BEHAVIORAL APPROACH TO SEXUAL DISORDERS: THE LAW OF PARSIMONY
The core of the behavioral evaluation is the identification of specific target behaviors. In the sexual area the target behaviors are usually phobias. To those who have not actually seen the dramatic changes in complex sexual problems that may be brought about through the reduction of a simple phobia, such an approach may seem to be simplistic. In actuality, it would be more correct to designate this approach as parsimonious.
The Law of Parsimony is central to scientific thinking. Essentially this law states that “of alternative explanations for a given phenomenon, choose the simplest, that requiring the fewest assumptions, provided it meets the facts adequately” (Schneirla). A corrolary to this law, as it may be applied to the therapeutic formulation, is never to use a complex, higher-level psychological pattern as the core of the formation, when an equally adequate formulation is available using simpler, lower-level behaviors. If the choice is between a simple conditioned response to a specific stimulus and a complex dynamic formulation involving internal conflict and assumptions of repression, instinctual drives, and unconscious fantasies, the logic of science compels us to accept the former- provided it meets the facts adequately.
In sexual treatment, there are several major reasons why therapists do not arrive at the most parsimonious treatment formulation, namely:
1. The confusion between genesis and maintenance. The psychological constellation that produced the sexual symptoms may not be involved in the maintenance of these symptoms. As already noted, the symptom pattern may achieve functional autonomy from the forces that caused it. As also previously noted, the problem behaviors may now be maintaining the original constellation. To arrive at the most parsimonious formulation, the therapist must focus on the psychological variables keeping the problem behavior active in the present, rather than on the variables originally causing it.
2. The failure to distinguish between teleological and automatic behaviors. Symptomatic behaviors often have certain consequences. A sexual dysfunction may result in humiliating the person or frustrating the partner. All too frequently this is interpreted in teleological terms. The purpose of the symptom is to achieve this self-humiliation or frustration of the partner. It is completely true that people are capable of behaving in such a purposive manner. People also are capable of acquiring automatic conditioned responses to specific stimuli or acquiring certain modes of behavior because of the impact of external contingencies of reinforcement. In those instances self-humiliation or partner frustration may be a by-product rather than a goal of the symptom. The Law of Parsimony requires that we choose the simpler, conditioning explanation over the purposive one, unless compelling reasons exist to do otherwise.
3. The failure to distinguish between precipitating and derivative disturbances. Usually patients with sexual problems come in surrounded by an aura of anxiety, depression, low self-esteem, marital or inter-personal problems, and other disturbances. There is a strong temptation to see the sexual problem as arising out of this disturbed context, as sometimes it does. However, many times these disturbances derive from the sexual malfunction, and to make them part of the therapeutic formulation is to complicate that formulation unnecessarily. Unless there are compelling reasons, it is usually most parsimonious to consider such disturbances as deriving from the symptom rather than as causing it.
A very common error along these lines is made with people with sexual variant behavior. Very common, particularly among fetishists and transvestites, are the derived feelings of “being a monster” or of being found out by other people and being contemptuously rejected. Many times these derived reactions are considered to be precipitating stimuli leading to the variant behavior. Hence, unnecessarily complicated formulations are set forth. Unless there is specific reason to believe otherwise, it is most parsimonious to exclude these reactions from the formulation.
4. The failure to discern when problems are independent of each other. When a person has several problems, the tendency all too often is to see them as being inter-related. Most often they are seen as covarying from a common root cause. Should a woman have a dysfunction of sexual arousal and a fear of authority, both problems are likely to be seen as stemming from an oedipal conflict regarding father. This often leads to an unnecessarily complex therapeutic formulation and a cumbersome treatment strategy. The most parsimonious formulation may see them as two simple, independent fears: the fear of not being aroused and the separate fear of authority. This conception requires the fewest assumptions. Unless there is specific and definite evidence to show that problems are inter-related, they should be considered to be independent of each other.
Therefore, formulating a sexual problem, even a complex one, in terms of one or several simple phobic reactions is not simplistic. Rather, it is fully scientific in its utilization of the most parsimonious explanation of the problem. Also, it often leads to the most effective course of therapeutic action.
*237/187/5*
Men’s Health
HOMOSEXUALISM: INCIDENCE AND ETIOLOGY
Incidence
There are no public health statistics on the incidence of either male or female homosexuality or bisexuality. The figures most commonly quoted are those of Kinsey, since subsequent smaller-scale studies confirm them. Kinsey rated homosexuality on a seven-point scale (0—6). A rating of six signifies exclusive or obligative homosexuality of long duration, most likely a lifetime. A man with a rating of three will have had more than incidental homosexual participation off and on for several years during adolescence or later, not necessarily for a lifetime, and not to the exclusion of heterosexual participation. Kinsey estimated a rating of from three to six for 10% of the adult male population, and of five or six for 3%. The figures for the female population are less definite but are estimated at one-half to one-third those for males. On the basis of these estimates, the predominantly homosexual male population in the United States today is approximately three million plus, and the female, one million or more.
There is disagreement, sometimes acrimonious, among experts as to the etiology of homosexuality, as there is also of heterosexuality and bisexuality. Theories range from loose assumptions of voluntary choice, through psychodynamic determinants in the personal biography, to hereditary predestinarianism. There is a good possibility based on experimental animal studies, that an anomaly in prenatal hormonal function may influence sexual pathways in the central nervous system to remain sexually undifferentiated or potentially bisexual. In human beings, an individual so affected would be vulnerable, or easily responsive to additional postnatal influences, primarily social influences that enter the brain through the eyes, ears, and skin senses, that might favor perpetuation of bi-potentiality or its resolution in a homosexual differentiation of gender identity/role. Once differentiated, a strongly homosexual gender identity/role tends to persist without changing.
There is not enough knowledge yet to formulate a rational program of prevention. Nonetheless, there is strong presumptive evidence that lifting the taboo on infantile and childhood sexuality, and responding positively to normal heterosexual rehearsal play in the early years, strongly favors heterosexuality at puberty and in adulthood. This evidence comes from anthropological studies and from experimental studies of psychosexual development in nonhuman primates.
*200/187/5*
Men’s Health
SEX DISCRIMINATION: HISTORY
Although thorough examinations of how women were regarded throughout history can be found elsewhere (Bullough; Taylor) it is nonetheless instructive to consider briefly a few central points. Stereotypes about women have had a long tradition in our culture, and it is important to view current events not as isolated happenings but as part of a historical progression. Particularly germane to the discriminatory treatment of women is the age-old image of women as inferior to men and the long-standing image of women as both physically and emotionally frail. The idea that women are inferior to men has been accepted throughout Western history. The Greeks excluded women from any political, intellectual, or social activities, and gave them no legal status or education. Women were viewed as equipped only to bear children and to maintain the home, and they often had no contact with anyone outside their immediate households (Arthur). Aristotle perhaps best articulated the Greek image of women when he wrote, “We should look on the female state as I being … a deformity”. Plato, although more diplomatic, was no less biased in his view, “All the pursuits of men are the pursuits of women also, but in all of them a woman is inferior to a man”.
Religious teachings also espoused this point of view (Hunter). In the creation story in the Book of Genesis, Eve is essentially an afterthought, created from Adam. Elsewhere in the Bible, women are depicted as property, first of their fathers, then of their husbands. Christianity, although ostensibly more liberal in its conception of women, largely through the writings of Paul, also has relegated women to a secondary status, allowing them no important role in the church. The Judeo-Christian tradition thus perpetuated the negative view of women so prevalent in antiquity. An alternative view of women began to emerge in France in the eleventh century. Chivalry came into being. Now a woman no longer was a man’s inferior but his inspiration to excellence and his duty to protect. Even so, women were confined to passive roles, waiting for knights to perform brave deeds to win their love. Although different, this also was a belittling role for women. Again their dependence upon men was highlighted, suggestive of a fundamental weakness and inability to cope with life’s realities.
These views of women, women as inferior and women as weak and dependent, have predominated through the centuries. The consequence has been the legitimization of the differential treatment of women. Even the courts, until very recently, accepted womanhood as a condition warranting different treatment by the law (Agate and Meacham). Using the commonly accepted cultural conception of women, United States Supreme Court Justice Bradley in 1873 explained why a state could constitutionally ban women from practicing law: “The natural and proper timidity and delicacy which belongs to the female sex evidently unfits it for many of the occupations of civil life” (Bradwell v. Illinois, 83 U.S. (16 Wall) 130, 141). It was not until almost a hundred years later that the Supreme Court first ruled that sex was not a permissible basis for differential legal treatment.
Stereotypes about what women are like are part of our heritage. Our legacy is the teaching that men and women are fundamentally different not only in the roles they have played, but also in their capabilities and talents.
*163/187/5*
Men’s Health
COMPETITION AND BALANCE OF SEXUALITY
Bateson’s analysis of Balinese culture is an excellent example of the need to move away from narrow definitions of sexuality and crude measures of it. Bateson’s article can be easily overlooked by sex researchers, as it usually is, because it is not written ostensibly about Balinese sexuality. Rather, it addresses the different construction of the Balinese cultural system, which is in a steady state, as contrasted with the Iatmul (New Guinea) and American cultural systems, geared toward cumulative interaction and climax. Bateson writes of Balinese children who learn to avoid cumulative interactions: “It is possible that some sort of continuing plateau of intensity is substituted for climax as the child becomes more fully adjusted to Balinese life”. The resulting Balinese adult is under tension, not in a competitive, climactic sense, but in a never-ending struggle to achieve balance and interpersonal stability: “The individual Balinese is forever picking his way, like a tightrope walker, afraid at any moment lest he make some misstep”.
Bateson documents the “lack of climax” in Balinese quarrels, which are not resolved or concluded, but rather are “pegged at a state”, another example of the substitution of plateau for climax. Likewise, during Balinese oratory things happen, but nothing develops. Interruptions which are both tolerated and accepted cause any tension that might be building to break under the stabilizing effect of the irrelevant interaction. Bateson also suggests that both the caste system and the village hierarchical structures remove contexts for competition, again replacing them with contexts that express natural order, stability, and balance.
To follow Bateson, we need to realize that social organizations usually contain multidimensional value systems of tremendous complexity and scope. Sexuality, in a system such as this, provides an organizing construct that elevates and identifies one value as governing social interaction on a given occasion. In other words, there are contexts in every social system which define the scope of interaction, by temporarily reducing the multidimensionality of culture to one dimension. In Iatmul, American, and many other societies, sexuality is such an organizing, reductive construct, providing a competitive context by selecting one value system out of many.
Bateson contrasts sexuality, as one of many competitive contests in Iatmul and American societies, with stability, the important organizing construct in Balinese social life. The Balinese emphasize performance and balance in their dance and in their appreciation of an activity as a process to be valued for itself, not because it is aimed at some distant goal. The implication is that this value system, with its emphasis on stability and process, will be expressed in the sexual life of Balinese. Sexual activity is a performance rather than a contest. It is not an activity with winners and losers, best represented in American society when one sexual partner can claim superior sexual ability and attractiveness vis-a-vis the other. Rather, it is a balancing activity in which economic and competitive considerations are replaced by ceremonial and artistic expression. In this way Bateson finds Balinese sexual life consistent with the value emphasis and emotional tone (he calls this “ethos”) found throughout the culture. Presumably, the focus of sexual activity remains on the balancing of relationships during an aesthetic experience, itself part of a process without a beginning with foreplay and an end in orgasm.
Lovemaking for the Balinese is an aesthetic confirmation of balance as a value in Balinese life. It is not a cumulation of interaction, leading toward climax, definition and conquest, as evident in American (and Iatmul) sexuality. In the American cultural system, sexuality is a value which focuses and assigns behavior; in Balinese culture sexual activity is aesthetic behavior which itself is governed by a larger value of stability and the noncompetitive personhood which accompanies it. Instead of focusing and limiting the parameters of the interaction, as does the imposition of “sexuality” as a value in American life, the Balinese value system addresses the issue of balance during lovemaking, quarreling, and orating. Because the Balinese view sexual intercourse as a station on the continuing plateau of intensity, it is not relegated to self-contained behavior during an artificially restricted occasion. This is the difference between Balinese and American sexual culture according to the general pattern of Bateson’s formulations. This analysis explains findings such as Belo’s, that sexual involvement between an upper-caste Balinese woman and a lower-caste man was treated severely as a case of bestiality. Balance and definition, even on the social level, must be maintained.
It is also known that because of the high level of tension in which each Balinese life is lived, Balinese performers expect and receive audience attention and involvement. Balinese performers do not need to work to command the attention of an audience, then, for this attention comes automatically from the audience’s equal concern for balance and continuity.
*126/187/5*
Men’s Health
CROSS-CULTURAL OBSERVATIONS: FREQUENCY
Average frequencies of marital coitus among groups vary from about two to five times per week (Gebhard). The Ecuadorian Cayapa Indians described by Altschuler thought that twice a week was an occasion for bragging by new husbands. This group has an exceptionally low level of sexuality, accompanied by avoidance of women, anxiety, inhibition about sexual matters, and much homo-erotic behavior among the men. Even the more virile and forward men can go for long periods with little sexual activity. Male sexual inadequacy is the norm, resulting apparently from high-anxiety socialization practices in the weaning and toilet training of children. The Inis Beag, an Irish folk community studied by Messenger has very strict rules of modesty and separation of the sexes from childhood on. Frequency of marital coitus is not known but is probably low. Men believe that intercourse is debilitating and drains energy needed for other work. Sexual inhibitions extend to avoidance of nudity at all times and shunning of sexual innuendoes and jokes, even with the most pallid content. Asked to compare the sexual desires of men and women, a married woman said, “Men can wait a long time before wanting it, but we can wait longer”.
Other people described by Davenport, Marshall, and Merriam, value sex highly, frequent copulation being an important part of their life styles. The Mangaians (Marshall) of central Polynesia engage in a high level of sexual activity before marriage, valuing frequent coitus, many partners, and multiple orgasms for their women. After marriage the male wishes to copulate with his wife every night, beginning to skip nights only after a decade or so of marriage. Davenport’s East Bay Melanesian group expects that sexual excitement will remain high during the early years of marriage, and it is usual for couples to have intercourse each day while they are in their garden and again at night after going to bed. Frequencies of three times in a twenty-four-hour period were not uncommon. Merriam, in his study of the Bala, a people of the Congo, collected data on frequency of intercourse by asking men, each morning, how many times they had had intercourse in the preceding twenty-four hours. Although the data may be less than reliable, the average over a ten-day period ranged from 1.2 to 1.9 acts of marital coitus per day. Even the men in their fifties and sixties reported having intercourse more than seven times per week.
These examples only suggest the variability of frequency of marital coitus among human groups. Obviously, it depends on factors such as attitudes toward sex, availability (as when the men are absent for long periods), restrictions and taboos, and the woman’s right of refusal. In general, if teachings are repressive with many negative sanctions and taboos, and if sex is thought to be dangerous and tinged with evil, frequency is low. But if attitudes are permissive, children’s exploratory activity indulged or encouraged, and people are rewarded for sexual interest and exploits, frequency is high.
*89/187/5*
Men’s Health
TREATMENT STRATEGIES OF ALZHEIMER’S DISEASE: DRUGS TO IMPROVE MENTAL FUNCTIONING
The discovery that the brain lacks adequate quantities of important chemicals such as the neurotransmitter acetyl choline resulted in a search for medication that would rectify either the deficiencies concerned or the results of these deficiencies. Traditionally there are three approaches to trying to deal with a situation in which a chemical is missing from the brain.
The first approach is to give the body more of the chemical in the hope that it will be passed to the brain, where it can carry out its normal function, or to provide the brain with other substances that it may be able to convert into the missing chemical. This approach has been tried for Parkinson’s disease and has been very effective in treating the symptoms in many people, although it doesn’t prevent the progress of the disease. For the treatment of Alzheimer’s disease, however, the results have been disappointing. Perhaps the best-known substance to have been tried is lecithin for which there have been many trials, some attempting to show an improvement in intellectual function and others with the more modest objective of showing that it might prevent or slow down further deterioration. There has however been very little evidence that lecithin and similar compounds have been beneficial.
A second approach to help the brain cope with a reduction in the level of an essential substance is to try to ensure that the little that is available lasts for as long as possible. Like most tissues in the body, the brain has the chemical processes to enable it to destroy most chemicals it is designed also to produce. This is essential in biological systems where a balance between production and destruction has to be maintained. We know that there are some drugs that slow down the destruction of acetyl choline and similar compounds, and it was hoped that the administration of these might result in a prolonged life for the small amounts of neurotransmitter produced, with an improvement in intellectual function.
Until recently this technique also seemed to be disappointing, but a new substance called tetrahydroaminoacridine (THA) has proved worthy of further evaluation. Significant improvements in intellectual ability were originally claimed for THA, but although these have failed to be substantiated by subsequent trials, it is beginning to look as if a proportion of patients with Alzheimer’s disease, but not other dementias, may acquire modest improvements in ability and behaviour with this drug. It is, unfortunately, a drug that produces many side-effects which may preclude its ever being generally available on prescription. It may, however, show us the way to development of more effective and safer drugs. Perhaps we have our feet one or two rungs up from the bottom of the long ladder of drug development for Alzheimer’s disease.
The third approach to dealing with a reduction in the amount of a neurotransmitter in the brain is to try to make the brain structures that are switched on by the depleted chemical more sensitive to the reduced amounts available. Although this approach is used in other neurological diseases with a modest degree of success, it has so far failed to be of much benefit to people with Alzheimer’s disease.
Since approaches aimed directly at affecting the missing chemicals have been unsatisfactory, although as mentioned THA is under further evaluation, researchers have turned to other methods of trying to improve brain function. One of the most exciting of these is the attempt to prevent or slow down the rate of cell death of the factory cells that produce the neurotransmitter chemicals. In other words, rather than trying to replenish the brain’s level of neurotransmitters by using tablets or injections that contain the missing chemicals or those that can be made into them, an attempt is being made to see whether it is possible to discover why the factory cells are dying or not working properly, in the hope that they can be made to fulfil their normal function once again. A modest degree of success has been achieved in understanding what is happening to these factory cells although it is not yet known whether this knowledge can be translated into an effective therapy. It seems as if some of the cells in the brain that make neurotransmitters need substances called trophic factors in order to carry out their normal functions and there is a suggestion that in some degenerative diseases of the brain, including Alzheimer’s disease, these trophic substances may be missing. It is hoped that it may be possible to supply the appropriate trophic factors to enable the cells to work properly, so that they in turn may produce the neurotransmitters that are required for normal brain functioning. Although this field of research holds great promise, it is too early yet to know whether it will be an effective form of treatment.
As well as the specific attempts to try to put right the biochemical abnormalities that occur in the brain in Alzheimer’s disease, there have been many other, rather more general approaches to developing drug treatments that may improve dementia, almost irrespective of the underlying cause. All sorts of drugs have been tried. Many of them were originally developed as vasodilators — medicines that would cause dilation of the blood vessels thereby improving the blood circulation to the brain. It is now known that this type of approach is unlikely to be of any benefit since it does not improve any of the conditions that cause dementia. Other drugs were thought to improve the metabolism — the biochemical processes — within cells and these too have proved disappointing. Many other methods have been tried, but so far, with the exception of people who have a treatable cause for their dementia such as a vitamin deficiency, there is no evidence that any medicine that is generally available is of any benefit in improving intellectual performance. This situation may change, however, within the next two or three years.
*111\138\2*
General Health
NURSING IN THE CASE OF ALZHEIMER’S DISEASE: USING THE TOILET
As a demented person becomes less steady on his or her feet, it is essential to ensure that rails are provided around the toilet area. Most falls occur when a person is in the process of standing up or sitting down; it is possible to get raised toilet seats that make it easier to get on and off.
For night-time use it may be better to have a commode put at the bedside. This is most useful if the bathroom is on a different floor to the bedroom. For men, a bottle-urinal may be helpful not only at night, but also during the day. It can be discreetly placed in a container at the side of the chair in which he is sitting, and regularly emptied.
When a man with dementia begins to forget to go to the bathroom and when, having got there, he has difficulty in remembering the routine, it may be easier for him to sit on the toilet to pass water than to stand up. This can be less problematical and less embarrassing for a wife or other carers.
Problems with using the bathroom and toilet, and many others such as dressing, are an area where the occupational therapist can give invaluable support and advice. This can usually be arranged through the general practitioner or health visitor.
*87\138\2*
General Health
BEHAVIOURAL AND PSYCHOLOGICAL PROBLEMS IN THE CASE OF ALZHEIMER’S DISEASE: PROBLEMS AT NIGHT
Those suffering from a dementing illness may well disturb other people’s sleep. Sometimes it is because they have a tendency to wander; sometimes they are disorientated and think that it is time to get up; sometimes they are frightened at night. Often, having gone to the bathroom they are unable to find their way back to the bedroom or have their attention diverted to something else with which they then become involved.
Many people with dementia are less active than they used to be during the daytime and may take more daytime naps than before. Try to make sure that they get adequate physical and mental activity during the day, to help promote sleep. It is also a good idea to try to ensure that they go the bathroom last thing before going to bed; restricting fluids during the evening, say after supper if this does not cause distress, can also help. Leaving a light on in the bathroom and having a low-wattage bulb on the landing can assist a confused person in getting around at night.
The bed needs to be comfortable and some relatives find that continental quilts are easier for a person with dementia to manage than blankets and sheets. It is probably best not to use cot-sides as they rarely manage to deter a wanderer and can be irritating. Sometimes, however, they can be helpful in preventing a person from falling out of bed if this is a problem.
If sufferers decide to get dressed and you have difficulty dissuading them, don’t worry — let them get on with it. They may well be prepared to go back to bed, even though fully clothed. Sometimes a warm drink works as it is often associated with the going-to-bed routine.
Finally, there are two important points. First, if wandering at night is a real problem, make sure there are no hazards to safety, like gas taps that could be turned on. Secondly, a step that can be taken is to ask the doctor to prescribe some sleeping medicines. These should be avoided except as a last resort and should only be tried for a few weeks at a time. Sometimes it can be left to the carer’s discretion to administer them intermittently, perhaps after having had two or three bad nights in a row. All medicines have side-effects and you must ask the doctor what to watch out for if they were to affect the person you are looking after.
*65\138\2*
General Health
DEVELOPMENT OF DIAGNOSTIC TESTS OF ALZHEIMER’S DISEASE: MONITORING THE CSF
Many of the diseases that afflict mankind can be diagnosed with relative ease by examining the blood for abnormal changes or looking for specific diagnostic indicators in other body fluids, for example the urine and, particularly for diseases that affect the nervous system, the cerebrospinal fluid (CSF). There are currently many studies seeking such ‘peripheral’ markers of the presence and severity of Alzheimer’s disease. If identified, not only might they help with diagnosis, but they might also assist in monitoring the effectiveness of treatment when this becomes available.
Some of the earliest attempts at isolating diagnostic markers involved examining the CSF for changes in its biochemistry that would reflect the biochemical abnormalities that we know occur in the brain. Although there have been some reports of differences between people with Alzheimer’s disease and normal people of the same age without any intellectual deficit, there has been too much overlap between the two groups to enable the biochemical differences in question to indicate reliably the presence or absence of the disease. Similar attempts have been made to examine the changes in the blood and again the results have been disappointing.
More recently, and in many ways more hopefully, researchers have been trying to identify changes in the CSF and the blood that relate not to the biochemical changes within the brain, but to the structural abnormalities that develop in Alzheimer’s disease. Attempts are in hand to try to make the diagnosis by proving that the blood or CSF contains substances which indicate that the brain, in its turn, contains more senile plaques or neurofibrillary tangles than it should. At the time of writing this seems a much more logical approach and several tests have arrived at the point of clinical trial. It will probably be a year or two, however, before we know whether they are going to live up to expectations.
*43\138\2*
General Health
UNTREATABLE CAUSES OF DEMENTIA: CEREBRAL TUMOURS
A cerebral tumour can cause dementia. Such tumours can be divided into two types – primary and secondary. Primary cerebral tumours are those that arise within the brain itself whereas secondary tumours spread there from a site somewhere else in the body, usually arriving via the bloodstream. Secondary tumours arise when a few cells from a tumour, say a cancer of the breast, are taken by the bloodstream and planted as seeds in the brain, where they grow and destroy brain tissue. Sometimes there are many small secondary deposits. They may cause all sorts of other symptoms and side-effects and don’t always cause dementia.
Since most brain tumours are unsuitable for X-ray therapy or surgical removal, it is usually only possible to treat the symptoms, such as headache. However, some primary tumours, especially one called a meningioma, can often be completely and safely removed. A meningioma can grow to a very large size and still be removed. It is therefore another of the treatable conditions that can be diagnosed from a brain scan. In most tumours, unfortunately, although treatment can be given to improve the quality of life of the person concerned, the tumour will eventually be responsible for the patient’s death.
*21\138\2*
General Health
