Human Sexuality

Objectives:

Identify the contributions of the key researchers into sexuality.

Know the structure and functions of the sexual organs of men and women.

Compare the sexual response cycles and dysfunctions of men and women.

Identify and assess the advantages and disadvantages of the various forms of birth control.

Identify sexual variations, gender identity disorders, and paraphilias.

Identify the causes, preventions, and treatments of STDs and disorders of the sex organs.

 

Masters and Johnson

Human Sexuality was explored by the Masters and Johnson research team, made up of William Masters and Virginia E. Johnson. They pioneered research into the nature of human sexual response and the diagnosis and treatment of sexual disorders and dysfunctions from 1957 until the 1990s.

Their work began in the Department of Obstetrics and Gynecology at Washington University in St. Louis and was continued at the independent not-for-profit research institution they founded in St. Louis in 1964, originally called the Reproductive Biology Research Foundation and renamed the Masters & Johnson Institute in 1978.

In the initial phase of their studies, from 1957 until 1965, they recorded some of the first laboratory data on the anatomy and physiology of human sexual response based on direct observation of 382 women and 312 men in what they conservatively estimated to be "10,000 complete cycles of sexual response." Their findings, particularly on the nature of female sexual arousal (for example, describing the mechanisms of vaginal lubrication and debunking the earlier widely-held notion that vaginal lubrication originated from the cervix) and orgasm (showing that the physiology of orgasmic response was identical whether stimulation was clitoral or vaginal, and proving that women were capable of being multiorgasmic), dispelled many long standing misconceptions.

They jointly wrote two classic texts in the field, Human Sexual Response and Human Sexual Inadequacy, published in 1966 and 1970 respectively. Both of these books were best-sellers and were translated into more than thirty languages.

Research Work

Masters and Johnson met in 1957 when William Masters hired Virginia Johnson as a research assistant to undertake a comprehensive study of human sexuality. (Masters divorced his first wife to marry Johnson in 1969. They divorced three decades later, largely bringing their joint research to an end.) Previously, the study of human sexuality (sexology) had been a largely neglected area of study due to the restrictive social conventions of the time, with one notable exception.

Alfred Kinsey and his colleagues at Indiana University had previously published two volumes on sexual behavior in the human male and female in 1948 and 1953, respectively (known as the Kinsey Reports), both of which had been revolutionary and controversial in their time. Kinsey's work however, had mainly investigated the frequency with which certain behaviors occurred in the population and was based on personal interviews, not on laboratory observation. In contrast, Masters and Johnson set about to study the structure, psychology and physiology of sexual behaviour, through observing and measuring masturbation and sexual intercourse in the laboratory.

As well as recording some of the first physiological data from the human body and sex organs during sexual excitation, they also framed their findings and conclusions in language that espoused sex as a healthy and natural activity that could be enjoyed as a source of pleasure and intimacy.

Female Reproductive System

The female reproductive system is designed to carry out several functions. It produces the female egg cells necessary for reproduction (called the ova or oocytes). The system is designed to then transport the ova to the site of fertilization where conception - the fertilization of an egg by a sperm - normally occurs in the fallopian tubes.

After conception, the uterus offers a safe and favorable environment for a baby to develop before it is time for it to make its way into the outside world. If fertilization does not take place, the system is designed to menstruate (the monthly shedding of the uterine lining). In addition, the female reproductive system produces female sex hormones that maintain the reproductive cycle.


What Parts Make-up the Female Anatomy?
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The female reproductive anatomy includes internal and external structures.


The function of the external female reproductive structures (the genitals) is twofold: To enable sperm to enter the body and to protect the internal genital organs from infectious organisms. The main external structures of the female reproductive system include:

  • Labia majora: The labia majora enclose and protect the other external reproductive organs. Literally translated as "large lips," the labia majora are relatively large and fleshy, and are comparable to the scrotum in males. The labia majora contain sweat and oil-secreting glands. After puberty, the labia majora are covered with hair.
  • Labia minora: Literally translated as "small lips," the labia minora can be very small or up to 2 inches wide. They lie just inside the labia majora, and surround the openings to the vagina (the canal that joins the lower part of the uterus to the outside of the body) and urethra (the tube that carries urine from the bladder to the outside of the body).
  • Bartholin's glands: These glands are located beside the vaginal opening and produce a fluid (mucus) secretion.
  • Clitoris: The two labia minora meet at the clitoris, a small, sensitive protrusion that is comparable to the penis in males. The clitoris is covered by a fold of skin, called the prepuce, which is similar to the foreskin at the end of the penis. Like the penis, the clitoris is very sensitive to stimulation and can become erect.

The internal reproductive organs in the female include:

  • Vagina: The vagina is a canal that joins the cervix (the lower part of uterus) to the outside of the body. It also is known as the birth canal.
  • Uterus (womb): The uterus is a hollow, pear-shaped organ that is the home to a developing fetus. The uterus is divided into two parts: the cervix, which is the lower part that opens into the vagina, and the main body of the uterus, called the corpus. The corpus can easily expand to hold a developing baby. A channel through the cervix allows sperm to enter and menstrual blood to exit.
  • Ovaries: The ovaries are small, oval-shaped glands that are located on either side of the uterus. The ovaries produce eggs and hormones.
  • Fallopian tubes: These are narrow tubes that are attached to the upper part of the uterus and serve as tunnels for the ova (egg cells) to travel from the ovaries to the uterus. Conception, the fertilization of an egg by a sperm, normally occurs in the fallopian tubes. The fertilized egg then moves to the uterus, where it implants into the lining of the uterine wall.

Clitoris:The clitoris is the female sexual organ found where the labia minora, or inner lips, meet. It consists of a rounded area or head, called the glans, and a longer part, called the shaft, which contains cavernous bodies similar to those of the penis.

The tissue of the inner lips normally covers the shaft of the clitoris, which makes a hood, or prepuce, to protect it. The only directly visible part of the clitoris is the glans, which looks like a small, shiny button.

The size and shape vary considerably among women. It can be seen by gently pushing back the skin of the clitoral hood. There is a high concentration of nerve endings in the clitoris and in the area immediately surrounding it.

The abundance of nerve endings in the clitoris makes it very sensitive to direct or indirect touch or pressure. Stimulation of the clitoral area can be very pleasurable.

In fact, providing its owner with sexual pleasure is the organ's only known function, and the clitoris is the only organ in either sex with pleasure as its sole function. It has nothing to do with getting pregnant, with menstruation, or with urination.

When a woman becomes sexually aroused, both the glans and the shaft fill with blood and increase in size. The glans can double in diameter. There is no evidence that a larger clitoris means more intense sexual arousal.

As erotic stimulation continues and orgasm approaches, the clitoris becomes less visible as it is covered by the swelling of tissues of the clitoral hood. This swelling is designed to protect the clitoris from direct contact, which, for some women, can be more irritating than pleasurable. It moves out again when the stimulation stops.

After orgasm the clitoris returns to its normal size within about ten minutes because the orgasm leads to a dispersal of the accumulated blood. If the woman doesn't have an orgasm, the blood that has flowed into the clitoris as a result of sexual arousal may remain there, keeping the clitoris engorged for a few hours. Many women find this uncomfortable.

A woman's clitoris can be stimulated through direct or indirect contact. During intercourse the penis does not contact the clitoris directly. The thrusting of the penis in the vagina, regardless of the position used, moves the labia minora, and it is this movement of the lips against the clitoris that usually creates the orgasm.

Direct contact with the clitoris by touching it with a finger, vibrator, or a tongue can cause more discomfort than pleasure for many women. For these women, more general rubbing or licking of the area around the clitoris is likely to feel better. Other women enjoy very intense direct stimulation. There is great variability in sensitivity of the clitoris and each woman.

When sexually aroused (usually a combination of psychological and physical stimulation), women’s breasts usually become enlarged and the nipples become erect. Of course, there are various reasons for enlarged breasts and erect nipples, but they are usually present to some degree when a woman is aroused. The enlargement of the breasts is usually slight enough that it is rarely noticed. The veins in the breasts also become more visible as the breasts swell. Additionally, the skin may flush during arousal especially on the chest and neck. This is most visible in fair-skinned individuals. Approximately 50-75% of women experience flush during arousal, while only about 25% of men experience flush.

During sexual arousal, a woman’s vagina and reproductive organs undergo several changes. The vaginal lining moistens with lubricating fluid within 10 to 30 seconds of the beginning of arousal. This fluid is believed to be the “sweating” of the vaginal walls. The sweating resulted from the increased blood supply and the engorgement of vaginal tissues. Also the vaginal walls lengthen and distend, which pulls the cervix and the uterus slowly back and up into the false pelvis (the part of the pelvis above the hip joint). The engorgement of the vagina is a type of vasocongestion, a phenomenon also seen in menstruation, REM sleep, allergic reaction, and deeply emotional responses.

The glans in the head clitoris also become swollen and erect like a penis. (The clitoris, after all, is homologous to the penis–for a better idea of how much like a penis a clitoris is, or really vice versa.) This reaction to arousal varies in degree between women. The labia majora swell as do the labia minora, though to a lesser degree.

Women’s blood pressure, breathing, and heart rate increase considerably during sexual arousal. This happens in order to accommodate the increased blood supply to various parts of the body with sufficient oxygen. Muscles throughout the body also become tense because of this. These and the above signs of arousal occur during the first two stages of the human sexual response as outlined by Masters and Johnson: excitement and plateau.

 

What Happens During the Menstrual Cycle?


Females of reproductive age experience cycles of hormonal activity that repeat at about one-month intervals.(Menstru means "monthly"; hence the term menstrual cycle.) With every cycle, a woman's body prepares for a potential pregnancy, whether or not that is the woman's intention. The term menstruation refers to the periodic shedding of the uterine lining.

The average menstrual cycle takes about 28 days and occurs in phases: the follicular phase, the ovulatory phase (ovulation), and the luteal phase.

There are four major hormones (chemicals that stimulate or regulate the activity of cells or organs) involved in the menstrual cycle: follicle-stimulating hormone, luteinizing hormone, estrogen and progesterone.


Follicular Phase

This phase starts on the first day of your period. During the follicular phase of the menstrual cycle, the following events occur:

  • Two hormones, follicle stimulating hormone (FSH) and luteinizing hormone (LH) are released from the brain and travel in the blood to the ovaries.
  • The hormones stimulate the growth of about 15-20 eggs in the ovaries each in its own "shell," called a follicle.
  • These hormones (FSH and LH) also trigger an increase in the production of the female hormone estrogen.
  • As estrogen levels rise, like a switch, it turns off the production of follicle-stimulating hormone. This careful balance of hormones allows the body to limit the number of follicles that complete maturation, or growth.
  • As the follicular phase progresses, one follicle in one ovary becomes dominant and continues to mature. This dominant follicle suppresses all of the other follicles in the group. As a result, they stop growing and die. The dominant follicle continues to produce estrogen.

Ovulatory Phase

The ovulatory phase, or ovulation, starts about 14 days after the follicular phase started. The ovulatory phase is the midpoint of the menstrual cycle, with the next menstrual period starting about 2 weeks later. During this phase, the following events occur:

  • The rise in estrogen from the dominant follicle triggers a surge in the amount of luteinizing hormone that is produced by the brain.
  • This causes the dominant follicle to release its egg from the ovary.
  • As the egg is released (a process called ovulation) it is captured by finger-like projections on the end of the fallopian tubes (fimbriae). The fimbriae sweep the egg into the tube.
  • Also during this phase, there is an increase in the amount and thickness of mucous produced by the cervix (lower part of the uterus.) If a woman were to have intercourse during this time, the thick mucus captures the man's sperm, nourishes it, and helps it to move towards the egg for fertilization.

Luteal Phase

The luteal phase begins right after ovulation and involves the following processes:

  • Once it releases its egg, the empty follicle develops into a new structure called the corpus luteum.
  • The corpus luteum secretes the hormone progesterone. Progesterone prepares the uterus for a fertilized egg to implant.
  • If intercourse has taken place and a man's sperm has fertilized the egg (a process called conception), the fertilized egg (embryo) will travel through the fallopian tube to implant in the uterus. The woman is now considered pregnant.
  • If the egg is not fertilized, it passes through the uterus. Not needed to support a pregnancy, the lining of the uterus breaks down and sheds, and the next menstrual period begins.

How Many Eggs Does a Woman Have?

During fetal life, there are about 6 million to 7 million eggs in the female ovaries. From this time, no new eggs are produced. The vast majority of the eggs within the ovaries steadily die, until they are depleted at menopause. At birth, there are approximately 1 million eggs; and by the time of puberty, only about 300,000 remain. Of these, 300 to 400 will be ovulated during a woman's reproductive lifetime. The eggs continue to degenerate during pregnancy, with the use of birth control pills, and in the presence or absence of regular menstrual cycles

Male Reproductive System

The purpose of the organs of the male reproductive system is to perform the following functions:

  • To produce, maintain and transport sperm (the male reproductive cells) and protective fluid (semen)
  • To discharge sperm within the female reproductive tract during sex
  • To produce and secrete male sex hormones responsible for maintaining the male reproductive system

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Unlike the female reproductive system, most of the male reproductive system is located outside of the body. These external structures include the penis, scrotum, and testicles.

  • Penis: This is the male organ used in sexual intercourse. It has 3 parts: the root, which attaches to the wall of the abdomen; the body, or shaft; and the glans, which is the cone-shaped part at the end of the penis. The glans, also called the head of the penis, is covered with a loose layer of skin called foreskin. (This skin is sometimes removed in a procedure called circumcision.) The opening of the urethra, the tube that transports semen and urine, is at the tip of the penis. The penis also contains a number of sensitive nerve endings.

The body of the penis is cylindrical in shape and consists of 3 circular shaped chambers. These chambers are made up of special, sponge-like tissue. This tissue contains thousands of large spaces that fill with blood when the man is sexually aroused. As the penis fills with blood, it becomes rigid and erect, which allows for penetration during sexual intercourse. The skin of the penis is loose and elastic to accommodate changes in penis size during an erection.

Semen, which contains sperm (reproductive cells), is expelled (ejaculated) through the end of the penis when the man reaches sexual climax (orgasm). When the penis is erect, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.

  • Scrotum: This is the loose pouch-like sac of skin that hangs behind the penis. It contains the testicles (also called testes), as well as many nerves and blood vessels. The scrotum acts as a "climate control system" for the testes. For normal sperm development, the testes must be at a temperature slightly cooler than body temperature. Special muscles in the wall of the scrotum allow it to contract and relax, moving the testicles closer to the body for warmth or farther away from the body to cool the temperature.
  • Testicles (testes): These are oval organs about the size of large olives that lie in the scrotum, secured at either end by a structure called the spermatic cord. Most men have two testes. The testes are responsible for making testosterone, the primary male sex hormone, and for generating sperm. Within the testes are coiled masses of tubes called seminiferous tubules. These tubes are responsible for producing sperm cells.

The internal organs of the male reproductive system, also called accessory organs, include the following:

  • Epididymis: The epididymis is a long, coiled tube that rests on the backside of each testicle. It transports and stores sperm cells that are produced in the testes. It also is the job of the epididymis to bring the sperm to maturity, since the sperm that emerge from the testes are immature and incapable of fertilization. During sexual arousal, contractions force the sperm into the vas deferens.
  • Vas deferens: The vas deferens is a long, muscular tube that travels from the epididymis into the pelvic cavity, to just behind the bladder. The vas deferens transports mature sperm to the urethra, the tube that carries urine or sperm to outside of the body, in preparation for ejaculation.
  • Ejaculatory ducts: These are formed by the fusion of the vas deferens and the seminal vesicles (see below). The ejaculatory ducts empty into the urethra.
  • Urethra: The urethra is the tube that carries urine from the bladder to outside of the body. In males, it has the additional function of ejaculating semen when the man reaches orgasm. When the penis is erect during sex, the flow of urine is blocked from the urethra, allowing only semen to be ejaculated at orgasm.
  • Seminal vesicles: The seminal vesicles are sac-like pouches that attach to the vas deferens near the base of the bladder. The seminal vesicles produce a sugar-rich fluid (fructose) that provides sperm with a source of energy to help them move. The fluid of the seminal vesicles makes up most of the volume of a man's ejaculatory fluid, or ejaculate.
  • Prostate gland: The prostate gland is a walnut-sized structure that is located below the urinary bladder in front of the rectum. The prostate gland contributes additional fluid to the ejaculate. Prostate fluids also help to nourish the sperm. The urethra, which carries the ejaculate to be expelled during orgasm, runs through the center of the prostate gland.
  • Bulbourethral glands: Also called Cowper's glands, these are pea-sized structures located on the sides of the urethra just below the prostate gland. These glands produce a clear, slippery fluid that empties directly into the urethra. This fluid serves to lubricate the urethra and to neutralize any acidity that may be present due to residual drops of urine in the urethra.

Castration

The concept of castration plays an important role in psychoanalysis.

Although castration literally means removal of the testes, in psychoanalytic terms the penis is seen as having more symbolic significance than the testes, and thus castration refers to the removal of the penis, and more so the removal of the phallus. And since the phallus is not merely the penis but rather the power and authority that the penis represents, any removal of that power is in effect a removal of the phallus even if the penis itself remains intact, and thus is castration. Thus, blindness, decapitation, dismemberment, mutilation, circumcision, rape, etc., can all be seen as forms of castration, for they all remove the phallus.

Women as lacking a penis and a phallus are always already castrated, and yet simultaneously there is also sometimes the idea that they can be castrated by the loss of power and authority.

Castration also plays an important role in psychoanalytically-influenced literary theory, for example Harold Bloom's The Anxiety of Influence. Poetry can also be seen as castrating, with male poets either being castrated through being outdone by their male predecessors (as in Bloom), or male poets (and even mere readers) being castrated by the force of the female sublime as conveyed to them through poetry (as in Maxwell). Catherine Maxwell identifies Philomela as being castrated by Tereus when he rapes and mutilates her.

 

How Does the Male Reproductive System Function?

The entire male reproductive system is dependent on hormones, which are chemicals that regulate the activity of many different types of cells or organs. The primary hormones involved in the male reproductive system are follicle-stimulating hormone, luteinizing hormone, and testosterone.

Follicle-stimulating hormone is necessary for sperm production (spermatogenesis) and luteinizing hormone stimulates the production of testosterone, which is also needed to make sperm. Testosterone is responsible for the development of male characteristics, including muscle mass and strength, fat distribution, bone mass, facial hair growth, voice change and sex drive.

How Does an Erection Occur?

The penis contains two chambers, called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa.

Erection begins with sensory and mental stimulation. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the open spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps to trap the blood in the corpora cavernosa, thereby sustaining erection. Erection is reversed when muscles in the penis contract, stopping the inflow of blood and opening outflow channels.

Foreplay

Foreplay is intimate psychological and physical acts between two or more people meant to increase sexual arousal.

Foreplay involves different acts such as kissing, touching, embracing, talking, and teasing. Sexual stimulation such as manual or oral stimulation of erogenous zones are considered foreplay. Of the various forms of foreplay, the most common include fellatio and cunnilingus.

  • Deep tongue kissing
  • Touching and massaging over clothing, also
  • Rubbing together erogenous zones over clothing
  • Undressing oneself or partner
  • There are many types of foreplay. Stimulation with the hands is the most common form, followed by oral stimulation. Foreplay is to provide sexual pleasure and arousal. The act is generally the act of preparing ones partner for sexual intercourse, though it does not exclude the chance of orgasm if applied rigorously.

Direct manipulation of naked erogenous zones is almost always considered foreplay. In women, this includes stimulation of the clitoris and vulva. In men, it includes stimulation of the penis and scrotum. For both sexes, it could include stimulation of nipples and anus.

Foreplay tends to become purely physical and intense. It reaches its peak in the moments just before intercourse, when it induces a strong mutual desire for penetration. Technically, foreplay ends with intromission, or the beginning of intercourse.

Intercourse

Vaginal sexual intercourse is also called coitus.. The purpose of vaginal intercourse is reproduction. Although reproduction is the purpose, intercourse is often performed exclusively for pleasure and as a way to express love and intimacy.

Intercourse may be preceded by foreplay, which leads to the sexual arousal of both partners, resulting in the an erection of the penis and natural lubrication of the vagina.

To engage in intercourse, the erect penis is inserted into the vagina and one or both of the partners move their hips to move the penis backward and forward inside the vagina to cause friction, typically without fully removing the penis. In this way, they stimulate themselves and each other, often continuing until orgasm in either or both partners is achieved. Penetration by the hardened erect penis is also known as intromission.

Intercourse is the basic reproductive method of humans. During ejaculation, which usually accompanies male orgasm, a series of muscular contractions delivers semen from the penis into the vagina.

The route of the sperm from the vault of the vagina is through the cervix and into the uterus, and then into the fallopian tubes. Millions of sperm are present in each ejaculation, to increase the chances of one fertilizing an egg. When a fertile egg from the female is present in the fallopian tubes, the male sperm joins with the egg resulting in fertilization and the formation of a new embryo. When a fertilized egg reaches the uterus, it becomes implanted in the lining of the uterus and a pregnancy has begun.

Sexual Response Cycle

The sexual response cycle refers to the sequence of physical and emotional changes that occur as a person becomes sexually aroused and participates in sexually stimulating activities, including intercourse and masturbation. Knowing how your body responds during each phase of the cycle can enhance your relationship and help you pinpoint the cause of any sexual problems.


What Are the Phases of the Sexual Response Cycle?


Sexual Response

The sexual response cycle has four phases: excitement, plateau, orgasm, and resolution. Both men and women experience these phases, although the timing usually is different. For example, it is unlikely that both partners will reach orgasm at the same time. In addition, the intensity of the response and the time spent in each phase varies from person to person. Understanding these differences may help partners better understand one another's bodies and responses, and enhance the sexual experience.


Phase 1: Excitement


General characteristics of this phase, which can last from a few minutes to several hours, include the following:

  • Muscle tension increases.
  • Heart rate quickens and breathing is accelerated.
  • Skin may become flushed (blotches of redness appear on the chest and back).
  • Nipples become hardened or erect.
  • Blood flow to the genitals increases, resulting in swelling of the woman's clitoris and labia minora (inner lips), and erection of the man's penis.
  • Vaginal lubrication begins.
  • The woman's breasts become fuller and the vaginal walls begin to swell.
  • The man's testicles swell, his scrotum tightens, and he begins secreting a lubricating liquid.

Phase 2: Plateau


General characteristics of this phase, which extends to the brink of orgasm, include the following:

  • The changes begun in phase 1 are intensified.
  • The vagina continues to swell from increased blood flow, and the vaginal walls turn a dark purple.
  • The woman's clitoris becomes highly sensitive (may even be painful to touch) and retracts under the clitoral hood to avoid direct stimulation from the penis.
  • The man's testicles are withdrawn up into the scrotum.
  • Breathing, heart rate, and blood pressure continue to increase.
  • Muscle spasms may begin in the feet, face, and hands.
  • Muscle tension increases.

Phase 3: Orgasm

This phase is the climax of the sexual response cycle. It is the shortest of the phases and generally lasts only a few seconds. General characteristics of this phase include the following:

  • Involuntary muscle contractions begin.
  • Blood pressure, heart rate, and breathing are at their highest rates, with a rapid intake of oxygen.
  • Muscles in the feet spasm.
  • There is a sudden, forceful release of sexual tension.
  • In women, the muscles of the vagina contract. The uterus also undergoes rhythmic contractions.
  • In men, rhythmic contractions of the muscles at the base of the penis result in the ejaculation of semen.
  • A rash, or "sex flush" may appear over the entire body.

Phase 4: Resolution

During this phase, the body slowly returns to its normal level of functioning, and swelled and erect body parts return to their previous size and color. This phase is marked by a general sense of well-being, enhanced intimacy and, often, fatigue. Some women are capable of a rapid return to the orgasm phase with further sexual stimulation and may experience multiple orgasms. Men need recovery time after orgasm, called a refractory period, during which they cannot reach orgasm again. The duration of the refractory period varies among men and usually lengthens with advancing age.

Masturbation

Masturbation is the self-stimulation of the genitals to achieve sexual arousal and pleasure, usually to the point of orgasm (sexual climax). It is commonly done by touching, stroking or massaging the penis or clitoris until an orgasm is achieved. Some women also use stimulation of the vagina to masturbate or use "sex toys," such as a vibrator.

Who Masturbates?

Just about everybody. Masturbation is a very common behavior, even among people who have sexual relations with a partner. In one national study, 95% of males and 89% of females reported that they have masturbated. Masturbation is the first sexual act experienced by most males and females. In young children, masturbation is a normal part of the growing child's exploration of his or her body. Most people continue to masturbate in adulthood, and many do so throughout their lives.

Why Do People Masturbate?

In addition to feeling good, masturbation is a good way of relieving the sexual tension that can build up over time, especially for people without partners or whose partners are not willing or available for sex. Masturbation also is a safe sexual alternative for people who wish to avoid pregnancy and the dangers of sexually transmitted diseases. It also is necessary when a man must give a semen sample for infertility testing or for sperm donation. When sexual dysfunction is present in an adult, masturbation may be prescribed by a sex therapist to allow a person to experience an orgasm (often in women) or to delay its arrival (often in men).

Is Masturbation Normal?

While it once was regarded as a perversion and a sign of a mental problem, masturbation now is regarded as a normal, healthy sexual activity that is pleasant, fulfilling, acceptable and safe. It is a good way to experience sexual pleasure and can be done throughout life.

Masturbation is only considered a problem when it inhibits sexual activity with a partner, is done in public, or causes significant distress to the person. It may cause distress if it is done compulsively and/or interferes with daily life and activities.

Is Masturbation Harmful?

In general, the medical community considers masturbation to be a natural and harmless expression of sexuality for both men and women. It does not cause any physical injury or harm to the body, and can be performed in moderation throughout a person's lifetime as a part of normal sexual behavior. Some cultures and religions oppose the use of masturbation or even label it as sinful. This can lead to guilt or shame about the behavior.

Some experts suggest that masturbation can actually improve sexual health and relationships. By exploring your own body through masturbation, you can determine what is erotically pleasing to you and can share this with your partner. Some partners use mutual masturbation to discover techniques for a more satisfying sexual relationship and to add to their mutual intimacy.

Sexual Dysfuction in Men

Male Genital and Sexual Disorders

A man's genitals—the prostate gland, penis, scrotum, and testicles—are responsible for the physical aspect of sexual function. Collectively, these organs are known as the male reproductive system. The prostate gland and the penis have double duty. Because urine passes through them, they are inevitably involved in how the urinary system functions. Thus, problems with the genitals can affect sexual function or, particularly if the prostate gland or penis malfunctions, urination.

Many older men retain the ability to achieve erections, have orgasms, and ejaculate (release semen at orgasm). Nonetheless, aging itself gradually affects sexual function. Erections occur less often, do not last as long, and are less rigid. The penis becomes less sensitive to touch. After orgasm, the penis becomes limp more rapidly, and having another erection takes longer. The volume of fluid ejaculated usually decreases, and ejaculation can occur with little forewarning. Sex drive may decrease, because the level of testosterone (the main male sex hormone) decreases.

Problems with sexual function can result from disorders of the genitals, other disorders, or mental and emotional factors (such as anxiety, fear, or stress). Many sexual problems result from a combination of these factors. Men sometimes feel pressure (from themselves or a partner) to perform well sexually, and they become distressed when they cannot. This feeling is called performance anxiety. Performance anxiety can further reduce a man's ability to enjoy sexual activity.

Benign prostatic hyperplasia, prostatitis, prostate cancer, inguinal hernia, erectile dysfunction (impotence), a decreased sex drive, and ejaculation abnormalities become more common with aging. Except for prostate cancer and, very rarely, benign prostatic hyperplasia, these disorders are not life threatening. However, they can cause distress and threaten a man's self-esteem. Men may find talking about these disorders difficult and embarrassing. They may feel that the subject is off-limits for discussion, even with their doctor. But men should not let these feelings prevent them from talking with a doctor, because many of the disorders can be effectively treated.

Impotence

What Causes Impotence?

Since an erection requires a sequence of events, impotence can occur when any of the events is disrupted. The sequence includes nerve impulses in the brain, spinal column, and area of the penis, and response in muscles, fibrous tissues, veins, and arteries in and near the corpora cavernosa.

Damage to arteries, smooth muscles, and fibrous tissues, often as a result of disease, is the most common cause of impotence. Diseases -- including diabetes, kidney disease, chronic alcoholism, multiple sclerosis, atherosclerosis, and vascular disease -- account for about 70 percent of cases of impotence. Between 35 and 50 percent of men with diabetes experience impotence.

Surgery (for example, prostate surgery) can injure nerves and arteries near the penis, causing impotence. Injury to the penis, spinal cord, prostate, bladder, and pelvis can lead to impotence by harming nerves, smooth muscles, arteries, and fibrous tissues of the corpora cavernosa.

Also, many common medicines produce impotence as a side effect. These include high blood pressure drugs, antihistamines, antidepressants, tranquilizers, appetite suppressants, and cimetidine (an ulcer drug).

Experts believe that psychological factors cause 10 to 20 percent of cases of impotence. These factors include stress, anxiety, guilt, depression, low self-esteem, and fear of sexual failure. Such factors are broadly associated with more than 80 percent of cases of impotence, usually as secondary reactions to underlying physical causes.

Other possible causes of impotence are smoking, which affects blood flow in veins and arteries, and hormonal abnormalities, such as insufficient testosterone.

How Is Impotence Diagnosed?
Patient History

Medical and sexual histories help define the degree and nature of impotence. A medical history can disclose diseases that lead to impotence. A simple recounting of sexual activity might distinguish between problems with erection, ejaculation, orgasm, or sexual desire.

A history of using certain prescription drugs or illegal drugs can suggest a chemical cause. Drug effects account for 25 percent of cases of impotence. Cutting back on or substituting certain medications often can alleviate the problem.

Physical Examination

A physical examination can give clues for systemic problems. For example, if the penis does not respond as expected to certain touching, a problem in the nervous system may be a cause. Abnormal secondary sex characteristics, such as hair pattern, can point to hormonal problems, which would mean the endocrine system is involved. A circulatory problem might be indicated by, for example, an aneurysm in the abdomen. And unusual characteristics of the penis itself could suggest the root of the impotence -- for example, bending of the penis during erection could be the result of Peyronie's disease.

Laboratory Tests

Several laboratory tests can help diagnose impotence. Tests for systemic diseases include blood counts, urinalysis, lipid profile, and measurements of creatinine and liver enzymes. For cases of low sexual desire, measurement of testosterone in the blood can yield information about problems with the endocrine system.

Psychosocial Examination

A psychosocial examination, using an interview and questionnaire, reveals psychological factors. The man's sexual partner also may be interviewed to determine expectations and perceptions encountered during sexual intercourse.

How Is Impotence Treated?

Most physicians suggest that treatments for impotence proceed along a path moving from least invasive to most invasive. This means cutting back on any harmful drugs is considered first. Psychotherapy and behavior modifications are considered next, followed by vacuum devices, oral drugs, locally injected drugs, and surgically implanted devices (and, in rare cases, surgery involving veins or arteries).

Psychotherapy

Experts often treat psychologically based impotence using techniques that decrease anxiety associated with intercourse. The patient's partner can help apply the techniques, which include gradual development of intimacy and stimulation. Such techniques also can help relieve anxiety when physical impotence is being treated.

Points to Remember

  • Impotence is a consistent inability to sustain an erection sufficient for sexual intercourse.
  • Impotence affects 10 to 15 million American men.
  • Impotence usually has a physical cause.
  • Impotence is treatable in all age groups.
  • Treatments include psychotherapy, drug therapy, vacuum devices, and surgery.

Premature Ejaculation

How does ejaculation occur?

Ejaculation, controlled by the central nervous system, happens when sexual stimulation and friction provide impulses that are delivered to the spinal cord and into the brain.
Ejaculation has two phases:

Phase I: Emission

The vas deferens (the tubes that store and transport sperm from the testes) contract to squeeze the sperm toward the base of the penis through the prostate gland. The seminal vesicles release secretions that combine with the sperm to make semen. The ejaculation is unstoppable at this stage.

Phase II: Ejaculation

The muscles at the base of the penis contract forcing semen out of the penis (ejaculation and orgasm) while the bladder neck contracts. Orgasm can occur without the delivery of semen (ejaculation) from the penis. Normally, erections are lost following ejaculation.

What is premature ejaculation?

Premature ejaculation (PE) is characterized by a lack of voluntary control over ejaculation. Many men occasionally ejaculate sooner than they or their partner would like during sexual activities. PE is a frustrating problem that can reduce the enjoyment of sex, harm relationships and affect quality of life. Occasional instances of PE might not be cause for concern. However, when the problem occurs frequently and causes distress to the man or his partner, treatment may be of benefit.

What causes premature ejaculation?

Although the exact cause of premature ejaculation (PE) is not known, new studies suggest that serotonin, a natural substance produced by nerves, is important. A breakdown of the actions of serotonin in the brain may be a cause. Studies have found that high amounts of serotonin in the brain slow the time to ejaculation while low amounts of serotonin can produce a condition like PE.

Psychological factors also commonly contribute to PE. Temporary depression, stress, unrealistic expectations about performance, a history of sexual repression, or an overall lack of confidence can cause PE. Interpersonal dynamics may contribute to sexual function. PE can be caused by a lack of communication between partners, hurt feelings, or unresolved conflicts that interfere with the ability to achieve emotional intimacy.

Can premature ejaculation develop later in life?

Premature ejaculation (PE) can occur at any age. Surprisingly, aging appears not to be a cause of PE. However, the aging process typically causes changes in erectile function and ejaculation. Erections may not be as firm or as large. Erections may be maintained for a shorter period before ejaculating. The feeling that an ejaculation is about to happen may be shorter. These factors can result in an older man having an ejaculation earlier than when he was younger.

Can both premature ejaculation and erectile dysfunction affect a man at the same time?

Sometimes premature ejaculation (PE) may be a problem in men who have erectile dysfunction (ED)—the inability to achieve and/or maintain an erection sufficient for satisfactory sexual performance. Some men do not understand that the loss of erection normally occurs after ejaculation and may wrongly complain to their doctor that they have ED when the actual problem is PE. It is recommended that the ED be treated first if you experience both ED and PE, since the PE may resolve on its own once the ED has been adequately treated.

When premature ejaculation (PE) happens so frequently that it interferes with your sexual pleasure, it becomes a medical problem requiring the care of a doctor. To understand the problem, the doctor will need to ask questions about your sexual history such as the following:

  • How often does the PE occur?
  • How long have you had this problem?
  • Is the problem specific to one partner? Or does it happen with every partner?
  • Does PE occur with all or just some attempts at sexual relations?
  • How much stimulation results in PE?
  • What type of sexual activity (i.e., foreplay, masturbation, intercourse, use of visual clues, etc.) is engaged in and how often?
  • How has PE affected sexual activity?
  • What is the quality of your personal relationships?
  • How does PE affect your quality of life?
  • Are there any factors that make PE worse or better (i.e., drugs, alcohol, etc.)?

Usually, laboratory testing is not necessary unless the history and a physical examination reveal something more complicated.

Sexual Dysfunction in Women
 
Dyspareunia is pain during sexual intercourse.

The pain of dyspareunia may be superficial, occurring in the genital area (in the vulva, including the opening of the vagina), or deep, occurring within the pelvis due to pressure on internal organs. The pain may be burning, sharp, or cramping.

Superficial pain during sexual intercourse has many causes. When women have sexual intercourse the first time, the membrane that covers the opening of the vagina (hymen), if still intact, may tear as the penis enters the vagina, causing pain and sometimes bleeding. When the vagina is inadequately lubricated, intercourse may be painful. (Inadequate lubrication usually results from insufficient foreplay or from the decrease in estrogen levels after menopause.) Inflammation or infection in the genital area (for example, affecting the vulva, vagina, or Bartholin's glands) or in the urinary tract can make intercourse painful. Herpes can cause severe genital pain. Other causes include injuries in the genital area, a diaphragm or cervical cap that does not fit properly, an allergic reaction to contraceptive foams or jellies or to latex condoms, a congenital abnormality (such as a rigid hymen or an abnormal wall within the vagina), and involuntary contraction of the vaginal muscles (vaginismus). Sexual intercourse may be painful for women who have had surgery that narrows the vagina (for example, to repair tissues torn during childbirth or to correct a pelvic floor disorder (see Pelvic Floor Disorders). Taking antihistamines can cause slight, temporary dryness of the vagina. During breastfeeding, the vagina may become dry because estrogen levels are low.

As women age, the lining of the vagina thins and becomes dry because estrogen levels decrease. This condition is called atrophic vaginitis. As a result, intercourse may be painful.

Deep pain after sexual intercourse may result from an infection of the cervix, uterus, or fallopian tubes. Other causes include endometriosis, pelvic inflammatory disease (including pelvic abscess), pelvic tumors (including ovarian cysts), and bands of scar tissue (adhesions) that have formed between organs in the pelvis after an infection or surgery. Sometimes one of these disorders results in the uterus bending backward (retroversion). The ligaments, muscles, and other tissues that hold the uterus in place may weaken, resulting in the uterus dropping down toward the vagina (prolapse (see When the Bottom Falls Out: Prolapse in the Pelvis). Such changes in position can result in pain during intercourse. Radiation therapy for cancer may cause changes in the tissues that make intercourse painful.

Psychologic factors can cause superficial or deep pain. Examples are anger or repulsion toward a sex partner, fear of intimacy or pregnancy, a negative self-image, and a traumatic sexual experience (including rape). However, psychologic factors may be difficult to identify.

Diagnosis and Treatment

The diagnosis is based on symptoms: when and where the pain occurs and when intercourse began to be painful. To try to identify the cause, a doctor asks the woman about her medical and sexual history and performs a pelvic examination.

Women should abstain from intercourse until the problem resolves. However, sexual activity that does not involve vaginal penetration can continue.

Superficial pain can be reduced by applying an anesthetic ointment and by taking sitz baths. Liberally applying a lubricant before intercourse may help. Water-based lubricants rather than petroleum jelly or other oil-based lubricants are preferable. Oil-based products tend to dry the vagina and can damage latex contraceptive devices such as condoms and diaphragms. Spending more time in foreplay may increase vaginal lubrication. Deep pain may be reduced by using a different position for intercourse. For example, a position that gives the woman more control of penetration (such as being on top) or that involves less deep thrusting may help.

More specific treatment depends on the cause. If the cause is thinning and drying of the vagina after menopause, using a topical estrogen cream or suppository or taking estrogen by mouth (as part of hormone therapy (see Menopause: Hormone Therapy) can help.

Inflammation and infection are treated with antibiotics, antifungal drugs, and other drugs as appropriate (see Some Vaginal Infections). If the cause is inflammation of the vulva (vulvitis), applying wet dressings of aluminum acetate solution may help. Surgery may be needed to remove cysts or abscesses, open a rigid hymen, or repair an anatomic abnormality. A poorly fitting diaphragm should be replaced with one that fits and is comfortable, or a different method of birth control should be tried.

If the cause of pain is the position of the uterus, a pessary, which resembles a diaphragm and is inserted into the vagina, can support and reposition the uterus. Using a pessary reduces the pain in some women.

Orgasmic disorder is the delay in or absence of sexual climax (orgasm) despite sufficiently long and intense sexual stimulation.

The amount and type of stimulation required for orgasm varies greatly from woman to woman. Most women can reach orgasm when the clitoris is stimulated, but only about half of women regularly reach orgasm during sexual intercourse. About 1 of 10 women never reach orgasm. Orgasmic disorder occurs when problems with orgasm are persistent and frequent, interfering with sexual function and causing distress.

Usually, women who have learned how to reach orgasm do not lose that ability unless poor sexual communication, conflict in a relationship, a traumatic experience, or a physical or psychologic disorder intervenes. Physical and psychologic causes are similar to those of sexual arousal disorder. Depression is a common cause.

Orgasmic disorder may result from lovemaking that consistently ends before the woman reaches orgasm. The woman may not reach orgasm because foreplay is inadequate, because one or both partners do not understand how the genital organs function, or because ejaculation is premature. Such lovemaking produces frustration and may result in resentment and occasionally in distaste for anything sexual. Some women who become aroused may not reach orgasm because they fear "letting go," especially during intercourse. This fear may be due to guilt after a pleasurable experience, fear of abandoning oneself to pleasure that depends on the partner, or fear of losing control.

Certain drugs, particularly selective serotonin reuptake inhibitors may inhibit orgasm.

Orgasmic disorder may be temporary, may occur after years of normal sexual function, or may be lifelong. It may occur all the time or only in certain situations. Most women who have a problem reaching orgasm also have a problem being aroused.

Diagnostic criteria for 302.73 Female Orgasmic Disorder 
 

A. Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis of Female Orgasmic Disorder should be based on the clinician's judgment that the woman's orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives. 

B. The disturbance causes marked distress or interpersonal difficulty. 

C. The orgasmic dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 

Specify type: 

Lifelong Type  
Acquired Type 

Specify type: 

Generalized Type  
Situational Type 

Specify

Due to Psychological Factors  
Due to Combined Factors

Diagnostic criteria for 302.72 Female Sexual Arousal Disorder 

A. Persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement. 

B. The disturbance causes marked distress or interpersonal difficulty. 

C. The sexual dysfunction is not better accounted for by another Axis I disorder (except another Sexual Dysfunction) and is not due exclusively to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. 

Specify type: 

Lifelong Type 
Acquired Type 

Specify type: 

Generalized Type 
Situational Type 

Specify

Due to Psychological Factors 
Due to Combined Factors

Diagnosis and Treatment

The diagnosis is based on the woman's description of the problem. To identify the cause, a doctor asks the woman about her sexual and medical history, including use of drugs, and performs a physical examination.

If the cause is psychologic, counseling for the woman, usually with her partner, often helps. Psychotherapy for the woman or the couple may be recommended. Physical disorders, if present, are treated.

Other useful measures include sensate focus exercises for couples, information about how the genital organs function, and Kegel exercises.


Sexual arousal disorder
is the persistent or recurring inability to attain or to maintain adequate vaginal lubrication and other physical responses of sexual excitement before or during sexual intercourse.

Usually, when a woman is sexually stimulated, the vagina releases lubricating secretions, the labia and clitoris of the vulva swell, and the breasts enlarge slightly. In sexual arousal disorder, these responses do not occur despite sufficiently long and intense sexual stimulation.

If the disorder has been present since puberty, the woman may not know how the genital organs (particularly the clitoris) function or what arousal techniques are effective. The lack of knowledge leads to anxiety, which worsens the problem. Many women who have sexual arousal disorder associate sex with sinfulness and sexual pleasure with guilt. Fear of intimacy and a negative self-image may also contribute.
If the disorder develops after a period of adequate sexual functioning, it may be due to a problem in the current sexual relationship, such as constant fighting or arguing. Depression is a common cause, and stress may contribute.


Physical causes include inflammation of the vagina (vaginitis), inflammation of the bladder (cystitis), endometriosis, an underactive thyroid gland (hypothyroidism), diabetes mellitus, multiple sclerosis, and muscular dystrophy.

Sexual arousal disorder may develop as women age. As menopause approaches, the lining of the vagina thins and becomes dry because the estrogen level decreases. As a result, the ability to become aroused declines, partly because sexual intercourse may be painful.

Taking drugs such as oral contraceptives, antihypertensives, antidepressants, or sedatives can cause sexual arousal disorder. Surgical removal of the uterus (hysterectomy) or breast (mastectomy) may damage a woman's sexual self-image, contributing to sexual arousal disorder.

Many women with sexual arousal disorder also lack sexual desire. Because the vagina does not become lubricated, sexual intercourse is usually painful or uncomfortable.

Diagnosis and Treatment

The diagnosis is based on the woman's description of the problem. To determine the severity of the disorder and identify the cause, a doctor asks the woman about her sexual and medical history (including use of drugs) and performs a physical examination. Tests to detect physical disorders, if thought to be the cause, may be performed.

If the cause is psychologic, counseling for the woman, usually with her partner, often helps. Individual psychotherapy or group therapy is sometimes useful. Physical disorders, if present, are treated. Postmenopausal women may benefit from treatment with estrogen or male hormones such as testosterone. Estrogen creams and suppositories reduce the thinning and drying of the lining of the vagina and thus may help with lubrication during intercourse. The use of in treating women with sexual arousal disorder is controversial.

Sensate focus exercises for couples can help relieve a couple's anxiety about intimacy and sexual intercourse. Learning about how the genital organs function can help. A woman can learn which arousal techniques are effective for her and her partner. Performing Kegel exercises can help because they strengthen the muscles involved in sexual intercourse.

Vaginismus is an involuntary contraction of muscles around the opening of the vagina that makes sexual intercourse painful or impossible.

Vaginismus may result from a woman's unconscious desire to prevent sexual intercourse. Pain experienced in the past during sexual intercourse can lead to vaginismus. Other reasons women do not want to engage in intercourse include fear of becoming pregnant, of being controlled by their partner, or of losing control. Sometimes vaginismus is caused by a physical disorder, such as a pelvic infection or scarring of the vaginal opening (due to injury, childbirth, or surgery). Irritation (due to douches, spermicides, or latex in condoms) may also cause vaginismus.

Because of the pain, some women who have vaginismus cannot tolerate sexual intercourse (that is, penetration of the vagina by the penis). However, sexual activity that does not involve penetration may be pleasurable. Some women cannot tolerate the insertion of a tampon and may need an anesthetic when a doctor performs a pelvic examination.

Diagnosis and Treatment

The diagnosis is based on the woman's description of the problem, her medical history, and the physical examination, including her reaction to a pelvic examination.

Physical disorders that may be causing or contributing to vaginismus are treated. If the cause is psychologic, counseling for the woman and her partner is usually helpful.

If vaginismus persists, the woman is taught a technique to relax the muscle spasms. The technique involves gradually widening (dilating) the vagina. The woman begins by inserting very small, lubricated plastic rods (dilators) into her vagina. The woman inserts slightly but progressively larger dilators as her level of comfort increases. Once the woman can tolerate having large dilators inserted without discomfort, she and her partner may try to have sexual intercourse again.

Kegel exercises, which strengthen the pelvic muscles, can be helpful if performed while the dilators are in place. For these exercises, the muscles around the vagina, urethra, and rectum—the muscles used to stop the flow of urine—are repeatedly squeezed hard and then relaxed 10 to 20 times. Performing the exercises several times a day is recommended. These exercises enable the woman to develop a sense of control over the muscles that were contracting involuntarily.

Sex Therapy: Sensate Focus Technique

The sensate focus technique may help couples that are having sexual difficulties because of psychologic rather than physical factors. The technique aims to make both partners aware of what each finds pleasurable and to reduce anxiety about performance. It is often used in the treatment of decreased libido, sexual arousal disorder, orgasmic disorder, and erectile dysfunction (impotence).
The technique has three steps. Both partners must become comfortable at each level of intimacy before proceeding to the next step.

  • The first step focuses on the sensation of touching, rather than the likelihood of sexual arousal or intercourse. Each partner takes turns touching any part of the other's body, except the genitals and breasts.
  • The second step allows partners to touch any part of the other's body, including the genitals and breasts. However, the focus remains the same—on the sensation of touching, not on sexual response. Intercourse is not allowed.
  • The third step involves mutual touching, eventually leading to sexual intercourse as the couple becomes more comfortable with touching and being touched. The focus is on enjoyment rather than on orgasm.

Kegel Exercises: Squeeze and Relax

Kegel exercises help strengthen the pelvic muscles, primarily those around the vagina, urethra, and rectum. Performing them regularly can help improve sexual function and prevent or reduce the involuntary loss of urine (urinary incontinence) or stool (fecal incontinence).

To perform these exercises, a woman squeezes the muscles used to stop the flow of urine for about 10 seconds, then relaxes for 10 seconds. The exercise is repeated 10 to 20 times in a row at least 3 times a day. Muscle tone usually improves in 2 to 3 months. Kegel exercises can be performed anywhere, whether a woman is sitting, standing, or lying down.

Finding the right muscles to squeeze can be difficult. The muscles can be identified by inserting a finger into the vagina and squeezing or by trying to stop the flow of urine. If pressure is felt around the finger or urine flow stops, the right muscles are being squeezed.

Pregnancy

A baby goes through several stages of development, beginning as a fertilized egg. The egg develops into a blastocyst, an embryo, then a fetus.

Fertilization

During each normal menstrual cycle, one egg (ovum) is usually released from one of the ovaries, about 14 days before the next menstrual period. Release of the egg is called ovulation. The egg is swept into the funnel-shaped end of one of the fallopian tubes.

At ovulation, the mucus in the cervix becomes more fluid and more elastic, allowing sperm to enter the uterus rapidly. Within 5 minutes, sperm may move from the vagina, through the cervix into the uterus, and to the funnel-shaped end of a fallopian tube—the usual site of fertilization. The cells lining the fallopian tube facilitate fertilization.

If a sperm penetrates the egg, fertilization results. Tiny hairlike cilia lining the fallopian tube propel the fertilized egg (zygote) through the tube toward the uterus. The cells of the zygote divide repeatedly as the zygote moves down the fallopian tube. The zygote enters the uterus in 3 to 5 days. In the uterus, the cells continue to divide, becoming a hollow ball of cells called a blastocyst. If fertilization does not occur, the egg degenerates and passes through the uterus with the next menstrual period.

If more than one egg is released and fertilized, the pregnancy involves more than one fetus, usually two (twins). Such twins are fraternal. Identical twins result when one fertilized egg separates into two embryos after it has begun to divide.

Development of the Blastocyst

Between 5 and 8 days after fertilization, the blastocyst attaches to the lining of the uterus, usually near the top. This process, called implantation, is completed by day 9 or 10.

The wall of the blastocyst is one cell thick except in one area, where it is three to four cells thick. The inner cells in the thickened area develop into the embryo, and the outer cells burrow into the wall of the uterus and develop into the placenta. The placenta produces several hormones that help maintain the pregnancy. For example, the placenta produces human chorionic gonadotropin, which prevents the ovaries from releasing eggs and stimulates the ovaries to produce estrogen and progesterone continuously. The placenta also carries oxygen and nutrients from mother to fetus and waste materials from fetus to mother.

The wall of the blastocyst becomes the outer layer of membranes (chorion) surrounding the embryo. An inner layer of membranes (amnion) develops by about day 10 to 12, forming the amniotic sac. The amniotic sac fills with a clear liquid (amniotic fluid) and expands to envelop the developing embryo, which floats within it.

As the placenta develops, it extends tiny hairlike projections (villi) into the wall of the uterus. The projections branch and rebranch in a complicated treelike arrangement. This arrangement greatly increases the area of contact between the wall of the uterus and the placenta, so that more nutrients and waste materials can be exchanged. The placenta is fully formed by 18 to 20 weeks but continues to grow throughout pregnancy. At delivery, it weighs about 1 pound.

Development of the Embryo

The next stage in development is the embryo, which develops under the lining of the uterus on one side. This stage is characterized by the formation of most internal organs and external body structures. Organ formation begins about 3 weeks after fertilization, when the embryo is first recognizable as having a human shape. Shortly thereafter, the area that will become the brain and spinal cord (neural tube) begins to develop. The heart and major blood vessels begin to develop by about day 16 or 17. The heart begins to pump fluid through blood vessels by day 20, and the first red blood cells appear the next day. Blood vessels continue to develop in the embryo and placenta.

 

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From Egg to Embryo

Human Sexuality Interns

Once a month, an egg is released from an ovary into a fallopian tube. After sexual intercourse, sperm move from the vagina through the cervix and uterus to the fallopian tubes, where one sperm fertilizes the egg. The fertilized egg (zygote) divides repeatedly as it moves down the fallopian tube to the uterus. First, the zygote becomes a solid ball of cells. Then it becomes a hollow ball of cells called a blastocyst. Inside the uterus, the blastocyst implants in the wall of the uterus, where it develops into an embryo attached to a placenta and surrounded by fluid-filled membranes.

Almost all organs are completely formed by about 8 weeks after fertilization (which equals 10 weeks of pregnancy). The exceptions are the brain and spinal cord, which continue to mature throughout pregnancy. Most malformations occur during the period when organs are forming. During this period, the embryo is most vulnerable to the effects of drugs, radiation, and viruses. Therefore, a pregnant woman should not be given any live-virus vaccinations or take any drugs during this period unless they are considered essential to protect her health.


Development of the Fetus

Placenta and Embryo at 8 Weeks

At the end of the 8th week after fertilization (10 weeks of pregnancy), the embryo is considered a fetus. During this stage, the structures that have already formed grow and develop. By 12 weeks of pregnancy, the fetus fills the entire uterus. By about 14 weeks, the sex can be identified. Typically, the pregnant woman can feel the fetus moving at about 16 to 20 weeks. Women who have been pregnant before typically feel movements about 2 weeks earlier than women who are pregnant for the first time. By about 23 to 24 weeks, the fetus has a chance of survival outside the uterus.

The lungs continue to mature until near the time of delivery. The brain accumulates new cells throughout pregnancy and the first year of life after birth.

At 8 weeks of pregnancy, the placenta and fetus have been developing for 6 weeks. The placenta forms tiny hairlike projections (villi) that extend into the wall of the uterus. Blood vessels from the embryo, which pass through the umbilical cord to the placenta, develop in the villi. A thin membrane separates the embryo's blood in the villi from the mother's blood that flows through the space surrounding the villi (intervillous space). This arrangement allows materials to be exchanged between the blood of the mother and that of the embryo.

The embryo floats in fluid (amniotic fluid), which is contained in a sac (amniotic sac). The amniotic fluid provides a space in which the embryo can grow freely. The fluid also helps protect the embryo from injury. The amniotic sac is strong and resilient.

Pregnancy causes many changes in a woman's body. Most of them disappear after delivery. In some women, certain disorders, such as a skin rash or gestational diabetes, develop during pregnancy. Some symptoms should be immediately reported to a doctor if they occur during pregnancy. They include the following:

  • persistent headaches
  • persistent nausea and vomiting
  • dizziness
  • disturbances of eyesight
  • pain or cramps in the lower abdomen
  • contractions
  • vaginal bleeding
  • leakage of amniotic fluid (described as "the water breaks")
  • swelling of the hands or feet
  • decreased or increased urine production
  • any illness or infection

General Health: Fatigue is common, especially in the first 12 weeks and again in late pregnancy. Getting enough rest is important.

Reproductive Tract: By 12 weeks of pregnancy, the enlarging uterus may cause the woman's abdomen to protrude slightly. The uterus continues to enlarge throughout pregnancy. The enlarging uterus extends to the level of the navel by 20 weeks and to the lower edge of the rib cage by 36 weeks.

The amount of normal vaginal discharge, which is clear or whitish, commonly increases. This increase is usually normal. However, if the discharge has an unusual color or smell or is accompanied by vaginal itching and burning, a woman should see her doctor. Such symptoms may indicate a vaginal infection. Some vaginal infections, such as trichomoniasis (a protozoan infection) and candidiasis (a yeast infection), are common during pregnancy and can be easily treated Breasts: The breasts tend to enlarge because hormones (mainly estrogen) are preparing the breasts for milk production. The breasts enlarge because the glands that produce milk gradually increase in number and become able to produce milk. The breasts may feel firm and tender. Wearing a bra that fits properly and provides support may help.

During the last weeks of pregnancy, the breasts may produce a thin, yellowish or milky discharge (colostrum). Colostrum is also produced during the first few days after delivery, before breast milk is produced. This fluid, which is rich in minerals and antibodies, is the breastfed baby's first food.

Heart and Blood Flow: During pregnancy, the woman's heart must work harder because as the fetus grows, the heart must pump more blood to the uterus. By the end of pregnancy, the uterus is receiving one fifth of the woman's blood supply. During pregnancy, the amount of blood pumped by the heart (cardiac output) increases by 30 to 50%. As cardiac output increases, the heart rate at rest speeds up from a normal prepregnancy rate of about 70 beats per minute to 80 or 90 beats per minute. During exercise, cardiac output and heart rate increase more when a woman is pregnant than when she is not. During labor, cardiac output increases by an additional 10%. After delivery, cardiac output decreases rapidly at first, then more slowly. It returns to the prepregnancy level about 6 weeks after delivery.

Certain heart murmurs and irregularities in heart rhythm may appear because the heart is working harder. Sometimes a pregnant woman may feel these irregularities. Such changes are normal during pregnancy. However, certain abnormal heart rhythms, which occur more often in pregnant women, may require treatment.

Blood pressure usually decreases during the 2nd trimester but may return to a normal prepregnancy level in the 3rd trimester.

The volume of blood increases by 50% during pregnancy. The amount of fluid in the blood increases more than the number of red blood cells (which carry oxygen). The result is mild anemia, which is normal. For reasons not clearly understood, the number of white blood cells (which fight infection) increases slightly during pregnancy and markedly during labor and the first few days after delivery.

The enlarging uterus interferes with the return of blood from the legs and the pelvic area to the heart. As a result, swelling (edema) is common, especially in the legs. Varicose veins commonly develop in the legs and in the area around the vaginal opening (vulva), sometimes causing discomfort. Clothing that is loose around the waist and legs is more comfortable and does not restrict blood flow. Wearing elastic support hose, resting frequently with the legs elevated, or lying on the left side usually reduces leg swelling and may ease the discomfort caused by varicose veins. Varicose veins may disappear after delivery.

Urinary Tract: Like the heart, the kidneys work harder throughout pregnancy. They filter the increasing volume of blood. The volume of blood filtered by the kidneys reaches a maximum between 16 and 24 weeks and remains at the maximum until immediately before delivery. Then, pressure from the enlarging uterus may slightly decrease the blood supply to the kidneys.


The activity of the kidneys normally increases when a person lies down and decreases when a person stands. This difference is amplified during pregnancy—one reason a pregnant woman needs to urinate frequently while trying to sleep. Late in pregnancy, lying on the side, particularly the left side, increases kidney activity more than lying on the back. Lying on the left side relieves the pressure that the enlarged uterus puts on the main vein that carries blood from the legs. As a result, blood flow improves and kidney activity increases.

The uterus presses on the bladder, reducing its size so that it fills with urine more quickly than usual. This pressure also makes a pregnant woman need to urinate more often and more urgently.

Respiratory Tract: The increased production of the hormone progesterone signals the brain to lower the level of carbon dioxide in the blood. As a result, a pregnant woman breathes faster and more deeply to exhale more carbon dioxide and keep the carbon dioxide level low. The circumference of the woman's chest enlarges slightly.

Virtually every pregnant woman becomes somewhat more out of breath when she exerts herself, especially toward the end of pregnancy. During exercise, the breathing rate increases more when a woman is pregnant than when she is not.

Because more blood is being pumped, the lining of the airways receives more blood and swells somewhat, narrowing the airways. As a result, the nose occasionally feels stuffy, and the eustachian tubes (which connect the middle ear and back of the nose) may become blocked. The tone and quality of the woman's voice may change slightly.

Digestive Tract: Nausea and vomiting, particularly in the mornings (morning sickness), are common. They may be caused by the high levels of estrogen and human chorionic gonadotropin (HCG), two hormones that help maintain the pregnancy. Nausea and vomiting may be relieved by changing the diet or patterns of eating. For example, drinking and eating small portions frequently, eating before getting hungry, and eating bland foods (such as bouillon, consommé, rice, and pasta) may help. Eating plain soda crackers and sipping a carbonated drink may relieve nausea. Keeping crackers by the bed and eating one or two before getting up may relieve morning sickness. No drugs specifically designed to treat morning sickness are currently available. If nausea and vomiting are so intense or persistent that dehydration, weight loss, or other problems develop, a woman may need to be treated with antiemetic drugs or be hospitalized temporarily and given fluids intravenously Heartburn and belching are common, possibly because food remains in the stomach longer and because the ringlike muscle (sphincter) at the lower end of the esophagus tends to relax, allowing the stomach's contents to flow backward into the esophagus. Heartburn can be relieved by eating smaller meals, by not bending or lying flat for several hours after eating, and by taking antacids. However, the antacid sodium bicarbonate should not be used because it contains so much salt (sodium). Heartburn during the night can be relieved by not eating for several hours before going to bed and by raising the head of the bed or using pillows to raise the head and shoulders.

The stomach produces less acid during pregnancy. Consequently, stomach ulcers rarely develop during pregnancy, and those that already exist often start to heal.

As pregnancy progresses, pressure from the enlarging uterus on the rectum and the lower part of the intestine may cause constipation. Constipation may be worsened because the high level of progesterone during pregnancy slows the automatic waves of muscular contractions in the intestine, which normally move food along. Eating a high-fiber diet, drinking plenty of fluids, and exercising regularly can help prevent constipation.

Hemorrhoids, a common problem, may result from the pressure of the enlarging uterus or from constipation. Stool softeners, an anesthetic gel, or warm soaks can be used if hemorrhoids hurt.

Pica, a craving for strange foods or nonfoods (such as starch or clay), may develop. Occasionally, pregnant women, usually those who also have morning sickness, have excess saliva. This symptom may be distressing but is harmless.

Skin: Mask of pregnancy (melasma) is a blotchy, brownish pigment that may appear on the skin of the forehead and cheeks. The skin surrounding the nipples (areolae) may also darken. A dark line commonly appears down the middle of the abdomen. These changes may occur because the placenta produces a hormone that stimulates melanocytes, the cells that make a dark brown skin pigment (melanin).

Pink stretch marks sometimes appear on the abdomen. This change probably results from rapid growth of the uterus and an increase in levels of adrenal hormones.

Small blood vessels may form a red spiderlike pattern on the skin, usually above the waist. These formations are called spider angiomas. Thin-walled, dilated capillaries may become visible, especially in the lower legs.

Hormones: Pregnancy affects virtually all hormones in the body, mostly because of the effects of hormones produced by the placenta. For example, the placenta produces a hormone that stimulates the woman's thyroid gland to become more active and produce larger amounts of thyroid hormones. When the thyroid gland becomes more active, the heart may beat faster, causing the woman to become aware of her heartbeat (have palpitations). Perspiration may increase, mood swings may occur, and the thyroid gland may enlarge. The disorder hyperthyroidism, in which the thyroid gland is truly overactive, develops in fewer than 1% of pregnancies.

Levels of estrogen and progesterone increase early in pregnancy because human chorionic gonadotropin, the main hormone the placenta produces, stimulates the ovaries to continuously produce them. After 9 to 10 weeks of pregnancy, the placenta itself produces large amounts of estrogen and progesterone. Estrogen and progesterone help maintain the pregnancy.

During pregnancy, changes in hormone levels affect how the body handles sugar. Early in pregnancy, the sugar (glucose) level in the blood may decrease slightly. But in the last half of pregnancy, the level may increase. More insulin (which controls the sugar level in the blood) is needed and is produced by the pancreas. Consequently, diabetes, if already present, may worsen during pregnancy. Diabetes can also begin during pregnancy. This disorder is called gestational diabetes).

Joints and Muscles: The joints and ligaments (fibrous cords and cartilage that connect bones) in the woman's pelvis loosen and become more flexible. This change helps make room for the enlarging uterus and prepare the woman for delivery of the baby. As a result, the woman's posture changes somewhat.

Backache in varying degrees is common, because the spine curves more to balance the weight of the enlarging uterus. Avoiding heavy lifting, bending the knees (not the waist) to pick things up, and maintaining good posture can help. Wearing flat shoes with good support or a lightweight maternity girdle may reduce strain on the back.

 

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Stages of Pregnancy
Although pregnancy involves a continuous process, it is divided into three 3-month periods called trimesters (weeks 0 to 12, 13 to 24, and 25 to delivery).

EVENTS

WEEKS OF PREGNANCY

 

1st Trimester

 

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The woman's last period before fertilization occurs.

0

Fertilization occurs.
The fertilized egg (zygote) develops into a hollow ball of cells called the blastocyst.

2

The blastocyst implants in the wall of uterus.
The amniotic sac forms.

3

The area that will become the brain and spinal cord (neural tube) begins to develop.

5

The heart and major blood vessels are developing. The beating heart can be seen during ultrasonography.

6

The beginnings of arms and legs appear.

7

Bones and muscles form. The face and neck develop.
Most organs are formed. Brain waves can be detected.
The skeleton is formed. Fingers and toes are fully defined.

9

The kidneys begin to function.
The fetus can move and respond to touch (when prodded through the woman's abdomen).
The woman has gained some weight, and her abdomen may be slightly enlarged.

10

2nd Trimester

 

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The fetus's sex can be identified.
The fetus can hear.

14

The fetus's fingers can grasp. The fetus moves more vigorously, so that the mother can feel it.
The fetus's body begins to fill out as fat is deposited beneath the skin. Hair appears on the head and skin. Eyebrows and eyelashes are present.
The placenta is fully formed.

16

The fetus has a chance of survival outside the uterus.
The woman begins to gain weight more rapidly.

23-24

3rd Trimester

 

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The fetus is active, changing positions often.
The lungs continue to mature.
The fetus's head moves into position for delivery.
On average, the fetus is about 20 inches long and weighs about 7 pounds. The woman's enlarged abdomen causes the navel to bulge.

25

DELIVERY

37-42

 

Sexually Transmitted Diseases

Genital herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses type 1 (HSV-1) and type 2 (HSV-2). Most genital herpes is caused by HSV-2. Most individuals have no or only minimal signs or symptoms from HSV-1 or HSV-2 infection. When signs do occur, they typically appear as one or more blisters on or around the genitals or rectum. The blisters break, leaving tender ulcers (sores) that may take two to four weeks to heal the first time they occur. Typically, another outbreak can appear weeks or months after the first, but it almost always is less severe and shorter than the first outbreak. Although the infection can stay in the body indefinitely, the number of outbreaks tends to decrease over a period of years.

Genital herpes

Results of a nationally representative study show that genital herpes infection is common in the United States. Nationwide, at least 45 million people ages 12 and older, or one out of five adolescents and adults, have had genital HSV infection. Between the late 1970s and the early 1990s, the number of Americans with genital herpes infection increased 30 percent.

Genital HSV-2 infection is more common in women (approximately one out of four women) than in men (almost one out of five). This may be due to male-to-female transmissions being more likely than female-to-male transmission.

HSV-1 and HSV-2 can be found in and released from the sores that the viruses cause, but they also are released between outbreaks from skin that does not appear to be broken or to have a sore. Generally, a person can only get HSV-2 infection during sexual contact with someone who has a genital HSV-2 infection. Transmission can occur from an infected partner who does not have a visible sore and may not know that he or she is infected.

HSV-1 can cause genital herpes, but it more commonly causes infections of the mouth and lips, so-called "fever blisters." HSV-1 infection of the genitals can be caused by oral-genital or genital-genital contact with a person who has HSV-1 infection. Genital HSV-1 outbreaks recur less regularly than genital HSV-2 outbreaks.

What are the signs and symptoms of genital herpes?

Most people infected with HSV-2 are not aware of their infection. However, if signs and symptoms occur during the first outbreak, they can be quite pronounced. The first outbreak usually occurs within two weeks after the virus is transmitted, and the sores typically heal within two to four weeks. Other signs and symptoms during the primary episode may include a second crop of sores, and flu-like symptoms, including fever and swollen glands. However, most individuals with HSV-2 infection may never have sores, or they may have very mild signs that they do not even notice or that they mistake for insect bites or another skin condition.

Most people diagnosed with a first episode of genital herpes can expect to have several (typically four or five) outbreaks (symptomatic recurrences) within a year. Over time these recurrences usually decrease in frequency.

What are the complications of genital herpes?

Genital herpes can cause recurrent painful genital sores in many adults, and herpes infection can be severe in people with suppressed immune systems. Regardless of severity of symptoms, genital herpes frequently causes psychological distress in people who know they are infected.

In addition, genital HSV can cause potentially fatal infections in babies. It is important that women avoid contracting herpes during pregnancy because a first episode during pregnancy causes a greater risk of transmission to the baby. If a woman has active genital herpes at delivery, a cesarean delivery is usually performed. Fortunately, infection of a baby from a woman with herpes infection is rare.

Herpes may play a role in the spread of HIV, the virus that causes AIDS. Herpes can make people more susceptible to HIV infection, and it can make HIV-infected individuals more infectious.

How is genital herpes diagnosed?

The signs and symptoms associated with HSV-2 can vary greatly. Health care providers can diagnose genital herpes by visual inspection if the outbreak is typical, and by taking a sample from the sore(s) and testing it in a laboratory. HSV infections can be difficult to diagnose between outbreaks. Blood tests, which detect HSV-1 or HSV-2 infection, may be helpful, although the results are not always clear-cut.

Is there a treatment for herpes?

There is no treatment that can cure herpes, but antiviral medications can shorten and prevent outbreaks during the period of time the person takes the medication. In addition, daily suppressive therapy for symptomatic herpes can reduce transmission to partners.

How can herpes be prevented?

The surest way to avoid transmission of sexually transmitted diseases, including genital herpes, is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Genital ulcer diseases can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of genital herpes only when the infected area or site of potential exposure is protected. Since a condom may not cover all infected areas, even correct and consistent use of latex condoms cannot guarantee protection from genital herpes.

Persons with herpes should abstain from sexual activity with uninfected partners when lesions or other symptoms of herpes are present. It is important to know that even if a person does not have any symptoms he or she can still infect sex partners. Sex partners of infected persons should be advised that they may become infected. Sex partners can seek testing to determine if they are infected with HSV. A positive HSV-2 blood test most likely indicates a genital herpes infection.

Syphilis

Syphilis is a sexually transmitted disease (STD) caused by the bacterium Treponema pallidum. It has often been called “the great imitator” because so many of the signs and symptoms are indistinguishable from those of other diseases.

How common is syphilis?

In the United States, health officials reported over 32,000 cases of syphilis in 2002, including 6,862 cases of primary and secondary (P&S) syphilis. In 2002, half of all P&S syphilis cases were reported from 16 counties and 1 city; and most P&S syphilis cases occurred in persons 20 to 39 years of age. The incidence of infectious syphilis was highest in women 20 to 24 years of age and in men 35 to 39 years of age. Reported cases of congenital syphilis in newborns decreased from 2001 to 2002, with 492 new cases reported in 2001 compared to 412 cases in 2002.

Between 2001 and 2002, the number of reported P & S syphilis cases increased 12.4 percent. Rates in women continued to decrease, and overall, the rate in men was 3.5 times that in women. This, in conjunction with reports of syphilis outbreaks in men who have sex with men (MSM), suggests that rates of syphilis in MSM are increasing.

How do people get syphilis?

Syphilis is passed from person to person through direct contact with a syphilis sore. Sores occur mainly on the external genitals, vagina, anus, or in the rectum. Sores also can occur on the lips and in the mouth. Transmission of the organism occurs during vaginal, anal, or oral sex. Pregnant women with the disease can pass it to the babies they are carrying. Syphilis cannot be spread through contact with toilet seats, doorknobs, swimming pools, hot tubs, bathtubs, shared clothing, or eating utensils.

What are the signs and symptoms in adults?

Many people infected with syphilis do not have any symptoms for years, yet remain at risk for late complications if they are not treated. Although transmission appears to occur from persons with sores who are in the primary or secondary stage, many of these sores are unrecognized. Thus, most transmission is from persons who are unaware of their infection.

Primary Stage

The primary stage of syphilis is usually marked by the appearance of a single sore (called a chancre), but there may be multiple sores. The time between infection with syphilis and the start of the first symptom can range from 10 to 90 days (average 21 days). The chancre is usually firm, round, small, and painless. It appears at the spot where syphilis entered the body. The chancre lasts 3 to 6 weeks, and it heals without treatment. However, if adequate treatment is not administered, the infection progresses to the secondary stage.

Secondary Stage

Skin rash and mucous membrane lesions characterize the secondary stage. This stage typically starts with the development of a rash on one or more areas of the body. The rash usually does not cause itching. Rashes associated with secondary syphilis can appear as the chancre is healing or several weeks after the chancre has healed. The characteristic rash of secondary syphilis may appear as rough, red, or reddish brown spots both on the palms of the hands and the bottoms of the feet. However, rashes with a different appearance may occur on other parts of the body, sometimes resembling rashes caused by other diseases. Sometimes rashes associated with secondary syphilis are so faint that they are not noticed. In addition to rashes, symptoms of secondary syphilis may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. The signs and symptoms of secondary syphilis will resolve with or without treatment, but without treatment, the infection will progress to the latent and late stages of disease.

Late Stage

The latent (hidden) stage of syphilis begins when secondary symptoms disappear. Without treatment, the infected person will continue to have syphilis even though there are no signs or symptoms; infection remains in the body. In the late stages of syphilis, it may subsequently damage the internal organs, including the brain, nerves, eyes, heart, blood vessels, liver, bones, and joints. This internal damage may show up many years later. Signs and symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. This damage may be serious enough to cause death.

How does syphilis affect a pregnant woman and here baby?

The syphilis bacterium can infect the baby of a woman during her pregnancy. Depending on how long a pregnant woman has been infected, she may have a high risk of having a stillbirth (a baby born dead) or of giving birth to a baby who dies shortly after birth. An infected baby may be born without signs or symptoms of disease. However, if not treated immediately, the baby may develop serious problems within a few weeks. Untreated babies may become developmentally delayed, have seizures, or die.

How is syphilis diagnosed?

Some health care providers can diagnose syphilis by examining material from a chancre (infectious sore) using a special microscope called a dark-field microscope. If syphilis bacteria are present in the sore, they will show up when observed through the microscope.

A blood test is another way to determine whether someone has syphilis. Shortly after infection occurs, the body produces syphilis antibodies that can be detected by an accurate, safe, and inexpensive blood test. A low level of antibodies will stay in the blood for months or years even after the disease has been successfully treated. Because untreated syphilis in a pregnant woman can infect and possibly kill her developing baby, every pregnant woman should have a blood test for syphilis.

What is the link between syphilis and HIV?

Genital sores (chancres) caused by syphilis make it easier to transmit and acquire HIV infection sexually. There is an estimated 2- to 5-fold increased risk of acquiring HIV infection when syphilis is present.

Ulcerative STDs that cause sores, ulcers, or breaks in the skin or mucous membranes, such as syphilis, disrupt barriers that provide protection against infections. The genital ulcers caused by syphilis can bleed easily, and when they come into contact with oral and rectal mucosa during sex, increase the infectiousness of and susceptibility to HIV. Having other STDs is also an important predictor for becoming HIV infected because STDs are a marker for behaviors associated with HIV transmission.

What is the treatment for syphilis?

Syphilis is easy to cure in its early stages. A single intramuscular injection of penicillin, an antibiotic, will cure a person who has had syphilis for less than a year. Additional doses are needed to treat someone who has had syphilis for longer than a year. For people who are allergic to penicillin, other antibiotics are available to treat syphilis. There are no home remedies or over-the-counter drugs that will cure syphilis. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done.

Because effective treatment is available, it is important that persons be screened for syphilis on an on-going basis if their sexual behaviors put them at risk for STDs. Persons who receive syphilis treatment must abstain from sexual contact with new partners until the syphilis sores are completely healed. Persons with syphilis must notify their sex partners so that they also can be tested and receive treatment if necessary.

Will syphilis recur?

Having syphilis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection. Only laboratory tests can confirm whether someone has syphilis. Because syphilis sores can be hidden in the vagina, rectum, or mouth, it may not be obvious that a sex partner has syphilis. Talking with a health care provider will help to determine the need to be re-tested for syphilis after treatment has been received.

How can syphilis be prevented?

The surest way to avoid transmission of sexually transmitted diseases, including syphilis, is to abstain from sexual contact or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Avoiding alcohol and drug use may also help prevent transmission of syphilis because these activities may lead to risky sexual behavior. It is important that sex partners talk to each other about their HIV status and history of other STDs so that preventive action can be taken.

Genital ulcer diseases, like syphilis, can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. Correct and consistent use of latex condoms can reduce the risk of syphilis, as well as genital herpes and chancroid, only when the infected area or site of potential exposure is protected.

Condoms lubricated with spermicides (especially Nonoxynol-9 or N-9) are no more effective than other lubricated condoms in protecting against the transmission of STDs. Based on findings from several research studies, N-9 may itself cause genital lesions, providing a point of entry for HIV and other STDs. In June 2001, the CDC recommended that N-9 not be used as a microbicide or lubricant during anal intercourse. Transmission of a STD, including syphilis cannot be prevented by washing the genitals, urinating, and or douching after sex. Any unusual discharge, sore, or rash, particularly in the groin area, should be a signal to refrain from having sex and to see a doctor immediately.

Gonorrhea

Gonorrhea is a sexually transmitted disease (STD). Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract, including the cervix (opening to the womb), uterus (womb), and fallopian tubes (egg canals) in women, and in the urethra (urine canal) in women and men. The bacterium can also grow in the mouth, throat, eyes, and anus.

How common is gonorrhea?

Gonorrhea is a very common infectious disease. CDC estimates that more than 700,000 persons in the U.S. get new gonorrheal infections each year. Only about half of these infections are reported to CDC. In 2004, 330,132 cases of gonorrhea were reported to CDC. In the period from 1975 to 1997, the national gonorrhea rate declined, following the implementation of the national gonorrhea control program in the mid-1970s. After a small increase in 1998, the gonorrhea rate has decreased slightly since 1999. In 2004, the rate of reported gonorrheal infections was 113.5 per 100,000 persons.

How do people get gonorrhea?

Gonorrhea is spread through contact with the penis, vagina, mouth, or anus. Ejaculation does not have to occur for gonorrhea to be transmitted or acquired. Gonorrhea can also be spread from mother to baby during delivery.People who have had gonorrhea and received treatment may get infected again if they have sexual contact with a person infected with gonorrhea.

Who is at risk for gonorrhea?

Any sexually active person can be infected with gonorrhea. In the United States, the highest reported rates of infection are among sexually active teenagers, young adults, and African Americans.

What are the signs and symptoms of gonorrhea?

Although many men with gonorrhea may have no symptoms at all, some men have some signs or symptoms that appear two to five days after infection; symptoms can take as long as 30 days to appear. Symptoms and signs include a burning sensation when urinating, or a white, yellow, or green discharge from the penis. Sometimes men with gonorrhea get painful or swollen testicles.

In women, the symptoms of gonorrhea are often mild, but most women who are infected have no symptoms. Even when a woman has symptoms, they can be so non-specific as to be mistaken for a bladder or vaginal infection. The initial symptoms and signs in women include a painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods. Women with gonorrhea are at risk of developing serious complications from the infection, regardless of the presence or severity of symptoms.

Symptoms of rectal infection in both men and women may include discharge, anal itching, soreness, bleeding, or painful bowel movements. Rectal infection also may cause no symptoms. Infections in the throat may cause a sore throat but usually causes no symptoms.

What are the complications of gonorrhea?

Untreated gonorrhea can cause serious and permanent health problems in both women and men.
In women, gonorrhea is a common cause of pelvic inflammatory disease (PID). About one million women each year in the United States develop PID. Women with PID do not necessarily have symptoms. When symptoms are present, they can be very severe and can include abdominal pain and fever. PID can lead to internal abscesses (pus-filled “pockets” that are hard to cure) and long-lasting, chronic pelvic pain. PID can damage the fallopian tubes enough to cause infertility or increase the risk of ectopic pregnancy. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube.

In men, gonorrhea can cause epididymitis, a painful condition of the testicles that can lead to infertility if left untreated. Gonorrhea can spread to the blood or joints. This condition can be life threatening. In addition, people with gonorrhea can more easily contract HIV, the virus that causes AIDS. HIV-infected people with gonorrhea are more likely to transmit HIV to someone else.

If a pregnant woman has gonorrhea, she may give the infection to her baby as the baby passes through the birth canal during delivery. This can cause blindness, joint infection, or a life-threatening blood infection in the baby. Treatment of gonorrhea as soon as it is detected in pregnant women will reduce the risk of these complications. Pregnant women should consult a health care provider for appropriate examination, testing, and treatment, as necessary.

Several laboratory tests are available to diagnose gonorrhea. A doctor or nurse can obtain a sample for testing from the parts of the body likely to be infected (cervix, urethra, rectum, or throat) and send the sample to a laboratory for analysis. Gonorrhea that is present in the cervix or urethra can be diagnosed in a laboratory by testing a urine sample. A quick laboratory test for gonorrhea that can be done in some clinics or doctor's offices is a Gram stain. A Gram stain of a sample from a urethra or a cervix allows the doctor to see the gonorrhea bacterium under a microscope. This test works better for men than for women.

Several antibiotics can successfully cure gonorrhea in adolescents and adults. However, drug-resistant strains of gonorrhea are increasing in many areas of the world, including the United States, and successful treatment of gonorrhea is becoming more difficult. Because many people with gonorrhea also have chlamydia, another sexually transmitted disease, antibiotics for both infections are usually given together. Persons with gonorrhea should be tested for other STDs.

It is important to take all of the medication prescribed to cure gonorrhea. Although medication will stop the infection, it will not repair any permanent damage done by the disease. People who have had gonorrhea and have been treated can get the disease again if they have sexual contact with persons infected with gonorrhea. If a person's symptoms continue even after receiving treatment, he or she should return to a doctor to be reevaluated.

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex condoms, when used consistently and correctly, can reduce the risk of transmission of gonorrhea.
Any genital symptoms such as discharge or burning during urination or unusual sore or rash should be a signal to stop having sex and to see a doctor immediately. If a person has been diagnosed and treated for gonorrhea, he or she should notify all recent sex partners so they can see a health care provider and be treated. This will reduce the risk that the sex partners will develop serious complications from gonorrhea and will also reduce the person's risk of becoming re-infected. The person and all of his or her sex partners must avoid sex until they have completed their treatment for gonorrhea.

Chlamydia

Chlamydia is a common sexually transmitted disease (STD) caused by the bacterium, Chlamydia trachomatis, which can damage a woman's reproductive organs. Even though symptoms of chlamydia are usually mild or absent, serious complications that cause irreversible damage, including infertility, can occur "silently" before a woman ever recognizes a problem. Chlamydia also can cause discharge from the penis of an infected man.

Chlamydia is the most frequently reported bacterial sexually transmitted disease in the United States. In 2004, 929,462 chlamydial infections were reported to CDC from 50 states and the District of Columbia. Under-reporting is substantial because most people with chlamydia are not aware of their infections and do not seek testing. Also, testing is not often done if patients are treated for their symptoms. An estimated 2.8 million Americans are infected with chlamydia each year. Women are frequently re-infected if their sex partners are not treated.

Chlamydia can be transmitted during vaginal, anal, or oral sex. Chlamydia can also be passed from an infected mother to her baby during vaginal childbirth. Any sexually active person can be infected with chlamydia. The greater the number of sex partners, the greater the risk of infection. Because the cervix (opening to the uterus) of teenage girls and young women is not fully matured, they are at particularly high risk for infection if sexually active. Since chlamydia can be transmitted by oral or anal sex, men who have sex with men are also at risk for chlamydial infection.

Chlamydia is known as a "silent" disease because about three quarters of infected women and about half of infected men have no symptoms. If symptoms do occur, they usually appear within 1 to 3 weeks after exposure.

In women, the bacteria initially infect the cervix and the urethra (urine canal). Women who have symptoms might have an abnormal vaginal discharge or a burning sensation when urinating. When the infection spreads from the cervix to the fallopian tubes (tubes that carry eggs from the ovaries to the uterus), some women still have no signs or symptoms; others have lower abdominal pain, low back pain, nausea, fever, pain during intercourse, or bleeding between menstrual periods. Chlamydial infection of the cervix can spread to the rectum.

Men with signs or symptoms might have a discharge from their penis or a burning sensation when urinating. Men might also have burning and itching around the opening of the penis. Pain and swelling in the testicles are uncommon. Men or women who have receptive anal intercourse may acquire chlamydial infection in the rectum, which can cause rectal pain, discharge, or bleeding. Chlamydia can also be found in the throats of women and men having oral sex with an infected partner.

If untreated, chlamydial infections can progress to serious reproductive and other health problems with both short-term and long-term consequences. Like the disease itself, the damage that chlamydia causes is often "silent."

In women, untreated infection can spread into the uterus or fallopian tubes and cause pelvic inflammatory disease (PID). This happens in up to 40 percent of women with untreated chlamydia. PID can cause permanent damage to the fallopian tubes, uterus, and surrounding tissues. The damage can lead to chronic pelvic pain, infertility, and potentially fatal ectopic pregnancy (pregnancy outside the uterus). Women infected with chlamydia are up to five times more likely to become infected with HIV, if exposed.

To help prevent the serious consequences of chlamydia, screening at least annually for chlamydia is recommended for all sexually active women age 25 years and younger. An annual screening test also is recommended for older women with risk factors for chlamydia (a new sex partner or multiple sex partners). All pregnant women should have a screening test for chlamydia.

Complications among men are rare. Infection sometimes spreads to the epididymis (a tube that carries sperm from the testis), causing pain, fever, and, rarely, sterility.

Rarely, genital chlamydial infection can cause arthritis that can be accompanied by skin lesions and inflammation of the eye and urethra (Reiter's syndrome).

In pregnant women, there is some evidence that untreated chlamydial infections can lead to premature delivery. Babies who are born to infected mothers can get chlamydial infections in their eyes and respiratory tracts. Chlamydia is a leading cause of early infant pneumonia and conjunctivitis (pink eye) in newborns.

There are laboratory tests to diagnose chlamydia. Some can be performed on urine, other tests require that a specimen be collected from a site such as the penis or cervix.

Chlamydia can be easily treated and cured with antibiotics. A single dose of azithromycin or a week of doxycycline (twice daily) are the most commonly used treatments. HIV-positive persons with chlamydia should receive the same treatment as those who are HIV negative.

All sex partners should be evaluated, tested, and treated. Persons with chlamydia should abstain from sexual intercourse until they and their sex partners have completed treatment, otherwise re-infection is possible.

Women whose sex partners have not been appropriately treated are at high risk for re-infection. Having multiple infections increases a woman's risk of serious reproductive health complications, including infertility. Retesting should be considered for women, especially adolescents, three to four months after treatment. This is especially true if a woman does not know if her sex partner received treatment.

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of chlamydia.

Chlamydia screening is recommended annually for all sexually active women 25 years of age and younger. An annual screening test also is recommended for older women with risk factors for chlamydia (a new sex partner or multiple sex partners). All pregnant women should have a screening test for chlamydia.

Any genital symptoms such as discharge or burning during urination or unusual sore or rash should be a signal to stop having sex and to consult a health care provider immediately. If a person has been treated for chlamydia (or any other STD), he or she should notify all recent sex partners so they can see a health care provider and be treated. This will reduce the risk that the sex partners will develop serious complications from chlamydia and will also reduce the person's risk of becoming re-infected. The person and all of his or her sex partners must avoid sex until they have completed their treatment for chlamydia.

Genital HPV infection

Genital HPV infection is a sexually transmitted disease (STD) that is caused by human papillomavirus (HPV). Human papillomavirus is the name of a group of viruses that includes more than 100 different strains or types. More than 30 of these viruses are sexually transmitted, and they can infect the genital area of men and women including the skin of the penis, vulva (area outside the vagina), or anus, and the linings of the vagina, cervix, or rectum. Most people who become infected with HPV will not have any symptoms and will clear the infection on their own.

Some of these viruses are called "high-risk" types, and may cause abnormal Pap tests. They may also lead to cancer of the cervix, vulva, vagina, anus, or penis. Others are called "low-risk" types, and they may cause mild Pap test abnormalities or genital warts. Genital warts are single or multiple growths or bumps that appear in the genital area, and sometimes are cauliflower shaped.

Approximately 20 million people are currently infected with HPV. At least 50 percent of sexually active men and women acquire genital HPV infection at some point in their lives. By age 50, at least 80 percent of women will have acquired genital HPV infection. About 6.2 million Americans get a new genital HPV infection each year.

The types of HPV that infect the genital area are spread primarily through genital contact. Most HPV infections have no signs or symptoms; therefore, most infected persons are unaware they are infected, yet they can transmit the virus to a sex partner. Rarely, a pregnant woman can pass HPV to her baby during vaginal delivery. A baby that is exposed to HPV very rarely develops warts in the throat or voice box.

Most people who have a genital HPV infection do not know they are infected. The virus lives in the skin or mucous membranes and usually causes no symptoms. Some people get visible genital warts, or have pre-cancerous changes in the cervix, vulva, anus, or penis. Very rarely, HPV infection results in anal or genital cancers.

Genital warts usually appear as soft, moist, pink, or flesh-colored swellings, usually in the genital area. They can be raised or flat, single or multiple, small or large, and sometimes cauliflower shaped. They can appear on the vulva, in or around the vagina or anus, on the cervix, and on the penis, scrotum, groin, or thigh. After sexual contact with an infected person, warts may appear within weeks or months, or not at all.

Genital warts are diagnosed by visual inspection. Visible genital warts can be removed by medications the patient applies, or by treatments performed by a health care provider. Some individuals choose to forego treatment to see if the warts will disappear on their own. No treatment regimen for genital warts is better than another, and no one treatment regimen is ideal for all cases.

Most women are diagnosed with HPV on the basis of abnormal Pap tests. A Pap test is the primary cancer-screening tool for cervical cancer or pre-cancerous changes in the cervix, many of which are related to HPV. Also, a specific test is available to detect HPV DNA in women. The test may be used in women with mild Pap test abnormalities, or in women >30 years of age at the time of Pap testing. The results of HPV DNA testing can help health care providers decide if further tests or treatment are necessary. No HPV tests are available for men.

There is no "cure" for HPV infection, although in most women the infection goes away on its own. The treatments provided are directed to the changes in the skin or mucous membrane caused by HPV infection, such as warts and pre-cancerous changes in the cervix.

All types of HPV can cause mild Pap test abnormalities which do not have serious consequences. Approximately 10 of the 30 identified genital HPV types can lead, in rare cases, to development of cervical cancer. Research has shown that for most women (90 percent), cervical HPV infection becomes undetectable within two years. Although only a small proportion of women have persistent infection, persistent infection with "high-risk" types of HPV is the main risk factor for cervical cancer.

A Pap test can detect pre-cancerous and cancerous cells on the cervix. Regular Pap testing and careful medical follow-up, with treatment if necessary, can help ensure that pre-cancerous changes in the cervix caused by HPV infection do not develop into life threatening cervical cancer. The Pap test used in U.S. cervical cancer screening programs is responsible for greatly reducing deaths from cervical cancer. For 2004, the American Cancer Society estimates that about 10,520 women will develop invasive cervical cancer and about 3,900 women will die from this disease. Most women who develop invasive cervical cancer have not had regular cervical cancer screening.

The surest way to eliminate risk for genital HPV infection is to refrain from any genital contact with another individual.For those who choose to be sexually active, a long-term, mutually monogamous relationship with an uninfected partner is the strategy most likely to prevent future genital HPV infections. However, it is difficult to determine whether a partner who has been sexually active in the past is currently infected.

For those choosing to be sexually active and who are not in long-term mutually monogamous relationships, reducing the number of sexual partners and choosing a partner less likely to be infected may reduce the risk of genital HPV infection. Partners less likely to be infected include those who have had no or few prior sex partners.

HPV infection can occur in both male and female genital areas that are covered or protected by a latex condom, as well as in areas that are not covered. While the effect of condoms in preventing HPV infection is unknown, condom use has been associated with a lower rate of cervical cancer, an HPV-associated disease.

Bacterial Vaginosis

Bacterial Vaginosis (BV) is the name of a condition in women where the normal balance of bacteria in the vagina is disrupted and replaced by an overgrowth of certain bacteria. It is sometimes accompanied by discharge, odor, pain, itching, or burning.

Bacterial Vaginosis (BV) is the most common vaginal infection in women of childbearing age. In the United States, as many as 16 percent of pregnant women have BV.

The cause of BV is not fully understood. BV is associated with an imbalance in the bacteria that are normally found in a woman's vagina. The vagina normally contains mostly "good" bacteria, and fewer "harmful" bacteria. BV develops when there is an increase in harmful bacteria.

Not much is known about how women get BV. There are many unanswered questions about the role that harmful bacteria play in causing BV. Any woman can get BV. However, some activities or behaviors can upset the normal balance of bacteria in the vagina and put women at increased risk including:

  • Having a new sex partner or multiple sex partners,
  • Douching, and
  • Using an intrauterine device (IUD) for contraception.

It is not clear what role sexual activity plays in the development of BV. Women do not get BV from toilet seats, bedding, swimming pools, or from touching objects around them. Women that have never had sexual intercourse are rarely affected.

Women with BV may have an abnormal vaginal discharge with an unpleasant odor. Some women report a strong fish-like odor, especially after intercourse. Discharge, if present, is usually white or gray; it can be thin. Women with BV may also have burning during urination or itching around the outside of the vagina, or both. Some women with BV report no signs or symptoms at all.

In most cases, BV causes no complications. But there are some serious risks from BV including:

  • Having BV can increase a woman's susceptibility to HIV infection if she is exposed to the HIV virus.
  • Having BV increases the chances that an HIV-infected woman can pass HIV to her sex partner.
  • Having BV has been associated with an increase in the development of pelvic inflammatory disease (PID) following surgical procedures such as a hysterectomy or an abortion.
  • Having BV while pregnant may put a woman at increased risk for some complications of pregnancy.
  • BV can increase a woman's susceptibility to other STDs, such as chlamydia and gonorrhea.

Pregnant women with BV more often have babies who are born premature or with low birth weight (less than 5 pounds).The bacteria that cause BV can sometimes infect the uterus (womb) and fallopian tubes (tubes that carry eggs from the ovaries to the uterus). This type of infection is called pelvic inflammatory disease (PID). PID can cause infertility or damage the fallopian tubes enough to increase the future risk of ectopic pregnancy and infertility. Ectopic pregnancy is a life-threatening condition in which a fertilized egg grows outside the uterus, usually in a fallopian tube which can rupture.

A health care provider must examine the vagina for signs of BV and perform laboratory tests on a sample of vaginal fluid to look for bacteria associated with BV.

Although BV will sometimes clear up without treatment, all women with symptoms of BV should be treated to avoid such complications as PID. Male partners generally do not need to be treated. However, BV may spread between female sex partners.

Treatment is especially important for pregnant women. All pregnant women who have ever had a premature delivery or low birth weight baby should be considered for a BV examination, regardless of symptoms, and should be treated if they have BV. All pregnant women who have symptoms of BV should be checked and treated. Some physicians recommend that all women undergoing a hysterectomy or abortion be treated for BV prior to the procedure, regardless of symptoms, to reduce their risk of developing PID.

BV is treatable with antibiotics prescribed by a health care provider. Two different antibiotics are recommended as treatment for BV: metronidazole or clindamycin. Either can be used with non-pregnant or pregnant women, but the recommended dosages differ. Women with BV who are HIV-positive should receive the same treatment as those who are HIV-negative. BV can recur after treatment.

BV is not completely understood by scientists, and the best ways to prevent it are unknown. However, it is known that BV is associated with having a new sex partner or having multiple sex partners. It is seldom found in women who have never had intercourse.

The following basic prevention steps can help reduce the risk of upsetting the natural balance of bacteria in the vagina and developing BV:

  • Be abstinent.
  • Limit the number of sex partners.
  • Do not douche.
  • Use all of the medicine prescribed for treatment of BV, even if the signs and symptoms go away.

PID

Pelvic inflammatory disease (PID) is a general term that refers to infection of the uterus (womb), fallopian tubes (tubes that carry eggs from the ovaries to the uterus) and other reproductive organs. It is a common and serious complication of some sexually transmitted diseases (STDs), especially chlamydia and gonorrhea. PID can damage the fallopian tubes and tissues in and near the uterus and ovaries. Untreated PID can lead to serious consequences including infertility, ectopic pregnancy (a pregnancy in the fallopian tube or elsewhere outside of the womb), abscess formation, and chronic pelvic pain.

Each year in the United States, it is estimated that more than 1 million women experience an episode of acute PID. More than 100,000 women become infertile each year as a result of PID, and a large proportion of the ectopic pregnancies occurring every year are due to the consequences of PID. Annually more than 150 women die from PID or its complications.

PID occurs when bacteria move upward from a woman's vagina or cervix (opening to the uterus) into her reproductive organs. Many different organisms can cause PID, but many cases are associated with gonorrhea and chlamydia, two very common bacterial STDs. A prior episode of PID increases the risk of another episode because the reproductive organs may be damaged during the initial bout of infection.

Sexually active women in their childbearing years are most at risk, and those under age 25 are more likely to develop PID than those older than 25. This is because the cervix of teenage girls and young women is not fully matured, increasing their susceptibilty to the STDs that are linked to PID.

The more sex partners a woman has, the greater her risk of developing PID. Also, a woman whose partner has more than one sex partner is at greater risk of developing PID, because of the potential for more exposure to infectious agents.

Women who douche may have a higher risk of developing PID compared with women who do not douche. Research has shown that douching changes the vaginal flora (organisms that live in the vagina) in harmful ways, and can force bacteria into the upper reproductive organs from the vagina.

Women who have an intrauterine device (IUD) inserted may have a slightly increased risk of PID near the time of insertion compared with women using other contraceptives or no contraceptive at all. However, this risk is greatly reduced if a woman is tested and, if necessary, treated for STDs before an IUD is inserted.

Symptoms of PID vary from none to severe. When PID is caused by chlamydial infection, a woman may experience mild symptoms or no symptoms at all, while serious damage is being done to her reproductive organs. Because of vague symptoms, PID goes unrecognized by women and their health care providers about two thirds of the time. Women who have symptoms of PID most commonly have lower abdominal pain. Other signs and symptoms include fever, unusual vaginal discharge that may have a foul odor, painful intercourse, painful urination, irregular menstrual bleeding, and pain in the right upper abdomen (rare).

Prompt and appropriate treatment can help prevent complications of PID. Without treatment, PID can cause permanent damage to the female reproductive organs. Infection-causing bacteria can silently invade the fallopian tubes, causing normal tissue to turn into scar tissue. This scar tissue blocks or interrupts the normal movement of eggs into the uterus. If the fallopian tubes are totally blocked by scar tissue, sperm cannot fertilize an egg, and the woman becomes infertile. Infertility also can occur if the fallopian tubes are partially blocked or even slightly damaged. About one in eight women with PID becomes infertile, and if a woman has multiple episodes of PID, her chances of becoming infertile increase.

In addition, a partially blocked or slightly damaged fallopian tube may cause a fertilized egg to remain in the fallopian tube. If this fertilized egg begins to grow in the tube as if it were in the uterus, it is called an ectopic pregnancy. As it grows, an ectopic pregnancy can rupture the fallopian tube causing severe pain, internal bleeding, and even death.

Scarring in the fallopian tubes and other pelvic structures can also cause chronic pelvic pain (pain that lasts for months or even years). Women with repeated episodes of PID are more likely to suffer infertility, ectopic pregnancy, or chronic pelvic pain.

PID is difficult to diagnose because the symptoms are often subtle and mild. Many episodes of PID go undetected because the woman or her health care provider fails to recognize the implications of mild or nonspecific symptoms. Because there are no precise tests for PID, a diagnosis is usually based on clinical findings. If symptoms such as lower abdominal pain are present, a health care provider should perform a physical examination to determine the nature and location of the pain and check for fever, abnormal vaginal or cervical discharge, and for evidence of gonorrheal or chlamydial infection. If the findings suggest PID, treatment is necessary.

The health care provider may also order tests to identify the infection-causing organism (e.g., chlamydial or gonorrheal infection) or to distinguish between PID and other problems with similar symptoms. A pelvic ultrasound is a helpful procedure for diagnosing PID. An ultrasound can view the pelvic area to see whether the fallopian tubes are enlarged or whether an abscess is present. In some cases, a laparoscopy may be necessary to confirm the diagnosis. A laparoscopy is a minor surgical procedure in which a thin, flexible tube with a lighted end (laparoscope) is inserted through a small incision in the lower abdomen. This procedure enables the doctor to view the internal pelvic organs and to take specimens for laboratory studies, if needed.

PID can be cured with several types of antibiotics. A health care provider will determine and prescribe the best therapy. However, antibiotic treatment does not reverse any damage that has already occurred to the reproductive organs. If a woman has pelvic pain and other symptoms of PID, it is critical that she seek care immediately. Prompt antibiotic treatment can prevent severe damage to reproductive organs. The longer a woman delays treatment for PID, the more likely she is to become infertile or to have a future ectopic pregnancy because of damage to the fallopian tubes.

Because of the difficulty in identifying organisms infecting the internal reproductive organs and because more than one organism may be responsible for an episode of PID, PID is usually treated with at least two antibiotics that are effective against a wide range of infectious agents. These antibiotics can be given by mouth or by injection. The symptoms may go away before the infection is cured. Even if symptoms go away, the woman should finish taking all of the prescribed medicine. This will help prevent the infection from returning. Women being treated for PID should be re-evaluated by their health care provider two to three days after starting treatment to be sure the antibiotics are working to cure the infection. In addition, a woman's sex partner(s) should be treated to decrease the risk of re-infection, even if the partner(s) has no symptoms. Although sex partners may have no symptoms, they may still be infected with the organisms that can cause PID.

Hospitalization to treat PID may be recommended if the woman (1) is severely ill (e.g., nausea, vomiting, and high fever); (2) is pregnant; (3) does not respond to or cannot take oral medication and needs intravenous antibiotics; or (4) has an abscess in the fallopian tube or ovary (tubo-ovarian abscess). If symptoms continue or if an abscess does not go away, surgery may be needed. Complications of PID, such as chronic pelvic pain and scarring are difficult to treat, but sometimes they improve with surgery.

STD (mainly untreated Chlamydia or gonorrhea) is the main preventable cause of PID. Women can protect themselves from PID by taking action to prevent STDs or by getting early treatment if they do get an STD. The surest way to avoid transmission of STDs is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of chlamydia and gonorrhea. An appropriate sexual risk assessment by a health care provider should always be conducted and may indicate more frequent screening for some women.

Any genital symptoms such as an unusual sore, discharge with odor, burning during urination, or bleeding between menstrual cycles could mean an STD infection. If a woman has any of these symptoms, she should stop having sex and consult a health care provider immediately. Treating STDs early can prevent PID. Women who are told they have an STD and are treated for it should notify all of their recent sex partners so they can see a health care provider and be evaluated for STDs. Sexual activity should not resume until all sex partners have been examined and, if necessary, treated.

Hepatitis B

Hepatitis B is a serious liver disease caused by a virus which is called hepatitis B virus (HBV). One out of 20 people in the United States have been infected with HBV some time during their lives. In 2004, an estimated 60,000 people were infected with HBV. People of all ages get hepatitis B and about 5,000 die each year from sickness caused by HBV.

HBV is spread by having sex with an infected person. You are at risk of HBV infection by sexual contact if you:

  • are a sex partner of someone who is infected with HBV
  • are sexually-active and are not in a long-term, mutually monogamous relationship (e.g., you have had more than one sex partner in the previous 6 months)
  • have other STDs
  • are a man having sex with a man

HBV is spread by exposure to infected blood from skin puncture or contact with mucous membranes. You are at risk of HBV infection from these exposures if you:

  • live in the same house with someone who is infected with HBV and share personal items such as toothbrushes, razors, etc…
  • shoot drugs
  • have a job that involves contact with human blood or body fluids
  • have end stage kidney disease

HBV is spread from an infected mother to her infant during birth.
HBV is not spread through food or water, sharing eating utensils, breastfeeding, hugging, kissing, coughing, sneezing, or casual contact.

Sometimes a person with HBV infection has no symptoms at all. Older people are more likely to have symptoms. You might be infected with HBV (and be spreading the virus) and not know it.
Symptoms might include yellow skin or yellowing of the whites of your eyes (jaundice); tiredness; loss of appetite; nausea; abdominal discomfort; dark urine; grey-colored bowel movements; or joint pain.

Some people who become infected with HBV develop chronic (lifelong) infection.
Chronic infection increases the risk for cirrhosis (scarring of the liver), liver cancer, and liver failure. About 15%-25% of people with chronic HBV infection might die prematurely from liver cirrhosis or liver cancer.

HBV can be spread from an infected mother to her infant during birth. To prevent spread of HBV from infected mothers to their infants, every woman should have her blood tested for hepatitis B surface antigen (HBsAg) during each pregnancy. Infants born to infected mothers need to get hepatitis B vaccine and another shot call HBIG (hepatitis B immune globulin) soon after birth to prevent infection.

A blood test is the only way to diagnose hepatitis B.

There are no medications available for recently acquired (acute) HBV infection. There are antiviral drugs available for the treatment of chronic HBV infection.

Hepatitis B vaccine is the best prevention against hepatitis B. Hepatitis B vaccine is recommended for all infants, for children and adolescents who were not vaccinated as infants, and for all unvaccinated adults who are at risk for HBV infection as well as any adult who wants to be protected against HBV infection.

The surest way to avoid transmission of all sexually transmitted diseases is to abstain from sexual intercourse, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex condoms, when used consistently and correctly, may reduce the risk of HBV transmission.
Never inject illegal drugs. If you are currently using, stop or get into a treatment program; if you can't stop, never share needles, syringes, water, or "works.”

Trichomoniasis

Trichomoniasis is the most common curable STD in young, sexually active women. An estimated 7.4 million new cases occur each year in women and men.

Trichomoniasis is caused by the single-celled protozoan parasite, Trichomonas vaginalis. The vagina is the most common site of infection in women, and the urethra (urine canal) is the most common site of infection in men. The parasite is sexually transmitted through penis-to-vagina intercourse or vulva-to-vulva (the genital area outside the vagina) contact with an infected partner. Women can acquire the disease from infected men or women, but men usually contract it only from infected women.

Most men with trichomoniasis do not have signs or symptoms; however, some men may temporarily have an irritation inside the penis, mild discharge, or slight burning after urination or ejaculation.

Some women have signs or symptoms of infection which include a frothy, yellow-green vaginal discharge with a strong odor. The infection also may cause discomfort during intercourse and urination, as well as irritation and itching of the female genital area. In rare cases, lower abdominal pain can occur. Symptoms usually appear in women within 5 to 28 days of exposure.

The genital inflammation caused by trichomoniasis can increase a woman's susceptibility to HIV infection if she is exposed to the virus. Having trichomoniasis may increase the chance that an HIV-infected woman passes HIV to her sex partner(s).

Pregnant women with trichomoniasis may have babies who are born early or with low birth weight (less than five pounds).

For both men and women, a health care provider must perform a physical examination and laboratory test to diagnose trichomoniasis. The parasite is harder to detect in men than in women. In women, a pelvic examination can reveal small red ulcerations (sores) on the vaginal wall or cervix.

Trichomoniasis can usually be cured with the prescription drug, metronidazole, given by mouth in a single dose. The symptoms of trichomoniasis in infected men may disappear within a few weeks without treatment. However, an infected man, even a man who has never had symptoms or whose symptoms have stopped, can continue to infect or re-infect a female partner until he has been treated. Therefore, both partners should be treated at the same time to eliminate the parasite. Persons being treated for trichomoniasis should avoid sex until they and their sex partners complete treatment and have no symptoms. Metronidazole can be used by pregnant women. Having trichomoniasis once does not protect a person from getting it again. Following successful treatment, people can still be susceptible to re-infection.

The surest way to avoid transmission of sexually transmitted diseases is to abstain from sexual contact, or to be in a long-term mutually monogamous relationship with a partner who has been tested and is known to be uninfected.

Latex male condoms, when used consistently and correctly, can reduce the risk of transmission of trichomoniasis. Any genital symptom such as discharge or burning during urination or an unusual sore or rash should be a signal to stop having sex and to consult a health care provider immediately. A person diagnosed with trichomoniasis (or any other STD) should receive treatment and should notify all recent sex partners so that they can see a health care provider and be treated. This reduces the risk that the sex partners will develop complications from trichomoniasis and reduces the risk that the person with trichomoniasis will become re-infected. Sex should be stopped until the person with trichomoniasis and all of his or her recent partners complete treatment for trichomoniasis and have no symptoms.

HIV Infection and AIDS:

AIDS (acquired immunodeficiency syndrome) was first reported in the United States in 1981 and has since become a major worldwide epidemic. AIDS is caused by HIV (human immunodeficiency virus). By killing or damaging cells of the body's immune system, HIV progressively destroys the body's ability to fight infections and certain cancers. People diagnosed with AIDS may get life-threatening diseases called opportunistic infections, which are caused by microbes such as viruses or bacteria that usually do not make healthy people sick.

More than 900,000 cases of AIDS have been reported in the United States since 1981. As many as 950,000 Americans may be infected with HIV, one-quarter of whom are unaware of their infection. The epidemic is growing most rapidly among minority populations and is a leading killer of African-American males ages 25 to 44. According to the Centers for Disease Control and Prevention (CDC), AIDS affects nearly seven times more African Americans and three times more Hispanics than whites. In recent years, an increasing number of African-American women and children are being affected by HIV/AIDS. In 2003, two-thirds of U.S. AIDS cases in both women and children were among African-Americans.

TRANSMISSION

HIV is spread most commonly by having unprotected sex with an infected partner. The virus can enter the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex.

Risky behavior
HIV can infect anyone who practices risky behaviors such as

  • Sharing drug needles or syringes
  • Having sexual contact, including oral, with an infected person without using a condom
  • Having sexual contact with someone whose HIV status is unknown

Infected blood
HIV also is spread through contact with infected blood. Before donated blood was screened for evidence of HIV infection and before heat-treating techniques to destroy HIV in blood products were introduced, HIV was transmitted through transfusions of contaminated blood or blood components. Today, because of blood screening and heat treatment, the risk of getting HIV from such transfusions is extremely small.


Contaminated needles

HIV is frequently spread among injection drug users by the sharing of needles or syringes contaminated with very small quantities of blood from someone infected with the virus. It is rare, however, for a patient to give HIV to a health care worker or vice-versa by accidental sticks with contaminated needles or other medical instruments.

Mother to child

Women can transmit HIV to their babies during pregnancy or birth. Approximately one-quarter to one-third of all untreated pregnant women infected with HIV will pass the infection to their babies. HIV also can be spread to babies through the breast milk of mothers infected with the virus. If the mother takes certain drugs during pregnancy, she can significantly reduce the chances that her baby will get infected with HIV. If health care providers treat HIV-infected pregnant women and deliver their babies by cesarean section, the chances of the baby being infected can be reduced to a rate of 1 percent. HIV infection of newborns has been almost eradicated in the United States due to appropriate treatment.

A study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) in Uganda found a highly effective and safe drug for preventing transmission of HIV from an infected mother to her newborn. Independent studies have also confirmed this finding. This regimen is more affordable and practical than any other examined to date. Results from the study show that a single oral dose of the antiretroviral drug nevirapine (NVP) given to an HIV-infected woman in labor and another to her baby within 3 days of birth reduces the transmission rate of HIV by half compared with a similar short course of AZT (Azidothymidine). For more information on preventing transmission from mother to child, go to http://aidsinfo.nih.gov/guidelines.

Saliva

Although researchers have found HIV in the saliva of infected people, there is no evidence that the virus is spread by contact with saliva. Laboratory studies reveal that saliva has natural properties that limit the power of HIV to infect, and the amount of virus in saliva appears to be very low. Research studies of people infected with HIV have found no evidence that the virus is spread to others through saliva by kissing. The lining of the mouth, however, can be infected by HIV, and instances of HIV transmission through oral intercourse have been reported.Scientists have found no evidence that HIV is spread through sweat, tears, urine, or feces.

Oral Sex Is Not Risk Free

Like all sexual activity, oral sex carries some risk of HIV transmission when one partner is known to be infected with HIV, when either partner’s HIV status is not known, and/or when one partner is not monogamous or injects drugs. Even though the risk of transmitting HIV through oral sex is much lower than that of anal or vaginal sex, numerous studies have demonstrated that oral sex can result in the transmission of HIV and other sexually transmitted diseases (STDs). Abstaining from oral, anal, and vaginal sex altogether or having sex only with a mutually monogamous, uninfected partner are the only ways that individuals can be completely protected from the sexual transmission of HIV. However, by using condoms or other barriers between the mouth and genitals, individuals can reduce their risk of contracting HIV or another STD through oral sex.

Oral Sex is a Common Practice

Oral sex involves giving or receiving oral stimulation (i.e., sucking or licking) to the penis, the vagina, and/or the anus. Fellatio is the technical term used to describe oral contact with the penis. Cunnilingus is the technical term which describes oral contact with the vagina. Anilingus (sometimes called “rimming”) refers to oral-anal contact. Studies indicate that oral sex is commonly practiced by sexually active male-female and same-gender couples of various ages, including adolescents. Although there are only limited national data about how often adolescents engage in oral sex, some data suggest that many adolescents who engage in oral sex do not consider it to be “sex;” therefore they may use oral sex as an option to experience sex while still, in their minds, remaining abstinent. Moreover, many consider oral sex to be a safe or no-risk sexual practice. In a national survey of teens conducted for The Kaiser Family Foundation, 26% of sexually active 15- to 17-year-olds surveyed responded that one “cannot become infected with HIV by having unprotected oral sex,” and an additional 15% didn’t know whether or not one could become infected in that manner.

Oral Sex and the Risk of HIV Transmission

The risk of HIV transmission from an infected partner through oral sex is much less than the risk of HIV transmission from anal or vaginal sex. Measuring the exact risk of HIV transmission as a result of oral sex is very difficult. Additionally, because most sexually active individuals practice oral sex in addition to other forms of sex, such as vaginal and/or anal sex, when transmission occurs, it is difficult to determine whether or not it occurred as a result of oral sex or other more risky sexual activities. Finally, several co-factors may increase the risk of HIV transmission through oral sex, including: oral ulcers, bleeding gums, genital sores, and the presence of other STDs. What is known is that HIV has been transmitted through fellatio, cunnilingus, and anilingus.

Other STDs Can Also Be Transmitted From Oral Sex

In addition to HIV, other STDs can be transmitted through oral sex with an infected partner. Examples of these STDs include herpes, syphilis, gonorrhea, genital warts (HPV), intestinal parasites (amebiasis), and hepatitis A.

Oral Sex and Reducing the Risk of HIV Transmission

The consequences of HIV infection are life-long. If treatment is not initiated in a timely manner, HIV can be extremely serious and life threatening. However, there are steps you can take to lower the risk of getting HIV from oral sex.

Generally, the use of a physical barrier during oral sex can reduce the risk of transmission of HIV and other STDs. A latex or plastic condom may be used on the penis to reduce the risk of oral-penile transmission. If your partner is a female, a cut-open condom or a dental dam can be used between your mouth and the vagina. Similarly, regardless of the sex of your partner, if your mouth will come in contact with your partner’s anus, a cut-open condom or dental dam can be used between your mouth and the anus.

At least one scientific article has suggested that plastic food wrap may be used as a barrier to protect against herpes simplex virus during oral-vaginal or oral-anal sex. However, there are no data regarding the effectiveness of plastic food wrap in decreasing transmission of HIV and other STDs in this manner and it is not manufactured or approved by the FDA for this purpose.

 

Casual contact

Studies of families of HIV-infected people have shown clearly that HIV is not spread through casual contact such as the sharing of food utensils, towels and bedding, swimming pools, telephones, or toilet seats. HIV is not spread by biting insects such as mosquitoes or bedbugs.

Sexually transmitted infections

If you have a sexually transmitted infection (STI) such as syphilis, genital herpes, chlamydial infection, gonorrhea, or bacterial vaginosis appears, you may be more susceptible to getting HIV infection during sex with infected partners.

EARLY SYMPTOMS OF HIV INFECTION

If you are like many people, you will not have any symptoms when you first become infected with HIV. You may, however, have a flu-like illness within a month or two after exposure to the virus. This illness may include

  • Fever
  • Headache
  • Tiredness
  • Enlarged lymph nodes (glands of the immune system easily felt in the neck and groin)

These symptoms usually disappear within a week to a month and are often mistaken for those of another viral infection. During this period, people are very infectious, and HIV is present in large quantities in genital fluids.

More persistent or severe symptoms may not appear for 10 years or more after HIV first enters the body in adults, or within 2 years in children born with HIV infection. This period of "asymptomatic" infection varies greatly in each individual. Some people may begin to have symptoms within a few months, while others may be symptom-free for more than 10 years.

Even during the asymptomatic period, the virus is actively multiplying, infecting, and killing cells of the immune system. The virus can also hide within infected cells and lay dormant. The most obvious effect of HIV infection is a decline in the number of CD4 positive T (CD4+) cells found in the blood-the immune system's key infection fighters. The virus slowly disables or destroys these cells without causing symptoms.

As the immune system worsens, a variety of complications start to take over. For many people, the first signs of infection are large lymph nodes or "swollen glands" that may be enlarged for more than 3 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

Some people develop frequent and severe herpes infections that cause mouth, genital, or anal sores, or a painful nerve disease called shingles. Children may grow slowly or be sick a lot.

WHAT IS AIDS?

The term AIDS applies to the most advanced stages of HIV infection. CDC developed official criteria for the definition of AIDS and is responsible for tracking the spread of AIDS in the United States.
CDC's definition of AIDS includes all HIV-infected people who have fewer than 200 CD4+ T cells per cubic millimeter of blood. (Healthy adults usually have CD4+ T-cell counts of 1,000 or more.) In addition, the definition includes 26 clinical conditions that affect people with advanced HIV disease. Most of these conditions are opportunistic infections that generally do not affect healthy people. In people with AIDS, these infections are often severe and sometimes fatal because the immune system is so ravaged by HIV that the body cannot fight off certain bacteria, viruses, fungi, parasites, and other microbes.

Symptoms of opportunistic infections common in people with AIDS include

  • Coughing and shortness of breath
  • Seizures and lack of coordination
  • Difficult or painful swallowing
  • Mental symptoms such as confusion and forgetfulness
  • Severe and persistent diarrhea
  • Fever
  • Vision loss
  • Nausea, abdominal cramps, and vomiting
  • Weight loss and extreme fatigue
  • Severe headaches
  • Coma

Children with AIDS may get the same opportunistic infections as do adults with the disease. In addition, they also have severe forms of the typically common childhood bacterial infections, such as conjunctivitis (pink eye), ear infections, and tonsillitis.

People with AIDS are also particularly prone to developing various cancers, especially those caused by viruses such as Kaposi's sarcoma and cervical cancer, or cancers of the immune system known as lymphomas. These cancers are usually more aggressive and difficult to treat in people with AIDS. Signs of Kaposi's sarcoma in light-skinned people are round brown, reddish, or purple spots that develop in the skin or in the mouth. In dark-skinned people, the spots are more pigmented.

During the course of HIV infection, most people experience a gradual decline in the number of CD4+ T cells, although some may have abrupt and dramatic drops in their CD4+ T-cell counts. A person with CD4+ T cells above 200 may experience some of the early symptoms of HIV disease. Others may have no symptoms even though their CD4+ T-cell count is below 200.

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

A small number of people first infected with HIV 10 or more years ago have not developed symptoms of AIDS. Scientists are trying to determine what factors may account for their lack of progression to AIDS, such as

  • Whether their immune systems have particular characteristics
  • Whether they were infected with a less aggressive strain of the virus
  • If their genes may protect them from the effects of HIV

Scientists hope that understanding the body's natural method of controlling infection may lead to ideas for protective HIV vaccines and use of vaccines to prevent the disease from progressing.

DIAGNOSIS

Because early HIV infection often causes no symptoms, your health care provider usually can diagnose it by testing your blood for the presence of antibodies (disease-fighting proteins) to HIV. HIV antibodies generally do not reach noticeable levels in the blood for 1 to 3 months following infection. It may take the antibodies as long as 6 months to be produced in quantities large enough to show up in standard blood tests. Hence, to determine whether you have been recently infected (acute infection), your health care provider can screen you for the presence of HIV genetic material. Direct screening of HIV is extremely critical in order to prevent transmission of HIV from recently infected individuals.

If you have been exposed to the virus, you should get an HIV test as soon as you are likely to develop antibodies to the virus-within 6 weeks to 12 months after possible exposure to the virus. By getting tested early, if infected, you can discuss with your health care provider when you should start treatment to help your immune system combat HIV and help prevent the emergence of certain opportunistic infections (see section on treatment below). Early testing also alerts you to avoid high-risk behaviors that could spread the virus to others.

Most health care providers can do HIV testing and will usually offer you counseling at the same time. Of course, you can be tested anonymously at many sites if you are concerned about confidentiality. Health care providers diagnose HIV infection by using two different types of antibody tests: ELISA and Western Blot. If you are highly likely to be infected with HIV but have been tested negative for both tests, your health care provider may request additional tests. You also may be told to repeat antibody testing at a later date, when antibodies to HIV are more likely to have developed.

Babies born to mothers infected with HIV may or may not be infected with the virus, but all carry their mothers' antibodies to HIV for several months. If these babies lack symptoms, a doctor cannot make a definitive diagnosis of HIV infection using standard antibody. Health care providers are using new technologies to detect HIV to more accurately determine HIV infection in infants between ages 3 months and 15 months. They are evaluating a number of blood tests to determine which ones are best for diagnosing HIV infection in babies younger than 3 months.

TREATMENT

When AIDS first surfaced in the United States, there were no medicines to combat the underlying immune deficiency and few treatments existed for the opportunistic diseases that resulted. Researchers, however, have developed drugs to fight both HIV infection and its associated infections and cancers.

HIV infection

The Food and Drug Administration (FDA) has approved a number of drugs for treating HIV infection. The first group of drugs used to treat HIV infection, called nucleoside reverse transcriptase (RT) inhibitors, interrupts an early stage of the virus making copies of itself. These drugs may slow the spread of HIV in the body and delay the start of opportunistic infections. This class of drugs, called nucleoside analogs, include

  • AZT (Azidothymidine)
  • ddC (zalcitabine)
  • ddI (dideoxyinosine)
  • d4T (stavudine)
  • 3TC (lamivudine)
  • Abacavir (ziagen)
  • Tenofovir (viread)
  • Emtriva (emtricitabine)

Health care providers can prescribe non-nucleoside reverse transcriptase inhibitors (NNRTIs), such as

  • Delavridine (Rescriptor)
  • Nevirapine (Viramune)
  • Efravirenz (Sustiva) (in combination with other antiretroviral drugs)

FDA also has approved a second class of drugs for treating HIV infection. These drugs, called protease inhibitors, interrupt the virus from making copies of itself at a later step in its life cycle. They include

  • Ritonavir (Norvir)
  • Saquinivir (Invirase)
  • Indinavir (Crixivan)
  • Amprenivir (Agenerase)
  • Nelfinavir (Viracept)
  • Lopinavir (Kaletra)
  • Atazanavir (Reyataz)
  • Fosamprenavir (Lexiva)

FDA also has introduced a third new class of drugs, known at fusion inhibitors, to treat HIV infection. Fuzeon (enfuvirtide or T-20), the first approved fusion inhibitor, works by interfering with HIV-1's ability to enter into cells by blocking the merging of the virus with the cell membranes. This inhibition blocks HIV's ability to enter and infect the human immune cells. Fuzeon is designed for use in combination with other anti-HIV treatment. It reduces the level of HIV infection in the blood and may be active against HIV that has become resistant to current antiviral treatment schedules.

Because HIV can become resistant to any of these drugs, health care providers must use a combination treatment to effectively suppress the virus. When multiple drugs (three or more) are used in combination, it is referred to as highly active antiretroviral therapy, or HAART, and can be used by people who are newly infected with HIV as well as people with AIDS.

Researchers have credited HAART as being a major factor in significantly reducing the number of deaths from AIDS in this country. While HAART is not a cure for AIDS, it has greatly improved the health of many people with AIDS and it reduces the amount of virus circulating in the blood to nearly undetectable levels. Researchers, however, have shown that HIV remains present in hiding places, such as the lymph nodes, brain, testes, and retina of the eye, even in people who have been treated.

Side effects

Despite the beneficial effects of HAART, there are side effects associated with the use of antiviral drugs that can be severe. Some of the nucleoside RT inhibitors may cause a decrease of red or white blood cells, especially when taken in the later stages of the disease. Some may also cause inflammation of the pancreas and painful nerve damage. There have been reports of complications and other severe reactions, including death, to some of the antiretroviral nucleoside analogs when used alone or in combination. Therefore, health care experts recommend that you be routinely seen and followed by your health care provider if you are on antiretroviral therapy.

The most common side effects associated with protease inhibitors include nausea, diarrhea, and other gastrointestinal symptoms. In addition, protease inhibitors can interact with other drugs resulting in serious side effects. Fuzeon may also cause severe allergic reactions such as pneumonia, trouble breathing, chills and fever, skin rash, blood in urine, vomiting, and low blood pressure. Local skin reactions are also possible since it is given as an injection underneath the skin.

Opportunistic infections

A number of available drugs help treat opportunistic infections. These drugs include

  • Foscarnet and ganciclovir to treat CMV (cytomegalovirus) eye infections
  • Fluconazole to treat yeast and other fungal infections
  • TMP/SMX (trimethoprim/sulfamethoxazole) or pentamidine to treat PCP (Pneumocystis carinii pneumonia)

Cancers
Health care providers use radiation, chemotherapy, or injections of alpha interferon-a genetically engineered protein that occurs naturally in the human body-to treat Kaposi's sarcoma or other cancers associated with HIV infection.

PREVENTION

Because no vaccine for HIV is available, the only way to prevent infection by the virus is to avoid behaviors that put you at risk of infection, such as sharing needles and having unprotected sex. Many people infected with HIV have no symptoms. Therefore, there is no way of knowing with certainty whether your sexual partner is infected unless he or she has repeatedly tested negative for the virus and has not engaged in any risky behavior. You should either abstain from having sex or use male latex condoms or female polyurethane condoms, which may offer partial protection, during oral, anal, or vaginal sex. Only water-based lubricants should be used with male latex condoms.Although some laboratory evidence shows that spermicides can kill HIV, researchers have not found that these products can prevent you from getting HIV.

Sexual Orientation

The science of sexual orientation – required reading

Sexual Deviation

History

The study of sexual deviancy began just before the turn of the 20th century as the taboo of discussing sexuality was beginning to lift. Early pioneers included Richard von Kraff-Ebing, Albert Moll, August Forel, Iwan Bloch, Magnus Hirschfield, Havelock Ellis, and Sigmund Freud. Their work was not well accepted, and they were regarded with disdain.

Several psychiatric concepts were prominent at this time. One of them was a constitutional predisposition of unknown origin called degeneration, which refers to an innate neurologic weakness that is transmitted with increased severity to future generations and produces deviations from the norm. Masturbation was blamed for a list of diseases including insanity, suicide, self-mutilation, and tuberculosis. The law of association of ideas suggests that when sex and another experience occur, one stimulus sets off the other.

Ellis worked against the prudish view of sex that existed at the time, and he advocated the decriminalization of homosexuality. Freud wrote on fetishism, masochism, and the theory of perversions. These early investigators of sexual deviation provide an important principal: "Not only must the act be studied, but also the person. The personal roots of deviance spring from an interaction of the individual's biological nature and his early life experiences."

Disorders of human behavior remain difficult to understand, identify, and treat. Few data are available, too much of our knowledge is based on speculation and unsupported theory, and societal stereotypes influence our perceptions. Good science-based research remains difficult, and monetary, ethical, and legal concerns complicate such research.

Sexual deviation is a term applicable to a subclass of sexual disorders termed paraphilias. Paraphilias are associated with arousal in response to sexual objects or stimuli not associated with normal behavior patterns and that may interfere with the establishment of sexual relationships. In modern classification systems, the term paraphilia is preferable to sexual deviation because it clarifies the essential nature of this group of behaviors (ie, arousal in response to an inappropriate stimulus).

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), the prevailing resource for diagnostic criteria of paraphilias, describes the essential feature of paraphilias as recurrent, intense, sexual urges and sexually arousing fantasies generally involving nonhuman objects, the suffering or humiliation of oneself or partner, or children or other nonconsenting persons. The DSM-IV-TR describes 8 of the more commonly observed paraphilias and makes reference to several other examples. People who experience one paraphilia may also experience other paraphilias, although the paraphilia may occur as an isolated event. Commonly, people who manifest paraphilias also exhibit personality disorders, substance abuse problems, or affective disorders.

Prevalence

Paraphilias are rarely diagnosed in clinical settings. Large commercial markets in paraphiliac pornography and paraphernalia are testaments that prevalence is high. Pedophilia, voyeurism, and exhibitionism are the most commonly observed behaviors in clinics that specialize in paraphilia treatment. Sexual masochism and sexual sadism are much less commonly observed. Approximately half of patients observed in clinics for treatment of paraphilias are married.

Differentials

Nonparaphiliacs may describe nonpathological use of sexual fantasies, behaviors, or objects as stimuli for sexual excitement. In patients with mental retardation, paraphilia should be distinguished from dementia, personality change due to general medical condition, substance intoxication, manic episode, or schizophrenia in which judgment, social skills, or impulse control are compromised.
When appropriate, public urination should be distinguished from exhibitionism.

Exhibitionism

The DSM-IV-TR diagnostic criteria for exhibitionism are as follows:

  • The patient reports recurrent, intense, sexual urges and sexually arousing fantasies related to exposing the genitals to a stranger. Symptoms must be present for at least 6 months.
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.

Generally, no attempt at further sexual activity with the stranger occurs, although a desire to shock the stranger sometimes exists or the exhibitionist may have a fantasy that the observer will become sexually aroused. Onset usually occurs in persons younger than 18 years but may occur later. The disorder causes significant stress or impairment in social, occupational, or other important areas of functioning. In 1975, Rooth classified 2 types of exhibitionism: Type I is the inhibited flaccid exposer, and type II is the sociopathic exposer who may have a history of other conduct. About half of adult women have witnessed indecent exposure sometime in their lives.

Exhibitionists, whether timid or brash, feel dominated by women and resent it. By exposing themselves, exhibitionists turn the table on women, dominating rather than being dominated. Exhibitionists view this act as making women their helpless victims, rather than being helpless before them. Some researchers have suggested that exhibitionists have a fragile sense of masculinity. Threats to masculinity are countered by demonstrations of manliness.

Exhibitionists have difficulty relating to women as whole people. Rather, women are present merely to provide both gratification and proof against castration. Many exhibitionists are very prudish with their wives. They go to great efforts to never look at their wives or be seen by them in the nude. Intercourse tends to be rigid and conventional.

Common to all exhibitionists is some abnormality in handling aggression and hostility. On the one hand, they must keep their anger under tight control, yet on the other hand they may become tyrannical with their family because they feel safe from retaliation.

Male genital exhibitionism is an indicator of future sexual offenses in some individuals. In a 1980 longitudinal study, Bluglass found that 7% of exhibitionists were later convicted of contact sexual offenses, including rape.

Genital exhibitionism is rare among women. This has been explained by the differences between the sexes in the development of the castration complex and the absence of a reassuring effect from showing a penis because of anatomic differences in women. Eber in a 1977 report and Kohut in a 1978 report view female exhibitionism as a disorder of bodily narcissism.

Presentation to physicians is common and may result from a sense of guilt and an inability to control the behavior. Sometimes the behavior is revealed as the result of a criminal offense. More serious underlying pathology is suggested when preferred scenes include defecation or small children.

Fetishism

The DSM-IV-TR lists the following diagnostic criteria for fetishism:

  • The patient experiences recurrent and intense sexual urges and sexually arousing fantasies involving the use of nonliving objects by themselves. Symptoms must be present for at least 6 months.
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.
  • The fetishes are not limited to articles of female clothing used in cross-dressing (transvestic fetishism) or devices designed for genital stimulation (eg, vibrators).

Common fetishistic objects include female underwear; rubber, plastic, or leather garments; specific articles of clothing such as shoes or boots; and bodily items such as hair, odors, or feces. The disorder is more common among males than females. Prevalence is unknown. It can often be traced from adolescence and usually persists.

In the context of psychoanalytic theory, in a 1996 publication Greenacre associates fetishism with a severe castration complex in males and a more complicated and less readily recognized set of relational reactions in females. For men, the fetish serves a defensive function, a reinforcing adjunct for a penis of uncertain potency. The fetish serves to increase the efficiency of the penis, which does not perform well without it. In women, fetishism is less common, largely because of anatomic differences that allow women to conceal inadequate sexual response more readily than men. Women can develop symptoms more comparable to male fetishism when the illusion of having a phallus has gained sufficient strength to approach delusional proportions. This occurs in rare cases in which severe disturbances in the sense of reality exist.

Treatment of the specific condition (fetish), rather than the primary underlying disorder (eg, organic pathology, personality disorder) generally is unsuccessful. A variety of treatment approaches have been tried, such as aversive conditioning, cognitive therapy, and psychotherapy.

Frotteurism

The DSM-IV-TR lists the following diagnostic criteria for frotteurism:

  • The patient experiences intense, recurrent, sexual urges and sexually arousing fantasies involving touching and rubbing against a nonconsensual person. Symptoms must be present for at least 6 months.
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors, or the patient has acted on the sexual urges.

Frotteurs typically act out their fantasies in crowded places (eg, public transportation vehicles, busy sidewalks), which allows for escape; the frotteur can claim that the touching was accidental. The frotteur rubs his genital area against the (usually female) victim's thighs or buttocks, or the frotteur fondles a woman's genitalia or breasts with his hands. While committing the act, the offender typically fantasizes about an exclusive, caring relationship with the victim.

Most acts occur in perpetrators aged 15-25 years, after which frequency gradually declines. Frotteurism has been noted to be equally common among older, shy, inhibited individuals. Fantasies of frotteuristic behavior without action have been reported as a stimulant to sexual arousal.

Voyeurism

The term voyeurism, from the French word meaning to see, refers to the fairly common desire to view nudity and acts of coition. Differentiating innocent enjoyment of nudity from behavior that is similar but deviant in other circumstances can be difficult.

The DSM-IV-TR diagnostic criteria for voyeurism are as follows:

  • The patient has recurrent and intense sexual urges and sexually arousing fantasies involving the act of observing an unsuspecting person who is naked, in the process of disrobing, or engaging in sexual activity. Symptoms must be present for at least 6 months.
  • The patient experiences significant distress or impairment in social, occupational, or other important areas of functioning because of the fantasies, urges, or behaviors.

When severe, the act of peeping constitutes the exclusive form of sexual activity. Onset usually is in persons younger than 15 years, and the disorder tends to be chronic. The wide extent of voyeuristic tendencies in the general population is evidenced in the common desire to indulge in exploitative activities such as live shows and pornography.

Pedophilia

The essential features of this disorder as described by the DSM-IV-TR include the following:

  • The patient reports recurrent and intense sexually arousing fantasies, sexual urges, or behaviors involving sexual activity with a prepubescent child or children, generally aged 13 years or younger.
  • Pedophiles must be aged 16 years or older and be at least 5 years older than the victim.
  • The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  • The clinician should specify if the person is attracted to males, females, or both; if the acts are limited to incest; and if the patient is attracted to children only (exclusive type) or both children and adults (nonexclusive type).

While female pedophiles are considered to be rare, discrepancies between the numbers of male and female offenders are tied to sexual stereotypes. Masculinity connotes sexual qualities, while femininity connotes maternal qualities and nurturance. When a female pets a child, she is nurturing. When a male pets a child, he is molesting. The majority of men who have had sexual contact with a woman when they were boys viewed it positively rather than negatively. Consequently, these acts were probably unreported. In one study, 16% of college males and 46% of prisoners reported having had sexual contact with older females, and half of the encounters involved intercourse. Mean age of males at the time of sexual contact was 12 years, and the females with whom they were involved were aged 20-30 years.

Many pedophiles have a personal history of unstable parent-child relationships as children and sexual abuse. The majority of pedophiles have a clear sexual preference. The undifferentiated or bisexual group accounts for only 5-25% of pedophiles. Most studies indicate that 60-90% of incidents of abuse involve girls.

Great variation exists among men who use children sexually. One third to one half prefer children as sexual partners. Others are attracted to children but act on their impulses only under stress. Some, who typically are younger than 30 years, are sociosexually underdeveloped, lack age-appropriate experience, and have feelings of shyness and inferiority. Unable to attain adult female contact, they continue prepubescent sexual patterns. Amoral delinquent youths (younger than pedophiles proper), lacking control when aroused, use whoever is close at hand. Patients with the situational type of pedophilia have no special preference for children, although they have sexual contact with children because of convenience or coincidence. Contact typically is brief and nonrecurrent. A residual category of offenders includes people with mental retardation, psychosis, alcoholism, senility, or dementia.

Approximately 37% of sexual assault victims reported to law enforcement agencies were juveniles (<18 y); 34% of all victims were younger than 12 years. One in 7 victims is younger than 6 years. Forty percent of offenders who victimized children younger than 6 years were juveniles (<18 y).

Eroticism

The distinction between erotica and pornography (as well as the lesser known genre of sexual entertainment, ribaldry) is difficult to identify as it is, to a degree, highly personal. Essentially, the difference lies in the individual's approach to sexuality and the sex act. Inexperience and a simplistic social model of sexuality tends to produce a prurient and undeveloped approach to sexual pleasure, which revels in the deliberate flouting and perversion of accepted moral principles. A more open view of sexuality tends to set the moral view aside and accepts that sexual gratification is the right of each human being and each has the right to pursue that in their own way without judgmental burdens being placed on them by external sources.

Erotic art tends to spring from this latter, more amoral viewpoint. Proponents for erotic art argue that such work is intended to be artistically interesting and deliberate rather than simply sexually stimulating, and is therefore not pornographic. Opponents see this as a pretentious stand as they believe that erotic art is indeed intended for sexual arousal.

The issue of whether a distinction can be made between erotica and pornography raises multiple complicated questions. These questions include whether aesthetic and erotic feelings are mutually exclusive, how the level of commercialism and tastefulness in an artwork can be objectively measured, and at what point they make the work pornographic.

In general, "erotica" refers to portrayals of sexually arousing material that hold or aspire to artistic, scientific or human merit, whereas "pornography" often connotes the commercial, prurient, morally valueless depiction of sexual acts, with little or no artistic value.

The distinction between erotica and pornography (as well as the lesser known genre of sexual entertainment, ribaldry) is difficult to identify as it is, to a degree, highly personal. Essentially, the difference lies in the individual's approach to sexuality and the sex act. Inexperience and a simplistic social model of sexuality tends to produce a prurient and undeveloped approach to sexual pleasure, which revels in the deliberate flouting and perversion of accepted moral principles. A more open view of sexuality tends to set the moral view aside and accepts that sexual gratification is the right of each human being and each has the right to pursue that in their own way without judgmental burdens being placed on them by external sources.

Sexual masochism

The essential features of this disorder as described by the DSM-IV-TR include the following:

  • The patient reports recurrent and intense sexual urges and sexually arousing fantasies involving the act (real, not simulated) of being humiliated, beaten, bound, or otherwise made to suffer. Symptoms must be present for at least 6 months.
  • The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.

Masochistic acts commonly involve a wide range of activities, such as restraint, blindfolding, beating, electrical shock, cutting, piercing, and humiliation (eg, being urinated or defecated on, forced to bark, verbally abused, forced to cross-dress). Some sexual masochists inflict pain through self-mutilation, and some engage in group activity or use services provided by prostitutes.

Hypoxyphilia is a dangerous form of masochism that involves sexual arousal by oxygen deprivation achieved by means of chest compression, noose, ligature, plastic bag, mask, or chemicals. Oxygen deprivation may be accomplished alone or with a partner. Data from the United States, England, Australia, and Canada indicate that 1-2 deaths per million population are reported each year.

Some sexually masochistic males also exhibit fetishism, transvestic fetishism, or sexual sadism. Masochistic sexual fantasies are likely present in childhood. Masochistic activities commonly begin by early adulthood, tend to be chronic, and the same act is generally repeated. Some individuals increase the severity of the act over time, which may lead to injury or death.

In 1926, Sadger observed a common association between homosexuality and masochism. In a 1977 report, Spengler found that 38% of exclusive homosexuals were sadomasochists, which provides some support for Sadger's observation.

Ritualized behavior is a noted feature of masochistic scenes; the slightest deviation from the script may result in failure to achieve the desired result. This feature is also viewed as a mechanism through which the masochist maintains control.

Sexual sadism

The DSM-IV-TR diagnostic criteria for sexual sadism are as follows:

  • The patient reports recurrent and intense sexual urges and sexually arousing fantasies involving the act (real, not simulated) in which the psychological or physical suffering (including humiliation) of one person is sexually arousing to another person. Symptoms must be present for at least 6 months.
  • The fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.

Sadistic fantasies or acts may involve activities such as dominance, restraint, blindfolding, beating, pinching, burning, electrical shock, rape, cutting, stabbing, strangulation, torture, mutilation, or killing. Sadistic sexual fantasies are likely present in childhood. Onset of sadistic activities commonly occurs by early adulthood, and it tends to be chronic.

Some individuals do not increase the severity of their sadistic acts; however, severity of the sadistic acts does usually increase over time. When practiced with nonconsenting partners, the activity is likely to be repeated until the perpetrator is apprehended. When sexual sadism is severe and associated with antisocial personality disorder, victims may be seriously injured or killed.

No clear lines divide sexual sadism and sexual masochism, and the predispositions are often interchangeable. The conditions may coexist in the same individual, sometimes in association with other paraphilias. This relationship is supported by the finding that those who entertain masochistic fantasies also engage in sadistic fantasies. In the context of psychoanalytic theory, Panken in a 1973 publication does not find that the conditions coexist in an individual and claims that the dynamics are different.

Transvestic fetishism

Transvestic fetishism is defined by DSM-IV-TR diagnostic criteria as follows:

  • The patient is a heterosexual male who has recurrent, intense, sexually arousing fantasies, urges, or behaviors involving cross-dressing. Symptoms must be present for at least 6 months.
  • These fantasies, urges, or behaviors cause significant distress or impairment in social, occupational, or other important areas of functioning.
  • If gender dysphoria is present, it should be specified.

Fetishistic transvestism is essentially unheard of in females. Women may cross-dress, but no literature (English) describes cross-dressing females who become sexually excited by the activity.
Other paraphilias

Sexual arousal may be obtained from a wide array of additional behaviors. Some are provided with the assistance of prostitutes, others find willing partners when needed. Other paraphilias include the following:

  • Scatologia (obscene phone calls)
  • Necrophilia (corpses)
  • Partialism (exclusive focus on part of body)
  • Zoophilia (animals)
  • Coprophilia (feces)
  • Klismaphilia (enemas)
  • Urophilia (urine)

The DSM-IV-TR diagnostic criteria for gender identity disorder (transsexualism) include strong and persistent cross-gender identification that extends beyond a desire for a perceived cultural advantage.

In children, gender identity disorder is defined by 4 or more of the following characteristics:

Boys have an aversion to their penis or testes, a belief the genitals will disappear, an aversion to rough-and-tumble play, and a rejection of male toys. Girls have a rejection of urinating in the sitting position, an assertion that they will grow a penis, an assertion that they do not want to grow breasts or menstruate, and an aversion toward normative feminine clothing.

  • Desire to be the other sex
  • Preference for cross-sex roles in play or preference for cross-dressing
  • Persistent fantasies of being the other sex
  • An intense desire to participate in stereotypical games and pastimes of the other sex
  • Strong preference for playmates of the other sex

Adolescents and adults may experience the following:

  • Desire to be the other sex
  • Frequent passing as the other sex
  • Desire to live or be treated as the other sex
  • Conviction that the person has the typical feelings and reactions of the opposite sex
  • Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex

Adolescents and adults may have a preoccupation with getting rid of primary and secondary sex characteristics, and they may believe that they were born as the wrong sex. People with gender identity disorder do not have a concurrent physical intersex condition. Patients report significant distress or impairment in social, occupational, or other important areas of functioning. For sexually mature patients, the clinician should specify if the patient is sexually attracted to females, males, both, or neither.

Prevalence

No recent epidemiologic studies have determined the prevalence of gender identity disorder. In Europe, 1 per 30,000 adult males and 1 per 100,000 adult females seek sexual reassignment surgery (SRS).

Differentials

The differential diagnosis should include nonconformity to stereotypical sex role behaviors, transvestic fetishism, gender identity disorder not otherwise specified (with a concurrent congenital intersex condition), and schizophrenia.

Proposed parental factors

Rooted in psychoanalytic theory, in a 1968 publication Stoller describes a typical background from which a male transsexual might emerge. A woman whose mother did not encourage her daughter's femininity grows up and marries a passive man for a relationship that is unsatisfactory for both but is often lasting. This depressed woman has a male child. A blissful symbiosis is established between mother and son. The father does not try to break the symbiosis and tends to stay away from home. Excessive physical and emotional closeness to the mother for too long leads to feminine identification and behaviors that secretly please the mother, who reinforces these behaviors. Stroller views this nonconflictual learning process as similar to imprinting. In contrast, he views homosexuality and transvestism as end results of defense against the trauma of dangerous and painful interpersonal relationships.

In a 1974 publication, Person and Ovesey postulate a different, yet still psychosocial, etiology based on a study of 10 primary transsexuals (individuals with gender identity disorder). Although all 10 envied girls and engaged in cross-dressing behavior starting at the age of 3-10 years, none believed he was a girl and 9 gave no history of feminine behavior. They were loners, with few age mates of either sex, and they had feelings of anxiety, depression, and loneliness. They were asexual and loathed their male characteristics. Their wish to be female was based on a fantasy of symbiotic fusion with the mother as a way to deal with extreme separation anxiety, thus falling diagnostically in the borderline spectrum of disorders.

Stoller describes the psychoanalytic etiology of female transsexualism as unclear but postulates some preliminary findings. Neither the mother nor father of the girl has a gender disorder. The mother is unable to function in the first months or year of her daughter's life because of deep depression (paranoia or physical illness in fewer cases). The child knows the mother is present but beyond emotional reach. The father does not minister to his wife; rather, he has the daughter minister to her. These transsexual females are described as vigorous, ungraceful, and unattractive in infancy. The father engages his daughter in activities that interest him, thus promoting masculine behavior. By the age of 4-5 years, she is already yearning to have the anatomic insignias of maleness, born out of pain and conflict from premature maternal separation. Note that these ideas are postulated but data are unavailable.

Retrospective studies in adult transsexuals show differences in recalled child-rearing patterns between transsexuals and normative groups. Male-to-female transsexuals characterized their fathers as less emotionally available, less warm, more rejecting, and overcontrolling. Female-to-male transsexuals characterized both parents as more rejecting and less emotionally warm, but they only characterized their mothers as more overprotective than their female controls did.

Biological factors

Biomedical research of transsexualism has investigated several areas. Girls with congenital adrenal hyperplasia (CAH), a condition causing prenatal exposure to a relatively high level of androgens, were examined to determine if male gender identity developed even if XX chromosome individuals were raised as females. A few such cases have been reported. In most cases, however, girls assigned and raised consistently as girls do not become transsexuals.

Transsexualism was not observed in males or females exposed to progestogens in utero, which might have antiandrogenic or androgenic qualities, nor was it found upon exposure to estrogenic drugs, such as diethylstilbestrol (DES). Nevertheless, some atypical aspects of gender role behavior have been observed.

In 1983, Dörner and colleagues found male-to-female transsexuals, like females, show a rise in luteinizing hormone (LH) levels after estrogen stimulation as a consequence of prenatal exposure to imbalanced sex steroid levels. The opposite occurred in female-to-male transsexuals. Other studies that used more rigorous endocrine methodology were unable to replicate this study's findings.

Several hypothalamic nuclei in humans have been reported to be sexually dimorphic with respect to size and/or shape: a sexually dimorphic nucleus (SDN) of the preoptic area of the hypothalamus (SDN-POA61), 2 cell groups in the anterior hypothalamus (isonicotinic acid hydrazide [INAH]-262-64 and INAH-362), the darkly staining posteromedial component of the bed nucleus of the stria terminalis (BNST-dspm), and the suprachiasmatic nucleus (SCN) and the central subdivision of bed nucleus of the stria terminalis (BSTc). These sex differences in the hypothalamus are believed to underlie sex differences in gender identity, reproduction, and sexual orientation. Clearly, more solid well-designed research into the biology of these disorders is needed.

Paraphilias

Multiprofessional assessment may be helpful, particularly when paraphilias result in criminal behavior. Assessment should include psychiatric history, psychosexual history, full standardized neuropsychological testing, behavioral analysis, physiological measurements, and risk assessment (for future offenses). Assess medical health (including brain), attitude toward offense, attitude toward victim, social stressors, substance abuse, and treatment recommendations.

Gender identity disorder (transsexualism)

Transsexualism is not a homogeneous phenomenon. Diagnosis is complicated because the results of psychological testing are not conclusive. Some individuals distort information to gain access to SRS. Diagnosis, therefore, needs to be extensive and, subsequently, is a time-consuming process.


Standards of care of the International Harry Benjamin Gender Dysphoria Association outline a 2-phase diagnostic process for patients seeking SRS treatment:

  • Phase I: A formal diagnosis is made using DSM or International Classification of Diseases (ICD) criteria. Risk factors are estimated to ensure the individual can tolerate the life changes that SRS will bring.
  • Phase II: The ability to live in the desired sex role is tested because the individual must live permanently in the desired sex role. The family is informed, and the patient's name is changed. Assessment of whether to administer hormone therapy is made. Psychotherapy is required.

Diagnostic procedures for adolescents seeking SRS include all of the above as well as the following:

  • The patient must show lifelong cross-gender identity that increased at puberty.
  • Serious psychopathology must be absent.
  • The person must be able to function socially without significant problems.

Preliminary follow-up observations include the following:

  • Heterosexual transsexuals appear to have poorer outcomes than homosexual transsexuals.
  • Gender-confused individuals (patients who do not meet the full criteria for transsexualism), transvestites, effeminate homosexuals, older individuals, and those resisting transsexualism generally have poorer post-SRS functioning.
  • Patients who have undergone female-to-male SRS tend to do better than male-to-female SRS individuals.

Treatment of Sexually Deviant Behavior

Paraphilias

A wide variety of people manifest various paraphilias. The level of severity, distress, and impairment (up to and including criminal behavior) resulting from these disorders also are highly variable. Consequently, treatment options vary and must take into account the specific needs of each individual case.
Treatment options may include psychotherapy, individual psychotherapy, group therapy, marital therapy, and family therapy. Cognitive behavioral therapy may be used with a 7-step approach, as follows:

  1. Aversive conditioning with ammonia or (masturbatory) satiation
  2. Confrontation of cognitive distortions (especially effective in groups)
  3. Victim empathy (show videos of victims and consequences to victims)
  4. Assertiveness training (social skills training, time management, structure)
  5. Relapse prevention (identifying antecedents to the behavior [high-risk situations] and how to disrupt antecedents)
  6. Surveillance systems (family associates who help monitor patient behavior)
  7. Lifelong maintenance

Pharmacotherapy may also be used.

  • Antiandrogens (to lower sex drive)
  • Medroxyprogesterone acetate (Provera) - 10 mg bid, double dose every 3 days up to 200 mg/d; maintain for 1 mo and adjust prn
  • Leuprolide acetate (Lupron) - IM

Selective serotonin reuptake inhibitors (SSRIs) may be prescribed to treat associated compulsive sexual disorders and/or to gain benefit from libido-lowering sexual side effects. Higher doses than are typically administered for depression are usually used.

  • Sertraline (Zoloft) - 150-200 mg/d
  • Fluoxetine (Prozac) - 20-80 mg/d
  • Fluvoxamine (Luvox) - 200-300 mg/d
  • Citalopram (Celexa) - 20-80 mg/d
  • Paroxetine (Paxil) - 20-60 mg/d

Gender identity disorder (transsexualism)

Psychological intervention may be beneficial. Individual treatment focuses on understanding and dealing with gender issues. Group, marital, and family therapy can provide a helpful and supportive environment.
Hormone therapy may also be necessary. In male-to-female individuals, original sex characteristics can be suppressed by luteinizing hormone–releasing hormone (LHRH) agonists, progestational compounds (eg, medroxyprogesterone acetate), spironolactone, flutamide, and cyproteronacetate. In male-to-female individuals, breasts, increased body fat, and a more feminine body shape can be promoted by ethinyl estradiol (0.1-0.5 mg/d) and conjugated estrogen (7.5-10 mg/d). In female-to-male individuals, facial and body hair promotion may be achieved with testosterone cypionate (200 mg IM every 2 wk).

Speech therapy may help male-to-female individuals use their voice in a more feminine manner.

Pharmacotherapy may be necessary for patients with comorbid psychiatric diagnoses. Approximately 50-70% of individuals with gender identity disorder manifest concurrent DSM-IV-TR axis II disorders, most commonly in Cluster B (eg, histrionic, borderline, antisocial, schizoid). They may also experience symptoms of depression, anxiety, or psychosis. Medications may include antidepressants, anxiolytics, and antipsychotics.

Patient and family education

As mentioned previously, neither paraphilia nor transsexualism is a homogeneous phenomenon. Furthermore, considerable variability exists within both categories. Nevertheless, a number of issues can be constructively discussed with patients and, when appropriate, with family members. The goal should be to enhance understanding about the issues being faced and the options available to address them.

In cases of paraphilia where significant potential for negative consequences to others poses genuine concern (eg, pedophilia, sexual sadomasochism), the need for long-term therapy and monitoring must be emphasized. Partners, family, and friends should be encouraged to understand the continuing potential for harm and their responsibility to take the necessary steps to protect themselves and others who may be at risk. Warning signs and coping strategies should be discussed and formulated.

When counseling individuals with gender identity disorder, patients should be educated about the differences between true transsexualism and other gender disorder issues such as transvestic fetishism, nonconformity to stereotypical sex role behaviors, gender dysphoria, and homosexuality. Patients and their families need to be educated about the complexities of these issues, the enduring nature of these disorders, and the challenges that gender disorders typically present. Treatment options should be discussed. When SRS is being considered, point out that the procedure does not produce a trouble-free life. Additionally, work and social adjustment issues need to be discussed, and plans for how to address these concerns need to be developed. The importance of continuing family support and understanding should also be addressed. Finally, the need for long-term therapy and social support should be discussed and encouraged when appropriate.

Paraphilias

Paraphilias may occur in isolation. Partners, family, and friends may never know that the person is affected. A paraphilia may exist as a discrete anomaly in an otherwise stable personality. More commonly, paraphilias coexist with personality disorders, substance abuse, anxiety disorders, or affective disorders. Limited knowledge and explanation exists as to why some people act on deviant urges and others do not. Persons with personality disorders who exhibit problems with self-esteem, anger management concerns, difficulty delaying gratification, poor ability to empathize with others, and faulty cognitions are particularly vulnerable. Predicting treatment outcomes is difficult. Long-term treatment gains appear to require approaches that address the underlying dynamics that go beyond the simple paraphilia itself. Treatment and prognosis need to be based on individual assessment.

Specific paraphilias

Exhibitionism: When sociopaths are excluded, group therapy with adults has been effective in improving social skills and providing support against additional offenses. Group therapy has been effective with shy inhibited adolescents, but not compulsive instinct-ridden adolescents. Individual psychotherapy has been helpful with many exhibitionists. Unfortunately, exhibitionism has one of the highest recidivist rates of all sexual offenses.

Fetishism: While it often begins in adolescence, fetishism usually persists. Treatment of the specific fetish rather than the primary underlying dynamic has not been very promising. Behavioral techniques show some promise, particularly when aided by adequate follow-up.

Pedophilia: Many abusers have had sexual fantasies about children for a long time. Consequently, this can be very difficult to change. The physician can attempt to reduce the intensity of pedophiliac fantasies and develop coping strategies for the abuser. The abuser must be willing to recognize that a problem exists and be willing to participate in treatment. This is not always the case. Dynamic psychotherapy, behavioral techniques, chemical approaches, and surgical interventions yield mixed results. Lifelong maintenance may be a pragmatic and realistic approach.

Sexual sadomasochism: Unfortunately, a person with sexual sadomasochism rarely presents for treatment until someone becomes an unwilling partner or is injured. The seriousness and intensity of these behaviors often increase over time. Prognosis varies depending on the depth of the underlying dynamics (especially poor when sociopathy is involved) and the motivation of the patient.

Sadomasochism and Freud

Sadomasochism is a normal part of psychosexual development when children put together gender difference and are on their way toward puberty. The anal phase of development is tied up with potty training and later issues of retention and rejection. In learning to excrete only when and where doing so is socially acceptable, a young child is faced with the immense responsibility of learning to control his or her anal sphincter. In doing so, the child works hard to retain exretia when he or she is supposed to, and to push it out or away also at the appropriate time. The child and parents are proud of all accomplishments and depressed by all failures in the process, and the child comes to place immense important on this rejection and retention. So much so, that the child's delight with successfully holding on and letting go manifests in the child's entire life, rather than only in regards to potty training. Emotionally speaking, the child will cling to a person or a toy, then push them away, then cling to them again, and repeat the process. All children go through this phase, but in most put it behind them and move on to the last phase of sexual development. An adult sadomasochist remains in this phase, and plays games with self and lovers in which identity is confused, and retention and rejection are enacted either emotionally or physically on the self or the sexual partner. According to Freud, the physical acts of violence are not what give the sadomasochist pleasure,it is the emotional content underlying the enactment that gives the sexual pleasure.

Sadism: In certain extreme cases, sadism and masochism can include fantasies, sexual urges or behaviour that cause significant distress or impairment in social, occupational, or other important areas of functioning, to the point that they can be considered part of a mental disorder. However, this is an uncommon case, and psychiatrists are now moving towards regarding sadism and masochism as not being regarded as disorders in themselves, but only as disordered when associated with other problems such as a personality disorder.

Masochism is a sexual disorder in which sexual arousal is derived from physical and emotional degradation. Masochism is explained in psychoanalysis as a destructive attitude in which the individual turns inward upon himself instead of outward upon others. It is coupled with sadism, in which sexual pleasure is derived from the infliction of pain or humiliation.

Gender identity disorder (transsexualism)

Existing case reports do not indicate that psychotherapy produces complete and long-term reversal of cross-gender identity. Transsexuals are not a homogeneous group. Some transsexuals do not show severe psychopathology. SRS may be a viable treatment solution for some. Satisfactory results are reported in 87% of male-to-female and 97% of female-to-male SRS patients.

Factors associated with relatively poor SRS postoperative functioning include transvestitism, effeminate homosexuality, SRS performed late in life, bad surgical results, suicidal intentions, inadequate social functioning, loss of work and family, noncooperative attitude toward clinicians, and enduring resistance towards being transsexual.

Outcome studies suggest that transsexuals without severe psychopathology are better off when treated promptly after diagnosis. Transsexuals with severe psychopathology, who are not homosexual, or those who have a late-onset gender identity disorder should not necessarily be excluded from SRS; however, they require more care and extensive evaluation and therapeutic support before SRS is deemed viable.

Paraphilias

Historically, 2 forms of physical treatment have been used. Both pose ethical questions.

Psychosurgery using stereotaxic tractotomy and limbic leucotomy may be performed. This is an invasive irreversible procedure that was used on a small number of subjects, primarily in Germany. Some success is reported in treatment of pedophilia, hypersexuality, and exhibitionism. Given the emotional, physical, and intellectual adverse effects, as well as available pharmacologic interventions, this procedure is not likely to be widely used. Bilateral orchidectomy (castration) has been used since the 19th century in Europe and America, although not in Western Europe since the 1970s. Pharmacologic interventions provide a reversible alternative, given negative adverse effects of the procedure (eg, weight disturbance, gynecomastia, hot flashes, osteoporosis and bone pain in elderly patients, depression).

Pharmacologic interventions used to suppress sexual behavior have included the major tranquilizers, estrogens, progestogens, LH-releasing analogue, antiandrogens, and SSRIs.

These treatments may offer genuine help to a variety of paraphiliac disorders; however, numerous adverse effects have been reported. Additionally, ethical, medical, and legal questions have been raised regarding issues of informed consent, including patients in hospital and prison settings.

Gender identity disorder (transsexualism)

Negative attitudes toward SRS appear to be changing among professionals, and scientific interest is increasing. Nevertheless, SRS does not promote a trouble-free life. Psychotherapy post-SRS may substantially improve overall outcome.

Controversy exists over whether adolescents should be allowed to pursue SRS. Many countries deny SRS to adolescents; however, early treatment may be beneficial in adolescents whose secondary sex characteristics have not yet fully developed (eg, facial hair, lowered voice, breast development). Parental involvement and approval is essential.

Teenage Pregnancy

Teenage parenthood is by no means a new social phenomenon. Historically, women have tended to begin childbearing during their teens and early twenties. During the past two decades the U. S. teenage birthrate has actually declined (Polit and others, 1982). In the late 1950s, 90 out of 1000 women under 20 gave birth as compared with 52 out of 1000 in 1978. Several factors contribute to the current attention focused on teenage pregnancy and parenthood.

1. There is currently a large number of young women in the 13 to 19 age range, so that while the birthrates are declining, the absolute number of teenagers is increasing.

2. These statistics do not distinguish between intentional and unintentional pregnancies, or pregnancies occurring in or out of wedlock. From the 1978 figures, only one in six pregnancies concluded as births following marriage, and eight in ten premarital teenage pregnancies were unintended.

3. The declining birthrate is not consistent for all teenagers: among those 14 or younger, the birthrate is increasing.

4. These trends are occurring at a time when contraceptives are increasingly available to teenagers as a means of avoiding unwanted pregnancy.

5. The evidence documenting the unfavorable consequences of unintended teenage pregnancy and teenage parenthood, whether intended or not, has continued to mount.

6. There is an unmistakable and dramatic trend away from teenagers giving their children up for adoption.

TEENAGE PREGNANCY RATE

Of the 29 million young people between the ages of 13 and 19, approximately 12 million have had sexual intercourse. Of this group, in 1981, more than 1.1 million became pregnant; three- quarters of these pregnancies were unintended, and 434,000 ended in abortion (WHAT GOVERNMENT CAN DO, 1984). The number of pregnancies increased among teenagers in all age groups during the 1970s, but among those who were sexually active the pregnancy rate has been declining. Because of increased and more consistent use of contraceptives by teenagers, the rate of pregnancy among them has been increasing more slowly than their rate of sexual activity. Although the number of teenagers who are sexually active increased by two-thirds over the 1970s, over half of U.S. teenagers are sexually inactive (TEENAGE PREGNANCY, 1981).

TEENAGE BIRTHRATE

About five percent of U. S. teenagers give birth each year. A recent study by the Alan Guttmacher Institute showed teen birthrates here to be twice as high as Canada, England, and Wales, three times as high as Sweden, and seven times higher than the Netherlands.

OUT OF WEDLOCK BIRTHS. Although slowed because of the availability of legal abortion, the rise in the out-of-wedlock birthrate has continued among almost all groups of teenagers. The rise has been steepest among 15- to 17-year-old whites. The number of premaritally conceived births legitimated by marriage has been ADOPTION AND CARE BY OTHERS. Almost all unwed teenage mothers keep their children in the household with them. Ninety-six percent of unmarried teenage mothers--90 percent of white and virtually all of black mothers--keep their children with them (although in many cases, grandparents or other relatives help take care of the baby).

REPEATED UNINTENTIONAL PREGNANCIES

As might be expected, 78 percent of births to teenages are first births. However, 19 percent are second births, and four percent are third or higher order births. The sooner a teenager gives birth after initiation of intercourse, the more likely she is to have subsequent births while still in her teens.

TEENAGE CONTRACEPTION

REASONS FOR NONUSE. Nearly two-thirds of unwed teenage women report that they never practice contraception or that they use a method inconsistently. According to the Guttmacher Institute (TEENAGE PREGNANCY, 1981), only nine percent of unmarried teenagers surveyed said that they did not use a method of contraception because they were trying to become pregnant or were already intentionally pregnant. Forty-one percent thought they could not become pregnant, mainly because they believed, usually mistakenly, that it was the wrong time of the month.

Of those who had realized they could get pregnant, the major reason given for not using a method was that they had not expected to have intercourse. Of the 15 percent who did not practice contraception because they were pregnant, the overwhelming majority were pregnant unintentionally. About eight percent said that they had wanted to use a method but "couldn't under the circumstances," or that they did not know about contraception or where to get it.

RELATIONSHIP TO PREGNANCY. The relationship between pregnancy and contraceptive use is dramatic: about 62 percent of sexually active teenagers who have never used a method have experienced a premarital pregnancy, compared to 30 percent of those who have used a method inconsistently, 14 percent of those who have always used some method (including withdrawal), and just seven percent of those who have always used a medically prescribed method (the pill, IUD, or diaphragm).

THE HEALTH BELIEF MODEL. Current research has examined the Health Belief Model (Zellman, 1984), a value-expectancy approach to explaining and predicting health behaviors that goes beyond straight information giving. This approach can be used to intervene in contraceptive use among teenagers. Because contraceptive action involves a preventive health decision followed by correct and consistent use, the model may have useful applications to both the prevention and compliance aspects of contraceptive behavior.

SEX EDUCATION

The subject of sex education remains a divisive one. On one side are those who argue that Americans should learn to accept adolescent sexuality and make guidance and birth control more easily available, as it is in parts of Europe. On the other side are those who contend that sex education is up to the parents, not the state, and that teaching children about birth control is tantamount to condoning promiscuity, or violating family religious beliefs and values.

SEX EDUCATION IN THE SCHOOLS. "Eight out of 10 Americans believe that sex education should be taught in schools, and seven out of 10 believe that such courses should include information about contraception" (TEENAGE PREGNANCY, 1981, p. 38). Only a handful of states require or even encourage sex education, and fewer still encourage teaching about birth control or abortion. Most states leave the question of sex education up to the local school boards. Only a minority, however, provide such instruction.

PARENTS AND SEX EDUCATION. Parents are a child's earliest models of sexuality; they communicate with their children about sex and sexual values nonverbally. However, most adolescents report that they have never been given any advice about sex by either parent, even though a majority of teenagers prefer their parents and counselors as sources of sex information.

Studies indicate that both parents and their children believe that they should be talking about sexuality, but that parents are extremely uncomfortable doing so (SEXUALITY EDUCATION, 1984). Organizations, including churches, schools, Planned Parenthood affiliates, and other agencies serving young people, offer programs designed to help parents teach their children about sexuality. Most would agree that sex education should start early, before a child's sexuality becomes an issue.

FAMILY PLANNING SERVICES

Most teenagers and adults approve of making contraceptives available to teenagers, and most parents favor family planning clinics providing birth control services to their children (TEENAGE PREGNANCY, 1981). The clinics have had the expected result of improving the quality and consistency of contraceptive use among teenagers. They have also been credited with preventing an estimated 689,000 unintended births, and probably a higher number of abortions, among teenagers.

However, most teenagers are sexually active for many months before ever seeking birth control help from a family planning clinic or physician (TEENAGE PREGNANCY, 1981). Very few come to a clinic in anticipation of initiating sexual intercourse, and many come because they fear--often correctly--that they are pregnant. The major reason teenagers give for the delay is concern that their parents will find out about the visit. Nevertheless, more than half of teenage patients have told their parents about their clinic visit, and only about one-quarter would not come if the clinic required parental notification. But most of these would continue to be sexually active, using less effective methods or no contraceptives and many thousands would get pregnant as a result.

SOLVING THE PROBLEM

Although we have most of the knowledge and resources needed to solve the problem of teenage pregnancy, we have failed to do so. Despite the growing public concern and the plethora of reports, there has been little action. The elements of a comprehensive national program have been put forward, with varying emphases, by a number of groups. Elements of such programs include (TEENAGE PREGNANCY, 1981):

- Realistic sex education. - An expanded network of preventive family planning services. - Pregnancy counseling services. - Adequate prenatal, obstetric and pediatric care for teenage mothers and their children. - Educational, employment and social services for adolescent parents. - Coverage by national health insurance of all health services related to teenage pregnancy and childbearing.

No one program can possibly solve the many problems that are associated with teenage pregnancy. The solution must come from many elements of society: parents, the churches, the schools, state and local legislatures and government agencies. Most people agree about the importance of reproductive health services and research for teenagers, but there is not yet the willingness to pay the costs for such programs in most communities of the nation.

Sexual Abuse

The act is considered abusive when one party (the offender) has a more sophisticated understanding of the significance and implications of the sexual encounter. Knowledge differential implies that the offender is either older, more developmentally advanced, or more intelligent than the victim. Generally, clinicians expect the offender to be at least 5 years older than the victim for the act to be deemed predatory. When the victim is an adolescent, some persons define the encounter as abusive only if the offender is at least 10 years older.  Thus, a consensual sexual relationship between a 15-year-old and a 22-year-old would not be regarded as abusive, if other case factors supported that conclusion.

- Generally, the younger the child, the less able she/he is to appreciate the meaning and potential consequences of a sexual relationship, especially one with an adult. Usually, the maximum age for the person to be considered a victim (as opposed to a participant) is 16 or 18, but some researchers have used an age cutoff of 13 for boy victims.  Apparently, the researchers felt that boys at age 13, perhaps unlike girls, were able to resist encounters with significantly older people and were, by then, involved in consensual sexual acts with significantly older people. However, clinicians report situations in which boys victimized after age 13 experience significant trauma from these sexual contacts.

- Situations in which retarded or emotionally disturbed persons participate in or are persuaded into sexual activity may well be exploitive, even though the victim is the same age or even older than the perpetrator.

Gratification differential  Finally, in most but not all sexual victimization, the offender is attempting to sexually gratify him/herself. The goal of the encounter is not mutual sexual gratification, although perpetrators may attempt to arouse their victims because such a situation is arousing to them. Alternatively, they may delude themselves into believing that their goal is to sexually satisfy their victims. Nevertheless, the primary purpose of the sexual activity is to obtain gratification for the perpetrator.

- In this regard, some activities that involve children in which there is not a 5-year age differential may nevertheless be abusive. For example, an 11-year-old girl is instructed to fellate her 13-year-old brother. (This activity might also be abusive because there was a power differential between the two children based on his superior size.)

Sexual Acts

The sexual acts that will be described in this section are abusive clinically when the factors discussed in the previous section are present as the examples illustrate. The sexual acts will be listed in order of severity and intrusiveness, the least severe and intrusive being discussed first.

Noncontact acts

Offender making sexual comments to the child

- Example: A coach told a team member he had a fine body, and they should find a time to explore one another's bodies. He told the boy he has done this with other team members, and they had enjoyed it.

Offender exposing intimate parts to the child, sometimes accompanied by masturbation.

- Example: A grandfather required that his 6-year-old granddaughter kneel in front of him and watch while he masturbated naked.

Voyeurism (peeping).

- Example: A stepfather made a hole in the bathroom wall. He watched his stepdaughter when she was toileting (and instructed her to watch him).

Offender showing child pornographic materials, such as pictures, books, or movies.

- Example: Mother and father had their 6- and 8-year-old daughters accompany them to viewings of adult pornographic movies at a neighbor's house.

Offender induces child to undress and/or masturbate self.

- Example: Neighbor paid a 13-year-old emotionally disturbed girl $5 to undress and parade naked in front of him.

Sexual contact

Offender touching the child's intimate parts (genitals, buttocks, breasts).

- Example: A father put his hand in his 4-year-old daughter's panties and fondled her vagina while the two of them watched "Sesame Street."

Offender inducing the child to touch his/her intimate parts.

- Example: A mother encouraged her 10-year-old son to fondle her breasts while they were in bed together.

Frottage (rubbing genitals against the victim's body or clothing).

- Example: A father, lying in bed, had his clothed daughter sit on him and play "ride the horse."

Digital or object penetration

Offender placing finger(s) in child's vagina or anus.

- Example: A father used digital penetration with his daughter to "teach" her about sex.

Offender inducing child to place finger(s) in offender's vagina or anus.

- Example: An adolescent boy required a 10-year-old boy to put Vaseline on his finger and insert it into the adolescent's anus as initiation into a club.

Offender placing instrument in child's vagina or anus.

- Example: A psychotic mother placed a candle in her daughter's vagina.

Offender inducing child to place instrument in offender's vagina or anus.

- Example: A babysitter had a 6-year-old boy penetrate her vaginally with a mop handle.

Oral sex****

Tongue kissing

- Example: Several children who had attended the same day care center attempted to French kiss with their parents. They said that Miss Sally taught them to do this.

Breast sucking, kissing, licking, biting.

- Example: A mother required her 6-year-old daughter to suck her breasts (in the course of mutual genital fondling).**

Cunnilingus (licking, kissing, sucking, biting the vagina or placing the tongue in the vaginal opening).

- Example: A father's girlfriend who was high on cocaine made the father's son lick her vagina as she sat on the toilet.

Fellatio (licking, kissing, sucking, biting the penis).

- Example: An adolescent, who had been reading pornography, told his 7-year-old cousin to close her eyes and open her mouth. She did and he put his penis in her mouth.

Anilingus (licking, kissing the anal opening).

- Example: A mother overheard her son and a friend referring to their camp counselor as a "butt lick." The boys affirmed that the counselor had licked the anuses of two of their friends (and engaged in other sexual acts with them).** An investigation substantiated this account.

Penile penetration

Vaginal intercourse

Example: A 7-year-old girl was placed in foster care by her father because she was incorrigible. She was observed numerous times "humping" her stuffed animals. In therapy she revealed that her father "humped" her. There was medical evidence of vaginal penetration.

Anal intercourse

- Example: Upon medical exam an 8-year-old boy was found to have evidence of chronic anal penetration. He reported that his father "put his dingdong in there" and allowed two of his friends to do likewise.

Intercourse with animals.

Dyadic sexual abuse. The most common circumstance of sexual abuse is a dyadic relationship, that is, a situation involving one victim and one offender. Because dyadic sex is the prevalent mode for all kinds of sexual encounters, not merely abusive ones, it is not surprising that it is the most common.

Group sex. Circumstances involving group sex are found as well. These may comprise several victims and a single perpetrator, several perpetrators and a single victim, or multiple victims and multiple offenders. Such configurations may be intrafamilial (e.g., in cases of polyincest) or extrafamilial. Examples of extrafamilial group victimization include some instances of sexual abuse in day care, in recreational programs, and in institutional care.

Sex rings. Children are also abused in sex rings; often this is group sex. Sex rings generally are organized by pedophiles (persons whose primary sexual orientation is to children), so that they will have ready access to children for sexual purposes and, in some instances, for profit. Victims are bribed or seduced by the pedophile into becoming part of the ring, although he may also employ existing members of the ring as recruiters. Rings vary in their sophistication from situations involving a single offender, whose only motivation is sexual gratification, to very complex rings involving multiple offenders as well as children, child pornography, and prostitution.

Sexual exploitation of children. The use of children in pornography and for prostitution is yet another circumstance in which children may be sexually abused.

Child pornography. This is a Federal crime, and all States have laws against child pornography. Pornography may be produced by family members, acquaintances of the children, or professionals. It may be for personal use, trading, or sale on either a small or large scale. It can also be used to instruct or entice new victims or to blackmail those in the pictures. Production may be national or international, as well as local, and the sale of pornography is potentially very lucrative. Because of the availability of video equipment and Polaroid cameras, pornography is quite easy to produce and difficult to track.

- Child pornography can involve only one child, sometimes in lewd and lascivious poses or engaging in masturbatory behavior; of children together engaging in sexual activity; or of children and adults in sexual activity.

- It is important to remember that pictures that are not pornographic and are not illegally obscene can be very arousing to a pedophile. For example, an apparently innocent picture of a naked child in the bathtub or even a clothed child in a pose can be used by a pedophile for arousal.

Child prostitution. This may be undertaken by parents, other relatives, acquaintances of the child, or persons who make their living pandering children. Older children, often runaways and/or children who have been previously sexually abused, may prostitute themselves independently.

- Situations in which young children are prostituted are usually intrafamilial, although there are reports of child prostitution constituting one aspect of sexual abuse in some day care situations.22 Adolescent prostitution is more likely to occur in a sex ring (as mentioned above), at the hand of a pimp, in a brothel, or with the child operating independently. Boys are more likely to be independent operators, and girls are more likely to be in involved in situations in which others control their contact with clients.

Ritual abuse. This is a circumstance of child sexual abuse that has only recently been identified, is only partially understood, and is quite controversial. The controversy arises out of problems in proving such cases and the difficulty some professionals have in believing in the existence of ritual abuse.

- As best can be determined, ritual sexual abuse is abuse that occurs in the context of a belief system that, among other tenets, involves sex with children. These belief systems are probably quite variable. Some may be highly articulated, others "half-baked." Some ritual abuse appears to involve a version of satanism that supports sex with children. However, it is often difficult to discern how much of a role ideology plays. That is, the offenders may engage in "ritual" acts because they are sadistic, because they are sexually aroused by them, or because they want to prevent disclosure, not because the acts are supported by an ideology. Because very few of these offenders confess, their motivation is virtually unknown.

- Often sexual abuse plays a secondary role in the victimization in ritual abuse, physical and psychological abuse dominating. The following is a nonexhaustive list of characteristics that may be present in cases of ritual abuse:

costumes and robes: animal, witch's, devil's costumes; ecclesiastical robes (black, red, purple, white);

ceremonies: black masses, burials, weddings, sacrifices;

symbols: 666, inverted crosses, pentagrams, and inverted pentagrams;

artifacts: crosses, athames (daggers), skulls, candles, black draping, representations of Satan;

bodily excretions and fluids: blood, urine, feces, semen;

drugs, medicines, injections, potions;

fire;

chants and songs;

religious sites: churches, graveyards, graves, altars, coffins; and

torture, tying, confinement, murder.

Most allegations of ritual abuse come from young children, reporting this type of abuse in day care, and from adults, who are often psychiatrically very disturbed and describe ritual abuse during their childhoods. Issues of credibility are raised with both groups. Moreover, accounts of ritual abuse are most disturbing, to both those recounting the abuse and those hearing it.

Scope of the Problem of Child Sexual Abuse

Clinicians and researchers working in sexual abuse believe that the problem is underreported. This belief is based on assumptions about sexual taboos and on research on adults sexually abused as children, the overwhelming majority of whom state that they did not report their victimization at the time of its occurrence.  Moreover, it is probably true that situations involving female offenders as well as ones with boy victims are underidentified, in part because of societal perceptions about the gender of offenders and victims.

Estimates of the extent of sexual abuse come from three main sources – research on adults, who recount their experiences of sexual victimization as children; annual summaries of the accumulated reports of sexual abuse filed with child protection agencies; and two federally funded studies of child maltreatment entitled the National Incidence Studies. In addition, anecdotal information is supplied by some convicted/self-acknowledged offenders, who report sexually abusing scores and even hundreds of children before their arrest.

Prevalence of Child Sexual Abuse

Studies of the prevalence of sexual abuse are those involving adults that explore the extent to which persons experience sexual victimization during their childhoods. Findings are somewhat inconsistent for several reasons. First, data are gathered using a variety of methodologies: telephone interviews, face-to-face interviews, and written communications (i.e., questionnaires). Second, a study may focus entirely on sexual abuse, or sexual abuse may be one of many issues covered. Third, some studies are of special populations, such as psychiatric patients, incarcerated sex offenders, and college students, whereas others are surveys of the general population. Finally, the definition of sexual abuse varies from study to study. Dimensions on which definitions may differ are maximum age for a victim, the age difference required between victim and offender, whether or not noncontact acts are included, and whether the act is unwanted.

The factors just mentioned have the following effects on rates of sexual abuse reported. Face-to-face interviews, particularly when the interviewer and interviewee are matched on sex and race, and multiple questions about sexual abuse may result in higher rates of disclosure.  However, it cannot be definitively stated that special populations such as prostitutes, drug addicts, or psychiatric populations have higher rates of sexual victimization than the general population, because some studies of the general population report quite high rates.   Not surprisingly, when the definition is broader (e.g., inclusion of noncontact behaviors and "wanted" sexual acts) the rates go up.

Rates of victimization for females range from 6 to 62 percent,29 with most professionals estimating that between one in three and one in four women are sexually abused in some way during their childhoods. The rates for men are somewhat lower, ranging from 3 to 24 percent, 30 with most professionals believing that 1 in 10 men and perhaps as many as 1 in 6 are sexually abused as children. As noted earlier, many believe that male victimization is more underreported than female, in part because of societal failure to identify the behavior as abusive. However, the boy himself may not define the behavior as sexual victimization but as sexual experience, especially if it involves a woman offender. Moreover, he may be less likely to disclose than a female victim, because he has been socialized not to talk about his problems. This reticence may be increased if the offender is a male, for he must overcome two taboos, having been the object of a sexual encounter with an adult and a male. Finally, he may not be as readily believed as a female victim.

The Incidence of Child Sexual Abuse

Incidence of a problem is defined as the number of reports during a given time frame, yearly in the case of sexual abuse. From 1976 to 1986, data were available on the number of sexual abuse cases reported per year to child protection agencies, as part of data collection on all types of maltreatment. These cases were registered with the National Center on Child Abuse and Neglect, and data were analyzed by the American Humane Association. Over that 10-year period, there was a dramatic increase in the number of reports of sexual abuse and in the proportion of all maltreatment cases represented by sexual abuse. In 1976, the number of sexual abuse cases was 6,000, which represented a rate of 0.86 per 10,000 children in the United States. By 1986, the number of reported cases was 132,000, a rate of 20.89 per 10,000 children. This represents a 22-fold increase. Moreover, whereas in 1976 sexual abuse cases were only 3 percent of all reports, by 1986, they comprised 15 percent of reports.

Striking though these findings may be, their limitations must be appreciated. First, current data are not available. Second, cases included in this data set are limited to those that would warrant a CPS referral, generally cases in which the abuser is a caretaker or in which a caretaker fails to protect a child from sexual abuse. Thus, cases involving an extrafamilial abuser and a protective parent are not included. Third, the data only refer to reported cases. This means those cases that are unknown to professionals and those known but not reported are not included. Moreover, these are reports, not substantiations of sexual abuse. The national average substantiation rate is generally between 40 and 50 percent. Substantiation rates vary from State to State and among locations.

The Effects of Sexual Abuse on its Victim

Concern about sexual abuse derives from more than merely the fact that it violates taboos and statutes. It comes principally from an appreciation of its effects on victims. In this section, the philosophical issue of why society is concerned about sexual abuse and documented effects will be discussed.

The Impact of Sexual Abuse

Regardless of the underlying causes of the impact of sexual abuse, the problems are very real for victims and their families. A number of attempts have been made to conceptualize the effects of sexual abuse.  In addition, recent efforts to understand the impact of sexual abuse have gone beyond clinical impressions and case studies. They are based upon research findings, specifically controlled research in which sexually abused children are compared to a normal or nonsexually abused clinical population. There are close to 40 such studies to date.

Finkelhor, whose conceptualization of the traumatogenic effects of sexual abuse is the most widely employed, divides sequelae into four general categories, each having varied psychological and behavioral effects.

Traumatic sexualization. Included in the psychological outcomes of traumatic sexualization are aversive feelings about sex, overvaluing sex, and sexual identity problems. Behavioral manifestations of traumatic sexualization constitute a range of hypersexual behaviors as well as avoidance of or negative sexual encounters.

Stigmatization. Common psychological manifestations of stigmatization are what Sgroi calls "damaged goods syndrome" and feelings of guilt and responsibility for the abuse or the consequences of disclosure. These feelings are likely to be reflected in self-destructive behaviors such as substance abuse, risk-taking acts, self-mutilation, suicidal gestures and acts, and provocative behavior designed to elicit punishment.

Betrayal. Perhaps the most fundamental damage from sexual abuse is its undermining of trust in those people who are supposed to be protectors and nurturers. Other psychological impacts of betrayal include anger and borderline functioning. Behavior that reflects this trauma includes avoidance of investment in others, manipulating others, re-enacting the trauma through subsequent involvement in exploitive and damaging relationships, and engaging in angry and acting-out behaviors.

Powerlessness. The psychological impact of the trauma of powerlessness includes both a perception of vulnerability and victimization and a desire to control or prevail, often by identification with the aggressor. As with the trauma of betrayal, behavioral manifestations may involve aggression and exploitation of others. On the other hand, the vulnerability effect of powerlessness may be avoidant responses, such as dissociation and running away; behavioral manifestations of anxiety, including phobias, sleep problems, elimination problems, and eating problems; and revictimization.

Our understanding of the impact of sexual abuse is frustrated by the wide variety of possible effects and the way research is conducted. Researchers do not necessarily choose to study the same effects, nor do they use the same methodology and instruments. Consequently, a particular symptom, such as substance abuse, may not be studied or may be examined using different techniques. Furthermore, although most studies find significant differences between sexually abused and nonabused children, the percentages of sexually abused children with a given symptom vary from study to study, and there is no symptom universally found in every victim. In addition, often lower proportions of sexually abused children exhibit a particular symptom than do nonabused clinical comparison groups. Finally, although some victims suffer pervasive and debilitating effects, others are found to be asymptomatic.

In addition, a variety of factors influence how sexual maltreatment impacts on an individual. These factors include the age of the victim (both at the time of the abuse and the time of assessment), the sex of the victim, the sex of the offender, the extent of the sexual abuse, the relationship between offender and victim, the reaction of others to knowledge of the sexual abuse, other life experiences, and the length of time between the abuse and information gathering. For example, the findings for child victims and adult survivors are somewhat different.

It is important for professionals to appreciate both the incomplete state of knowledge about the consequences of sexual abuse and the variability in effects. Such information can be helpful in recognizing the wide variance in symptoms of sexual abuse and can prevent excessive optimism or pessimism in predicting its impact.

* When children are victims, sexual comments are usually made in person. However obscene remarks may be made on the telephone or in notes and letters.

** Activities in parenthesis are not illustrative of the sexual act being defined.

*** Sexual contact can be either above or beneath clothing.

**** The offender may inflict oral sex upon the child or require the child to perform it on him/her or both.

***** These statistics from the revised second National Incidence Study reflect the revised definition of child abuse and neglect, which includes the combined total children who were demonstrably harmed and threatened with harm.

Indicators Of Child Sexual Abuse

Sexual abuse may result in physical or behavioral manifestations. It is important that professionals and the public know what these are because they signal possible sexual abuse. However, very few manifestations (e.g., gonorrhea of the throat in a young child) are conclusive of sexual abuse. Most manifestations require careful investigation or assessment.

Unfortunately, early efforts at cataloging indicators of sexual abuse were problematic. They included extremely rare findings, such as blood in a child's underpants and signs that could be indicative of many problems or no problem at all, such as "comes early to school and leaves late." Recent efforts to designate signs of sexual abuse are more helpful.

They differentiate between physical indicators and psychosocial indicators. Although physical indicators may be noted by many people, a definitive determination is generally made by a medical professional. Similarly, anyone may observe psychosocial indicators; however, often but not always, a mental health professional is responsible for forming an opinion that the symptoms are indicative of sexual abuse.

A differentiation is made between higher and lower probability indicators. That is, some indicators are diagnostic of sexual abuse, whereas others may be consistent with or suggestive of sexual abuse but could indicate other circumstances or conditions as well.

In this chapter, higher probability findings and lower probability physical indicators are discussed first. A comparable discussion of psychosocial indicators will follow. It should not be surprising that the indicators specified in this chapter are similar to the effects described in the previous chapter since indicators are to a large extent the effects of sexual abuse before disclosure. Therefore, these indicators should become a focus of treatment and not simply used to support or rule out an allegation of sexual abuse.

Medical Indicators of Child Sexual Abuse

Significant progress has been made in the medical field in the determination of sexual abuse. Medical professionals are no longer limited to the presence or absence of a hymen as the indicator of possible sexual abuse. A variety of types of genital findings have been documented. In addition, notable progress has been made in identifying anal findings. Moreover, physicians are able to describe the effects of different kinds of sexual activity, and subtle findings can be documented using magnification (a colposcope or otoscope).

However, this progress is not without its controversies. Knowledgeable and conscientious physicians may differ regarding conclusions about certain physical findings. This difference of opinion is primarily due to the fact that data collection regarding the physical signs of sexual abuse has preceded careful documentation of characteristics of genitalia and anal anatomy of children who have not been sexually abused and of variations among normal children. These legitimate differences of opinion have been augmented by challenges to the medical documentation from defense attorneys, their expert witnesses, and alleged offenders.

It is also important to appreciate that for the majority of sexually abused children there are no physical findings. These findings, particularly vaginal ones, are most useful with prepubertal victims. As children become older, the possibility of consensual sexual activity needs to be considered. Further, changes that occur with puberty render insignificant some symptoms that have great significance in young children.

Two High-Probability Physical Indicators

Despite the progress noted above, the highest probability indicators are ones identified over 10 years ago. They are:

pregnancy in a child and

venereal disease in a child.

The reason these findings are high probability is because there is little dispute over the fact that they require sexual activity.

Some professionals assume that pregnancy in a child less than age 12 signals abuse although others designate the age of 13 or 14. Of course, not all situations in which children of these ages become pregnant are abusive, and pregnancy in older adolescents can be a consequence of sexual abuse.

Venereal disease may be located in the mucosa of the vagina, penis, anus, or mouth. The upper age limits for venereal disease raising concern about sexual abuse are similar to those for pregnancy. In addition, there is a lower age limit, usually of 1 or 2 months, because infants may be born with venereal disease acquired congenitally if the mother has the disease.

Interestingly, variations are found within the medical community regarding the certainty that sexual activity causes particular venereal diseases in children. Specifically, there is consensus that syphilis and gonorrhea cannot be contracted from toilet seats or bed sheets, but some differences of opinion exist about other venereal diseases (genital herpes, condyloma acuminata or venereal warts, trichomonas vaginalitis, and urogenital chlamydia), despite the conclusion that such infections are caused by sexual contact in adults.   In a recent review of the research, Smith, Benton, Moore, and Runyan conclude that there is "strong evidence" that all of these venereal diseases are sexually transmitted, except for herpes, for which there is "probable evidence." They also review the evidence on human immunodeficiency virus (HIV) and conclude that there is strong evidence it is sexually transmitted as well, unless contracted pre- or perinatally.

Sexual Indicators

Sexual indicators vary somewhat depending on the child's age. The discussion of these indicators will be divided into those likely to be found in younger sexually abused children (aged 10 or younger) and those likely to be found in older sexually abused children (older than age 10). However, this distinction is somewhat arbitrary, and within these two groups there are children at very different developmental stages. Finally, indicators that are important for children of all ages are noted.

Sexual Indicators Found in Younger Children

These behaviors are high-probability indicators because they represent sexual knowledge not ordinarily possessed by young children.

Statements indicating precocious sexual knowledge, often made inadvertently.

- A child observes a couple kissing on television and says that "the man is going to put his finger in her wee wee."

Sexually explicit drawings (not open to interpretation).

- A child draws a picture of fellatio.

Sexual interaction with other people.

- Sexual aggression toward younger or more naive children (represents an identification with the abuser).

- Sexual activity with peers (indicates the child probably experienced a degree of pleasure from the abusive activity).

- Sexual invitations or gestures to older persons (suggests the child expects and accepts sexual activity as a way of relating to adults).

Sexual interactions involving animals or toys.

- A child makes "Barbie™* dolls" engage in oral sex.

The reason sexual knowledge is more compelling when demonstrated by younger children than older ones is that the latter may acquire sexual knowledge from other sources, for example, from classes on sex education or from discussions with peers or older children. Even younger children may obtain knowledge from sources other than abuse. However, children are not likely to learn the intimate details of sexual activity nor for example, what semen tastes like and penetration feels like without direct experience.

Another indicator often cited is excessive masturbation. A limitation of this as an index of sexual abuse is that most children (and adults) masturbate at some time. Thus, it is developmentally normal behavior, which is only considered indicative of sexual abuse when "excessive." However, a determination that the masturbation is excessive may be highly subjective. The following guidelines may be helpful.

Masturbation is indicative of possible sexual abuse if:

- Child masturbates to the point of injury.

- Child masturbates numerous times a day.

- Child cannot stop masturbating.

- Child inserts objects into vagina or anus.

- Child makes groaning or moaning sounds while masturbating.

- Child engages in thrusting motions while masturbating.

Sexual Indicators Found in Older Children

As children mature, they become aware of societal responses to their sexual activity, and therefore overt sexual interactions of the type cited above are less common. Moreover, some level of sexual activity is considered normal for adolescents. However, there are three sexual indicators that may signal sexual abuse.

sexual promiscuity among girls,

being sexually victimized by peers or nonfamily members among girls, and

adolescent prostitution.

Of these three indicators, the last is most compelling. One study found that 90 percent of female adolescent prostitutes were sexually abused. Although there has not been comparable research on male adolescent prostitutes, there are clinical observations that they become involved in prostitution because of sexual abuse.

A High-Probability Sexual Indicator for All Children

Finally, when children report to anyone they are being or have been sexually abused, there is a high probability they are telling the truth. Only in rare circumstances do children have any interest in making false accusations. False allegations by children represent between 1 and 5 percent of reports.  Therefore, unless there is substantial evidence that the statement is false, it should be interpreted as a good indication that the child has, in fact, been sexually abused.

Nonsexual Behavioral Indicators of Possible Sexual Abuse

The reason that nonsexual behavioral symptoms are lower probability indicators of sexual abuse is because they can also be indicators of other types of trauma. For example, these symptoms can be a consequence of physical maltreatment, marital discord, emotional maltreatment, or familial substance abuse. Nonsexual behavioral indicators can arise because of the birth of a sibling, the death of a loved one, or parental loss of employment. Moreover, natural disasters such as floods or earthquakes can result in such symptomatic behavior.

As with sexual behaviors, it is useful to divide symptoms into those more characteristic of younger children and those found primarily in older children. However, there are also some symptoms found in both age groups.

Nonsexual Behavioral Indicators in Young Children

The following symptoms may be found in younger children:

sleep disturbances;

enuresis;

encopresis;

other regressive behavior (e.g., needing to take transitional object to school);

self-destructive or risk-taking behavior;

impulsivity, distractibility, difficulty concentrating (without a history of nonabusive etiology);

refusal to be left alone;

fear of the alleged offender;

fear of people of a specific type or gender;

firesetting (more characteristic of boy victims);

cruelty to animals (more characteristic of boy victims); and

role reversal in the family or pseudomaturity.

Nonsexual Behavioral Indicators in Older Children

eating disturbances (bulimia and anorexia);

running away;

substance abuse;

self-destructive behavior, e.g.,

- suicidal gestures, attempts, and successes and

- self-mutilation;

incorrigibility

criminal activity; and

depression and social withdrawal.

Nonsexual Behavioral Indicators in All Children

Three types of problems may be found in children of all ages:

problems relating to peers,

school difficulties, and

sudden noticeable changes in behavior.

Summary

Sexually abused children may manifest a range of symptoms, which reflect the specifics of their abuse and how they are coping with it.

Suspicion is heightened when the child presents with several indicators, particularly when there is a combination of sexual and nonsexual indicators. For example, a common configuration in female adolescent victims is promiscuity, substance abuse, and suicidal behavior. Similarly, the presence of both behavioral and physical symptoms increases concern. However, the absence of a history of such indicators does not signal the absence of sexual abuse.

An Emotional Reaction Consistent With the Abuse Being Described

Children may have a variety of emotional reactions to sexual abuse, depending on the characteristics of the child and the abuse. The following are common emotional reactions and associated child or abuse characteristics:

reluctance to disclose: characteristic of most children except possibly for very disturbed or very young children;

embarrassment: a rather mild response often found in disturbed and young children;

anger: more characteristic of boy victims (but not always evident);

anxiety: noted frequently in adolescent girls;

disgust: a typical reaction to oral sex;

depression: often present in victims who care for the abuser or feel they are responsible;

fear: typical of cases in which the child has been injured or threatened during the course of the victimization; and

sexual arousal: another response sometimes found in disturbed and young children.

Treatment Of Child Sexual Abuse

Treatment of child sexual abuse is a complex process. Orchestration of treatment in the child's best interest is a genuine challenge. Moreover, it is often difficult to know how to proceed because there are so few outcome studies of treatment effectiveness.

In this chapter, case management issues are discussed; a model for understanding why adults sexually abuse children is proposed; treatment modalities are described; and treatment issues are examined. The focus of the discussion is primarily on intrafamilial abuse.

Case Management Considerations

One of the reasons sexual abuse treatment is such a challenge is that it occurs in a larger context of intervention. Therefore, coordination is of utmost importance and ideally is provided by a multidisciplinary team. Treatment issues are then handled by the team as part of overall intervention.

The team usually consists of the various professionals directly involved in the case and their consultants and, as noted earlier, begins its activity at the time of case investigation. The composition and functioning of teams vary by locality, and the level of participation of team members often varies depending on the stage of the intervention. In an intrafamilial case, the members active at the treatment stage will ordinarily include the Child Protective Services (CPS) and/or foster care workers, the therapists treating various family members, professionals providing other services (e.g., homemaker, parenting guidance), a representative from the prosecutor's office, and relevant consultants. The frequency of meetings will depend on the needs of the case and how the team is structured.

The following issues are the most important of those the team should consider at this stage of intervention: separation of the child and/or the offender from the family, the role of the juvenile court, the role of the criminal court, the treatment plan for the family, visitation, and family reunification.

Case management decisions are often provisional; that is, they are based on what information about the family members and their functioning is available when decisions are made. Treatment is often a diagnostic process. The positive or negative responses of family members to treatment determine future case decisions. Outcomes of court proceedings can impinge upon and alter case management decisions and treatment.

The team meets periodically to assess progress and make future plans. Because of the complexity of case management decisions and the fact that a decision in one realm can have an impact on other aspects of the case, especially on treatment progress and outcome, multidisciplinary decision making is crucial. In the absence of a multidisciplinary team, such decisions should be made in consultation with other relevant professionals.

Before the implementation of the treatment plan, the following case management decisions should be addressed:

Should the child remain a part of the family?

Do the courts have a role in the case?

Is there a question of visitation?

Guidelines for making these decisions will be discussed.

Should the Child Live With the Family?

The preferred outcome in cases of sexual abuse, as in other types of child maltreatment, is that after intervention the family will be intact.

Generally at the time of disclosure of the sexual abuse, the offender is not separated from the family. The victim may be removed if the mother is unable or unwilling to protect and support the victim or if the victim wishes to be removed. Many professionals advocate the removal of the offender even in circumstances in which the victim is removed.

After these initial decisions, a longer term plan must be made about whether the child should be a part of the family and, if so, whether or not that family should include both parents. This plan will be based on an assessment of each parent.

Aspects of the functioning of both parents outlined previously in the discussion of risk assessment should be examined in deciding about the child's future living situation. These include the following factors for the offender:

the extent of the offender's sexually abusive behavior;

the degree to which the offender takes responsibility for the sexual abuse;

the number and severity of the offender's other problems, for example;

- substance abuse,

- violent behavior,

- mental illness, and

- mental retardation.

Regarding the nonoffending parent, the following factors should be assessed:

reaction to knowledge about the sexual abuse,

quality of relationship with the victim,

level of dependency on the offender, and

the number and severity of other problems.

Other possible problems are similar for the nonoffending parent and the offender.

Although these factors are universally useful to consider, in specific cases other factors may be important or even overriding.

Offenders who have engaged in a small number of sexual acts, have taken responsibility for their behavior, and have few other problems are judged to have positive findings in these key areas and are usually treatable. Negative findings in these three areas mean that the prognosis for positive treatment outcome is quite guarded. When mothers are protective of victims when they discover the sexual abuse, have good relationships with victims, are not unduly dependent on the offender, and do not have other significant problems, their treatment prognosis is positive. Again negative findings mean that the treatment prognosis is poor.

These proposed variations in parental functioning suggest four possible combinations: both parents may have positive findings, indicating a good treatment prognosis (case type 1); the nonoffending parent may have positive findings, and the offender negative ones (case type 2); the offender may have positive findings and the nonoffending parent negative ones (case type 3); and finally, both parents may have negative findings (case type 4).

Different combinations argue for different intervention plans and long-term goals.

This matrix suggests how professionals hope to be able to make decisions. However, the parents are usually more complex than the matrix suggests. Probably in the majority of cases, the parents present a mixed picture, rather than appearing to have either a very good or bad prognosis. Moreover, as already suggested, there may be gaps in information about the family when treatment planning is undertaken and parental functioning is not static. Progress or lack of progress in treatment may result in reconsideration of the initial placement and treatment plan. Because of these complexities, most sexually abusive families should and do receive a trial of treatment. This generally entails individual treatment for all parties and the appropriate use of groups. Initial case decisions are periodically evaluated based on treatment outcome and reassessed accordingly. In addition to being useful in placement and treatment planning decisions, the matrix may offer guidance in terms of court intervention. Most professionals would agree that the Juvenile Court should be involved in all four types of cases, perhaps with the exception of a small number of those falling into case type 1. These might be cases in which the offender confesses to his wife or family, the family seeks treatment, and the abuse is then reported to CPS by their therapist.

Author: US Department of Health and Human Services

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