Weight loss and diet plan for a healthy lifestyle.

In general, treatment with only one of the agents [monotherapy] has been found to be inferior to treatment with two or more of the drugs [combination therapy). Most providers have now abandoned monotherapy because the data so clearly demonstrate that combination therapy works significantly better. However, combination therapy raises the possibility of more potential side effects and involves greater cost. Thus, once again, any treatment plan must be individualized.

The goal of treatment is to decrease the viral load to undetectable levels. If the viral load is greater than 30,000 to 50,000, then medication should be considered even if the T-helper-cell count is stable and a person is feeling well physically. If the T-helper-cell count is decreasing, or a person is experiencing progression of the infection with various opportunistic infections, then medications should be considered even if the viral load is low and stable.

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If a person who has not been immunized has been exposed to one who is infectious with hepatitis B, the exposed person should receive the vaccination series as well as a dose of immune globulin specifically directed against hepatitis B. The vaccination itself, if given after exposure, offers some protection against acquiring the infection. Adding a shot of immune globulin improves the outcome. Immune globulin is a collection of antibodies that help to protect against infection on an acute basis; it provides a “boost” for the immune system, but only for a short time, so the vaccination series is given at the same time to offer long-term immunity as well.

Vaccination plus immune globulin is a good idea after sustaining a needle-stick injury, receiving a bite from someone who is a carrier of hepatitis B or newly infected with hepatitis B, or sexual exposure to a person who is either a carrier or newly infected. If a person has sex with an infected partner, this combination can be given within fourteen days after the contact, but it offers the most protection if given within forty-eight hours of exposure. If there is a significant exposure from a needle-stick injury or from an exposure on a mucosal surface (such as the eyes or mouth), then this combination should be given within twenty-four to forty-eight hours after the exposure. In both of these scenarios, the follow-up vaccinations must be given at one- and six-month intervals.

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incidence: very common

cause: bacterium (Chlamydia trachomatis)

symptoms: burning with urination, discharge (but often none)

treatment: antibiotics

WHAT IS IT?

Recognized since 1970, chlamydia infections are among the most common genital infections. They are caused by the bacterium Chlamydia trachomatis. In addition to genital infections, chlamydia can also cause eye infection in newborns.

Some types of Chlamydia trachomatis can cause lymphogranuloma venereum (LGV), another sexually transmitted infection (see the entry for this disease). Other species of Chlamydia cause different infections. Chlamydia pneumoniae, for example, causes respiratory infection, and Chlamydia psittaci, which is transmitted from birds to humans, also causes a respiratory illness. Here the discussion will be limited to sexually transmitted Chlamydia trachomatis infections.

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If you are diagnosed with an infection, your health care provider may recommend that your partner be screened or treated for that infection. If this presents problems—because of any number of issues that can arise in our relationships with other people—you can ask your provider for suggestions about the best way to handle the situation. Sometimes role playing, with the health care provider acting as your partner, can help you find an effective way to communicate this news. You may want your provider to call your partner for you, or you may want to come to the office or clinic together so that everything can be explained. As discussed earlier, in some instances the local or state health department will help you notify your partner or partners. It may or may not be possible to determine who had the infection first, and in any case that’s not the most important thing: the most important thing is for both partners to receive treatment. It is a sign of respect and concern for your partner to let him or her know what is going on with you. Lack of symptoms doesn’t always mean lack of infection: even without symptoms, he or she could have the infection. This is the time to ask any questions, no matter how silly they may seem. The provider is there not only to diagnose and treat your infections, but also to educate you about STDs and help prevent you from putting yourself or anyone else at risk in the future. Abstinence and safe sex practices will usually be discussed Health care providers expect to receive phone calls from patients, so if you have questions about what was discussed during the examination, do not hesitate to contact your health care provider.

Regular sexual health care check-ups are as important a part of maintaining your health and well-being as a blood pressure check or a cholesterol screen. If you are currently sexually active, or are thinking about becoming active, find a health care provider in your community with whom you feel comfortable discussing these issues. Your health is worth it.

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Contrary to common misperceptions, not all itching in the female genital area is caused by yeast infections. Because of the availability of over-the-counter yeast treatments, however, many women self-treat for genital itching with these medications and never receive professional evaluation of their symptoms. For this reason, some women never receive an accurate diagnosis of what’s really causing their symptoms. For instance, a herpes outbreak may cause genital itching, which a woman may think is caused by a yeast infection; she may start treating herself with an over-the-counter cream. Her symptoms resolve, and she believes she has successfully treated the yeast infection, when in fact the herpes outbreak merely resolved on its own, which it will do without treatment. So even if you think your symptoms are “typical yeast” symptoms, it is a good idea to be evaluated by a health care provider while you are having symptoms (especially the first time you have these symptoms), or if the symptoms recur frequently.

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Understanding Our Values about Sex

Each of us develops ideas about what is right, responsible, worthwhile, and moral. These ideas are called values. Families and communities share many values in common. Values held by most of the people in a society are called social values. Many social values are also sexual values. These reflect what behaviors and traits are considered feminine and what behaviors and traits are considered masculine. They also determine what behaviors are considered right and what behaviors are wrong.

Sexual values differ dramatically from one society to another. Among the Inuit people in the Arctic, it is acceptable for men to share their wives with other men who visit their homes. In Afghanistan, on the other hand, women and men are stoned to death for extramarital sex. In some societies, adolescent boys and girls are kept strictly separated until marriage. In others, such as the Trobriand Islands, children are encouraged to practice sexual intercourse before puberty.

Economics, politics, and religion shape the sexual values of a society as they become part of a society’s customs and traditions. As economic, political, and religious needs change, so do sexual values. Some societies develop a high tolerance for the development of personal and private sexual values. Others are more restrictive and insist on conformity to the dominant social and sexual values. As a pluralistic society, the United States welcomes people from cultures all over the world. They bring a wide range of differing sexual values. Our sexual values are influenced by theirs, and theirs are influenced by ours.

Formal and Informal Values

All societies have two sets of values to guide private and public behavior. There are formal values based on ideals that are defined by religions, governments, and other official groups. They shape a society’s laws, rules, and expectations. We also have informal values that reflect our everyday behavior. Our informal values may not match our formal values. For example, although oral sex is against the law in many states, most sexually active people ignore those laws.

Social values have a great impact on autonomy—how free each of us is to exercise our own will. As we balance our public and private lives, we often question our formal and informal values: How much freedom can an individual be allowed? When should society set limits? How do we balance autonomy with social responsibility? These questions are particularly important when we talk about sex.

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Signs of Child Sexual Abuse

Physical signs of child sexual abuse include weight gain or loss, abdominal pain, vomiting, urinary tract infections, or pain in the genital areas.

Behavioral signs may include sleeping problems, nightmares, withdrawal from others, loss of toilet training, or frequent bathing. When they are being sexually abused, children may become preoccupied with their sexuality .They may indulge in excessive masturbation or sex play. Children who are sexually abused may also abuse younger children.

The emotional effects of sexual abuse include low self-esteem, guilt, shame, and depression. Suicide attempts, eating disorders, drug and alcohol abuse, intimacy problems, and sexual dysfunction can also be responses to child sexual abuse.

Incest

When sexual abuse of children happens within the family, it is called incest. Incest is a controversial topic. Some adults report that their incestuous relationships as children were positive. This is especially true of those who recall exploratory sex play with siblings of about the same age. Many others recall that these relationships were confusing and harmful.

Incest, especially between parent and child, can have serious emotional effects on children. They may become less able to feel safe and secure, even when they become adults. Like other children who are abused, they may feel such guilt and shame that they grow up having difficulty with intimacy, self-esteem, body image, and sexual pleasure.

These aftereffects may be especially confusing. Children may experience some erotic pleasure and some comfort by being so close to a parent. At the same time, they may fear and distrust the parent whom they love and with whom they want to feel safe. They may be so ashamed and confused by their feelings that they don’t know what to do or where to turn. They may try to keep it all a secret within themselves.

Children and adults who suffer the effects of incestuous relationships may benefit from professional mental health care to relieve the shame, guilt, anger, and sexual conflict they feel.

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The line drawn between “early normal” and pathologically early or precocious puberty is somewhat arbitrary. In the leading American handbook of pediatric endocrinology, van der Werft ten Bosch refrains from giving a definition of sexual precocity other than “the appearance of symptoms and signs of puberty earlier than is to be expected in a child with a particular genetic and environmental background.” He finds it desirable that a child of either sex who begins pubertal changes before age nine years have detailed medical investigation. By contrast, some endocrinologists agree with Bierich’s definition by which the term sexual precocity is used for girls, and if they show signs of sexual maturity before their sixth birthday (menarche before their eighth birthday), and for boys, if signs of sexual maturity appear before their eighth birthday. Precocious puberty can be secondary to a variety of more general medical abnormalities, including a lesion in the brain or the peripheral endocrine glands. It also can be idiopathic or spontaneous without any other physical disorder. Children with idiopathic precocious puberty show a hormonal pattern similar to that of normal children during puberty, including the pubertal pattern of sleep-associated LH release (Boyar and others), and in girls, an enhanced (in some cases even exaggerated) gonadotropin response to JLH-RH administration (Reiter and others). It is not yet quite clear, however, if idiopathic precocious puberty can simply be equated with an early timed but otherwise completely normal puberty: for instance, Bidlingmaier and others found considerably lower basal gonadotropin and estrogen levels in girls with precocious puberty than in normally maturing girls of the same developmental stage, although those patients who were examined repeatedly at short intervals, showed an almost cyclic pattern of their estradiol levels similar to the pattern of normal pubertal girls before menarche. The authors speculate that enhanced receptor sensitivity or changes in the concentration of sex-hormone binding globulin may play a role in idiopathic precocious puberty, in addition to the premature neural activation of the hypothalamic-pituitary-gonadal system. Clarification of this issue is obviously important to the interpretation of future behavioral studies on such children. A girl with precocious puberty typically has to cope with an early growth spurt putting her on the growth level of other children who are two or three years older than her chronological age, so that a six-year-old girl may be as tall as one who is eight or nine years old. At the same time, she will begin to show pubic and axillary hair, breast enlargement, and menstruation. The psychosexual development of girls with precocious puberty is not well researched. In an early medical review, Reuben and Manning cited eighty-three cases of pregnancy below age fifteen years—thirty of those below age twelve years—and claimed that the majority of the young women had a history of precocious puberty; they screened their own eight female cases of precocious puberty without pregnancy and noticed “sexual desire” only in one, mentally defective girl. Kinsey and others, in examining cases of precocious puberty, “have rarely found sexual activities which exceeded those ordinarily found among normal children of the same age.” In a follow-up study of fifteen girls with idiopathic precocious puberty (ages ten to twenty-five years) by Money and Walker, apart from case reports the only more recent study that deals with this particular issue, masturbation and sex play did not appear to be increased. Normal sexual curiosity occurred more or less consistent with age and independent from the precocious puberty. Premarital intercourse did not occur earlier than normally expected (age seventeen years and up), with the exception of one girl who became pregnant at age eleven and was the only mother in the sample. Contrary to the typical fears of parents and teachers, precocious sexual behavior did not seem to be a frequent concomitant of precocious puberty in these girls. We do not know, however, how representative the sample was for such patients in general.

Precocious puberty occurs less frequently in boys than in girls. The overall somatic effects in boys with precocious puberty are analogous to the ones in girls. Parental fear is even higher than with girls that their sexual behavior will become a problem at an early age; however, this fear seems to be largely unwarranted. Money and Alexander studied eighteen boys with precocious puberty; four of them had the idiopathic condition and fourteen were virilized as a result of congenital adrenal hyperplasia. In the latter condition, the adrenal is defective and produces high amounts of androgens leading to the typical signs of male pubertal maturation except for testicular development, since the hypothalamic-pituitary-gonadal axis is not involved. Onset of the corrective glucocorticoid treatment may occasionally induce true precocious puberty. The authors found that sociosexual behavior typically was only moderately ahead of chronological age. Erotic fantasies and masturbation occurred considerably earlier than usual, but the fantasy content was often very immature and reflected the age-typical lack of adequate sex information. Homosexuality and paraphilias did not develop. Unfortunately, the two diagnostic groups were not compared to each other.

In summary, the clinical studies of precocious puberty provide some evidence for hormonal effects on sexual behavior, more so in boys than in girls. In most cases, the effects are usually not very dramatic and do not involve uncontrollable overt sexual behavior.

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Not only the amount but also the nature of stimulation between the infant and mother is important. When the infant is suckling, it reciprocates by putting fingers into the mother’s mouth; she responds by moving her lips on the baby’s fingers. The baby moves its fingers; she responds with a smile. All the while the baby studies her face with rapt attention. Infants pat the mother’s breast while sucking, pat her face, turn a cheek to be kissed, clasp her around the neck, lay a cheek on hers, hug, and bite. “Such little scenes can be observed in endless variations in any mother-child couple”. Some of the expressions of affection through patting and hugging may be spontaneous, while others are learned in the infant’s encounters with mother and other adults.

If a responsive woman is the mother of a non-cuddling infant, there is considerable challenge to her adaptability, as with a cuddly baby and a nonresponsive mother. Some mothers make it clear that breast feeding is at best a duty and is not physically nor emotionally pleasurable. If the suckling experience seems unworthy or shameful to her, the mother may not be able to acknowledge it or may feel the need to find acceptable excuses. In the United States, illness or physical inadequacy are commonly accepted as “good” reasons for not suckling infants.

In contemporary American culture, the breasts play a more prominent part in the erotic encounters of adults than they do in suckling experiences with infants. In societies in which suckling is generally accepted, infant-mother separation is not easily tolerated by either participant. In speaking to Ganda women, Ainsworth relates that a number of mothers said they enjoyed breast feeding, and one confessed with embarrassment that it was so satisfactory to her that though her child was over twelve months of age she was reluctant to wean him. Matthews, in describing the infant-mother sensory contact among the Yorubas of Nigeria, reports that a strict breast-feeding routine would be difficult to attain because the mothers, determined and obstinate, were not easily separated from their babies for long. The baby remains from birth until about the second year of life almost constantly in close physical contact with the mother who feeds it at irregular intervals, usually determined by the infant’s crying.

Among the Dahomey, mothers regularly carry their infants about with them, and the infants seldom have other nurses. Close bodily contact and suckling are continued for two to three years. There is no cohabiting between husband and wife during this period if the man has other wives. To what extent the infant becomes a “lover” surrogate in such long absences from marital coitus is a moot question. Infant and mother frequently stay in continuously close sensory contact in many societies characterized by late weaning.

Besides the suckling encounters, in a few primitive societies adults participate actively in the erotic stimulation of infants and young children. Among the Kazak, adults who are playing with small children, especially boys, excite the young one’s genitals by rubbing and playing with them. Autogenital stimulation by the young child is accepted also as a normal practice. Among the Balinese, playing and teasing with the genitals is common. A mother will pat her baby girl on the vulva and exclaim, “Pretty! Pretty!”. A boy’s penis will be stroked and rubbed. After he has urinated, he will be dried by a flick of his penis. As he grows older, his penis will be pulled and stretched and ruffled, and often he will attempt to keep his balance when learning to walk by holding on to it. Babies are comforted and quieted by manipulating the genital organs. In fact, in Bali, a baby, especially a baby’s genitals, are toys with which to play. There is much delight taken in stimulating and playing with the baby to watch it respond.

There has been a strong taboo in the United States on suckling an infant in public or even on including photographs in magazines of infants suckling, whereas bottle feeding in public and pictures of bottle-feeding infants are acceptable. In America, a young mother often starts suckling her infant without having once observed another woman suckling an infant. Lactation failure, or the inability to suckle infants, fluctuates greatly over short periods of time, suggesting that it is triggered by psychological rather than by physiological factors. For instance, national surveys indicate that the rate of breast-feeding infants in the United States fell by almost half during a ten-year period. Likewise, during twenty years in Bristol, England, the number of three-month-old breastfed infants dropped from seventy-seven to thirty-six percent. In an obstetric clinic in France the proportion of babies not suckled increased from thirty-one to fifty-one percent in five years. This change is so rapid that it cannot be attributed to hereditary factors and major physiological changes in function would be unlikely in the absence of radical stresses such as starvation or epidemic disease.

It is reasonable to assume that there is in the United States a preoccupation with words and articulated culture rather than with touch. There has been a prudery and anxiety about physical contact and erotic matters. With this assumption in mind, Clay observed the behavior of forty-five children and their mothers at three public beaches patronized by persons of different social classes. One of the patterns he observed was the lack of contact between infant and mother on the beach. The majority of encounters between infant and mother were of two kinds: first, taking care of the infants and, second, controlling their behavior. Far less frequent were intimate contacts expressing love and attachment. Parents rewarded “desexualized” motor performance that kept the infant away from the mother. Girl children received more physical touches than did boys, and they were in physical contact with their mothers longer than were the boys. For mothers of young children, having a good time at the beach did not appear to include mothers enjoying their offspring in a direct, personal, affective, tactile, and sensual encounter. Upper- and working-class mothers were more inclined to comfort their children with tactile contacts; middle-class mothers offered distractions, mostly food. Middle-class mothers seemed more interested in meeting friends at the beach than in relating to their children. Small children were expected to play alone away from the parents. These observations and conclusions, however, must be regarded as suggestive rather than definitive.

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For obvious reasons one cannot experimentally manipulate the prenatal environment of human beings to produce cases of hermaphroditism or intersexuality as can be done with rodents or nonhuman primates. However, there are cases of human hermaphroditism (intersexuality) produced by nature, similar to those produced experimentally in animals.

One such form of human intersexuality occurring in XX females is the adrenogenital syndrome. This is a genetic autosomal recessive condition in which the adrenal cortex of the fetus fails to synthesize one of its proper hormones, Cortisol. Instead, it secretes an excess of androgen. In some cases, there is an associated deficit in salt retention. Affected females are born with a hypertrophied clitoris. In some cases masculinization is so complete that instead of an enlarged clitoris, there is a penis and empty scrotum.

In some instances, an XX adrenogenital baby is assigned and reared as a boy. But the more common practice, once the diagnosis has been established, is to institute a program of surgical feminization consistent with assigning and rearing the baby as a girl—even if a sex re-announcement is necessitated.

The endocrine treatment for all babies with the adrenogenital syndrome, discovered in 1950, is therapy with a synthetic form of Cortisol, the missing adrenocortical hormone. This therapy, if begun neonatally and continuously maintained, suppresses excessive postnatal androgen production. Then, at the expected time of puberty, girls with the adrenogenital syndrome develop a feminine physique. Their menses may be late, the time of onset being variable. They will ovulate in adulthood and can expect to conceive pregnancies.

Adrenogenital girls treated since infancy are of special interest to gender identity/role theory because of their history of prenatal androgenization subsequently corrected. Their psychosocial and psychosexual development has been followed longitudinally at The Johns Hopkins Hospital and at Children’s Hospital at Buffalo. The evidence to date is that fetal androgenization does influence subsequent development of behavior, though only to a limited degree.

Behaviorally, girls with the adrenogenital syndrome are described as having a high level of athletic energy as demonstrated by their interest and participation in organized group competitive sports, usually with boys. For example, they become involved in boys’ neighborhood football, basketball, or baseball. They are accepted by the boys because of their superior athletic skills. They do not assert themselves to obtain a high rank in the dominance hierarchy of boys.

Adrenogenital girls do not display much interest in dolls or stereotypic girls’ games. During childhood, they do not show much interest in babies, romance, and marriage, as compared to their unaffected sisters.

Girls with the adrenogenital syndrome show an interest in boys and dating much later in adolescence than do their peers. Divergent from their age-mates in this respect, they often become relatively isolated from them.

Recently it has been possible to obtain the first follow-up information on the psychosexual status of adrenogenital girls, now young adults, who have a history of being hormonally normal as the consequence of cortisone therapy started in infancy. Money and Schwartz (1976) and Schwartz (unpublished Sc.D. dissertation) report findings suggesting a greater incidence of bisexual and homosexual imagery than would be expected by chance. A replication study is needed.

Not all of the 46,XX infants with the adrenogenital syndrome are assigned and reared as girls. In the past, some were assigned and reared as boys, especially those born with a completely formed penis and fused scrotum as a result of extreme fetal androgenization. Although their counterparts who are reared as girls differentiate a female gender identity/ role, these boys differentiate a male gender identity/role, performing sexually as men with women partners.

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