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THE EFFECTS OF ILLNESS AND DRUGS ON SEXUAL FUNCTION: DRUGS THAT ALTER SEXUAL PERFORMANCE

Many drugs are now known to alter the sex drive of both men and women but the most dramatic and well-proven effects are usually only noted in men because a woman can have intercourse even if she is not highly aroused.

Alcohol in moderation is said to enhance sexual responses, but is in fact a common cause for a temporary loss of potency.

These lists summarise some of the known sexual side-effects of drugs:

Drugs interfering with ejaculation

Antipsychotic drugs Antihypertensive drugs

Thioridazine (Mellaril) Reserpine (Serpasil)

Perphenazine (Fentazin or Guanethidine (Ismelin)

Triptafen) Methyldopa (Aldomet)

Trifluoperazine (Stelazine) Debrisoquine (Declinax)

Haloperidol (Serenace) Bethanidine (Esbatal)

Guanoxan (Envacar)

Antidepressant drugs Guanaclor (Vatensol)

Pargyline (Eutonyl) Phenoxybenzamine

Imipramine (Tofranil) hydrochloride (Dibexyline)

Amitriptyline (Tryptizol)

Clomipramine (Anafranil) Other drugs

Heroin

Methadone

Drugs interfering with erection Antihypertensive drugs

Antipsychotic drugs Methyldopa (Aldomet)

Fluphenazine (malicate) Guanethidine (Ismelin)

Thiordazine (Melleril) Clonidine (Catapres)

Benperidol (Anquil) Reserpine (Serpasil)

Chlorpromazine (Largactil) Guanoxan (Envacar)

Guanoclor (Vatensol)

Mood-modifying drugs

Lithium Spironolactone (Aldactone)

Imipramine (Tofranil) Bethanidine (Estabal)

Protriptyline (Concordin) Other drugs

Tranylcypromine (Parnate) Clofibrate (Atromid-S)

Desipramine (Pertofran)

Clomipramine (Anafranil)

Phenelzine (Nardil)

Amitriptyline (Tryptizol)

Drugs that interfere with female orgasm

Antidepressant drugs

Phenelzine (Nardil)

Clomipramine (Anafranil)

Few drugs are known to affect female orgasm but common sense dictates that many that affect men could well affect women too.

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SEX AIDS

These have been used for thousands of years and are now widely available through marital-aid and sex shops, either directly or by mail order. Almost all sex aids are sold to couples to enhance their foreplay and to increase the pleasure they get from intercourse. The biggest-selling sex aid by far is the vibrator and it is used on the male or female genitals and in the vagina or anus. A word of caution is necessary about using vibrators in the back passage. Quite a lot of people enjoy having a vibrator in the anus when masturbating or even during intercourse and this is fine provided it does not then get put into the vagina where it could cause a troublesome infection. Anything that has been in the anus should be washed thoroughly before being put into the vagina. The second problem is that by putting the vibrator too deeply into the anus it can get lost and this is very dangerous because it will have to be removed surgically.

Sexy underwear and various types of condoms (sheaths) are probably the next best-selling lines in a sex shop but both are, of course, available elsewhere too. These are purely for fun and can do no harm but there is a word of warning about putting rings and other things around the penis. When the penis is limp it will obviously be easy to put a ring around it, but when it is erect the ring may be impossible to remove.

Other available sex aids include dildoes, strap-on penises, implements and clothing for

sado-masochistic games, preparations which might help erection or delay male orgasm, and other things, all of which amount to sex toys for adults. For more solitary use are sex dolls for both sexes, artificial vaginas, which some couples find useful in training men to prolong intercourse and penis enlargers which probably help to maximise erection so making the penis seem larger. For those who have no partner or whose partner is unavailable such aids are an alternative to plain masturbation, an affair, or a prostitute.

Much hostility is unreasonably directed against sex-shops but provided their window displays are not offensive, they could be regarded more as an assistance to at least some couples, to enhance their erotic value to each other. Anything which helps men and women to love each other more should not be condemned out of hand. Insofar as they may assist harmful, perverse behaviour, they are more questionable.

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SEX-RELATED DISEASES: THE AIDS VIRUS (HIV)

AIDS is caused by the human immune deficiency virus, always referred to as HIV, of which there are two types – HIV I which causes most infections and HIV II which is found in parts of Africa. The latter appears to be more benign.

Where HIV came from is not known but it made its appearance in the US and Europe in the mid ’70s. Recent evidence suggests that it existed in monkeys in Africa before this but in a form harmless to man. Some people think that some 15 to 20 or more years ago it changed its properties, that is, mutated, and acquired its present capacity to infect and harm humans.

One reason why an effective vaccine against the virus is not likely to be available for many years is that the virus still mutates rapidly and so may well elude any vaccine devised.

The virus is not very infectious and is passed from one person to another only by infection either through the skin, as in drug abuse, blood transfusions or cuts; or through vaginal or anal penetration. Once it is securely established in the body it begins to reproduce but this provokes the body’s defences to take steps against it. One of these is the eventual production of antibodies which destroy the virus. However, some of the viruses avoid these defences, probably by hiding away in the bone marrow and brain. These hidden viruses then gradually destroy the body’s immune system, hence the name of the virus and the disease. As the immune system is destroyed, the victim loses the capacity for defence against all kinds of infections with other organisms which are usually dealt with easily. The infected person is often well until this final stage is reached, which takes several years and sometimes it is only when things get this serious that it is realised the individual was infected with HIV years before. It is this illness which comes in the final stage, when the immune system is immobilised, which is called AIDS.

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MASTURBATION: FANTASIES, IN PERSPECTIVE

Masturbation is a psychosexual act which incorporates both fantasy and physical stimulation. Some men and women claim never to fantasise during masturbation. As a rule they seem to fare as well as anyone else both in masturbation and intercourse, so the deficiency is apparently not usually serious. Presumably their fantasy is unacceptable to their conscious mind and so is repressed into the unconscious. The dissociation of the act and the thought is presumably the result of guilt and sometimes the point of the repression appears to be to avoid a particular situation or homosexual or incestuous thoughts. Fantasies are, of course, a rich source of information about the sexuality of an individual and can be of tremendous importance in the treatment of sexual problems.

Allowing for the shame people feel about discussing fantasies they regard as unusual, the range of sexual fantasy is enormous. The same fantasy theme may be used for a period of time but is usually varied slightly. Reliving previous sexual experiences, possibly in an elaborated form, is a common source of fantasy material. Most fantasies can be grouped into people fantasies and practice fantasies. In the first, the fantasy is of sex with someone the person knows or members of the opposite sex in photographs or stories. In the practice type of fantasy the person concentrates on the sexual activity rather than on any particular partner.

In men with sexual problems the fantasy often ends in foreplay activities and no penetration is involved. Often the fantasy is of being fellated. In people fantasies, men who are scared of women often use either schoolgirls or much older women. This is commonplace in adolescent boys who want intercourse but are still at the stage where their fears are greater than their desires. Passive men who have not fully resolved their early attraction to their mothers often have fantasies of being in total control of the woman. Deviations and perversions reveal themselves in fantasy. Sometimes they only show their presence in a sudden change in fantasy as orgasm approaches. Some individuals, more often men than women, see someone else instead of themselves performing sexually in their fantasies. This usually points to excessive anxiety about intercourse, which may be the basis of voyeurism.

To generalise from large numbers of individuals it seems that women fantasise more extensively but less deviantly than do men. In spite of the oft-made claim that women’s sexuality can be expressed only in the context of a loving relationship, this certainly does not seem to be the case, to judge from their fantasies. Adult women usually start the fantasy with themselves naked in the presence of the man without ‘explaining’ how it came about.

Adolescent and pre-adolescent girls may find fantasies of being naked exciting and often use stripper fantasies. In their fantasies women often portray themselves as being overwhelmed. This is evidence of their residual guilt about sex and reduces objections from their conscience. In this way fantasies of being forced to have sex; the use of restraint; of being had by many men; and of being a slave-girl commonly arise. As well as these fantasies many, if not most, women also have fantasies about one or more men they actually know.

In perspective-It is difficult to escape the conclusion that if masturbation, in the full psychosexual sense, proceeded with less difficulty in adolescence, then intercourse would be improved to the benefit of the man-woman relationship. Opposition to masturbation may have made sense to some people in the past as a control against sexual expression becoming rampant, but there is no justification for repressing it today. In fact the reverse is the case; those individuals who are most accepting of their sexuality in all its forms are the ones who are most responsible about its expression.

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PREGNANCY AND CHILDBIRTH: AFTER THE BIRTH

If you go home early you will be back in your own bed and able to cuddle each other and be especially loving towards the baby. Breastfeeding often proceeds more easily with the baby in bed and you will have fewer broken nights than you would getting up to get bottles ready. Many women who feed their babies in bed hardly wake up at all – they usually turn on to one side and the baby feeds on and off all night in the early weeks. This is also pleasant for the husband who does not lose his wife to another room for half the night. He can cuddle his baby too. You should not take a little baby into bed with you if you are very obese, or if you are drunk or on sleeping pills or other narcotic drugs. In any of these circumstances you could suffocate the baby. The vast majority of people around the world have their babies in bed with them and no doubt always have done.

If you are in hospital, be sure to see plenty of your man and cuddle up to each other and to the baby as much and as often as you can. Look after your baby all the time and keep him with you twenty-four hours of the day, in your bed if you are allowed to.

The return to sex after birth is very much a personal matter. Some women who have had no stitches (an episiotomy can leave a woman sore for many months) can go back to sex in two weeks, but most do not feel like intercourse this early. Breastfeeding makes a woman’s sexual organs return to normal more quickly than would be the case had she started to bottle-feed, and totally breastfeeding women return to intercourse earlier.

By about six weeks the majority of women feel ready for intercourse again but if there is any pain you should talk to your doctor or obstetrician at the post-natal check up. While waiting for intercourse to be comfortable again you can enjoy other types of love-making. Many women want to return to having orgasms a few days after birth and there is no harm at all in this. In fact it is probably positively beneficial because it seems to help the uterus return more quickly to its normal state. But whenever you return to sex be sure to be well protected with contraception. Whilst you would be unlucky to conceive in the first month or two after birth it can and does happen. Women who breastfeed exclusively and on demand, whenever the baby or they want and who have no long gaps, night or day between feeds, on average do not ovulate for about fourteen months after the birth, but the bottle-feeding mother and the woman who breastfeeds on a restricted basis can do so within a few weeks. Talk to your doctor at the post-natal check-up about which form of contraception would be best.

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HIV TRANSMISSION: EXCHANGE OF FLUIDS FROM MOTHER TO CHILD

An infected mother can transmit HIV to her child either through the placenta when the baby is in the womb, by exposure to vaginal secretions at birth, or through breast milk by breastfeeding after delivery. Most children who are born to infected mothers acquire the infection while in the womb or at delivery, but breastfeeding is discouraged if the mother is HIV positive.

Eighty-five percent of women who are HIV positive are of childbearing age, and between 1 and

2 percent of pregnant women in urban settings in the United States are HIV positive. Because testing is not mandatory, many women do not know they are infected and that their children are at risk.

While in the womb, a baby receives antibodies from the mother through the placenta. Infants born to mothers who are HIV positive almost always have antibody to HIV when they are born, whether or not they are infected. For this reason, tests are performed to determine if the infant has the virus and not just the antibody. These include tests to detect the genetic material of the virus (the polymerase chain reaction test and the branched HIV-DNA amplification test, also known as the viral load test) and tests that identify one of the proteins or antigens found on the surface of the virus (the p24 antigen), as well as culturing for HIV (These tests are described in the next section, “Testing for HIV”) If a child is at risk for infection, testing should be performed periodically from birth until the child reaches one year of age. A child who continues to test positive at one year is truly infected.

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STD: TESTING FOR GONORRHEA

Testing for gonorrhea involves an examination, during which cultures are taken from any area that was exposed to a partner and therefore is a potential site of infection. These areas include the urethra for men, the cervix and urethra for women, and the throat and anal area for men and women, if these areas have been exposed.

For men, a swab of the discharge from the urethra is taken, examined under the microscope, and tested. The bacterium can often (but not always) be seen under the microscope. As with tests for nongonococcal urethritis (NGU) and chlamydia, the examination is most accurate if the man does not urinate beforehand. To culture for gonorrhea, the urethral swab is brushed across a plate that contains substances on which N. gonorrhoeae grows; it can take up to forty-eight hours for the growth to be evident. For women, a pelvic examination must be performed to diagnose genital gonorrhea. Swabs are taken from the cervix, the urethra, or both, and these are tested in the same way.

New screening tests for gonorrhea are currently being evaluated. One, called a DNA probe, consists of “going fishing” for the DNA of the gonorrhea bacterium with a piece of DNA that matches it and attaches to it. Other newer and more sensitive tests (the polymerase chain reaction and the ligase chain reaction) look specifically for DNA of the bacterium and can detect small amounts by amplifying the DNA so that it can be detected. These tests can be used on either secretions or urine from men and women.

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SPECIAL ISSUES CONCERNING PREGNANCY AND STDS

Sexually transmitted infections and pregnancy share a connection on several levels. Certain STDs can make it difficult or even impossible for a woman to get pregnant. Others may make a woman more likely to lose a pregnancy, and still others may cause infection of the baby either in the womb or at delivery, resulting in lifelong problems for the child.

It is often a very painful connection, made more so because many of these complications could be avoided through education and routine screening during pregnancy.

Many pregnant women are not adequately screened because of the assumption on the part of their health care providers that “nice women” don’t get STDs—which, as I emphasize throughout this book, is not the case. Anyone can contract an STD if she or he is not aware of the risks. Furthermore, many women do not or cannot get adequate health care during their pregnancies, and simple, potentially lifesav-ing screening is therefore not performed. Health care providers must become better educated about STDs, be able to advise patients wisely about the risks they face, and be on the lookout during pregnancy for any potential problems.

What follows is a summary of some of the links between STDs and pregnancy. For a more detailed discussion about each STD and its effects on pregnancy.

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PROSTATE CANCER SCREENING AND DIAGNOSIS: BIOPSY

Just a few years ago, biopsy of the prostate was done “blind”—doctors couldn’t see what they were doing—and as the biopsy needle hit the prostate, the impact sometimes caused the gland to “flip” or rotate slightly, so the biopsy wasn’t actually in the part of the tissue doctors thought they were reaching. Today, using transrectal ultrasound as a guide, urologists can see what they’re doing as they’re doing it. So a biopsy of the prostate is more accurate—and, because the needle is smaller, less painful—than ever before.

Another breakthrough in biopsy technique, besides improved ultrasound technology, has been the development of the springloaded biopsy gun, a tiny device that’s attached to a doctor’s finger. The smaller needle means urologists can be more precise in targeting a core of abnormal tissue—even if it’s surrounded by normal-looking cells. It also means that you’ll feel only slight discomfort.

Using transrectal ultrasound as a guide, urologists can see what they’re doing as they’re doing it. This is a big improvement over the biopsy techniques that were used just a few years ago. This way, a biopsy of the prostate is more accurate—and, because the needle is smaller, less painful—than ever before. The biopsy device is ingeniously designed to capture a core of abnormal-looking tissue (each core of tissue is about a millimeter thick), instead of just a few cells. Pathologists then study these samples under the microscope.

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THE URINARY TRACT: PROSTATE AND URETHRA

The prostate is a muscular, walnut-shaped gland about an inch and a half long, which sits directly under the bladder. Its main function is to manufacture part of the fluid that makes up semen, the solution that transports sperm. During orgasm (the climax of sexual intercourse), the prostate’s muscles contract and force this fluid into the urethra, the main conduit for urinary and sexual fluids. (Sperm, produced by the testes, is also launched into the urethra at this time, along with fluid made by the seminal vesicles.)

The prostate changes with age: When a man reaches his mid-40s, it tends to enlarge, beginning with the innermost cells, those surrounding the urethra. In benign prostatic hyperplasia (BPH), the growing prostate begins to choke the urethra, which runs through it at a thirty-five-degree angle. This slow strangulation is why the prostate can have such an impact on urine flow. We will discuss the prostate in much greater detail in the next section, which covers the reproductive system.

The Urethra

After its short, angled trip through the prostate, the urethra continues its winding course to the penis, the portal by which urine exits the body at last. The urethra, whose total length is about eight inches, is divided into three segments—prostatic, membranous (between the prostate and penis), and penile. Like the prostate, it is involved in both the urinary and reproductive systems; it serves as a conduit not only for urine but also for secretions from the ejaculatory ducts and the prostate. The prostatic urethra, too, is equipped with a means to prevent fluid backup—a ring of smooth muscle that works with the bladder neck as a clamp during ejaculation. This clamp keeps semen from flowing the wrong way, up into the bladder, and directs its course downward, out the urethra.

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