Medsarticles. Medical Weblog

The rapid treatment of sexual dysfunctions as formulated by Helen Singer Kaplan is psycho-dynamic and behavioral, and integrates structured sexual experiences into conjoint therapeutic sessions (Kaplan). Kaplan’s treatment method combines behavioral sexual tasks designed specifically for each couple, tailored both to the sexual dysfunction of the individual and the interpersonal functioning of the dyad, with psychodynamic insights and dyadic approaches, including dream interpretations, and gestalt and transactional techniques. Two ways in which the Kaplan method differs from other techniques is that the treatment milieux need not be a sequestered locale but could include performance of the patients in the privacy of their own home, and that a single therapist can be as effective as co-therapists of opposite sexes.

Kaplan states that “all therapeutic maneuvers are mainly at the service of the primary objective of sex therapy: “the relief of the sexual symptoms” (italics in the original) … In the course of sex therapy intrapsychic and transactional conflicts are almost invariably dealt with to some extent” (Kaplan). The latter may be true in a limited sense in other schools of sex therapy; in Kaplan’s method it is much more deliberate and prominent. The resistances that arise in response to the structured sexual tasks often must be treated by other (nonsexual) modalities to allow the sexual aspects of the therapy to proceed. On the other hand, if more profound resistances are evoked, their resolution may have a more profoundly therapeutic effect.

In summary, the Kaplan method may be seen as a “task-centered form of crises intervention which presents an opportunity for rapid conflict resolution. Toward this end the various sexual tasks are employed, as well as the methods of insight therapy, supportive therapy, marital therapy, and other psychiatric techniques as indicated” (Kaplan).

*244/187/5*

The basic hypothesis that Breuer and Freud had advanced in the famous Studies (1893-1895) was that “hysterics suffer from reminiscences,” and that the cure of the hysterical symptoms lies in the gradual uncovering of those traumatic memories and their re-enactment and reactivation in the present together with the intense charge of emotion connected with those infantile traumatic experiences. It was the cathartic release or abreaction of this emotional charge which allowed the symptom to be relieved and dispelled. Freud and Breuer found in a number of instances that the exact recollection of such early traumatic memories did, in fact, lead to the relief of hysterical symptoms. This allowed them to think of a discharge theory of emotion and to conceptualize their findings in terms of a theory of cathexis and discharge which was based upon economic principles, derived from the scientific culture in which they were thinking and working. Thus, psychoanalysis found its origin in the early dealing with matters of sexual conflict and trauma and the corresponding repression, which led to dissociation in the mind of the hysteric and a re-expression of traumatic conflicts in neurotic symptomatology.

There was, however, a fly in the ointment. Only after several years of convinced application of this traumatic theory of neurosis did Freud begin to question his findings. Not only was he not always able to find the traumatic reminiscence, but the hypothesis that sexual infantile trauma were so frequent such that every neurotic patient would be suffering from such an infantile seduction was a bit hard to swallow—even in turn-of-the-century Vienna. Moreover, Freud had embarked on an interesting exercise that was to change the course of psychoanalytic history. He had begun his own self-analysis, working on his own dreams and discovering in himself the roots of repressed and conflicted aspects in his own psychic development.

The outcome was dramatic. In September 1897, his doubts and uncertainties reached a crisis, and he wrote to his good friend Wilhelm Fliess in the following terms:

Let me tell you straight away the great secret that has been slowly dawning on me in recent months. I no longer believe in my neurotica. This is hardly intelligible without an explanation; you yourself found what I told you credible. So I shall start at the beginning and tell you the whole story of how the reasons for rejecting it arose. The first group of factors was the continual disappointment of my attempts to bring my analysis to a real conclusion, the running away of people who for a time had seemed my most favorably inclined patients, the lack of the complete success on which I had counted, and the possibility of explaining my partial successes in other, familiar ways. Then there was the astonishing thing that in every case . . . blame was laid on perverse acts by the father, and realization of the unexpected frequency of hysteria, in every case of which the same thing applied, though it was hardly credible that perverted acts against children were so general . . . Thirdly, there was the definite realization that there is no “indication of reality” in the unconscious, so that it is impossible to distinguish between truth and emotionally charged fiction. (This leaves open the possible explanation that sexual fantasy regularly makes use of the theme of the parents.) Fourthly, there was the consideration that even in the most deep-reaching psychosis the unconscious memory does not break through, so that the secret of infantile experience is not revealed even in the most confused states of delirium. When one thus sees that the unconscious never overcomes the resistance of the conscious, one must abandon the expectation that in treatment the reverse process will take place to the extent that the conscious will fully dominate the unconscious (Freud).

One can understand Freud’s reluctance to abandon the seduction hypothesis, since he had put years of effort into developing it and had accumulated a considerable amount of evidence that seemed to support it, but he could not reconcile the aspects of the hypothesis that did not seem consistent with other undeniable data. The shift in perspective was perhaps the most significant that has ever taken place in psychoanalytic thinking. Freud realized that rather than real parental seductions traumatizing the infant sexually, the possibility now arose that the inherent sexuality of the infant was beginning to express itself in sexual fantasies about the parents. The emphasis shifted in Freud’s thinking and in the direction of his investigation of the neuroses from reality factors to sexual fantasies. Freud’s abandonment of the seduction hypothesis was also reinforced by the results of his own self-analysis. In analyzing his own dreams and in recovering early infantile memories, he began to discover the elements of infantile sexual wishes and desires in himself. He then realized that what he was dealing with was in some fundamental sense a basic characteristic of infantile experience. The role of infantile sexuality in psychoanalytic thinking had been established.

*207/187/5*

The core issue in treatment discrimination centers on women’s performance evaluations in work settings. Such evaluations form the basis of decisions about pay raises, promotions, employee utilization, and training opportunities. First we will consider the differences shown to occur in evaluating the work of men and women. Second, we will consider the discrepancy in how male and female success is interpreted. Last, we will explore reactions to women in nontraditional careers and their potential implications for the treatment of these women.

One result of our society’s unfavorable stereotyping of women is the prejudicial evaluation of their work. That is, their achievements are viewed in a way that fits with our beliefs; consequently their work is devalued simply because they are women. Inquiries in the past several years have been designed to examine the scope and parameters of this sexually based bias.

A study by Goldberg explored prejudice toward women in areas of intellectual and professional competence. College women were asked to evaluate published professional articles representing several disciplines: linguistics, law, art history, dietetics, education, and city planning. For each article, half the subjects believed the author was a male and the other half, a female. Goldberg hypothesized that when confronted with an identical work product, women would value the work of men more highly than that of women. The results confirmed this hypothesis; subjects tended to rate all of the articles more highly when they were attributed to male authors than to female authors.

Using the same experimental procedure, however, Pheterson (reported in Pheterson and others) found sex bias to be absent in a group of uneducated middle-aged women. In contrast to Goldberg’s findings, these women evaluated the professional work of women to be equal to and in some instances even more favorable than the professional work of men.

A subsequent study (Pheterson, Kiesler, and Goldberg) attempted to reconcile the divergent results from these two investigations. Speculating that differences in the respective subject populations may provide the clue to the differing results, the authors suggested that as contrasted to the college students in Goldberg’s study, the uneducated women in Pheterson’s study may have viewed the very fact that an article is published to be an indication of success. It thus was postulated that when a work product has uncertain status, the man’s rather than the woman’s would be valued more highly, but when it is perceived to be of definitively high quality, the woman’s would be judged equal to or even superior to the man’s. To test these ideas, women college students judged paintings which were (a) attributed to men or women creators and (b) depicted as either entries or prize winners in art competitions. The data supported the major hypotheses: when the paintings were thought to be entries, male work was judged superior, but this did not occur when the painting was thought to be a prize winner. The authors thus conclude that sex-bias does not exist when a woman’s success has been proved by the acclaim of others.

Another study expands this notion. Heilman asked both high school students and undergraduates to evaluate the intellectual value and general popularity of two different course offerings when the instructor was presented as a male or female. Results indicated that when the course described was highly technical, requiring extensive knowledge of quantitative skills, no sex bias was evident. However, when the course described was not highly technical and more qualitative, it was differentially evaluated depending upon the sex of the instructor, with those taught by women severely devalued. The interpretation used reasoning similar to that used by Pheterson and her colleagues. It is argued that the fact that a woman has accomplishments in a field ordinarily populated only by men may in and of itself conclusively confirm the quality of her work, thus precluding discrimination on the basis of sex. A similar explanation can be made of studies by Hamner, Kim, Baird, and Bigoness and Bigoness in which women were rated as superior to men when they performed equivalently doing the heavy physical chores of a grocery store stock clerk.

These data, taken together with those provided by Pheterson and others suggest that not under all conditions are women and their work subject to prejudice. It appears that information about the quality of an individual’s work, whether implicitly or explicitly derived, eliminates sex-linked biases in its evaluation. When ambiguity exists, as is far more frequent, prejudicial evaluations seem to abound.

This thesis can account for the repeatedly demonstrated occurrence of sexual discrimination in performance evaluations conducted early in an employee’s tenure or by individuals who do not have continuous contact with her. It is only in rare instances that there is no ambiguity about effectiveness in either of these situations. But how can one account for the discriminatory treatment of women who have been on the job and for whom concrete evidence of their success is available? It appears that high performance evaluations are not sufficient to ensure fair and equal treatment. Other dynamics are at work.

*170/187/5*

If the meaning of a sexual act does vary in different cultures, a recent report from the New Guinea highlands demonstrates that the “same” physical act can have a different meaning and lead to different consequences within one cultural system. I refer to Berndt’s analysis of adultery among New Guinea mountain people. Berndt finds three crucial contexts for adultery: (1) within the lineage, (2) outside the village but within the district, and (3) outside the district. If the partner in adultery were a covillager, the affair would have only minor repercussions if discovered; in fact Berndt found intravillage adultery was often condoned. However, when persons from different villages were engaged in adulterous activity (context 2), the episode could lead to fighting, and in cases in which district boundaries are crossed (context 3), outright warfare could ensue.

These New Guinea people have a different tolerance for such activity, depending on these crucial contexts. Berndt finds that interdistrict adultery is generally viewed in the idiom of warfare, that is, as an act of one political unit asserting its supremacy over another. Although stealing or enticing a woman away for sexual purposes is viewed as a “legitimate” activity, it risks the retaliatory reprisal of an entire political unit, since many men in addition to the husband will feel that they have been wronged and that their sexual prowess has been questioned. When faced with adultery (or even what in our terms might better be called “forced sex,” but for which the New Guinea men nevertheless held the female responsible), men take these contextual issues into account, determining whether or not they themselves personally have been injured and assessing just what kind of an injury they have suffered.

Likewise, “rape” as a universal behavioral concept must be put into context. Gladwin and Sarason, for example, described copulation with a sleeping woman on Truk, but ethnographic evidence did not ascertain whether it was rape. A Mehinaku male might seize the wrist of a female and demand sex (Gregor), which poses the question of boundary between forceful coercion and rape. Murphy uncovered a certain case of rape when Mundurucu men gang raped a recalcitrant female who had failed to submit to male authority. Gregor reports a Mehinaku female who had been bold enough to enter a man’s house suffered a similar fate.

If Marshall is correct in stating that “rape does not carry the serious social connotation on Mangaia that it does in European society”, then what point is there to hypothesizing about rape in the Polynesian case at all? In answer to this question I refer to Carroll’s observation that the natives of the Polynesian island of Nukuoro themselves hypothesize about rape. To Nukuoro rape is important conceptually, because it marks the logical obverse of the inherent balance in sexual relationships. Additionally, rape is intrinsically unsatisfying from the male Nukuoroan point of view, since the persuasive/attractive dimension would be totally lost.

The domination of male over female symbolized by and enacted through rape in Western culture may be joined to other forms of political action elsewhere in the world. In certain South African groups a man can face vindictive charges of rape after sex with consent of the woman, should he renege on his promise to give her a gift (Laubscher). Hockings found a comparable political definition in India: “From a male Toda point of view a Toda girl who has given herself to a Badaga has probably been raped by him, and the offender is lucky if he escapes a serious beating at the hands of the woman’s husband or husbands”.

*133/187/5*

Changes in endocrine function and reproductive structures are more gradual, less pronounced, and seem to occur somewhat later for males than for females. Unlike females, males have no abrupt change of life.

Circulating androgens in males are relatively constant after puberty, showing only gradual declines until about age forty or forty-five. After the mid-forties, androgen levels are about 55 to 60% of what they were earlier. After age sixty-five, values are about 30% of those in the thirties. In advanced age, about seventy-five, androgens have dropped 85 to 90% compared with levels before thirty. Paschkis reported 8 to 20 mg/day total urinary 17-keto-steroids in sexually mature males; values of less than 5 mg/day were not uncommon among elderly men. The fact that aging affects testicular cells known to produce androgen and correlates in time with declining androgen levels is taken as evidence that declining androgen levels are primarily a result of testicular decline. Because androgen levels decrease in both males and females (Dorfman and Shipley), it suggests that the adrenals may also be involved (Gherondache).

Conclusions about pituitary activity in males parallel those for females. Although gonadotropin levels are not as high in aging men as in aging women, there is evidence of increased anterior pituitary activity. Paschkis reported 4 to 24 mouse weight units of urinary gonadotropins as typical of his sample of sexually mature males under fifty. In subjects in their sixties and seventies, amounts up to 96 m.w. units have been found.

It is debatable whether there are significant changes in estrogen levels in males. Pincus reported no change in total estrogen levels, although specific estrogen groups showed some decline. Gherondache has reported that total estrogen output in aging men is reduced by about 30$ and progesterone output declines about 60%.

Compared with young men, testicles of males fifty-five and older seem smaller and less firm (Rubin). Although there is little change in testicular weight with age, there are marked changes in testicular tissue. The number of Leydig cells decreases progressively with age and changes as early as twenty-five or thirty years have been observed in some men (Tillinger). The reduced number of secretory cells follows rather closely the lowered levels of androgen, suggesting a functional relationship. The lipid content of Leydig cells decreases after the fourth decade (Lynch and Scott). However, the lipid content of Sertoli cells increases with age. The functional significance of this is unknown.

Spermatogenesis which occurs continuously in sexually mature males is reduced in older men, although total inability to produce sperm is rarely found even in very old men. Molnar reported that the number of sperm in the ejaculate of men in their sixties was about 30% lower than at previous ages and in much older men, this percentage decrease was even greater. Reduced spermatogenesis is thought to be related to changes in the seminiferous tubules and to decreased androgen levels. Aging males display a proliferation of connective tissue along the basement membrane of the seminiferous tubules (Engle; Molnar) which may interfere with effective sperm production. Alterations in the size and shape of sperm are more frequently seen in aging men.

Genital tract and duct systems require androgens for maintenance. Lowered androgen levels contribute to age-related changes. The seminal vesicles show weight reduction after age sixty and display decreased secretory activity. The prostate gland often follows a predictable sequence of change beginning as early as the forties and ending in the mid-fifties with muscular atrophy and fibrosis (Moore; Steward and Brandes). There often is dramatic enlargement in the seventies and eighties. This sequence of prostate changes is not inevitable but occurs with a high relative frequency in aging men. Enzyme and secretory activity of the prostate is reduced. Since the prostate contributes 20% and the seminal vesicles 60% to the total volume of seminal fluid, reduced secretory activity of these accessory structures results in lower amounts of ejaculate as well as a change in the composition of semen in older males.

There is no male analogue for female menopause, although reports of “menopausal” symptoms in middle-aged males crop up in the clinical literature from time to time. Since male reproductive capability shows only gradual changes and since there are no abrupt hormonal alterations, the analogy is a loose one at best. Benjamin has reported male patients with symptoms of irritability, insomnia, depression, and hot flashes. These symptoms tended to occur in the sixties and seventies. Other reports suggest that they may come earlier with the onset of prostate difficulties. Rubin cited a study of 273 men with menopausal complaints. In that sample, 90% complained of nervousness with a similar proportion claiming impotence. Eighty-one percent said they experienced a loss of libido, and the same percentage experienced irritability and fatigue. Libido and sexual capability, although the least frequent of female menopausal complaints, were much more common in this male sample. Lowered androgen levels may have been responsible for libidinal changes in these men. Menopausal women who experience abrupt estrogen (but not androgen) changes do not show these libidinal changes (or at least do not report them as frequently). In fact, Masters and Johnson report increases in libido in some segments of their postmenopausal sample. Since androgens underlie libido in both males and females, it is reasonable to suppose that the relatively greater androgen decline in older males (compared with older females) should lead to more pronounced libidinal changes in males. The degree to which physical condition and sexual expectations affect libido for both males and females is unknown, so libidinal changes cannot be tied solely to hormonal shifts.

Endocrine and reproductive tract changes also are accompanied by altered abilities in sexual capacity.

*97/187/5*