Having major bowel surgery and ending up with a colostomy or an ileostomy can have major psychological effects on the sex life of the individual and his or her partner. As well as this there are often very real neurological problems caused by the removal of key nerves along the bowel. Impotence and sexual dysfunction are very common after the removal of lower bowel cancers but surgery for non-malignant conditions produces far fewer problems.

An American study found that men were more supportive of their wives after such surgery than the other way round, but that women are more afraid of being unacceptable to their husbands. There are now ‘ostomy’ (stoma) nurses in most large hospitals who can advise those about to undergo such surgery about the problems and how to overcome them right from the beginning. There are also ‘ostomy’ clubs in most Western countries whose members have seen and heard it all before and can be very helpful and encouraging.

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These are rare forms of sexual perversion but ones which can and do often affect otherwise happily married, family men, so they are worth looking at here. Transvestites get sexual pleasure from wearing the clothes of the opposite sex. They usually look at themselves in a mirror and are excited by the signs of sexual arousal in themselves. Masturbation is usually the result. Sometimes a woman partner will be involved, some being willing to provide female attire and make-up. Either intercourse or masturbation may then be the outcome.

Some cross-dressers do not become sexually aroused but describe a sense of peace and contentment which comes over them. These are probably not true transvestites because there is no arousal. Both, however, no doubt reflect some disturbance in the early relationships with their mothers. Around four years of age many boys go through a stage of putting on their mother’s clothes, presumably because their softness symbolically represents the mother’s skin. However, there is evidence that more mothers of transvestites would have preferred a girl than other mothers and some even treat their little boys like girls for some years.

Where a transvestite responds to only one article of clothing, such as knickers, the distinction between him and the fetishist is difficult to make. More commonly, the transvestite will put on his wife’s, or his own, female attire when she is out. His general interest in other sexual activities, including intercourse, is usually low.

How common transvestism is in women is an open question and some experts believe it does not occur at all. This is improbable and some causes of orgasm problems in women may be due to its presence. Psychotherapy can be an effective treatment for tranvestism.

Most transvestites indulge their interest only occasionally, although some need to expand their activities so that they are dressed as the opposite sex most of the time. They do not usually want to change sex: as one said, ‘I’m just a cock in a frock’, but he nevertheless had a female name for himself in the role.

Where there is a desire to change sex (the individual believing he or she is a member of the opposite sex trapped in the wrong body), the condition is known as transsexualism. As well as wearing the clothes of the opposite sex, these people want to be rid of the body they have and replace it with one which resembles that of the opposite sex. As a result they seek hormone therapy and surgery. Women want testosterone so as to grow a beard, break their voice and, perhaps, enlarge the clitoris, and surgery to have their breasts and their uterus removed. Men want oestrogen to create breasts, reduce beard growth and make their contours more rounded and surgery to remove their genitals and construct a vagina. Most seem to be more sexually inhibited than sexually expressive and their preoccupation with their sex-change is obsessional. However, they can subsequently regret and resent the change. If frustrated in their quest, however, the transsexual can become depressed and suicidal. Although transsexuals may be homosexual, the problem is not basically one of which sex they are orientated towards sexually but rather one of gender-identity. They have identified their gender incorrectly. Mothers of male transsexuals (like those of transvestites) also more commonly wanted a girl than other mothers and it is said that they feminise the boy from childhood onwards. The father does not rescue the child and is usually distant. These mothers are often said to be unfeminine and disappointed tomboys themselves.

Transsexuals say they have always known that they were of the wrong sex and need to belong to and be accepted by everyone as a member of the opposite sex. At school such boys usually relate only to girls and girls become their reference or peer group. They put on female clothing and continue to do so in spite of any rebuke or punishment. They may even say they want babies. Successful attempts have been made to rescue boys from a future of transvestism or transsexualism by therapy administered before puberty. The justification is that gender-role disturbance (an incomplete or unsatisfactory acceptance of the masculine role in boys or the feminine role in girls) or cross-gender identification (the belief that one belongs to the opposite sex) leads to so much disorganisation and unhappiness that it should be prevented if at all possible. Girl transsexuals can be treated successfully even in adolescence. In their cases it is usually the mothers who have been neglectful and the fathers who have taken care of them and encouraged masculine tendencies. The fathers perhaps wanted boys, or wanted to exclude the mothers from their relationships with the girls.

Again, as with all these perversions and deviations, often the child’s rearing has so scarred his or her development that he or she is trapped into believing and feeling the way he or she does. For the families of the individual involved things can be very difficult and professional assistance is almost always needed. Self-help groups can be a great help.

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The antibody tests are now very accurate and anyone can be tested by asking their GP; going to a Sexually Transmitted Diseases (STD) Clinic which can be found in the phone book under STD or VD clinic; or to a private test centre.

However, before a test is carried out counselling will be given. This is wise for two reasons. First, it offers the opportunity to discuss sexual behaviour and receive advice on how to cut down risks and second, it begins to prepare the individual for the fact the test may come back positive.

Although most people who are HIV-positive (those who have antibodies thereby showing they are carrying the virus) are well until AIDS starts, it is not known how many people are carrying the virus. One way to find out would be to test everyone compulsorily. The British government is against this.

Blood is taken from thousands of people every day for all manner of tests and another way would be to test such samples for the presence of HIV antibodies without telling the patients. This is known as involuntary testing but the snag is what to do if the result is positive. Do you tell the patient or the spouse? Some people commit suicide when told. It was found in New York that actual AIDS patients are 66 times more likely to commit suicide than are other people. Once told, the individual will have difficulty in obtaining life insurance honestly and may even be refused a mortgage. In one survey 14 per cent of people in the UK said that they would refuse to work with anyone who was HIV-positive so if the news leaks out the individual might lose his job. In consequence this method is not being used.

A variant of involuntary testing is to do anonymous testing on the routine blood samples mentioned above. In this form of testing the blood samples have the name of the patient removed. The idea is that this will give us some idea of how the virus is spreading in the community which would be useful in planning prevention. Many members of the medical profession are against this form of testing.

So it comes down to voluntary or, as it is called, ‘informed’ testing. Obviously anyone in the high-risk groups mentioned above, if they can face up to it, should ask for tests. The British government plans to ask pregnant women to agree to be tested, partly to find out if HIV is spreading in the heterosexual population and partly so that anyone found to be positive can be advised about the pregnancy. Women’s Health Concern say that they are being inundated with requests for tests from women who are worried because they have had many partners; because they have been with bi-sexual men; or because they are planning a pregnancy. If everyone were as sensible as these women we would be much better informed about the spread of the virus.

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All parents bringing up their children want to see them grow up to become well-balanced, mature adults, and much of what parents do for and with their children has this end in view.

When it comes to concepts of physical maturity definitions are relatively easy. A person can be said to be physically mature when he can reproduce himself or when bone growth has stopped. These two ages do not coincide in man, so even physical maturity is not a simple concept.

But if physical maturity is difficult to pin-point, emotional and psychological maturity is nearly impossible to define. All of us eventually mature physically but many people never fully mature emotionally and psychologically – they remain as children in certain respects all their lives and often this is to their disadvantage.

Two interlinked themes are involved in the concept of emotional maturity. One relates to the development of the individual as such and the other is concerned with the way he or she relates to others. So clearly, any definition or concept of maturity has implications both for the individual and for society at large.

Central to the personal aspect of maturity is the comparison between a child and an adult. A very young child is totally dependent on its parents, particularly its mother; it takes rather than gives; consumes rather than produces (except for noise and body-waste); is unreasonable and unreasoning, being governed solely by instincts; is intolerant of discomfort and frustration; is egocentric (being concerned only with its own feelings and having no concern for the welfare of those around it); and is prone to outbursts of rage and anxiety. Yet within this young child lie blueprints for physical and psychological development and under the influences of these

blueprints the child gradually progresses from childhood to adulthood.

From the biological point of view the function of an adult is to reproduce and rear children. Obviously, a child cannot fulfil these tasks. The process by which he or she becomes fitted to do so is what we call maturation. It is widely thought that children are best produced and reared by a mature man and a mature woman who love each other and have a sense of commitment to each other and to their child. For such a state of affairs to come about, the two individuals obviously have to have the necessary confidence and social skills to attract a mate in the first place; sufficient inter-personal skills to keep him or her; a sufficient degree of emotional development to love and be loved; and sufficient sexual skills to have intercourse. In order to continue the relationship in a reasonably happy and efficient way they, as a rule, need to be able to give and receive support and love and they need to be reasonably independent, so as not to overburden each other or anyone else, and yet be capable of asking for help when they are confronted with situations which are beyond their capabilities.

As far as their child is concerned, they need to be able to provide for it, protect it, accept its independence and not to have unrealistic expectations of it. They should be sufficiently close to each other not to want to make a special love-object of the child or to use it as a weapon against each other and not to take out on the child the anger they may occasionally feel towards each other. Each must accept that they have responsibility for it and that in this respect, over the years, the father’s role is no less important than the mother’s. They should be sufficiently secure to allow the child to be, within reason, itself and not to try to turn it into some form of apostle for, or replica of, themselves.

The child’s interests, which are not necessarily synonymous with the child itself, usually need to be placed first and foremost, especially when he or she is very young and, above all, the child needs to be loved not because it is good and pleases its parents, but because of itself.

However, another set of factors influences progress towards maturity. A child is exposed to his or her family and to the experiences of life. Such exposure affects personality, psychosexual, emotional and other development. The topic is vast but a few examples might help by way of illustration.

Being born largely unwanted and subsequently being less than adequately loved exposes a child to feelings of inadequacy and uselessness which undermines all other development, even physical. Children who are severely neglected emotionally, or are unloved, do not grow physically the way they should, boys being worse affected, at least physically, than girls. The situation is complicated because the child may not obviously lack for anything: in fact it may be spoiled by the parents out of guilt. As adults such people may be less than mature because they demand rather than give love. Frequently they become ‘neurotic’ about love, perpetually demanding proof of it, and watching the partner for any sign of what they regard as evidence of not being love. Most commonly they are depressive, self-critical and generally unable to love themselves adequately. They may be suicidal or promiscuous.

Where a mother or mother substitute is generally unmotherly, it is thought that schizophrenia may result in the child, as may alcoholism. A boy reared in this setting, for example, may subsequently fear all women or hate them overtly or covertly and children of either sex may later display ‘mother-hunger’ or ‘father-hunger’ in which they seem to try to revert to childhood to be loved by a woman or a man as a parent. All shades of such effects can occur and in some instances the child’s perceptions of reality are governed by rivalry with brothers and sisters more than by any defect in its mother or father. On the other hand, over-close, over-demanding,

over-indulgent, seductive, remote or rejecting parents of either sex can distort the psychological development of a child of the opposite sex.

Parents who refuse to allow their child to grow up and treat him or her perpetually as if he or she were younger than his or her years, who oppose independence and, in an effort to meet their own needs, encourage the child to cling to them, run the risk of producing an immature adult who will always want to be dependent on his or her spouse or anyone else (perhaps including those from the social services or psychiatrists). Such individuals regress to childhood as soon as they encounter any difficulty in life.

In a household in which rules are few and lax, children remain impulsive and self-indulgent and in one in which they are over-harsh, they become inhibited and anxious. Where the rules are inconsistent the children become indecisive and confused.

Attitudes are conveyed in a similar way. Thus a child may, for example, be taught to fear failure, ill health or a lack of money more than anything else. Alternatively, he or she may be trained to have excessive fears about the opinions, real or assumed, of others, or may develop an undue fear of or contempt for authority.

In a similar way a child may learn that sex is excessively private, dirty or sinful, and so on. If children develop serious inhibitions about sexual matters they may later lack sufficient drive to overcome their fears, which will impair their social and emotional as well as sexual development.

A child’s capacity to experience anxiety, which has a natural survival value for the human species, is probably over-utilised by most parents in child rearing. It is very easy to do this, especially if the parents were reared this way themselves, but it is a real disadvantage to the child, who will grow up to become anxious about almost everything.

Instead of inducing anxiety, try to give positive reasons why your child should or should not do things. If you are always threatening ill effects as the result of various activities it will be hardly surprising if the child actually believes that most behaviour produces a negative outcome and then grows up to fear or be anxious about most things.

In the same way parents can teach their children to be hostile to others, but even more commonly they fail to deal adequately with the hostility that arises in their children towards their brothers and sisters and even towards themselves. Behind this is probably the failure to deal with fear, especially the fear of the loss of love. On the other side of the coin, many parents threaten to stop loving their child if he or she does things they do not approve of. This is especially harmful behaviour. Whatever the child does, especially a young one, he or she needs to know that he or she is loved and to threaten to withdraw that love -or to do things which make the child feel it has been withdrawn – is a form of psychological torture which is harmful if frequently repeated.

These and similar concepts obviously have implications for society and inter-personal relationships within it. A lack of maturity damages the individual, the institution of marriage, parenting and society in general. Emotional immaturity is often the root cause of criminality, social inadequacy, disruptive politics and extreme religious fervour. At the same time we have to admit that emotional immaturity can sometimes be a spur to achievement which is creative rather than destructive.

In one sense we never grow up – we simply become more elaborate. The child is present in every adult as it was in childhood. A truly mature individual is still in contact with the child within him – or herself and can allow it out to play occasionally without becoming childish. Retaining the child-like capacity to experience total pleasure, to be free of all criticism of someone who is loved, to be full of curiosity and excitement and to retain a sense of wonder are all, paradoxically, elements of maturity. Presumably too, progress towards maturity involves the shedding of the unpleasant results for the personality of the bad aspects of one’s rearing.

Apart from hatred and envy, already mentioned, and an undue fear of condemnation by others or God for natural behaviour which is harmless to others, senseless shame, especially about sex and inappropriate guilt need to be controlled. The tendencies to tell lies to avoid trouble, to denigrate others out of fear or jealousy, to be spiteful over minor wrongs, to be unduly suspicious over the motives of others and to need to obtain love and approval from all, thereby leading to insincerity, should ideally be eliminated. A capacity not only to accept failure without disintegration or discouragement but also to learn lessons from it and to be stronger needs to be developed especially in a culture such as ours in which the middle classes at least give children the impression that what they achieve is the true measure of their worth.

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If the pressures on the woman from the baby, from herself and from those around her are considered and if we bear in mind that her relationship with her baby is a straightforward

interpersonal one rather than an overwhelming instinctive form of mother-love, then baby battering becomes easily understandable. Increasing research is now suggesting that the way a baby behaves influences its mother’s reactions and not just the other way round. The way a baby responds to what its mother does greatly influences the way she in turn behaves. So, as in any interpersonal relationship, both parties influence the actions and reactions of the other. In contrast to the typical picture of an indifferent, neglectful mother, the battering mother is often one who does care. She desperately wants the baby to love her but it may seem to her not to do so. It cries inconveniently or incessantly after she has done her very best for it and this she may see as rejection and criticism. Babies are designed to cry instinctively to ensure their survival and though experienced mothers are very sensitive to these calls the inexperienced mother can have real problems recognising them or knowing what to do.

As far as prevention is concerned it is known that anything which fosters the inter-personal relationship is protective for the baby. Keeping the baby with its mother all the time right from the birth is important, as is encouraging her to experience maximum physical pleasure from it. Both of these things help the bonding process between them.

Because of our cultural attitudes battering parents are far more likely to be punished than helped – especially if they are men. Often the circumstantial odds are so stacked against them that at the particular moment when they resort to battering, they seem to have no other option. Parents Anonymous is a self-help organisation run by parents who have been in this position, for others who fear they might batter or who actually have battered their babies.

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Deciding to be tested for HIV is usually a difficult step. Even for those who believe they are at low risk, the process can be nerve wracking. A person must be emotionally ready to be tested, because obviously the test results may be life altering. That person must be tested because he is ready to be tested, not because he feels pressured by someone else. A person who is going to be tested should consider how she will react if the results are positive or if they are negative. Anyone considering having an HIV test should consider these questions:

— Do you want to bring someone with you when you get your results?

— Before you are tested, do you want to tell a friend or sexual partner that you are going to be tested?

— Do you have someone to talk with after you are tested?

— If you test negative, what will you do in the future to lower your risk of becoming infected?

If you test positive, the person who gives you your results should be able to offer referral to a clinic that cares for persons infected with HIV (if the facility where you are tested does not provide that care) and also, if you wish, refer you to support services to address psychological issues. It is also a good idea to have the test repeated if a positive result is obtained, especially if you are at low risk for infection, on the chance that there was an error at the laboratory.

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incidence: common

cause: virus (hepatitis A)

symptoms: nausea, yellowing of the skin, diarrhea

treatment: none (usually resolves on its own)

WHAT IS IT?

Hepatitis A is a virus that causes infection and inflammation of the liver. It has been recognized since the 1960s as a virus distinct from hepatitis B. One often hears of outbreaks of hepatitis A associated with improper food handling in restaurants, but hepatitis A can be transmitted sexually as well, especially through oral-anal contact. So far, hepatitis A and hepatitis B are the only sexually transmitted infections that can be prevented with a vaccination.

HOW COMMON IS IT?

Approximately 30,000 people are diagnosed with hepatitis A each year in the United States, but the Centers for Disease Control estimates that over 100,000 new cases may occur each year in this country. Most of these cases are not the result of sexual transmission. Many people are symptom free or do not seek care for their symptoms.

It is estimated that by the time they reach young adulthood, 15-25 percent of the people in the United States have been infected with hepatitis A, usually by consuming contaminated food or water. As people age, the likelihood that they have acquired hepatitis A increases, with blood tests of more than 75 percent of adults over age seventy showing infection. In the industrialized world, improvements in sanitation have decreased the number of people infected in childhood, whereas in developing countries, where sanitation and water quality may be inadequate, childhood infection is still very common. In many countries, more than 90 percent of children are infected by age five. Infection in childhood may not be a bad thing: most children who become infected with hepatitis A are symptom free, whereas most adults are symptomatic, and although fatalities are rare from hepatitis A, most of the deaths that do occur are in newly infected adults. People who have not been vaccinated or received immune globulin (see the next section) prior to travel to areas of the world where hepatitis A is very common are at increased risk of infection as well.

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If a woman becomes pregnant while she is infected with certain STDs, or acquires them during the pregnancy, there is an increased risk that she will not be able to carry the pregnancy to term. For example, gonorrhea and chlamydia can cause preterm delivery, miscarriage, premature rupture of the membranes, and infection in the uterus after the delivery. Syphilis, which will be discussed in more detail later in this chapter, can also cause miscarriage and preterm labor. By a common and usually benign infection of the vaginal area (which is usually not considered a sexually transmitted infection), can cause similar problems in pregnancy, as can trichomoniasis, which is a sexually transmitted vaginal infection.

The herpes virus, which causes a very common genital infection that is often symptom free and thus remains undiagnosed, can adversely affect pregnancy. Infection during the first trimester increases a woman’s risk of miscarriage. A woman who becomes infected with herpes while she is pregnant is at risk of transmitting the virus to the child (either in the womb or at delivery), especially if she becomes infected during the last trimester of the pregnancy. For women with a history of genital herpes who become pregnant, this happens much less frequently.

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You will usually be asked about your understanding of sexually transmitted infections—what causes them, how they are transmitted, and so on—and be given a chance to have all your questions answered. This is a great time to get accurate information about STDs; with that information, you can make changes in your life that will put you at lower risk for acquiring an STD.

If your health care provider does not bring up these questions, you may want to bring up the topic yourself. Here are examples of ways in which you might start off the discussion:

— “I have just started a new relationship, and my partner and I have decided that we want to be tested for sexually transmitted diseases.”

— “I have concerns about sexually transmitted infections.

There are a few questions I want to ask you.”

— “Is there anything unusual that you noticed during the examination today? I have concerns about sexually transmitted infections.”

In addition to the questions listed, you will be asked about your medical history regarding nonsexually transmitted infections or other illnesses. You will be asked what medications you take and if you are allergic to any medications. You will be asked if you have taken any antibiotics within the last month or so, since this may influence which tests are done and when. (If you took an antibiotic within the previous few weeks, you may test negative for certain bacterial STDs even if you do have the infection.)

If you are a woman, you will be asked when your last period was, if you have ever been pregnant, and if so, how the pregnancy turned out. Did you have the baby, lose the baby (a spontaneous abortion), or have an abortion (an induced abortion)? You will also be asked when you last had a Pap smear and if you’ve ever had an abnormality on a Pap smear (the section on genital warts in Part II explains why this question is important).

Before you leave the office or the clinic, try to express all your concerns. Nevertheless, it may take a while during the visit before you feel comfortable, and it’s possible that you’ll overlook something. Find out how to contact your health care provider after you leave. That way you can call if any more concerns or questions occur to you later.

If your health care provider does not seem to have the answers you are looking for, or if you feel uncomfortable for any reason, you may want to consider a visit to another clinic or health care provider to get the help you need.

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The cervix is a round structure that sits at the end of the vaginal canal. It is visible during a gynecological examination, and a woman can sometimes feel the cervix herself by inserting one or two fingers into the vagina. It looks like a small doughnut. The cervix has an opening, called the os, through which menstrual blood flows during a period. For fertilization to occur, sperm must pass through the os and into the uterus and Fallopian tubes, to reach the egg released by the ovary during ovulation.

Two types of cells are found on the cervix. The columnar cells are on the inside of the cervix, and they are also found inside the uterus. Sometimes these cells are seen on the outside of the cervix (a condition called ectopy), especially in younger women and women who are taking birth control pills. As women age, these cells move into the cervix and can only be reached with an instrument such as the brush used to collect cells for a Pap smear. These cells may become inflamed and move to the outside again when a woman has an infection of the cervix (called cervicitis).

The second type of cell is the squamous cell. These are located on the outside of the cervix and are also found in the vagina. The place on the cervix where the columnar cells and the squamous cells come together is called the transformation zone or squamocolumnar junction. It is here that precancerous or cancerous changes can occur, and cells for a Pap smear are taken from the transformation zone during screening for cervical cancer.

The cervix can become infected with STDs. Cancer of the cervix can also occur; it is caused by certain strains of the human papillomavirus, which also causes genital warts. Pap smears are an excellent screen for cervical cancer and are part of the yearly examination recommended for all sexually active women. During the Pap smear, cells that are removed with a brush from the cervix are sent to a laboratory for examination under a microscope.

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