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It is this that most people call love in everyday speech but clearly true love is much more complex. Love at this adult stage brings together a love-object and a sex-object. This needs a little explanation. An ‘object’ in psychological jargon is a thing with which an individual is able to indulge his instinctual needs. A mother can therefore be a love-object to a baby and a wife a sex-object to a husband. When adults are in love, if they are mature, their love-object and their sex-object is one and the same person.

However, for many these two are separate. Some men, for example, cannot have a meaningful sexual relationship with someone they love (their wife, for instance) because they see her as untouchable. Such men (and there are-many of them) will be able to have perfectly enjoyable sex outside marriage but not within it. Most, if not all, of this attitude is, of course, in the man’s unconscious – he does not realise that it is happening unless it is pointed out to him. Others see their partners purely as sex-objects and have little or no love-object relationship with them. Such a couple can be happy loving their children, their home, their possessions, or whatever, and enjoy each other purely as sex-objects.

The ideal marriage blends the two in perfect harmony to satisfy both the childhood craving for love and the adult craving for sex.

The thing to remember is that, whatever sex books may suggest, sex alone is never enough. We all need loving ‘rewards’ in life from one source or another. Psychologists call such rewards ‘strokes’ and say, quite rightly, that we all need ‘stroking’ throughout our lives.

Adults who love each other stroke each other (physically or metaphorically) as much as they need and a good relationship is built up of physical and psychological strokes that demonstrate the partners’ love for each other. This begins to explain why people have such different ideas of what loving someone means. Many people with marital problems say, if he (she) really loved me they would/wouldn’t do . . .’ But the partner may not realise that this is the definition of love to which they are supposed to be adhering.

Communication is vital within any loving relationship because each of us is unique and we all need to get our strokes in different ways. Some want all their strokes to be physical and require an active sex life as a proof of the other’s love. Others want praise, outward signs of affection, practical signs of love, and so on, as their sources of strokes. In a short chapter such as this we cannot possibly do anything more than scratch the surface of this subject, but interested readers should examine their lives to see what they like best in the form of strokes and then discuss with their partners why they are not getting them – if they are not. The giving and receiving of strokes is the hallmark of mature adult love.

The final stage of love expands one’s love for an adult to a love of all mankind.

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This is regarded as an embarrassing topic by women since leakages of urine can occur in intercourse. Up to a quarter of women are said to be affected at some time in their lives. Of these two thirds pass urine on penetration and one third at orgasm. This latter observation raises the question as to whether women can really ejaculate as the G-spot enthusiasts claim, or could it just be urine? Recent research in which tampons blocked off the vaginal opening and fluid was meticulously collected from the urinary passage showed that the vast majority of women who ejaculate do not lose urine. The liquid is very like prostatic fluid.

Some cases of urine leakage are due to stress incontinence and others to so-called detrusor instability – a local muscle weakness. Both conditions exist and give trouble at other times as well as during intercourse. Some of the sufferers are utterly miserable and anxious as a result of the symptoms.

Stress incontinence-Some women leak a little urine when coughing, laughing or undertaking physical effort. The reason is that the circular muscle, at the base of the bladder, which is like a rubber band, is incompetent and when pressure rises inside the abdomen, as it does when doing these things, the muscle cannot prevent the flow of some urine from the bladder to the urethra. Various operations exist to relieve the condition. A tampon inserted before strenuous activity can prevent stress incontinence and pelvic muscle exercises can cure it.

Detrusor instability-Learning to be dry in infancy consists of establishing the control of the conscious mind over the reflex tendency of the bladder to empty when it is full. Urination then occurs only at socially convenient times and places. In detrusor instability this control is lost and the urgent and frequent passage of urine results along with symptoms of stress incontinence in some women. Bladder retraining is used to relieve the condition. The woman keeps a urinary diary for a week showing when and where she urinated. She is then taught to delay emptying her bladder by initially encouraging her to wait for half an hour between pees. Gradually she is encouraged to wait for 3 to 4 hours. Various medicinal drugs may have to be used, especially for those in this group who are incontinent at orgasm.

More generally, it seems that urination does, or can, have more significance for women then men, at least in our culture. Reasons

advanced by women to explain the situation have included the fact that the act is less ‘tidy’ in women than in men; that our culture makes female urination into a bigger secret and a greater shame than male urination; and that even in childhood girls begin to feel inferior because they are taught to pull down underclothing and crouch to urinate. Correspondence magazines such as ‘Forum’ have recently included many letters from women discussing the pleasures of standing to urinate, the delights of knicker wetting and the modifications necessary to male type urinals to make them suitable for use by women. Whilst all this may revolt some women it does suggest that, perhaps, the emotions attached to female urination are weakening-if only in a tiny sub-fraction of the population. If so more women with problems might feel able to come forward for treatment instead of putting up with them out of unnecessary shame.

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The Cynthia Payne case and the almost continuous revelations in the press concerning relationships between prominent men and prostitutes show that the topic arouses enormous public interest. ‘Male patrons of female prostitutes are usually married and so the topic is of interest here.

What is a prostitute? A prostitute is a person, male or female, who, in part or in whole, makes a livelihood by gratifying the sexual desires of other individuals, either male or female, within transient relationships, in return for remuneration. Although male prostitutes and even brothels exist to satisfy women and although homosexual and lesbian prostitutes are available to members of their own sex, by far the most common form of prostitution is that in which a man pays a woman.

Most prostitutes do the job to make money – and it can be very lucrative. Sometimes it may pay for the woman’s drug habit. More basic reasons for going into the profession include a lack of training for anything else, boredom, loneliness, being drawn into it by friends, and sexual gratification (this latter is usually, but not always, strenuously denied by the prostitute). A woman prostitute may be punishing her mother or taking revenge on her father who she felt could not possibly love her. Some may not have resolved the problems associated with releasing the childhood bond they had with their father, and for them taking money from men is a symbolic, child-like way of taking love.

Some prostitutes think they can meet ‘better’ men than would otherwise be possible and some hope for a marriage to a rich and powerful client. Others who feel, or used to feel, unattractive as women can get repeated boosts to their morale which seem to them to prove they are desirable. A number of prostitutes who work heterosexually (with men clients) are lesbian and yet others may be latently lesbian and use heterosexual prostitution to ward off the tendency.

Women prostitutes who cater for both sexes are becoming increasingly common.

Most female prostitutes have an understandable willingness to satisfy most clients’ demands, if only to ensure their return (because most prostitutes like a regular clientele), and possibly have a greater capacity to undertake and even enjoy a diversity of sexual behaviour than does the average woman. This is fortunate because many prostitutes say that the majority of their clients want something in addition to, or even in place of, normal intercourse. A prostitute may have to dress up in special clothes, provide special equipment, utter special words, undertake special acts, and be prepared to bring her client to orgasm by a whole variety of means. Of these, oral sex, carried out by and to her, is increasingly popular. The customer might simply want to look at her (she need not necessarily be naked) whilst he masturbates himself (sometimes he will not even want to do that) or ejaculate on her. More commonly he wants her to carry out these acts on him. Some men ask prostitutes to have anal intercourse with them using a dildo or a vibrator. Yet others may only want, they claim, to reform or rescue her, whilst others brutalise her out of a hidden religious motivation or in symbolic revenge against all women. As a result of these many, often strange, requests, the average prostitute has to be able to look after herself and to remain in control of the situation. This she can do very well because as a matter of professional pride she only occasionally gets ‘carried away’ by what is going on and she knows exactly where to draw the line. Even so, prostitutes are open to danger from their more weird clients and this is a danger of which they are only too well aware.

Some prostitutes specialise in particular areas of sexual behaviour, common examples being humiliation, bondage and flagellation, all of which are much more widespread than is generally believed. A variant of this is the ‘mistress’ type of prostitute who has an on-going relationship with her submissive clientele which may even be carried out through the post. Others specialise is using pornography to arouse and excite the man. More specialist set-ups also exist such as saunas and massage parlours where the clients are eventually masturbated, the euphemism for which is ‘hand-relief. In others the clients are in separate rooms and look at naked women through a window. Other prostitutes may be specialised in the way they get their clients.

Call-girls and women who work through an escort agency are two common examples.

Male homosexual prostitutes, who are usually young, are said to pay more attention to the physical appearance of would-be clients than do their female counterparts. Like the latter they usually deny any desire for sexual pleasure themselves and they also often deny that they are actually homosexual. Nevertheless, they erect and ejaculate with male clients and, it is said, usually pursue a homosexual life-style when they have to give up prostitution. Although some dress and behave effeminately, most try to emphasise their masculinity.

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Let us now look at the sexually transmitted diseases in turn. But before doing so let us consider vaginal discharges because they can cause such confusion and worry.

Vaginal discharge-The normal, healthy vagina produces a whitish secretion with a characteristic odour. The amount of this fluid produced varies considerably from day to day and with the stage of the menstrual cycle. This discharge is different from the lubrication which occurs during sexual arousal, when all healthy women produce clear fluid. Normal vaginal secretions have a very characteristic smell which turns many men on sexually. Unfortunately, the advertising industry has done its best to portray the vagina as needing frequent cleaning and many women believe they should wash out their vagina with a douche, on a bidet, or mask their natural odour with deodorants. None of these is necessary. Simply wash the outside regularly and leave the inside to take care of itself. If you think you have too much of the normal secretions, or if the secretion smells unpleasant or makes you itch.

Two common diseases produce a vaginal discharge. One is thrush (moniliasis or candidiasis) and the other trichomoniasis.

Foreign body in the vagina-This is the third commonest cause of an abnormal vaginal discharge. Usually it is a forgotten tampon. Other things put into the vagina can also be forgotten and cause a discharge. Such discharges are usually yellow and smelly and need to be sorted out by a doctor if you cannot easily get the foreign body out yourself.

Disorders of the cervix-These are a fairly common cause of vaginal discharge and there are many of them. The fluid tends to be brown or blood-stained, and slimy. Any such discharge must be seen by a doctor at once. Many a simple condition can be diagnosed and dealt with by out-patient treatment.

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Why can’t I just leave it all to the school or someone else?

You can if you want to and many parents do. But if you do, don’t then get upset if what they tell your child is not what you would have said. If you have specific ideas about any area of sexual knowledge you should ensure that your children understand your position, even if one day they choose to reject it. Young people will eventually make up their own minds about sexuality just as they do about everything else, but if you want to influence them because you care for and love them it is silly to leave the imparting of sex information to others – they simply will not understand, love or care for your child in the way you do.

Of course there is no reason why the two options should be mutually exclusive. Start off by answering all your children’s questions when they are young and then help them to understand what they hear at school and discuss it with them if they want to do so.

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The test most commonly used to follow the course of a person’s illness is the CD4 or T-helper-cell count. As mentioned earlier, the immune system that is attacked and destroyed by HIV; the number of circulating CD4 cells at any gave time offers insight into the progression of the illness and information about prognosis and response to therapy. Another type of immune system cell, the CD8 cell or T-suppressor cell, can also be measured, and the ratio of CD4 to CD 8 cells can be useful in monitoring the progress of the infection. These tests are not used to determine if someone has HIV infection. People with other medical problems can demonstrate a decline in their CD4-cell level for various reasons, and those with HIV can have normal CD4 counts.

Culture

Evaluation of the virus through culture is a technique that is not used in routine clinical practice, but mostly in the research setting. HIV is clinics) can help clarify these results if your health care provider has not explained them clearly difficult to grow in culture, and the process takes a long time. The tests described previously are more sensitive and cheaper.

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WHAT IS IT?

Hepatitis B is a virus that causes liver inflammation and damage. Recognized since the 1960s, it is a serious health concern in the United States and worldwide. The virus can cause acute as well as chronic infection, which increases the risk of later complications. So far, hepatitis B and hepatitis A are the only sexually transmitted infections that can be prevented with a vaccination.

HOW COMMON IS IT?

Approximately 300,000 people are infected with hepatitis B every year in the United States, and each year approximately 5000 people die as a result of the infection. Approximately 10 percent of the population in the United States show evidence of infection on blood testing. Even in the era of HIV and safer sex, the number of people newly infected is continuing to increase.

In the 1990s about 25 percent of new infective cases were transmitted by heterosexual contact, about 30 percent through the sharing of equipment for injection drug use, and 5-10 percent by sexual contact between men. Between 35 and 40 percent of people newly infected do not fall into any of these groups, however. Before the 1980s and awareness of the existence of HIV the group with the largest number of hepatitis infections was men who have sex with other men, but with the advent of safer sex practices in this group, heterosexual transmission is now more common.

The risk of becoming infected with hepatitis B increases with the number of sexual contacts a person has. People who have sex in exchange for money are at very high risk. Persons who have been diagnosed with another sexually transmitted disease are also at higher risk of being infected with hepatitis B, through unsafe sexual practices. In one study of 2000 people who were patients at an STD clinic, 28 percent of those twenty-five and older showed evidence of hepatitis B infection, whereas 7 percent of those younger than twenty-five showed evidence of infection. About 5 percent of those infected in the United States become carriers of the infection, as discussed later in this section.

There are some geographic differences in patterns of hepatitis B infection. In most Southeast Asian and some African countries, the rate of infection is high. About 90 percent of people in these countries have evidence in their blood of previous or current infection with hepatitis B, and approximately 10-20 percent of them are carriers of the infection.

Mothers who are chronically infected with hepatitis B have a greater than 80 percent chance of infecting their unborn children while in the womb and during delivery. If a child is infected, there is a high probability that he or she will become a carrier of hepatitis B as well; however, steps can be taken to help protect against infection of the newborn.

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The goal of treatment of BV is to rebalance the bacteria in the vagina, so that the predominant bacteria are once again the “good” bacteria, Lactobacillus, and the numbers of the “bad” bacteria are decreased. (Even a woman without BV may have some of the “bad” bacteria in her vagina, but unless they predominate they will not cause BV.) There are several ways to treat BV using either topical creams or oral medication.

The treatment of BV relieves symptoms, so that if a woman has BV but is symptom free, she may choose not to treat the condition. There are two exceptions. As mentioned previously, if an invasive genital procedure, such as the insertion of an IUD, is to be performed, which may cause the bacteria to travel up into the pelvic region, then the symptom-free woman with BV should be treated. In addition, in pregnancy, treatment should be considered because of the risks that the infection poses to both the mother and the child if left untreated, especially if a woman has delivered a premature infant in the past.

BV can be treated topically by applying cream or gel or orally by taking pills. Topical treatments include metronidazole gel and clindamycin cream; they are applied in the vagina for five days and seven days, respectively. A cream that was used in the past, triple-sulfa cream, is still prescribed by some health care providers, but it is not effective. If a woman is pregnant, clindamycin cream is usually not used because it isn’t as effective.

Oral metronidazole can be taken by mouth for seven days or in a single dose. The single dose is easier but is a little less effective. The other choice for oral treatment is taking oral clindamycin for seven days. Although oral metronidazole in the past was not thought to be safe in women during the first trimester of pregnancy because of its potential for harming the infant, the likelihood of any harm coming to the fetus from this drug has recently come into question.

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1. The skin will be examined. This is necessary because certain STDs cause rashes on the body as well as in the genital area.

2. If you are having symptoms in the mouth and throat, or have performed oral sex on a partner, the health care provider will inspect those areas with a bright light and may swab the throat to obtain samples to test for infections such as gonorrhea and chlamydia.

3. The skin of the genital area will be examined for rashes, sores, or bumps, some of which may be very small or may not be causing any symptoms you can feel, so you may not even know they are there. If a health care provider finds something, he or she may want to swab the area to facilitate specific tests to help in diagnosis. Sometimes a biopsy of a lesion is necessary to make the diagnosis. To take a biopsy, a small piece of tissue is removed and then examined in the laboratory. Some skin bumps—such as those caused by the virus that causes genital warts (human papillomavirus) or molluscum contagiosum—may be treated at this time.

The labia majora will be spread to see if there are any rashes, bumps, or sores on the labia minora or at the opening of the vagina.

The lymph nodes of the genital area will be examined. These glands are part of the immune system and sit at the top of the legs, in the groin area,- they may be swollen and tender when infection is present.

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The discharge of bacterial vaginosis is usually white to slightly gray in color and is usually not accompanied by significant irritation of the labia or vagina, although there may be mild itching. There is often a strong odor from the vagina, often described as a fishy odor, which can be more prominent after sexual intercourse or during menstruation. The symptoms may sometimes resolve on their own, only to recur again later.

Barbara had not had sex in over a year, so she was surprised when she noticed a discharge from her vagina. The discharge had a fishy odor and was grayish in color. There was a little bit of itching on her labia, but not as bad as when she had had yeast infections in the past. She tried douching, but the odor persisted—if anything, it got worse. She went to see her nurse practitioner, who did a careful pelvic examination and found evidence of bacterial vaginosis after examining vaginal secretions under the microscope. The nurse practitioner explained that bacterial vaginosis is not an STD, although it is more common in women who have been sexually active at some time in their lives.

Barbara was given samples of metronidazole cream to use for five days, and her symptoms went away. She was advised not to douche, because although douching may lessen some of the symptoms, it doesn’t cure vaginal infections. In fact, it may obscure evidence of the problem on examination, making diagnosis more difficult.

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