who will not be at risk for being the victims. as a society, as a country, we have to realize that this is indeed an epidemic, that 25% of the women experience this act. we have to become mobilizedto a, to make counseling andreatment services available to victims, to provide treatment to offders, and to work out prevention strategies geared toward ousociety and the way women are treated. i don't want people ever saying that they accept me and that i'm ok. i want people to hatewhat i. but i'm a rson. those are things that i done. i've ho tell that to my wife. i want her to always ha what i done because i hate what i done. bupeople in society should know

that i'm a human being and that i can live a successful life with the proper treatment. it's like an alcoholic-- one day at a time. and, uh... the only thing ian do not do it again and maybe be involved in educating other people. this has really spread across the country really heavy-duty. and so i know my victim suffered that night. i didn't physically hit my victims but i scared them to death. and when you're 3oo pounds-- i didn't need a weapon. i was a weapon. if i could change anything, that's what i would change-- to be able to take the pain away from my victims. this is a fertilized human egg. person's genetisexiseterned. the mentconcepti atirth, the newborn's sexual organs

almost always match that genetic ideity. how personal sexual identity develops from that point on, however, is not well understood, but it is clearly influenced sometimes, tre is a confusion between a person's psical se anhis or her peonal sexl identity, sometimes, tre is a confusion crting a gender dysphoria--e tera an extremenhpiness out e's biogical sex. dysphoriais what led d to t pgram in human sexty anto dr. eli coleman. i guess fr the time wavery young, couldn't understand why everyone kept telling me that i was a girl and i should be dointhgs that girls do. that i was a girl because as far as i was concerned, i was a boy, and didn't understand.

there was a lot of confusion. didn't know how to relate to... anyone else. uh... it's just very uncomfortable. it makes you feel crazy. this is a female-to-male transsexual who always thought of herself as a boy. she had extreme discomfort with her body as it changed from a you girl to an adult woman. and with those changes, there was increasing anxiety and discomfort about her breasts, her genitalia, and also out their gender role. their role as a female feltery uncomfortable. tentimes, they just feel that somehow they were just given the wrong body. in their mind, they felt themselves to be

of the other sex. i know that when i started going through puberty, um... i decided that-- up until tt time, i d figured that everyone was wrong and eventually i would prove it to them, as irrational and illogical as that sounds. i decided thated they were all right, and i was all wrong and i must be crazy. that was the only explanation i could come up with. i had never heard of transsexualism. i thought i was the only one like is. i know at one point in time, i remember my mother coming into my bedroom and telling me that maybe it was time i start wearing a bra, and i told her, "no way. i'll cut them off first." and shlaughed.

i'm sure that no one ever knew just how serious i was about that. i did truly consider it at one point in time, and the only reason that i didt do it was because i would bleed death, and everyone would know how crazy i was. the only thing iould do would be to try and be what everyone said i was. after several years of counseling, brad began ting male hormones. they changed his body shape, lowered his voice, and led to the growth of facial and body hair. he had a double mastectomy to remove his breasts. he had a hysterectom toemove his fallopian tubes and ovaries. brad dided not to have a penis constructeom his female genitalia are intact, and he is capable of having an orgasm. like most female-tmale transsexuals, brad has always beenattrac.

this is not an easdecision cause it's a rather irreversible step once you go through hormonal and sex resignment. and this person, because ofamily influence, social influence, is very reluctant abou pursuing that and spends a lot of time trying to consider if that was rely the right solution for her. unlike brad, many people with gender dysphoria often seek out surgery as the answer to their problem, a situation dr. coleman cautions against. too many patients who ve gender dysphoria, or discomfort with tir own gender, have aot of other problems that may be related to their gender dysphoria or not, and one of theblems is th they start developing an obsessive thought that somehow this gender change is going to gically solve a lot their problems in their life.

and it's a rude awakening when they complete surgery and discover that there are still a lot of problems for them. so in ouapproach here in our clinic, we like them to resolve a lot their psychological problems and issues before reassignment, and then we have much more confidence that they are going to be successful in their reassigned role afterwards. brad has been a man r less than a year. he still will confront many issues, but this major issue-- whether he imale or female-- has been resolved. i feel now like i'm one person, whereas before, i always felt like i was kind of a real confusing mixture of two dferent people.

not only two different people-- when you think of yourself as two different people, usually it's of two different people of the same sex. it would be hard for anyone who hasn't experienced it to imane what it's like to fl emotnally and mentally one sex and appear to other peoplephysi. it's... it's, uh... there's no way to really expln it, i don't thin but i do n feel like itone person. i feel quiteece in who i am. there are times when a person is unable to participate sasfactori ifor emotional reass, some sometimes for physical reasons. but when this happens on a regar basis and the rsonos the ability or dire toave sex, this is coidered sexual dysfunction. onin thr adults in the uted states

have experienced one form of sexual dysfuncti or another making this one of the most prevalent of pchological conditions. there are three basic types of sexl dysfunction-- of pchological a loss of desire for sex, the inility to beasic types seally aroused,tion-- and eier a lack ofrgasm or an inability to contr orgasm. human sexualunctioning depends on a number factors. on a biological level, the nervous system, the circulatory system, and the endocrine syst all work to produce thnecessary physical mponents reired for sexual arousal and orgasm. the psychological coonents of fantasy and desire are equally important in achieving aroal and satisfaction sexual dysfunction can occur when thehysical or emotional elemts go awry. helen singer kaplan is a psychiatrist and a sex therapist. a seal disorder is a physical dysfunction--

a man cannot have an ertion, a woman can have no orgasms, or sex hurts, or there's no desire. those are physical dysfunctions, and they are the common pathway for a variety of physical stress or psychological problems, relationship problems, et cetera. that's why i call them psychosomatic. it merely means that if a man comes into my office and cat have an erection or has a problem keeping an erection, i first have to find out, is he taking medication? is he having quarrels with his wife? was he religiously brought up and feels sex is shameful? does he have a neurotic problem? dr. carson describes a dysfunction common to yog men-- the inability to contr orgas hardly aeagoes by that i don't have a young man show up at my doorstep looking very-- i' learned to recognize it now--

looking very scared and traumatized. he's at my doorstep, and i say-- because i've learned by this time what to eect-- "what happened?" "well, i don't know. it just went too fast." this problem, premature ejaculation, is a common sexual dysfunction, occurring in approximately 35% of theale population. the treatment for premature ejaculion consists of teaching the male how to slow down his e. specific exercises are used to help the man recognize and control the sensatns leading up to orgasm. techniques such as this became popular in sex therapy as a result of the work of william masters and virginia johnson in the 197os. thr work changed much of the thinking about sexual dysfunctions. these methods are very interesting. they differentiate sex therapy fromther forms of treatment.

the behavior aspect of sex therapy is carried out in the privacy of theouple's home. ge very specific sexual homework assignments, and there's never any sex in the office. patients are oftenisappointed and relieved to find that out, but only a charlatan would have sex in the office. we tell them exactly what to do at home. if the man has performance anxiety, impotence, we give one set of instructions. if the woman has difficulty having orgasm, we give another set of instructions. if her vagina's very tight, we give a third set of instructions. the patients then report the results of these interntions. very often, we find that these work, but just as often, there is resistance because there are also deeper problems, and these deeper problems need psychodynamic interventions.

the reon i call sex therapy, or the new sex therapy, integrated is because we use-- it's an integration of two modes of treatment which were always thought to be incompatible-- behavioral and psychodynamic. very simply-- and this is probably an oversimplification-- we use behavioral cognitive homework assignments, instructions, redefinitions, to modify the immediate causes of sexual problems, which, by the way, are different for the different disorders, and then if the patient feels anxiety, feels vulnerable, resists in some way, we then use psychodynamic methods of delving into the deeper problems and clarifying and resolving these. masters and johnson introduced another important concept in sex therapy-- they considered the couple, raer than the individual, as the focus the attention.

it's rich to do them as a couple because there is no uninvolved partner when there's a sexual problem. they are both involved in this. dr. domeena renshaw is director the loyola seal dysfunctionlic her clinic, couples are seen by three peoe-- dr. renshaw and a male and female therapist. couples ten come to the clinic one blaming the other, saying, "you three fix him. he's not interested," or, "you three fix her. if we don't fix this, we're going to divorce." under that kind of threat, a lot of couples arve. sometimes, there is no blame, anit's important to look at the relationship. it takes two to make le. therefore, it takes two in a quicker way to fix it. the couple become each other's therapist in the pross of couples therapy. therefore, it's very rich.

so the couple is the focal point of therapy even when it's one partner who seems to have the problem. there are people who want to participate sex but cannot-- a man who is unable to have an erection or a woman who is physically unresponsive to sexual stimulation. such problems called ousal disorder there are many potential caus, though it was once thought that these disorders were totally emotional. there was a common misconception which was only recently corrected that the great majority, 98%, say, of sexual sfunction had a psychologic origin, was exclusively psychogenic. that's really true among younger people, but in the over-5o population, which we are now seeing more and more of, by the way, this is not true. at least 5o% of tients wi sexual complaints

over the age of 5o have some organic or medical component. they're either taking drugs with sexual side effects or they have diabetes or arteriosclerosis or hormone deficiencies. complicationarise when the physical problems are combined with emotional ones such as anxiety, perhaps over sexu performance, anger, substance abuse, or stress-- the death of a loved one. treatmt for an arousal disorder has several goals-- to increase intimacy without eliciting feelings of guilt or betrayal, to learn techniques to compensate for the influence of age or medication, and perhaps most important, to chae attudes about what constitutes s. what is sex therapy? i think, today, despite the sexual revolution, what we do in the sex clinic still isiving-- 8o% of the strength

of the therapy is giving sex education to the couples, evenophisticatedouples who say they know the mechanics and the anatomy. this approach to therapy haoften been criticized because it apprs to miss underl. dr. renshaw disagree perhaps 1o% of the patients that we see will need further therapy, and then we give them a referral of a therapist. arthere some that refuse? yes, there are. you cannot coerce someone who doesn't think they need therapy to gand get it. i don'know how to separate sex therapy from relationsp therapy and from psychotherapy in looking at what's going on with the individual. we also use relationship therapy to build the relationship in which the sexual activity is going to be helpful. also, e relationship trapy

takes away from one feeling burdened with the blame, and they become less defensive. that's an portanaspect of what we're trying to do all of us are on the same side, each partner and the team, to impve the relationship. relationship therapy is the beginning. for arousal disorders and for other sexual problems, sometimes new techniques have to be learned. no man with a hand or a mouth needs to be impotent. if he isensitive to his partner's needs, he can stimulate her by hand or by mouth, and he may get aroused in therocess of her arousal. she must also be sensitive to his needs. she can stimulate him by hand or by mouth, and he can get aroused and have an orgagasm without penetration. with this kind of education, bothartners can be helped to a ,

and then therapy c be considered a success. one of the moscommon sexs is desire disorder one of the moscommon sexs an inhibited s drive. it has been estimated at... our relationship became almostonexistent. i was tired. i was angry. i was irritable. i didn't have much of a desire for anything. specifically, there was no sexual desire. mel and jan have been married for 2o years. it wasn't until well into their marriage that they began to experience problems in their sexual relationship. we became farther and farther apart. at that point, we went to a clinic to seek some help. they went to dr. rshaw. desire dorders are interesting things. en we stted the clinic in '72,

there was no definition, and patients are our textbook my first surpris was having a ung, healthy athletic coach of 34 o presented "i not interested in sex. "i've got erections. "i've got no problem complenghe act "when we do t tother which twice a year. i just he other thingso do." this wasn't even dined at the time. i just called them dds--desire disorders, which means that the whole wavelength of thinking about sex engh to feel sexual was ssing, that there were other priorities in the mind of the individual. what causes a desi disorder? the way jan tells their story, it was mel's snoring, but she knows something more serious was going on.der? i must have been going through

some difficult times of my own at that time, because married to somebody for over 2o years, i certainly would have heard m snore at some point those first 19 years. we then had to deal with anger, which is a big wall that builds up like brick-by-brick sentment between couples. there's hot anger in the bedroom if couples say nasty things to each other, and thers anger if you didn't do anything about it. in a lot oinstances when we were having these difficulties, jan didn't want any kind of a relationship-- physical, particularly. if the feelings are bad, th notng is right,tionship-- and it makes it very difficult for them to get together. those are real everyday problems. life is a road that is filled wh emotional potholes. i'm the type of person that is a very outward, warm

loving type person. i need physical contact. i always have, and i always will. when i didn't have physical contact, it drove me up a wall. part of their therapy was dr. renshaw's relationship therapy. in many instances, it has been years since a couple spent quality time together. at first, it may be difficult. it was the cave man attitude-- grab her by the hair and say, "it's time to ve our time alone." no telephone, noids, no dog. and weid that. we made the time, i think that's the main crux of it-- you have to make tim for each other. you have to learn again and get reacquaintedabout each . another typical therapeutic techniqudr. renshaw used with mel and jan is called sensate focus,

a way of concentrating attention on the pleasurable feelings that just being touched eves. nsate focus is practiced at home, and themphasis is not on intercourse but in evoking pleasurable sensations in other ways. when they learn touching, it's like this brand-new, marvous, woerful aphrodisiac. it because theye nevedone that. they've ne for the groin only. that's only 1/1oo of the body. thskin is the largest organ in the body. it is filled with thousan and mlions of little nee endings that secrete endorphins and enkephalins, ich have been called thhains hormones. it was becoming aware of each other sexuly touching your face one at aime, your ears, just gently caressing each oth separately without any type of intercourse.

and even if you had a desire, you weren't supposed to go through with it. she said, "you have plenty otime. don't worry. we'll get there. don't rush it." it was something to look forward to. it was our time. once you learn how to correct that, at that point, everything seemto fall into place. the relationship got better. the attitudes got better. we got together, which was a big thing because i had been totally shut out, and it made a big difference. i loveer very much. sometimes i get frustrated, but i look at it in a different way. it's ok now, where before, it wasn't ok. human xual behavior occurs along a very broad spectrum. as we ha sn, a person's sual beliefs aanbehaors. some problems people have with sexuality

affect only themselves but can still cause deep emotional or physical distress. others are danrous to thendividual and to society. all of them can have a negative impact on a person's emotional well-being until the barriers tt get in the way are addressed. within the past 25 years new approaches to treating these disorders ha been developed. dave is learning new ways to control his sexual excesses. ge is being taught how to avoid repeating his offenses jan and mel have reconciled and have become better friends and lovers. today, sexual disorders are probably the most treatable of the medical anpsychiatric disorders. that's come about because we have learned a great deal in the last 2o, 25 years about the causes of sexual problems. what you find in the paraphilias is that the person is not able to feel sexual attraction and to fall in love

except under the extraordinary circumstances. for some sex offenders, we've found that the first change from their usual emotion state to t ste that indicates they're resuming an abusive pattern is emotional. we he to look at factors within each dividu, that is, their ability to control their impulsive impulses, factors within the family-- were there models for aggression? and not necessarily sexual aggression. the reason treatment of sexual disorders was so inadequate was that the scientific study of sex wwe've only been able to study sex scientifically in the last 25 years. that's why a the progress we've taed about has occurred in the last two decades. we still have a long way to go, but we are so much better off.

captiong performed the national captiong initut inc. captions copyright 1991 alvin h.erutter

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