for the co-addict, sex is often a sign of love, she may be lulled into believing everything is really all right, offer forgiveness and bind up her wounded spirit and go on. She is later shattered to discover the unaccounted for time and secrecy has returned.

Roots of the Partner's Behavior

The reason the behavior of both the addict and co-addict cannot be stopped by self-control is that the roots of their behavior go far back, usually to their growing-up period. Typically, the individuals in the coupleship were given unclear, unhelpful and unworkable covert and overt messages by her/his caretakers about trust, about how important s/he is, what to expect from others and how to get needs and wants met. As an adult, this person may struggle to make relationship connections and to solve life problems. However, the messages they were given earlier about how to navigate in life usually fail her/him;they often turn out to be ineffective at best and disastrous or dangerous at worst.

A Typical Story

In a typical scenario, Chris and Bobby were introduced to each other one night by mutual friends who were helping Chris celebrate her birthday. She was feeling somewhat vulnerable, not only having had a few drinks to celebrate, but she had just broken up with her boyfriend of two years. When Bobby was introduced to her, sparks between the two of them began to fly immediately. He was charming, attentive, intelligent; also somewhat inebriated. The emotional pain Chris had experienced since the breakup began to dissolve. When Bobby asked to take her home that night, she felt that something miraculous was happening. Although she declined to have sex, they engaged in some heavy petting. The went out together the next night, and soon they were seeing each other on a regular basis. A sexual relationship developed quickly which Chris described as incredible.

One day after they had been dating several weeks, Chris was at Bobby's apartment when the phone rang. Since Bobby had just stepped out to get the mail, the answering machine picked up. A female voice began leaving a message saying she couldn't wait to see him and that she was looking forward to giving him a blow job for his upcoming birthday. Stunned, Chris told Bobby what she had heard, and, in a somewhat irritated manner, he explained that the woman leaving the message was an old girlfriend who had been bugging him to get back together and there was nothing to it.

Before long, however, Chris began to notice that whenever they were out, Bobby's eyes would follow any woman with a bra size over 32A. He would sometimes make lewd comments under his breath or smile in a trance-like manner. And sometimes at parties, Bobby would frequently cozy up to some of the other females and ignore her. Once, he even disappeared for a while during a party, and when Chris looked for him, he was outside in a secluded spot with another woman. When Chris started to confront Bobby about what she was seeing, Bobby dismissed her complaints as "stupid" and said that she was beginning to get on his nerves by being so possessive. Chris, not wanting to lose Bobby, decided she'd better back off with the "jealousy."

The doubts she began to experience about whether she was "enough" for him prompted her to begin to visit Victoria's Secret for some lingerie. She also highlighted her hair and went on a body-wrecking quick weight loss diet to lose 10 pounds. After that, Bobby was very attentive for a while and Chris again felt she had solved the problem of Bobby's wandering eye. After Chris agreed to and engaged in some sexual activities that Bobby had been asking her to do, but that she had felt uncomfortable in doing, Bobby surprised her by agreeing to get married. At the bachelor party the night before, Bobby got drunk, barely made it through the wedding and reception and quickly passed out once they were in their hotel.

Fast forward a few years and a couple of kids later. Bobby is now frequently late in coming home. Sometimes when the phone rings and Chris answers, there's silence on the other end. They fight a lot. Chris accuses Bobby of not loving her and the kids and she alternately tries to set things right by being seductive and then angrily telling him how he is hurting her by the way he acts toward her. She walks on eggshells to keep from upsetting him and hushes the kids when he comes home so he won't get angry about their noise. Exhausted, confused, she wonders just what there is to live for.

One day, when opening the mail, she sees a credit card bill that astounds her. The bill is for $450 worth of charges for '900' numbers and visits to a modeling studio. When she confronts Bobby, he at first denies any knowledge of the bill, saying it must be a mistake and then, finally, he tells Chris that he has been engaging in the sexual activities they're being billed for. Chris is rocked to her very core. She questions everything about herself: her intelligence, her sexuality, her reality. Hasn't she been faithful and dedicated to the relationship? Why has this happened? What the co-addict doesn't know is that her partner has a disease called sexual addiction and that she is not responsible for it and she cannot fix it.

The Partner Has a Debilitating Condition Too

It is important, therefore, to recognize that not only her partner has a disease and has developed an irrational way of living and being, but that she, the co-addict, has as well. Each person will need help in erasing or ameliorating the dysfunctional messages they learned during childhood and adolescence that predisposed him/her to their respective diseases and the unfortunate consequences of the addictions.

THIS IS NOT THE SAME AS SAYING THE COADDICT IS RESPONSIBLE FOR THE ADDICT'S BEHAVIOR. He is responsible for his own disease and recovery efforts. However, his taking charge of his life WILL NOT disrupt the co-addict's beliefs and learned behavior of pleasing and controlling. Her belief system was developed long before the sexual addict came on the scene, although the consequences of her beliefs may have intensified in the relationship. Therefore, the "baggage" stays unless both the sexual addict and co-addict get help. Even leaving the relationship will not erase the co-addict's needs to deal with her own issues. Time and again, research has indicated that even when a co-addict leaves a relationship, she almost always picks someone else similar in characteristics to the last partner. Without help, this is the way the co-addict lives her life.

What to Do If You Need and Want Help

If you have related to the information presented in the foregoing and would like more information about getting help, visit the treatment section.

Find out about female sexual dysfunction among older women and the treatments that lead to active sexual lives.

Summary & Participants

Despite what many people think, older women can lead healthy and active sexual lives. But this doesn't mean it will always be easy. Our panel will discuss the challenges to an elder woman's sexual life, and how to face them.

Host:
Mark Pochapin, MD
Weill Medical College of Cornell University, New York

Participants:
David Kaufman, MD
Columbia University, College of Physicians and Surgeons
Patricia Bloom, MD
Mount Sinai-New York University Medical Center
Dagmar O'Connor, PhD
Columbia University

Webcast Transcript

MARK POCHAPIN, MD: Hi, thank you for joining us today. Today we're going to focus on people who are considered "the elderly." However, when we think about elderly people, we often think about people who are not very active. Today, not only are we going to talk about activity, but also we're going to talk about sexual activity.

Starting with us today are a few of my guest panelists. To my left is Dr. David Kaufman, who's an assistant professor of clinical urology at Columbia University. Welcome. Sitting next to David is Dr. Patricia Bloom. She's the chief of geriatric medicine at St. Luke's/Roosevelt Hospital here in New York City. Welcome, Patricia. Sitting next to her is Dr. Dagmar O'Connor, who's a psychologist, a sex therapist, and really the first woman sex therapist to be trained by Masters and Johnson in New York City. Thank you all for joining us today.

Let's start off with sex and the elderly woman. When we talk about "elderly woman," what are we talking about? David, what is considered to be elderly now?

DAVID KAUFMAN, MD: I think that really has changed dramatically over the last few decades. As the Baby Boomers are getting older, it's really hard to consider somebody over the age of 55, which might have been considered a senior in the past, as elderly, because they're just really exhibiting behavior patterns that they've been exhibiting for a long time. I think that probably for the purposes of this discussion, we should really be speaking about the eighth decade of life if my panelists agree with me there.

DAGMAR O'CONNOR, PhD: I often think that the woman feels old when she enters menopause. That's the first real sign of loss of reproductiveness and the purpose of life. That is the time when most of the trouble starts in terms of sexual functioning.

PATRICIA BLOOM, MD: So you would say anytime between 45 and 55.

DAGMAR O'CONNOR, PhD: I would think so.

PATRICIA BLOOM, MD: Although technically speaking, as a geriatrician, it's over the age of 65. But I will agree with David that our, I guess as all of us approach, we like to push it.

DAVID KAUFMAN, MD: I don't like the 45 part being considered elderly.

PATRICIA BLOOM, MD: But especially talking about sexual activity, I think what is interesting is that people don't even conceive of people over the age of 80 being sexually active. But I think you would agree, surveys show that actually the majority of people over the age of 65 are still sexually active. And even when you get into the 80 and above, still about a quarter to a third of elderly, even women and men, have sexual activity. And that's something that people generally don't think about or wouldn't believe is true.

MARK POCHAPIN, MD: Right. It's actually, certainly not a topic that you hear much about. It's not a focus in either medical schools or in the curriculum, and it's something that seems to be appropriate, given the fact that there are plenty of people who are sexually active who are considered elderly.

DAGMAR O'CONNOR, PhD: I treat quite a few couples who are in their eighties, and it's a surprise. They would never dare to tell their grandchildren or their children that they could sneak away and see a sex therapist.

MARK POCHAPIN, MD: Let's start with the physical changes. Obviously, as someone gets older, there are physical changes that occur in their body. David, what is occurring in a woman from a medical perspective that might make sexual activity different?

DAVID KAUFMAN, MD: I think what comes to mind first is, along with menopause and the changes that accompany menopause, there's a decrease in the ability of women to lubricate as they get older, and that certainly impacts on their ability to enjoy sex, and perhaps participate in sex because of their lack of enjoyment.

There are also medical conditions that occur, such as atrophic vaginitis, which occurs as women get older, where the tissue itself becomes less elastic and the vaginal opening becomes smaller, and that also interferes with a person's ability to participate in sex, and certainly enjoy sex. Now, all of these problems have medical solutions to them, and I'm sure Dr. Bloom takes care of these conditions on a regular basis.

MARK POCHAPIN, MD: Now, what do you do? Do you actually address these problems with the patient, or do they actually tell you about them?

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PATRICIA BLOOM, MD: That's a very good question. In fact, a big part of what I do is training young physicians. And we really have to remind them to ask about sexual activity because, as I said, people have assumptions that, if you're over a certain age, you're not sexually active. And I think it's very helpful for elderly people, if the doctor does ask them. Because, as you said, they might be somewhat embarrassed or think that it's not a problem that's okay to bring up in the office. So, yeah, I think the physician should ask.

In addition, the actual changes in the vagina and the surrounding tissues are a critical part of what affects older women, but in addition to that are their medical conditions, which can influence either their interest or their ability. And there's a whole range of that, from women with heart disease, who might get chest pain when they're vigorously sexually active, to people with lung disease who might get breathless, or people with arthritis who have difficulty positioning themselves.

And then there's the whole affect of conditions, which influence women's self-esteem, which might just be changes in the body. We live in such a society that thinks you have to be a svelte, lithe young thing to be sexually active. So there might just be embarrassment about shifts in body composition or having a stomach. Or, farther down the line would be things like having had a mastectomy or a colostomy bag or other conditions like that, where women would really have a loss of self-esteem and feel embarrassed, especially if it's with a new partner. Then the situation of having a new partner late in life is a whole new thing that Dagmar probably deals with.

DAGMAR O'CONNOR, PhD: It's a very difficult thing. I think even younger women have body image problems. And then it gets quadrupled when you get into old age. But the nice thing about old age, remember, that your partner also loses his eyesight. It's not as dramatic. But many of the women prefer to have sex in the dark. Many of their partners, men, are much more visually oriented than women and it becomes a problem. "Why do we always have to have it in the dark?"

PATRICIA BLOOM, MD: Do you find that you can convince women to somehow shed that embarrassment and feel somehow more accepting of their bodies?

DAGMAR O'CONNOR, PhD: Absolutely.

PATRICIA BLOOM, MD: How do you get them to do that?

DAGMAR O'CONNOR, PhD: I run sexual self-esteem workshops for women of all ages, and men as well. Part of it is learning to love your body the way it looks right now. And I remember a woman who said to me "I didn't learn to love my body until I lost it."

MARK POCHAPIN, MD: That's very interesting. I think sort of in a crisis-oriented society, you could see that happening. In all medical care, it seems to be related to when something's a problem, people address.

DAGMAR O'CONNOR, PhD: It's also important that some of these problems, vaginal problems, there are things you can do about them, and by the time they end up with me in the sex therapy, some of the thinning of the vagina and the painful intercourse can be taken care of by some friction, and what I call traffic. The tissue is the same as any tissue in our body. The more we rub it, if we don't do it too much, the more it stretches. So I work a lot with women to make them more comfortable by just practical means. And also getting them ointments or lubrication.

MARK POCHAPIN, MD: How do women come to a sex therapist? In other words, do they come on their own? Is it a physician that refers them? Is it a urologist or geriatrician? Because as we said earlier, this is really a subject that doesn't get much attention.

DAGMAR O'CONNOR, PhD: A mixture. I get referrals from all of you, and I also get referrals from my book/video packet, which is a do-it-yourself video packet for sex therapy. Couples start using it, and then they get stuck somewhere and they call me. And the so-called transference has already taken place. They know me already.

Also by friends. You feel safe when you have a friend who says "I know this person, and they make me feel safe." So that's another way.

MARK POCHAPIN, MD: The self-esteem issue is interesting to me because that's obviously an issue that's not age-related. That begins way back but seems to become more of an issue as someone gets older. Or maybe it just becomes more of a focus. But how do you address that? What do you do about someone who really doesn't have the self-esteem to move ahead?

DAGMAR O'CONNOR, PhD: It's very often asking them to confront the problem upfront. If you learned that you have to look like a model in order to be sexual, you have to start looking at what you've got. And I have the women stand nude in front of a mirror and look at their bodies and draw pictures, as an artist. I say: "I don't want any comparisons." You've got to come away from this event loving five things about your body. They may start with their feet or their fingernails, but they slowly have to grow to love it. You only do that if you look at it often.

MARK POCHAPIN, MD: Pat, as a geriatrician, you see someone, let's say, for a problem with chronic lung disease or a problem with chronic heart disease. You put it in the appropriate social setting. When does the issue of sex and sexual function come up? Is that something that you bring up with every patient you see? Or is it something that you wait to be addressed with you?

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PATRICIA BLOOM, MD: I try, as part of the initial assessment, to ascertain whether people are sexually active. If they are, is it satisfying? Are they having problems with it? If they're not, do they wish they were? That sort of gives them permission to talk about it. They might not want to explore it very much on that visit, but at least it opens the door to communication. And then, hopefully, I on every visit will ask them if there's anything else they're concerned about. They may bring it up on subsequent visits, see if it's not something that's bothering them at the time of their initial visit.

But I think having an open door kind of dialogue is helpful. Similarly, I think with, talking about self-esteem, a lot of these issues have to do with communication. Getting into what does the person want. That is at the basis of all of these issues, whether it's with a partner, an old partner or a new partner. And, interestingly, for some elderly people, that's the biggest issue. They don't have a partner.

There are some interesting relationships that form as a result of that. Some women who've been heterosexual all their lives may form a very nice relationship with another woman. And some people who just don't have a partner at all might find that self-expression of sexuality is something that they enjoy exploring in their later years.

DAGMAR O'CONNOR, PhD: Making love to yourself, as I call it, is an important part of being sexual. It's not what we say is shameful that we do quickly, but when you make love you give yourself foreplay, and you take your time, and you give yourself love.

PATRICIA BLOOM, MD: The thing that it's important, I think, for everyone to remember, is that when we're talking about elderly people, people who are elderly now, whether you're talking about 65 or 75 or whatever, most of that category of people grew up, their whole lives, not talking about sex. I think that people's willingness to be open and talk about sex came later. There has been a sexual revolution.

DAVID KAUFMAN, MD: There has been a sexual revolution, certainly, lately, because of the pharmaceutical.

MARK POCHAPIN, MD: In older patients?

DAVID KAUFMAN, MD: Well, I think so. I think in everybody. But since the advent of some of the new pharmaceuticals that have come out, of course, Viagra (sildenafil citrate) by Pfizer, where there are now commercials on television with ex-presidential candidates talking about their sexual problems, it really has opened up the door and allowed for people to come and acknowledge that there may or may not be a problem in their lives. And I think they are speaking about it more.

When it hit the pharmacy shelves, my office was inundated with people who are suddenly facing the fact that they do have a problem. And now that they knew that there was something available that was fairly easy to take, a pill, they were really coming out of the woodwork looking for answers.

And since we're on the topic of women right now, there has been some amount of research, based in Boston, of using this drug Viagra (sildenafil citrate) in the treatment of female sexual dysfunction. When the news articles hit the stands about the results of that research, I had a tremendous number of women ask me questions about its possible role in their treatment.

MARK POCHAPIN, MD: There is a role, possibly, for women using Viagra (sildenafil citrate)?

DAVID KAUFMAN, MD: That's still under examination. I don't know how technical you want to get right now, but there's no question that drugs such as Viagra (sildenafil citrate) will increase clitoral blood flow. Which is really analogous to what Viagra (sildenafil citrate) does in men, that it improves the quality of the erection. And that's been proved with Doppler ultrasound, that clitoral blood flow does increase. Now, of course, female sexuality is probably more complicated that than, so just because they have increased clitoral blood flow doesn't mean that their sex drive and their ability to enjoy sex, and their ability to reach orgasm, for instance, is necessarily improved. But the drug does work, and it does do what it's supposed to do, which is increase blood flow.

MARK POCHAPIN, MD: The point being that there are now drugs being aimed at older people, for the sole purpose of engaging in sex, is really something that goes along with the fact that we have to start talking about that.

Well, I appreciate the three of you on our panel tonight. It's a very interesting topic. I certainly learned quite a bit, and I'm sure our audience has learned quite a bit as well. Older people have a life, and with that life, they should enjoy the same pleasures that they did when they were younger.

This is Dr. Mark Pochapin. Thank you for joining us tonight.

If there's one age group that parents wring their hands over, it's teenagers between the ages of fourteen and seventeen. They are in the throes of adolescence, which often means they are moody, private, likely to take risks, and likely to challenge authority and conventions. One day they behave like five-year-olds, the next like mature adults.

Most teenagers have entered puberty, and are actively exploring their sexuality, and it can be a profoundly confusing time.

Below, two adolescent health experts discuss what parents and their middle adolescent children need to know about sex and sexuality.

What is one of the primary concerns among teenagers, as their hormone levels are increasing and they are beginning to see changes in their bodies?

DAVID BELL, MD: One of the main things teenagers want to know is that everything is normal. They're comparing themselves a lot with their peers, and part of the process is to figure out what's normal and what's not.

JENNIFER JOHNSON, MD: There's a lot of comparing of naked bodies among kids, they're thinking, "What's he look like, compared with what I look like?" That's what happens in the showers in the gym. Of course, no one admits to looking at anybody else, but they do it because they're coming to terms with their new body and seeing it compared with other people's bodies. It's really important.

In terms of sexual development, is masturbation normal at this time?

JENNIFER JOHNSON, MD: Yes, I think the majority of kids have masturbated, especially by the time they've reached the ages of sixteen or seventeen. Most kids do it, regardless of what they've been told about it.

Medically, we know that masturbation is perfectly safe and, in fact, can be a very healthy outlet for these strong sexual drives that kids are experiencing.

Are wet dreams normal at this age as well?

DAVID BELL, MD: Yes. During their sleep at some point during puberty, boys may have a nocturnal emission, or a "wet dream." Basically, it's the release of semen or sperm during the night, during their sleep.

Is this disturbing for some boys?

DAVID BELL, MD: Yes. And that's one important reason for parents to have a discussion with their teenage boys about wet dreams before they happen, just as we do with females before their first period, to prepare them for it. If a boy does not know what a wet dream is, he may think he urinated in the bed, and that can be devastating.

Is same-sex experimentation normal at this time as well? How common is it?

JENNIFER JOHNSON, MD: We don't have a lot of information about how common same-sex experimentation is. But certainly when and if it does happen, it's very normal. Again, it's a way for teenagers to assess their own growth, and compare themselves to their peers.

DAVID BELL, MD: I think it is important both for parents and for the teenager not to label their sexual orientation based on episodes like these.

JENNIFER JOHNSON, MD: Right. Sexual orientation is often still emerging in adolescents, and sometimes it changes during a person's life. It's important to differentiate sexual orientation from sexual behavior, because guys and girls may have same-sex sexual experiences and be completely heterosexually oriented.

By the same token, boys and girls who are gay may have heterosexual relationships, including intercourse, and not have homosexual experiences until later in life.

Are children between the ages of fourteen and seventeen having sex? What does the research tell us?

JENNIFER JOHNSON, MD: The national data show that by the time teenagers are in their senior year of high school, about 60%, maybe 70% of boys have had sex, and probably about 50% of girls have had sex. By 'sex', they mean oral sex or intercourse.

So if you want to view it strictly in behavioral terms, having sex in high school is, in our society, a normative behavior, meaning more people do it than don't.

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Do you find that kids who want to abstain from sex feel comfortable in abstinence? Or do they feel a lot of pressure to be sexually active?

JENNIFER JOHNSON, MD: In some schools, there are very, very strong abstinence movements, and the cool thing to do is to say you're not going to have sex. But it varies a lot from teenager to teenager and from peer group to peer group.

One thing that is very certain is that the behavior in a peer group is the indication of the level of risk for a member of that group. If my daughter is hanging around with girls who smoke and drink beer at parties, I know that she in danger, because certain risk behaviors, like smoking, are linked with the initiation of sexual activity.

DAVID BELL, MD: There's also data from the Adolescent Health Survey that shows that the more connected teenagers are to either their family, to school, or to extracurricular activities, the safer they are in their relationships and behaviors.

What are the statistics on contraception use among sexually active teenagers?

JENNIFER JOHNSON, MD: One of the recent nationally representative surveys of teenagers found that, in contrast to the 1970s, almost two-thirds of teenagers use contraception the first time they have sex. That is a far cry from the 10-20% that we were seeing in the Seventies.

Is this increase a result of education campaigns?

JENNIFER JOHNSON, MD: Yes, I think so. Kids know about birth control and why it's important to use it. And, in general, they have access to at least condoms.

Teenagers may not ask their parents directly for information about sex, but do they want to hear what their parents have to say on the subject?

DAVID BELL, MD: I think, in some respects, yes, they do, but it's a delicate balance of when and how to deliver the information.

Sometimes the adolescent will ask about sex in reference to a friend. That opens up an opportunity for the teenager to share their own values and thoughts.

JENNIFER JOHNSON, MD: Parents need to know what's going on in these areas. On the other hand, I think it's important for parents to recognize that teenagers are becoming independent and they do, to some extent, have rights to privacy. They do have the right to have time alone in their room without anybody being in there.

That doesn't mean that parents can't talk to kids. But rather then just telling them what you think, you may open the door a lot better if you ask their opinion too.

I also think it's really important for parents to spend time with their teenager. It is very helpful, in terms of keeping communication open and demonstrating your commitment, if you do something together that you both enjoy doing.

DAVID BELL, MD: Some of the best conversations with your teenager come at unexpected times, whether riding in a car or on a camping trip...it's not this formal, sit-down talk about the birds and the bees.

SHOULD you be open with your kids about your sex life?

Q: Most Parents I know hide their sex lives from their children. My wife and I would like to be more open with our 2-year-old daughter without causing her harm. How much physical attention is appropriate to demonstrate in front of a 2-year-old?

Radio Psychologist Dr. Joy Browne: Simply put, one of the principal tasks facing parents is creating healthy boundaries between themselves and their child. Sexually speaking, this translates into making sure that the sexual natures of both adults and children are respected, but not intertwined. You breach that respect when you expose your bright, aware 2-year-old to sexual intimacies between you and your wife.

Children are sexual creatures from infancy and they regularly explore their own bodies, even if they are not knowledgeable about what they are doing. So think of your daughter as someone eager to learn about the fascinating world of pleasurable sensations. You'll be teaching her by example when you or your wife talk to her (she will absorb your tone of voice and your anxiety level), when you dress her, show her affection, play with her, and tell her the names of the parts of her body. In fact, on an almost daily basis you will be deliberately or inadvertently demonstrating something new and profoundly important about love and relationships, and she'll be eating up every word and gesture with a spoon. And that's a serious responsibility for you to keep.

But an excess of openness can be dangerous; lines must be drawn. Kissing and affectionately caressing in a nonsexual manner in your daughter's presence is a great way to model grown-up love.

The meaning of "privacy" is something that you'll have to introduce to your daughter soon enough anyway, when she starts spontaneously exploring her own pleasure zones (if she hasn't already!). For instance, you and your wife will be the ones to show her that there's a better place than the front steps of your house or the middle of the supermarket aisles to do what I've heard called the "happy wiggle." If you haven't created private space for intimate acts, how can she be expected to grasp the concept when you try to explain it?

For more guidance on this complex subject, visit the Sexuality, Education and Information Council of the United States at www.siecus.org, or read From Diapers to Dating: A Parent's Guide To Raising Sexually Healthy Children by Debra W. Haffner.

Drugs That Cause Sexual Dysfunction
Drug	Mechanism	Impact
Oral contraceptive pills	Reduced testosterone production	Decreased desire
	Increased sex hormone-binding globulin (SHBG)
SSRIs (Selective Serotonin Reuptake Inhibitors)	Activate 5-hydroxytriptamine	Inhibit arousal
		Delay or absence of orgasm
SERMs (Selective Estrogen Receptor Modulators)	Act as antiestrogen	Increase vaginal dryness
Phytoestrogens
Estrogen
		Increase dyspareunia (painful or difficult intercourse)
Spironolactone
Steroids
Codeine containing analgesics (pain killers)	Acts as antiandrogens	Decrease desire
Chronic alcohol abuse
B-blockers (beta-blockers)	Antiadrenergic effects	Impair lubrication
Tricyclic antidepressants	Anticholinergic effects	Impair lubrication
Monoamine oxidase inhibitors
Antipsychotics	Anticholinergic effects	Impair lubrication
	Dopamine blocking effects	Impair arousal and orgasm
Cyproterone acetate	Act as antiandrogen	Decreased desire
Medroxyprogesterone
Citalopram	Increase prolactin	Decrease desire
Paroxetine

Antidepressants that activate dopaminergic (bupropion (Wellbutrin), venlafaxine(Effexor)), central noradrenic receptors (mirtazepine, bupropion, venlafaxine) and 5-hydroxytriptamine (5-HT) A1 and 2C receptors (nefazodone (Serzone), mirtazepine) may augment sexual response. Those that activate other 5-HT receptors, prolactin and gamma-aminobutyric acid reduce sexual response."

Source: Vaginal Anatomy and Physiology by Sohail A. Siddique, MD (J Pelvic Med Surg 2003;9:263-272)

Antihypertensive agents:

Aldomet (alpha-methyldopa): Used to treat high blood pressure results in decreased libido and sexual arousal in 10 to 15% of women who use it in low dosages, and up to 50% of women who use it in high dosages. Many of the drugs used to treat high blood pressure impair sexual function in women. There are numerous drugs available to treat this illness, a woman may need to try several different ones, or combinations, to find one that doesn't affect her sexuality adversely. Source:Masters and Johnson on Sex and Human Loving page 520.

"Traditional blood pressure lowering medications, like reserpine and guanethidine, often cause sexual dysfunction in men, along with dizziness and depression, and for this reason many doctors have moved away from them. Beta-blockers marketed under the names Inderal, Lopressor, Corgard, Blocadren, and Tenormin have fewer side effects, but many people who take them still complain of sexual dysfunction. In recent years calcium channel blockers, marketed as Adalat, Procardia, Calan, Isoptin, Verelan, Cardizem, Dilacor XR, and Tiazac have become more popular, in part because they have less effect on sexual function." Source:For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. Pages 89, 91

All the drugs outlined below have been shown to cause erection problems in men. They are also associated with sexual dysfunction in women, including decreased libido, decreased arousal, and orgasmic disorder.

Drug Type:	Brand Names:	Prescribed For:
Beta-Adrenergic Blocker	Inderal, Lopressor, Corgard, Blocadren, Tenormin	High Blood Pressure
Calcium Channel Blocker	Adalat, Procardia, Calan, Isoptin, Verelan, Cardizem, Dilacor XR, Triazac	High Blood Pressure

 

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Sedatives:

Librium (chlordiazepoxide) and are tranquilizers. They can sometimes cause erectile dysfunction and anorgasmia, inability to orgasm. Source: Masters and Johnson on Sex and Human Loving page 520.

Quaalude (methaqualone) is a barbiturate. Barbiturates can depress the functions of the nervous system impairing sexual function. Source: Masters and Johnson on Sex and Human Loving page 520.

"Sedatives: These include medications like alprazolam, marketed as Xanax, and Valium. They are prescribed to relieve anxiety, but they can also cause a loss of sexual desire and arousal." Source: For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. Pages 90, 92

All the drugs outlined below have been shown to cause erection problems in men. They are also associated with sexual dysfunction in women, including decreased libido, decreased arousal, and orgasmic disorder.

Drug Type:	Brand Names:	Prescribed For:
Antianxiety	Xanax	Anxiety

Antihistamines:

Antihistamines used to treat allergies and sinus ailments can result in drowsiness and a reduction in vaginal lubrication. Drowsiness will result in a decreased ability to stay awake for sex. Reduced lubrication can be perceived as vaginal pain during intercourse. Source: Masters and Johnson on Sex and Human Loving page 520.

Antidepressants:

Antidepressants: Prozac (fluoxetine), , Paxil (paroxetine), Luvox (fluvoxamine), and Serzone (Nefazodone). These are all "selective serotonin reuptake inhibitors (SSRIs)". They can cause decreased sex drive and delayed orgasm. 1 to 25% of people using SSRIs report some sexual impairment. Zoloft and Luzox have the lowest reported side effects, Paxil the highest. Women may need to try one or more of these to find one that doesn't adversely affect her sexually. Antidepressants may improve a woman's desire and enjoyment of sex as she will feel less depressed and more in the mood for it. A new class of antidepressants, the first of which is MK869, are as effective as Paxil without the sexual side effects. Source: Girlfriends Magazine, December 1998, Page 18. Dr. Beth Brown.

"Antidepressants: Tricyclic antidepressants like clomipramine, marketed as Anafranil, causes sexual dysfunction in nearly half of the patients who take it. Anafranil has actually been used for premature ejaculation in men because it delays orgasm. Other tricyclics, like Elavil, Tofranil, Sinequan, and Pamelor can cause dry mouth, dizziness, constipation, and lethargy. For these reasons, many people prefer Prozac, the first of a new generation of enormously effective antidepressants that have fewer unpleasant side effects. Prozac is a selective serotonin reuptake inhibitor, or SSRI, and works by enhancing the action of the brains chemical serotonin. But Prozac, like the newer SSRI Zoloft, causes sexual dysfunction - usually delay in reaching orgasm, or an inability to reach orgasm - in as many as 60 percent of patients. Paxil, another SSRI, can cause a loss of libido." Source:For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. Pages 90, 92

All the drugs outlined below have been shown to cause erection problems in men. They are also associated with sexual dysfunction in women, including decreased libido, decreased arousal, and orgasmic disorder.

Drug Type:	Brand Names:	Prescribed For:
Tricyclic Antidepressant	Anafranil, Elavil, Tofranil, Sinequan, Pamelor	Depression
Selective Serotonin Reuptake Inhibitor (SRRI)	Prozac, Zoloft, Paxil, etc.	Depression

A visitor, Patrick, had this to say:

RE: Orgasm difficulties and SSRI antidepressants (both genders)

Although you've probably heard this before, I think it's important, so I'll "repeat." Orgasm can be delayed, difficult, or impossible for people taking SSRI type antidepressants (Prozac, Luvox, Paxil, Zoloft, etc.))

Also:

• Both sex and cuddles can still be great fun for both.
• The overall success of these drugs can be so wonderful that it's still worth taking them.
• Talking with female friends has let me know that this happens to men & women in very similar ways.

As this points out, sex can be fun and enjoyable even in the absence of orgasm, for both men and women. Placing to much emphasis on orgasm can have an adverse affect on an individual or couple. Sex is much more than just orgasm.

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Neuroleptics:

"These include antipsychotic drugs, like Thorazine, Haldol, and Zyprexa, which cause sexual dysfunction as well as significant emotional blunting in some patients." Source: For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. Pages 90, 92

All the drugs outlined below have been shown to cause erection problems in men. They are also associated with sexual dysfunction in women, including decreased libido, decreased arousal, and orgasmic disorder.

Drug Type:	Brand Names:	Prescribed For:
Antipsychotic	Thorazine, Haldol, Clozaril, Seroquel, Zyprexa, most others	Psychotic disorders, manic phase of manic depression, severe nausea or vomiting, preoperative sedative

Anticonvulsants:

"Antiseizure drugs, including phenobarbital, marketed as Luminal, as well as Dilantin, Mysoline, and Tegretol, can cause sexual dysfunction. " Source:: For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. Pages 90, 92

All the drugs outlined below have been shown to cause erection problems in men. They are also associated with sexual dysfunction in women, including decreased libido, decreased arousal, and orgasmic disorder.

Drug Type:	Brand Names:	Prescribed For:
Anticonvulsants, hypnotic	Luminal, Dilantin, Mysoline, Tegretol	Seizures

Antiulcer Drugs:

"Cimetidine, or Tagamet, was the first of a new class of highly effective ulcer drugs that are also used to treat serious heartburn. It works by blocking the secretion of stomach acid. Although side effects are not common, adverse reactions include impotence in men. We do not yet know the sexual function side effect in women." Source:For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D. Pages 90, 92

All the drugs outlined below have been shown to cause erection problems in men. They are also associated with sexual dysfunction in women, including decreased libido, decreased arousal, and orgasmic disorder.

Drug Type:	Brand Names:	Prescribed For:
H2 Receptor Antagonist	Tagamet	Ulcers

Anticancer Drugs:

"Tamoxifen, a drug prescribed to delay the recurrence of breast cancer that is marketed as Nolvadex, can cause vaginal bleeding, vaginal discharge, menstrual irregularities, genital itching, and depression. Patients on tamoxifin must be monitored for development of endometrial cancer." Source:e: For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. Pages 91, 92

Birth Control Pills:

"Many women taking birth control pills enjoy sex far more than before because they have been freed from their fear of pregnancy. But some women who take progestin-dominant pills complain of a loss of libido and vaginal dryness because of the hormone shifts caused by the pills." Source: For Women Only by Jennifer Berman, M.D., and Laura Berman, PH.D.. Pages 91, 93

All the drugs outlined below have been shown to cause erection problems in men. They are also associated with sexual dysfunction in women, including decreased libido, decreased arousal, and orgasmic disorder.

Drug Type:	Brand Names:	Prescribed For:
Progestin-dominant Oral Contraceptive	Ortho 7/7/7, Cyclen, Tricyclen	Birth Control

NonSteroidal Anti-Inflammatory Drugs (NSAIDs):

Stacy had this to say about NSAIDs and rheumatoid arthritis:

"I've been on a range of medications for rheumatoid arthritis over the past 11-12 years. It's been my experience that all NSAIDs (Nonsteroidal Anti-Inflammatory Drugs) make it more difficult to reach or sustain full arousal, and all reduce natural lubrication, but not all do to the same degree. I've gathered from conversations with other women with RA that this may be a common problem, although with the majority of NSAIDs our experiences of which were worse varied considerably. Some of this was probably due to differential dosages, and to differing med schedules, but in general individual response to NSAIDs varies quite a bit. The one possible exception was Naproxen: almost all the women I've spoken with who've been on it for RA have mentioned not only these side-effects but also that it appeared to lower desire. This is also the only one I'm aware of that lists potential sexual side-effects in its information sheet, not for women, but for men: impotence and lowered libido."

When there are sex problems, there are psychological issues involved. That's where a good sex therapist can help.

Bob became increasingly embarrassed as he talked about his problem with premature ejaculation. He claimed that can only 'last' for two minutes and felt that he was not much of a man. His 'problem' has kept him from dating.

Sally was beside herself with fear as she harshly castigated herself for not being able to achieve orgasm. She feared she would lose her husband because of her 'condition.'

Most sexual dysfunction occurs because of faulty beliefs and attitudes about sexuality, poor habits, ignorance, and early experiences. There are some sexual dysfunctions that are precipitated by physiological, biological, or chemical factors. However, all physiological dysfunctions have a psychological component. When men are unable to obtain or maintain an erection, whether from physiological or psychological causes, they feel inferior, less manly. When a woman is unable to reach orgasm she feels less feminine. Therefore, in all cases of sexual dysfunction, it is necessary to attend to the psychological aspects of the difficulty and what it means to the individual.

Physiological factors. Some of the more common non-psychological precipitants of sexual dysfunction include hormonal imbalance, medications, neurological impairment, substance abuse (even nicotine dependence can cause erectile dysfunction), alcohol dependency, physiological disorders, and even vitamin deficiency. Certain illnesses and medications can have side effects that affect sexual functioning including impotence and increased or decreased libido.

Many people prefer to think of only a medical approach to sexual dysfunction since it is more acceptable to one's self-image to believe that there is an organic basis for the dysfunction. Even in those instances when there is a recognizable medical condition affecting sexual functioning, the psychological component cannot be overlooked. We all have varying psychological reactions to physical illness or impairment. This psychological reaction can exacerbate the physical problem. This is especially true for infertility problems. Most people who have difficulty conceiving a child choose to investigate the medical aspects to the exclusion of the psychological aspects. Yet we all know of many cases where a couple after years of frequenting the fertility clinics to no avail, finally decide to adopt a child only to conceive a few months afterward. This can suggest that psychological factors were at play.

Psychological factors.. Most sexual dysfunctions have a psychosocial etiology. Dr. Helen Singer Kaplan states, "In a general sense we see the immediate causes of the sexual dysfunctions as arising from an anti-erotic environment created by the couple which is destructive to the sexuality of one or both. An ambiance of openness and trust allows the partners to abandon themselves fully to the erotic experience."

She lists four specific sources of anxiety and defenses against full sexual enjoyment: 1) Avoidance of or failure to engage in sexual behavior which is exciting and stimulating to both partners. 2) Fear of failure, exacerbated by pressure to perform, and overconcern about pleasing one's partner rooted in fears of rejection. 3) A tendency to erect defenses against erotic pleasure. 4) Failure to communicate openly and without guilt and defensiveness about feelings, wishes and responses. Psychological reactions to traumatic events also affect sexual functioning. For example, child molestation, rape, abuse all can contribute to later sexual dysfunction.

Common Sexual Dysfunctions

The following are the most common forms of sexual dysfunction. They are all treatable with a high probability of success.

Male Dysfunctions

Inhibited Sexual Desire. Inhibited sexual desire or response refers to the lack of desire for erotic sexual contact. In almost all cases when there is a lack of sexual desire, the underlying causes are psychological in nature. Avoidance of sexual contact because of fears of rejection, failure, criticism, feelings of embarrassment or awkwardness, body image concerns, performance anxiety, anger towards a partner or women in general, lack of attraction towards a partner, all play a part in reducing or eliminating the sexual response. Most men are too uncomfortable to talk to their partner or anyone else about these issues, preferring to simply avoid sex or attribute their lack of sexual appetite to stress, worries, etc. Some of these men have a very active fantasy life and prefer the solitude of masturbation to the intimacy of sexual relations.

Premature Ejaculation. Premature ejaculation is the most common dysfunction and it is the easiest to treat. Masters and Johnson define premature ejaculation as the inability to delay ejaculation long enough for the woman to orgasm fifty percent of the time. (If the woman is not able to have an orgasm for reasons other than the rapid ejaculation of her partner, this definition does not apply.) Other therapists define premature ejaculation as the inability to delay ejaculation for thirty-seconds to a minute after the penis enters the vagina.

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For the most part, premature ejaculation most often occurs as a function of a learned response. Early sexual experiences were often hurried in nature. Even masturbatory activity had to be hurried for fear of being caught. From youth onward men have trained themselves to be more concerned with the end result and their own pleasure rather than with the sexual process and their partner. The object of sex for most of these men, was and often continues to be, ejaculating as quickly as possible. This rapid ejaculating pattern can easily become a way of life after even only a few episodes. It then begins to create a pattern of anxiety in the male each time he engages in coitus thus increasing the probability of it occurring. Fearful of displeasing their partner and feeling inadequate as a function of it, men often would rather avoid sex rather than experience the humiliation and discomfort.

Retarded Ejaculation or Ejaculatory Incompetence. Ejaculatory incompetence is the opposite of premature ejaculation and refers to the inability to ejaculate inside the vagina. Men with this difficulty may be able to maintain an erection for 30 minutes to an hour, but because of psychological concerns about ejaculating inside a woman, they are not able to achieve orgasm. Usually, they do not experience sexual intercourse as satisfying. One of the reasons this dysfunction goes undetected is because the male's partner is satisfied and often is able to achieve several orgasms as a function of the man's inability to ejaculate. Most of the men who suffer from retarded ejaculation can readily achieve orgasm through masturbation or in some cases through fellatio. Many factors contribute to this condition, some of which are religious restrictions, fear of impregnating, and lack of physical interest or active dislike for the female partner. In addition, such psychological factors as ambivalence toward one's partner, suppressed anger, fear of abandonment, or obsessional preoccupation also play a significant role in developing retarded ejaculation.

Primary & Secondary Erectile Dysfunction. Primary erectile dysfunction refers to a man who has never been able to maintain an erection for purposes of intercourse either with a female or a male, vaginally or rectally. In secondary impotence, a man cannot maintain or perhaps even get an erection but has succeeded at having either vaginal or rectal intercourse at least one time in his life. The occasional failure to get an erection is not to be confused with secondary impotence. Familial, societal, and intrapsychic factors contribute to primary impotence. Some of the more common influences are (1) performance anxiety, (2) a seductive relationship with a mother, (3) religious beliefs in sex as a sin, (4) traumatic initial failure, (5) anger toward women, and (6) fear of impregnating a woman.

Female Dysfunctions

General Dysfunction. These dysfunctions, according to noted sexologist, Dr. Helen Singer Kaplan, "are characterized by inhibition in the general arousal aspect of the sexual response. On a psychological level, there is a lack of erotic feelings." Manifested by lack of lubrication, her vagina does not expand, and "there is no formation of an orgasmic platform. She may also be inorgasmic. In other words, these women manifest a universal sexual inhibition which varies in intensity."

Orgastic Dysfunction. The most common sexual complaint of women involves the specific inhibition of orgasm. Orgastic dysfunction refers solely to the impairment of the orgastic component of the female sexual response and not arousal in general. Nonorgastic women can become sexually aroused and in fact enjoy most other aspects of sexual arousal. Inhibition and guilt about masturbation, discomfort with one's body, and difficulty giving up control, contribute to orgastic dysfunction. With a combination of education and practice, most women can be taught to achieve orgasm.

Vaginismus. This relatively rare sexual disorder is characterized by a conditioned spasm of the vaginal entrance. The vagina involuntarily closes down tight whenever entry is attempted, precluding sexual intercourse. Otherwise, vaginismic women are often sexually responsive and orgastic with clitoral stimulation. Similar attitudes to those found in impotent males are often found in these women. Religious taboos, physical assault, repressed or controlled anger, and a history of painful intercourse all contribute to this dysfunction.

Sexual Anesthesia. Some women complain that they have no feelings on sexual stimulation, although they can enjoy the closeness and comfort of physical contact. Clitoral stimulation does not evoke erotic feelings though they do feel a sensation of being touched. Dr. Kaplan believes that sexual anesthesia is not a true sexual dysfunction, but rather represents a neurotic disturbance and should be treated through psychotherapy rather than sex therapy.

As with sexual dysfunctions in men, the female dysfunctions also have to be understood from a social, familial and psychological perspective. Attitudes, values, childhood experiences, adult trauma, all contribute to the sexual response in women. The attitudes and values of her partners, as well as their sexual technique, play a major role in the sexual response as well. An inept or mysogynistic lover can significantly affect the female response. Since a woman often does not want to "damage the male ego," she will try to accommodate her responsiveness to him often sacrificing her satisfaction in the process. She then builds up a secondary inhibition to sexual arousal in order to avoid the frustration accompanying an unsatisfying sexual experience. This inhibition or accommodation then becomes a habituated conditioned response.

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Inhibited sexual desire. As indicated above, inhibited sexual desire is almost always caused by psychological factors (some medications cause a reduction in sexual desire). Since women in our society are often more concerned with intimately connecting to their partner (as compared to men who are more often phallocentric and more concerned with orgasm), women become more sensitive to the psychological climate. When women feel that they are being used, exploited, misunderstood, rejected, unappreciated, and unattractive, their sexual desire will often be affected. Unexpressed anger and hurt can lead to depression, which affects desire. Sometimes these emotions are expressed in passive-aggressive ways, sexual withdrawal being one manifestation. Sexuality, especially for women, is more than a form of pleasure and release; it is a form of communication.

Sex Therapy

Sex therapy provides information and counseling on all aspects of human sexuality, including enhancing sexual pleasure, improving sexual technique, and learning about contraception and venereal diseases. Sex therapy is used in the treatment of all of the dysfunctions discussed earlier. In many cases treatment is relatively short, requiring specific techniques, homework, and practice. In some cases, the underlying issues are more complicated. They may require an exploration into historical and psychological factors, both conscious and unconscious, that are contributing to the dysfunction. However, there is a very high probability of success, even in those cases, if people are motivated, cooperative, and willing to learn.

Unfortunately, most people would rather live with sexual dysfunction and a less than satisfying sex life than seek help. The embarrassment they feel in discussing their sex life with a professional is too great. There are others who have adjusted to their sex life and despite the fact that their spouse might be unhappy, they refuse to seek help. When these people hear that their spouse is unhappy about their sex life, they experience it as a criticism, become defensive, and often become either hurt or angry, rather than open themselves up to exploration with a sex therapist.

Four common causes of sexual dysfunction:

1. Stress. Often unidentified, stress can produce temporary sexual dysfunction which can become permanent. Unfortunately, people often consider sexuality such a private matter that they are reluctant to discuss it with others. Even those who have had sexual difficulties as a consequence of disease or surgery have difficulty seeking sex therapy to facilitate adjustment to the dysfunction. Many men prefer to needlessly avoid sex altogether rather than seek professional help. Their pride gets in the way of sexual satisfaction.

2. Attitude. One of the most significant contributing factors in sexual dysfunction is your attitude toward the dysfunction. If you view it as a diminishing your self-worth and reflecting negatively on your overall value as a human being, sex therapy will take a little longer since we first have to overcome these initial feelings.

3. Motivation. Another contributing factor is your motivation and that of your spouse or partner. Your partner's cooperation, participation, and support can accelerate the process and in many cases is essential for effective treatment. Remember, when one member of the dance team is impaired, the team is impaired. Sex therapy, like sex itself, is a cooperative venture.

4. Performance anxiety. This is frequently a prime cause of sexual dysfunction. People become so preoccupied with their sexual performance or the performance of their partner, that they lose sight of the process. Enjoying the pleasure involved in being together, the pleasure of human touch, and the process of lovemaking ought to be the primary focus. Many individuals are more concerned with their "reviews" than they are with whether they are enjoying themselves.

Good listening skills make you a better communicator. Here are 21 ways to develop and enhance effective listening skills.

How to Show Good Listening Skills

Remember: Everyone wants to be heard, to feel "listened to" and understood.

1. Express concern and desire to help
2. Ask about feelings and thoughts
3. Suspend judgment
4. Try to develop trust (provide an environment of warmth and acceptance)
5. Use a person's name
6. Let the person know you are listening (attending behaviors):
7. Communicate undivided attention; resist distractions
8. Nod
9. Paraphrase or repeat the essence of person's messages
10. Agree when genuine
11. Repeat or summarize main ideas ("facilitative listening")
12. Listen "between the lines" for the underlying "feeling" message
13. Empathize with and "reflect" their feelings ("I understand what you're saying." "I think I know what you're feeling." "I can understand that you're feeling angry; It must be very frustrating.")
14. Acknowledge concerns and fears, without supporting misperceptions
15. Discourage discussion of any delusion and focus on "here and now"
16. Problem-solve (only when the person is ready)
17. Explore ways (options) for the person to have their needs met
18. Break down concerns into manageable problem-solving steps (non-judgmental, solution-oriented approach)
19. "Brainstorm" together
20. Try to provide a face-saving solution; explore acceptable compromises
21. Do not:
    • Argue
    • Interrupt
    • Scold or lecture
    • Offer false reassurances
    • Be overly logical and rational, or try to "fix" the problem before thoroughly understanding
    • Trivialize the circumstances or feelings
    • Try to convince them of their irrationality
    • Overly challenge or confront
    • Invade physical space

Body language (non-verbal behavior) communicates important messages. The following may be helpful in reducing others' anger and assisting an individual in calming themselves:

• Eye contact (not too intense)
• Interpersonal distance (not too close); Respect personal space; Do not move toward an agitated person
• Restrict body movement to a minimum; Minimize sudden behaviors
• Maintain an "open" position (do not cross arms or legs; hands unclenched)
• Maintain same eye level (sit or stand depending on student's position)
• Speak softly and reassuringly

Introduction

Research has enabled many men and women, and young people living with human immunodeficiency virus (HIV), the virus that causes acquired immunodeficiency syndrome (AIDS), to lead fuller, more productive lives. As with other serious illnesses such as cancer, heart disease or stroke, however, HIV often can be accompanied by depression, an illness that can affect mind, mood, body and behavior. Treatment for depression helps people manage both diseases, thus enhancing survival and quality of life.

Despite the enormous advances in brain research in the past 20 years, depression often goes undiagnosed and untreated. Although as many as one in three persons with HIV may suffer from depression,1 the warning signs of depression are often misinterpreted. People with HIV, their families and friends, and even their physicians may assume that depressive symptoms are an inevitable reaction to being diagnosed with HIV. But depression is a separate illness that can and should be treated, even when a person is undergoing treatment for HIV or AIDS. Some of the symptoms of depression could be related to HIV, specific HIV-related disorders, or medication side effects. However, a skilled health professional will recognize the symptoms of depression and inquire about their duration and severity, diagnose the disorder, and suggest appropriate treatment.

Depression Facts

Depression is a serious medical condition that affects thoughts, feelings, and the ability to function in everyday life. Depression can occur at any age. NIMH-sponsored studies estimate that 6 percent of 9- to 17-year-olds in the U.S. and almost 10 percent of American adults, or about 19 million people age 18 and older, experience some form of depression every year.2,3 Although available therapies alleviate symptoms in over 80 percent of those treated, less than half of people with depression get the help they need.3,4

Depression results from abnormal functioning of the brain. The causes of depression are currently a matter of intense research. An interaction between genetic predisposition and life history appear to determine a person's level of risk. Episodes of depression may then be triggered by stress, difficult life events, side effects of medications, or the effects of HIV on the brain. Whatever its origins, depression can limit the energy needed to keep focused on staying healthy, and research shows that it may accelerate HIV's progression to AIDS.5,6

HIV/AIDS Facts

AIDS was first reported in the United States in 1981 and has since become a major worldwide epidemic. AIDS is caused by the human immunodeficiency virus (HIV). By killing or damaging cells of the body's immune system, HIV progressively destroys the body's ability to fight infections and certain cancers.

The term AIDS applies to the most advanced stages of HIV infection. More than 700,000 cases of AIDS have been reported in the United States since 1981, and as many as 900,000 Americans may be infected with HIV.7,8 The epidemic is growing most rapidly among women and minority populations.9

HIV is spread most commonly by having sex with an infected partner. HIV also is spread through contact with infected blood, which frequently occurs among injection drug users who share needles or syringes contaminated with blood from someone infected with the virus. Women with HIV can transmit the virus to their babies during pregnancy, birth, or breast-feeding. However, if the mother takes the drug AZT during pregnancy, she can reduce significantly the chances that her baby will be infected with HIV.

Many people do not develop any symptoms when they first become infected with HIV. Some people, however, have a flu-like illness within a month or two after exposure to the virus. More persistent or severe symptoms may not surface for a decade or more after HIV first enters the body in adults, or within two years in children born with HIV infection. This period of "asymptomatic" (without symptoms) infection is highly individual. During the asymptomatic period, however, the virus is actively multiplying, infecting, and killing cells of the immune system, and people are highly infectious.

As the immune system deteriorates, a variety of complications start to take over. For many people, their first sign of HIV infection is large lymph nodes or "swollen glands" that may be enlarged for more than three months. Other symptoms often experienced months to years before the onset of AIDS include:

• Lack of energy
• Weight loss
• Frequent fevers and sweats
• Persistent or frequent yeast infections (oral or vaginal)
• Persistent skin rashes or flaky skin
• Pelvic inflammatory disease in women that does not respond to treatment
• Short-term memory loss

Many people are so debilitated by the symptoms of AIDS that they cannot hold steady employment or do household chores. Other people with AIDS may experience phases of intense life-threatening illness followed by phases in which they function normally.

Because early HIV infection often causes no symptoms, a doctor or other health care worker usually can diagnose it by testing a person's blood for the presence of antibodies (disease-fighting proteins) to HIV. HIV antibodies generally do not reach levels in the blood which the doctor can see until one to three months following infection, and it may take the antibodies as long as six months to be produced in quantities large enough to show up in standard blood tests. Therefore, people exposed to the virus should get an HIV test within this time period.

Over the past 10 years, researchers have developed antiretroviral drugs to fight both HIV infection and its associated infections and cancers. Currently available drugs do not cure people of HIV infection or AIDS, however, and they all have side effects that can be severe. Because no vaccine for HIV is available, the only way to prevent infection by the virus is to avoid behaviors that put a person at risk of infection, such as sharing needles and having unprotected sex.

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Get Treatment for Depression

While there are many different treatments for depression, they must be carefully chosen by a trained professional based on the circumstances of the person and family. Prescription antidepressant medications are generally well-tolerated and safe for people with HIV. There are, however, possible interactions among some of the medications and side effects that require careful monitoring. Specific types of psychotherapy, or "talk" therapy, also can relieve depression.

Some individuals with HIV attempt to treat their depression with herbal remedies. However, use of herbal supplements of any kind should be discussed with a physician before they are tried. Scientists recently discovered that St. John's wort, an herbal remedy sold over-the-counter and promoted as a treatment for mild depression, can have harmful interactions with other medications, including those prescribed for HIV. In particular, St. John's wort reduces blood levels of the protease inhibitor indinavir (Crixivan-®) and probably the other protease inhibitor drugs as well. If taken together, the combination could allow the AIDS virus to rebound, perhaps in a drug-resistant form.

Treatment for depression in the context of HIV or AIDS should be managed by a mental health professional. For example, a psychiatrist, psychologist, or clinical social worker - who is in close communication with the physician providing the HIV/AIDS treatment. This is especially important when antidepressant medication is prescribed so that potentially harmful drug interactions can be avoided. In some cases, a mental health professional that specializes in treating individuals with depression and co-occurring physical illnesses such as HIV/AIDS may be available. People with HIV/AIDS who develop depression, as well as people in treatment for depression who subsequently contract HIV, should make sure to tell any physician they visit about the full range of medications they are taking.

Recovery from depression takes time. Medications for depression can take several weeks to work and may need to be combined with ongoing psychotherapy. Not everyone responds to treatment in the same way. Prescriptions and dosing may need to be adjusted. No matter how advanced the HIV, however, the person does not have to suffer from depression. Treatment can be effective.

It takes more than access to good medical care for persons living with HIV to stay healthy. A positive outlook, determination and discipline are also required to deal with the stresses of avoiding high-risk behaviors, keeping up with the latest scientific advances, adhering to complicated medication regimens, reshuffling schedules for doctor visits, and grieving over the death of loved ones.

Other mental disorders, such as bipolar disorder and anxiety disorders, may occur in people with HIV or AIDS, and they too can be effectively treated. For more information about these and other mental illnesses, contact NIMH.

Remember, depression is a treatable disorder of the brain. Depression can be treated in addition to whatever other illnesses a person might have, including HIV. If you think you may be depressed or know someone who is, don't lose hope. Seek help for depression.

Source:National Institute of Mental Health. NIH Publication No. 02-5005

References

¹Bing EG, Burnam MA, Longshore D, et al. The estimated prevalence of psychiatric disorders, drug use and drug dependence among people with HIV disease in the United States: results from the HIV Cost and Services Utilization Study. Archives of General Psychiatry, in press.

²Shaffer D, Fisher P, Dulcan MK, et al. The NIMH Diagnostic Interview Schedule for Children Version 2.3 (DISC-2.3): description, acceptability, prevalence rates, and performance in the MECA Study. Methods for the Epidemiology of Child and Adolescent Mental Disorders Study. Journal of the American Academy of Child and Adolescent Psychiatry, 1996; 35(7): 865-77.

³Regier DA, Narrow WE, Rae DS, et al. The de facto mental and addictive disorders service system. Epidemiologic Catchment Area prospective 1-year prevalence rates of disorders and services. Archives of General Psychiatry, 1993; 50(2): 85-94.

⁴National Advisory Mental Health Council. Health care reform for Americans with severe mental illnesses. American Journal of Psychiatry, 1993; 150(10): 1447-65.

⁵Leserman J, Petitto JM, Perkins DO, et al. Severe stress, depressive symptoms, and changes in lymphocyte subsets in human immunodeficiency virus-infected men. Archives of General Psychiatry, 1997; 54(3): 279-85.

⁶Page-Shafer K, Delorenze GN, Satariano W, et al. Comorbidity and survival in HIV-infected men in the San Francisco Men's Health Survey. Annals of Epidemiology, 1996; 6(5): 420-30.

⁷Centers for Disease Control and Prevention (CDC). HIV/AIDS Surveillance Report, 2000; 12(1): 1-44.

⁸Guidelines for national human immunodeficiency virus case surveillance, including monitoring for human immunodeficiency virus infection and acquired immunodeficiency syndrome. MMWR, 1999; 48(RR-13): 1-27, 29-31.

⁹Centers for Disease Control and Prevention (CDC). HIV Prevention Strategic Plan Through 2005. Draft, September 2000.

Adjustment disorder with depressed mood is a common type of adjustment disorder. All adjustment disorders are caused by one or more stressors, big or small, that negatively impact someone’s life. Adjustment disorders are quite personal; an event that decreases one person’s ability to cope might not faze another person at all. That second person, though, might have difficulty coping with a different event. In adjustment disorders, people’s reactions are unique as well. Sometimes, reactions are similar to depression, so the person is said to have adjustment disorder with depressed mood.

Symptoms of Adjustment Disorder with Depressed Mood

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the accepted authority on mental health disorders, discusses adjustment disorder with depressed mood as one of six types of adjustment disorders. When someone experiences adjustment disorder, he/she doesn’t receive a vague diagnosis of adjustment disorder alone; instead, the diagnosis is categorized by type according to the person’s unique symptoms.

Adjustment disorder with depressed mood is diagnosed when someone’s symptoms are primarily depressive in nature.

Reaction to a life change or another type of stressor can lead to a subjective, personal experience of depression. The symptoms of adjustment disorder with depressed mood can include

• Low mood, sadness
• Increased tearfulness, frequent crying spells
• Sense of hopelessness
• Decreased self-esteem
• Anhedonia—loss of a sense of pleasure
• Lack of motivation
• Feeling of loneliness and isolation
• Suicidal ideation or behavior

Adjustment disorder with depressed mood can feel dark and heavy, as though the stressor zapped one’s energy and joy. This can make dealing with the stressor difficult.

Difference between Adjustment Disorder with Depressed Mood and Major Depression

It can be tricky to differentiate adjustment disorder with depressed mood from depressive disorders. The symptoms are so similar that occasionally adjustment disorder with depression is referred to as a situational depression.

The key to distinguishing between the two mental health conditions is the word “situational.” Adjustment disorder with depressed mood is conditional upon a particular situation, a life change or a stressor of some sort. The stressor can be of any severity, but it must cause disruption to the person’s life. When the disruption is experienced as depression, it’s adjustment disorder with depressed mood.

When depressive symptoms occur without a stressor or before a stressor has occurred, the diagnosis is a depressive disorder such as major depressive disorder. Life doesn’t always happen in a neat, orderly fashion, and sometimes multiple stressors build up slowly; thus, it can sometimes be hard to determine which came first, the stressor or the depressive symptoms. In such cases, the level of the depressive symptoms can provide a clue. The more symptoms of depression a person has and the longer they last, the more likely it is that he/she has a depressive disorder rather than adjustment disorder with depressed mood.

Adjustment Disorder with Depressed Mood is Temporary and Treatable

If you’ve experienced one or more stressors and now are feeling symptoms of depression, it could quite possibly be adjustment disorder with depressed mood. A visit to a doctor or mental health professional will help determine this.

The wonderful news about adjustment disorder with depressed mood is that it can be overcome. Effective adjustment disorder treatment exists, and it involves addressing the stressor as well as treating the symptoms, in this case, the symptoms of depression.

Once the stressor is removed or the person has learned to adjust to and cope with it, adjustment disorder with depressed mood subsides within six months. Adjustment disorder with depressed mood won’t forever negatively impact one’s life.

article references

The way you speak, the words you use, reflect your level of assertiveness. Learn how to communicate assertively.

The following are suggestions regarding the language of assertiveness.

• "I" statements:
  I think...
  I feel...
  I want...

• Statements of Personal Reference and Personal Meaning:
  "This is the way I see it"
  "In my opinion..."
  "This is how I feel"
  "This is what it means to me"

• Statements of Request:
  "I" want...
  "I" need...

• Statements offering compromise:
  "I" would like this...
  What would you like?
  "I" think...What do you think?
  "What would be an acceptable compromise?"
  "Can we work this out--What time is agreeable to you?"

• Asking for time:
  "I'd like to discuss this in an hour"
  Taking time to think, know what you want to be different,
  thinking of compromise, etc.

• Asking for clarification--instead of ASSUMING.

• AVOID demanding and blaming statements:
  You make me...
  You think...
  You should/shouldn't...
  It's your fault...
  Don't you think...
  If only you would...

Specific Verbal Skills

• "I" think statements

• Broken record--repeating what you want, persistence

• Acknowledge what other is saying, then repeat your view, opinion, need, etc.

• Provide feedback--respond to what other person is saying

Language Formula

• I feel--state your feeling

• When (describe behavior)

• Because (concrete effect or consequence on your situation)

• I'd prefer (offer compromise)