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.
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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.
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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.
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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.
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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.
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MYTH: IMPOTENCE IS USUALLY A PSYCHOLOGICAL, NOT A PHYSICAL PROBLEM.
Fact: If you think this is true, you’re certainly not alone. Many health professionals still believe “ifs all in your head.” We’ve talked with many patients who were told just that, despite a history of health problems that could easily account for the impotence.
Michael, for example, is a 70-year-old with a history of vascular problems. A complete examination and tests revealed that these blood-flow difficulties made it impossible for him to have an erection. After some discussion with his wife and physician, Michael decided to have a penile implant. (We discuss these in detail in chapter 8.)
Shortly before the surgery, Michael visited another physician on an unrelated matter. Upon hearing that Michael was having the operation, the doctor tried to discourage him. “If s unnecessary surgery,” he insisted. “The problem is in your mind.” Michael wisely ignored this inaccurate information. Since having the surgery he’s enjoyed a very satisfying sex life.
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ERECTION PROBLEMS: THE IGNORANCE TRAP
Whatever the specific type of erection problem, it can make a man feel like an essential part of his identity is gone. He can become very depressed, critical of himself and insecure about his partner. Without a doubt, for many men erection difficulties can cause far more stress than other health problems.
And men often suffer that stress alone, since the whole subject of potency is taboo. Joseph, the divorced college professor, has friends who can talk about almost anything—but the subject of erections is still off limits. “After all, a guy who’s impotent doesn’t say, ‘Hi, just call me limpy,’” jokes Joseph.
Fred would certainly agree. A 39-year-old married man, Fred has never talked about sex or potency with male friends. “I don’t know men who really talk about sex. One summer I worked in a factory to make money for school, and the guys on the assembly line would brag about all the women they had. But it was just showing off.” Fred believes most men are not comfortable showing their vulnerability to another man. “Men are taught to be self-reliant, not to complain a lot. A lot of men think talking about problems is just complaining. And sex is one of the most difficult areas to talk about in any kind of meaningful way.” This reticence makes it difficult for a man to get accurate information.
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POLYCYTHEMIA
Polycythemia means that the body produces too many red blood cells. Excessive amounts of red blood cells can cause you to feel weak and tired. You may experience headaches and develop high blood pressure because the blood becomes stickier than normal. There is an increased tendency for blood clots to form, and this can lead to thrombosis in any organ of the body.
Polycythemia is diagnosed by the finding of a very high hemoglobin on a blood count. In addition, the white blood cells and platelets may be increased. Sometimes special tests to verify that the body is making too much blood (red cell volume), are done to confirm the diagnosis.
Treatment usually consists of removing some of the excess blood (phlebotomy) every few weeks. This treatment must continue for life. Because of the increased blood volume, the increased blood pressure, and excessive stickiness of the blood there is a risk of strokes and damage to the heart and kidneys. If you have polycythemia, you should be treated periodically by your physician or hematologist experienced in dealing with this disease. Most older people with this disorder can be kept healthy for many years with treatment.
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DIABETES MELLITUS
In diabetes mellitus the body’s blood sugar control becomes impaired. This disease is not the same as diabetes insipidus, an illness of the pituitary gland, in which excess urine is passed. Excess urine is also passed in diabetes mellitus, but the urine contains a large amount of sugar (glucose). (Diabetes insipidus is discussed at end of this chapter.)
The amount of glucose in your blood is determined by a number of factors. The different types of carbohydrates that are ingested are converted into glucose, a simple sugar that stimulates the pancreas to increase its output of the hormone insulin. Insulin helps the body metabolize carbohydrates, converting nutrients into glucose. The manner in which glucose and other nutrients are used by your body is also governed by the amount of insulin produced. The amount of glucose in your blood varies with the amount of food that you eat and the amount of exercise that you do.
If there is too little insulin, the level of glucose in your blood rises. If the glucose reaches a certain level, it begins to leak through the kidneys and “spills” into your urine. It is important to measure the amount of glucose in your urine with special testing kits that can be used at home.
As you grow older, your pancreas may become less able to produce enough insulin to fill your needs. If you are overweight, you may be putting an extra load on your pancreas. Even though there appears to be enough insulin, its effect is impaired because of the excess weight.
The most common type of diabetes mellitus in older individuals is called adult onset or non-insulin-dependent diabetes. This may affect you much more gradually than the kind that begins in younger people. Although it is not quite so dangerous, it must be treated carefully and controlled properly for you to maintain well-being and avoid complications.
Many people have latent diabetes mellitus. This means that your body has trouble controlling the blood glucose level, but this may not become obvious until you take certain medications or experience certain stressful illnesses. You will not develop diabetes mellitus because of the medications or illness, but you have a tendency toward it, and it manifests itself for the first time under these stressful circumstances, during a heart attack or pneumonia, for example. Diuretics and cortisone therapy may also cause latent diabetes to become evident.
Diabetics are in greater danger of developing infections, especially of the urinary tract. They also develop narrowing of the blood vessels as a result of atherosclerosis, which can result in an increased tendency to strokes, ischemic heart disease, peripheral vascular disease, kidney ailments, and eye disease. It appears that if care is taken to control the diabetes, the risk of these complications decreases.
Diabetics may develop ischemic heart disease without the usual symptoms of chest pain, and a heart attack (myocardial infarction) also may be experienced without chest pain and be revealed incidentally on a cardiogram long after the attack occurred.
If you are diabetic, you should take great care of your feet. Your nails should be cut properly (straight across) with the assistance of a physician, podiatrist, or chiropodist or by yourself after proper instruction if you feel secure and comfortable in the technique. Any foot infection or injury must be treated immediately to prevent progression and the possible risk of impaired blood supply and gangrene.
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HOW IS THE CAUSE OF BACK PAIN DIAGNOSED?
If you have never suffered from back problems and suddenly develop back pain, you should have a physical examination to make sure that the nerves from your spinal cord have not been impinged upon by the vertebrae. Your doctor should check your reflexes and the strength and feeling in your legs and feet. He should check to see that your symptoms do not affect your bladder or bowel. Damage to nerves going to these organs can occur if the nerves are pressed upon by tumors or bony outgrowths from an arthritic spine. Difficulty with urination, constipation, or diarrhea are warning signs.
The next step should include a plain X-ray of your spine. If the diagnosis is elusive, sometimes a bone scan, a myelogram, and CAT or MRI scans, may be needed to determine whether there is excessive pressure on the nerves within the spinal canal.
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