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From the above account, one cannot escape what is most central to and best understood in psychoanalysis, namely, sexuality as a dynamic force in the etiology of various neurotic conditions. This has been one of the most important discoveries of psychoanalysis and is important to all psychoanalytic treatment. However, one should not let this obscure one’s view of what psychoanalysis is about and what it is for. I will take the rather strong position here that psychoanalysis is not a specific treatment for sexual disorders. There are other therapies that contend for that honor and perhaps come nearer to filling the bill than psychoanalysis does, although in my judgment we are far from having achieved anything like an effective, therapeutic approach to such difficulties. Even the best of such sex therapy techniques, employed by the most experienced and skilled clinicians, yield results that are less than satisfactory in a large number of cases. We now have only a poor understanding of why such specific therapies are relatively successful in some cases yet seem to fail over the long-run with many.

The implication of my statement that psychoanalysis is not a specific therapy for sexual disorders is that, in my judgment, psychoanalysis would not be indicated simply because a patient suffers from some sexual disorder. That a patient is frigid or impotent or suffers from premature ejaculation is not sufficient grounds for treating such a patient in psychoanalysis. When patients suffer from more deeply engrained and enduring forms of sexual disturbance relating to various forms of perversion, fetishism, transvestitism, homosexuality, psychoanalysis is still not a specific treatment, in my judgment, but in such cases there are almost inevitably other grounds upon which the decision to enter psychoanalysis might be made. In the latter sorts of cases, there are usually long-standing personality defects and impairments, or neurotic conflicts underlying the disordered sexual behavior which call for a deep and thorough analysis of the patient’s object-relations, both those in his current life and those in the past, as well as re-examination and regressive reworking of the patient’s developmental experience itself. Psychoanalysis is the specific therapy for such an undertaking.

Not only can it be said that psychoanalysis is not a specific sexual therapy, but in implementing its efforts psychoanalysis does not focus on the sexually disordered symptom. Sexual behavior together with its associated wishes, fantasies, attitudes, impulses, dreams, and so on, are subjected to careful examination in an effort to gain a deeper understanding of their meaning in the patient’s life and in connection with underlying conflicts and their developmental roots. As analysis progresses, as conflicts are reopened and re-examined and gradually resolved, and as the therapeutic changes begin to occur, particularly those modifying superego dynamics and increasing autonomy and conflict-free operation by the ego, the symptoms begin to wane. Not only do they become less frequent in the patient’s experience, but their compulsive and often driven quality seems to become less intense so that the patient gradually becomes relatively symptom-free.

The hysterical female patient who had suffered from frigidity finds her orgastic potential increasing and becoming more readily available, as she is able to work through the underlying oedipal conflicts and to recognize that her symptoms are related to underlying conflicts over sexual impulses towards her father and their gratification. As this aspect of her symptoms becomes more consciously apparent to her and is gradually resolved in the treatment, the symptom of frigidity is also resolved. Similarly, the young man whose difficulties with premature ejaculation have caused him considerable embarrassment and difficulty, finds that as he is able to handle more effectively his conflicts over aggression and self-assertion, and is able to surrender his somewhat infantile position of inadequacy, he too finds that little by little the annoying symptom seems to dissolve and disappear. In none of these cases was the analytic effort directed at the symptom itself, but rather to the underlying personality configurations, conflicts, and developmental issues pervasive influencing the patient’s life, of which the sexual symptom was merely one limited expression.

The issues in such symptomatic cases are somewhat different from the more deeply engrained perversions, particularly homosexuality. Recently analysts have directed a great deal of attention to homosexuality and the possibilities for its treatment. Certainly the attitudes toward homosexuality have changed over the last three-quarters of a century. Freud’s opinion at the time of the Three Essays was that little could be done for homosexual patients except suppression of symptoms by hypnotic suggestion. The attitude among clinical psychoanalysts toward the treatment of homosexuality has become considerably more optimistic, although at the same time the awareness of the complex personality structure underlying homosexual symptomatology and behavior has deepened.

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A paraphilia is not, by definition, a pathology. Rather, it becomes pathological when it becomes too severe, too insistent, and too noxious to the partner, or to the self. In mild form, paraphiliac imagery and the behavior it engenders may be simply a part of love play. For example, a playful degree of biting, slapping, or pinching qualifies as sadistic but is harmless when the play is between consenting partners.

In medicine generally, and in sexology in particular, there are many occasions when one is confronted with the issue of how to establish criteria of pathology. When, for example, does an elevation in temperature become a fever? Or a shortness of stature, dwarfism? Or an insufficiency of food, malnutrition? The criterion point adopted in answer to such questions may have great practical significance. In Peking, for example, Westerners in the diplomatic corps recently may have been denied a Chinese driving license because their blood pressure, judged normal at home, would be elevated according to the norms of the Chinese who have a lower average blood pressure.

There is always something arbitrary about the choice of a criterion of normalcy. It is arbitrary even to choose the statistical norm—it may be normal to be infested with hookworm or schistosomiasis in certain locales, but it is not healthy. The criterion of health versus pathology involves a chain of logical reasoning that sooner or later brings one into direct confrontation with a value judgment. The personal criterion of pathology may be too much pain, suffering, and loss of the feeling of well-being. The social criterion may be too much harm to, or threat of endangering the health or well-being of others. The well-being of others may be covertly or implicitly defined as their political, legal, moral, spiritual, or religious well-being.

In matters of sexual health, as in behavioral health in general, social criteria have traditionally dominated personal ones. They have been powerfully religious and legalistic, but politically and ethnically arbitrary. This arbitrariness is presently under fire, and to some extent there is today a social re-examination of criteria and standards. In their 1974 referendum, for example, the membership of the American Psychiatric Association confirmed the action of their committee on nomenclature in changing the status of homosexuality from disease to non-disease.

The mood of society today is toward the greater tolerance of the principle of live and let live sexually, provided both partners are consenting adults or, if young, of like age. There is no fixed dividing line between the tolerable and the intolerable, socially, and no criterion for establishing one. A workable criterion, which is both expedient and pragmatic, is the criterion of mutual consent between erotic partners, up to the point of noxious injury to health and well-being. This criterion rules out lust murder, rape, abusive sadism, a masochist’s self-arranged torture and death by homicide, enforced amputation of the partner by an amputee fetishist, enforced celibacy or erotic deprivation of the partner by a transsexual, and the like. Other forms of erotic expression, subject to the proviso of mutual consent, are not ruled out. Any individual whose form of erotic expression engenders too great a loss of well-being is, however, eligible for whatever therapy sexological medicine may be able to offer.

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The study of “sex” and the “law” immediately taps a Pandora’s box of social, philosophical, and political conundrums. Merely providing preliminary definitions of the two terms may not adequately delineate the domain of study. Indeed, each concept compels the analyst to consider a world of discourse and of human interaction.

“Law,” when restricted in its connotations to those entailing legal forms and systems can be at least minimally demarcated for analysis. Yet even when “law” is reified as an explicitly enacted or habitual set of rules for behavior, its conceptions will vary. (On one level, of course, it is that very variation which strengthens the processes of American jurisprudence.) Although the law is generally presumed to serve the “good” of the community, the puzzle which Swift posed in Gulliver’s Travels continues to be true: “How . . . should [it] come to pass, that the law, which was intended for every man’s preservation, should be any man’s ruin.”

Gulliver notwithstanding, in sociological investigation, a society’s codified law does provide an arena within which to consider a people’s notion of itself and of others. Most obviously, laws speak about and express sanctioned behavior and specify other, less tolerable or intolerable (illegal) activities and interactions. Law separates that which should be from that which should not be. More significantly, law is built upon and contains implicit assumptions about the nature of things as they are. Under-girding the formalized prescriptions and prohibitions of a legal system lie pervasive, taken-for-granted conceptions of and about reality.

Law is created and enforced by particular groups of people who may not represent the interests of all a society’s participants, some of whom may, as Swift put it, face their ruin through the law’s hand. Correspondingly, laws frequently become the subject of dispute; the very founding of the American nation was represented, if not actually caused by revolutionary dispute over the proper application of British laws of taxation. The obviousness of refutation and protest can, however, conceal fundamental similarities in the way disputing groups understand nature or conceive the limits and possibilities for action. Legal cases and court decisions tend to frame areas of divergence, to focus on issues of disagreement. Equally significant to sociological study are unspoken agreements and shared assumptions; such assumptions often remain tacit, precisely because they are so “obvious,” yet they provide a ground on which conflict can be created, shifted, or resolved.

We are concerned here with the application of law to and the interrelation between law and sex. If it is discomforting to attempt definitions of law, it may be impossible to define sex. Even the most immediate definition—”two divisions of organic beings distinguished as male and female respectively” (Oxford English Dictionary)—has ramifications. If one takes “sex” to imply modes of behavior, the connotations amplify and spread almost unendingly. Since Freud’s work, the forms and referents of sex appear to practically everyone, practically everywhere. Shulamith Firestone suggests that Freud merely said it; he constructed an important theory based on notions of sexuality, because he described a key characteristic of his era: “Freudianism is so charged, so impossible to repudiate because Freud grasped the crucial problem of modern life: Sexuality” (Firestone).

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Since Freud’s exploration of childhood sexuality, there have been a number of clinical and developmental studies in this area. These include the clinical observations of normal and pathological behavior in children and adults, experimental studies of sexuality and patterns of behavior among children and animals, and some longitudinal studies of children who early in life displayed sex-type behavior not congruent with their biological sex assignment.

There is considerable controversy as to what constitutes “sexual behavior” during childhood, since childhood sexual behavior, no matter how closely it imitates the adult sexual experience, does not lead to the orgasm which is the goal of sexual relationship during adulthood. Freud defined sexuality in much broader terms. To him, sexual behavior is motivated by the libidinal drive or its derivatives, and the goal is to discharge energy, as a result of which the individual experiences pleasure and avoids the pain of undischarged energy. The gradual organization and transformation of the libidinal drive’s source, objects, and aims, in the course of development, finally lead to genital sexuality as observed among normal individuals – namely, the capacity for a heterosexual and affectionate relationship with a non-incestuous love object.

Because there is no orgastic experience during the first five years of life when the major organization and transformation of libidinal drives occurs, many investigators have looked for a manifestation of sexuality in male and female differences in children’s behavior. Animal studies among mammals and primates (Beach) show that animals frequently display specific sexual behavior such as mounting and stimulating genitals before they reach adulthood and become capable of sexual intercourse. It seems that these early sexual experiences are crucial for the mature animal to become sexually competent. Inexperienced adult male monkeys often are incapable of sexual intercourse even with a receptive female. Harlow’s study with monkeys has demonstrated clearly the relation between early maternal experiences and sexuality during adulthood. Monkeys raised by wire surrogate mothers during infancy were incapable of sexual intercourse. The females rarely became pregnant and even when they did succeed in giving birth, their maternal behavior was atypical. Instead of exhibiting the usual maternal behavior such as holding, feeding, grooming, and protecting their young, they showed aggressive and assaulting behavior aimed at the destruction of their offspring.

Sex-type behavior can be differentiated much more readily in young animals than in human children. The behavior of the male infant rhesus monkey is visibly aggressive, and the female infants display more “passive” behavior such as sitting quietly and allowing other animals to approach them. The preadolescent male monkey plays mostly in a group of the same age and sex. His play consists largely of aggressive, rough-and-tumble chasing. The female preadolescent, especially if she is small and weak, is excluded from the male group. There seems to be some similarity between the preadolescent monkey’s social behavior and that of preadolescent humans in Western societies. Boys and girls lean toward exclusive homosexual grouping at around eight to twelve years of age (Thumpson and Horrocks).

Prepubertal sex play is common among most mammals (Beach). This includes not only the display of behavior usually leading to sexual contact among adults, but also direct genital stimulation. In humans there also is evidence (from everyday observation by parents and nursery and kindergarten teachers) of different sex-play roles and sexual activities among the very young (Issacs). In societies and cultures in which the expression of sexuality is not repressed as it is in Western cultures, there are reports (Malinowski) that there often is sexual play among children that does not violate the kinship taboos of the culture.

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Because of the attention in our professional literature given to problem sexuality, its causes and treatment, it is interesting to find that significantly high percentages of married people find their sex lives to be pleasurable and satisfying. Though Kinsey’s studies did not report data on satisfaction with marital sex, Hunt presented some findings which indicate the extent to which his sample viewed the sexual part of their marriage as positive. Among the youngest married male cohort, 99% termed their marital coitus “mostly” or “very” pleasurable, as did at least 94% of the older cohorts. The married women in this sample presented a somewhat different picture. The percentage rating their marital coitus “very pleasurable” rose from 57% for the under-twenty-five cohort to a high of 63% for the thirty-five to forty-four age groups. Thereafter, the highly positive appraisal dropped, with only 45% of the forty-five to fifty-four group and 38% of the fifty-five and over group giving their marital sex such a rating. Adding the “mostly pleasurable” responses to these resulted in 88% for the under-twenty-five women, 93% for those between thirty-five and forty-four, followed by a decline to 91 and 83%, respectively, for women in the next two decades.

The Tavris and Sadd Redbook study found that happiness and sexual satisfaction were related to religiosity and freedom of communication with husbands. The more religious the wives, the more likely they were to report their marital sex as good or very good. Eyen so, two-thirds of the nonreligious or moderately religious wives rated their sex lives good to very good, compared with 88% of the very religious wives.

The strongest indicator of sexual and marital satisfaction for the Redbook wives was the ability to discuss sex with their husbands. “The more they talk, the better they rate their sex lives, their marriages, and their overall happiness”. For example, of the 47% who “always” or “often” discuss sex with their husbands, 56% and 43%, respectively, rated their sex lives as “very good.”

Meanwhile, a survey of British wives reported in Sexuality Today concluded that 54% of them are contented with their sex lives. The “average woman” in this sample of 836 wives makes love about twice a week; more than a fourth consider themselves “pretty sexy.”

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Many older people like to think back over their lives and this can give great pleasure. One of the assets that a dementia sufferer usually has are his or her early memories. This ability is sometimes used therapeutically in day hospital and elsewhere, for example encouraging people with dementia to draw pictures of their past, use photographs and other visual material to make a collage, or write notes if this is still possible. A folder of relevant material or a box of objects relating to the past can be used many times in an attempt to bring out happy memories. Old photographs of family, friends, holidays, weddings, and so on are also helpful. Records, or somebody playing music from the past on the piano, will often evoke memories that may stimulate conversation.

An alternative approach is to use stimuli, such as pictures or music, as part of a simple game. Often the questions can be made up as one goes along and a single object can be used repeatedly as the basis for different questions.

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Coping with dementia can generate two different types of family problem. The first is the stress that can be caused by the demands that the disease process makes on the carers and often their children. The second, connected with the first, is the ill-feeling that can sometimes be fostered within families because one or two members feel that they are taking most, if not all, of the responsibility and providing the greater part of the care.

It is important that all members of the family are involved in making decisions about the pattern of care that is to be provided and the support that is required. If you are a lone carer among others who are helping only a little or not at all, it may help to arrange a family conference so that they are all aware of how you are feeling and what you are having to cope with. If you are beginning to feel that you have gone as far as you can on your own, make this plain in a sensitive way and ask the others not just whether they can help, but how they can help. If the time has come when lack of additional support means the sufferer will have to go into an institution, for example, they have to realize that this is a family decision and not just yours. You have done all that you can and they are saying that they have done all that they can. Even if you are the mainstay of the care that is being given to your relative with dementia, it is not just you that is responsible for any change in the pattern of care, but all your family together. In other words, the change is occurring not just because you can’t carry on but because they can’t help either. Above all, don’t carry on nurturing ill feelings beneath an apparently unworried outward appearance. Dementia is a family disease, and the whole family has a responsibility to anyone suffering from it.

When younger relatives take an aged parent with dementia into their household, this often has an impact on their own children. Children can suffer anything from the loss of their bedroom to less personal attention from their parents, though they tend to be remarkably good at coping with situations like this and adapt very well. It is often the parents’ worries on behalf of their children that are the problem, rather than the effect on the children themselves. Sometimes, however, children can be affected adversely and there is no way of predicting this in advance. Fear, particularly in younger children, can often be overcome by explaining what is going on and why their grandparent is now so different, and also letting them see how you handle situations and relate to their grandparent. Very often children form a delightful relationship with a demented elderly person, particularly in the earlier stages of dementia, and this is probably beneficial to all involved. Children’s love can be very different from that of adults — a natural expression of affection rather than a feeling of duty, which is so often a part of the emotional relationship between an adult and his or her ageing parent.

The biggest problems usually involve teenagers. They may be embarrassed to bring their friends home and feel isolated as a result; they can feel reluctant to let their friends know the situation, in case they become the object of ridicule. There may also be clashes, either because they are asked to help or because although they would like to, it would conflict with the demands made upon them by the usual teenage activities. It is very important that they understand what is going on; sometimes, as is the case with younger children, teenagers can make a major and very positive contribution to the care of a person with dementia.

It is essential, when accepting an older person with dementia into your home, not to expect that the whole family should arrange their lives around the sufferer. The other family members will still need time and attention from each other, possibly even more so than before, and everyone will have to be very sensitive about one another’s needs. Hostility or aggression in one member of the family should not be allowed to spread; rather, the underlying stresses and strains should, if possible, be addressed.

In some cases, despite the best of intentions, taking a relative with dementia into the family is disastrous. If this happens, you have to rest content with the knowledge that you have at least tried to do the best that you can. It is important not to feel guilty about exploring alternative approaches to care. It is the integrity of your own immediate family that is most important. If this breaks up, not only will the sufferer lose out, but so will everybody else. Take seriously any tendency to arguments and family unhappiness before it goes too far.

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Much of what has been said about the relationship between patients, relatives, and general practitioners is also true in the context of the hospital clinic. There are, however, several practical points that should be borne in mind. Aim to arrive at least ten minutes before the appointment time or, if parking is likely to be difficult, even earlier. If transport has been arranged by the hospital make sure that you are ready a good quarter of an hour before the time that the ambulance or car is due. It is very likely that you will have to wait for some time both before seeing the doctor and while some of the assessment is taking place, although you will be involved in quite a lot of this yourself. It is important therefore to take something to occupy yourself and if possible something that will occupy your relative with dementia. It is also a good idea to make sure you know where the toilets are and if you have to make use of them, let the nurse in charge of the waiting area know where you are going, and that you won’t be long. If you have to leave your relative in the waiting area, make sure that the nurse knows that he or she will be unattended, particularly if wandering is a problem. If your appointment is near a mealtime, ask whether there is a cafeteria for patients in the hospital or take sandwiches. It is better to do this than risk going without a meal. Make sure that the clothes your relative is wearing are easy to take off as he or she will probably need to be examined fully.

Remember that the staff at the clinic are there to help you. It may well be more difficult to talk to them than it is to your own general practitioner whom you know better and whom you see in relatively familiar surroundings. Even if the doctors, nurses, and others seem busy and hurried, remember that you have come a long way to see them, probably at great inconvenience to yourself and possibly others, and that it is important that you leave the clinic with a clear idea of the present position and what is going to happen next. After all, if you return home and find that one of your most pressing questions hasn’t been answered, it won’t be as easy to find out the answer as if you had only to repeat a visit to the general practitioner’s surgery.

Despite being well-organized, many people nevertheless discover when they arrive home that they have forgotten something that was said or have forgotten to mention something. Don’t worry about this! There are two courses of action that you can take. One is to make an appointment to see the family doctor and ask him whether he could answer the question for you or find out the answer. The other approach, possibly the better of the two, is to write a letter to the specialist explaining the position and putting the question again.

I would like to stress again that although the staff in hospital clinics may well seem more difficult to approach, either because they are less familiar than the local general practitioner or because they seem exceptionally busy, it is important that you take this opportunity of finding out the answers to your questions. Don’t be intimidated by them. As long as you ask your questions in a courteous and friendly manner, you will most likely be treated with consideration.

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Many people suffer from hardening of the arteries, including those of the brain, as they grow older. This means that the wall of the blood vessels thickens and narrows, causing a slowing down of the blood flow. It is, however, not this narrowing that causes the dementia, but a complete blockage causing the death of brain cells. Many people live with narrowed arteries for twenty or thirty years without any effect on their intellect; it is only a sudden, complete blockage that causes a stroke and an accumulation of these blockages that leads to MID. In many cases disease in the cardiovascular system elsewhere — outside the head — has resulted in small particles or clots travelling along the arterial system to a small artery in the brain that they then block, depriving that part of the brain of its blood supply with the resulting death of cells. This therefore is the sudden blocking off of small arteries referred to above whereas arteriosclerosis, when it occurs, blocks off arteries very slowly and may take years to cause significant narrowing of a blood vessel. It is not therefore always arteriosclerosis in the brain itself that causes the problems, but changes in the blood vessels elsewhere in the body, especially those between the heart and the top of the neck. Further causes of small strokes are discussed later.

Infarcts in the brain look similar, irrespective of the way in which they are caused. When they have been present for a long time there is often a small hole as the body’s natural processes remove the dead tissue. This hole usually fills up with fluid. Where this hasn’t happened there is usually a patch of softened material. Examining the brain with the naked eye can usually reveal all of these changes. Looking down the microscope will confirm that the microscopic changes that one expects to be associated with a stroke are also present.

If enough tissue is destroyed, there will be a reduction in brain size and weight with enlargement of the ventricles inside the brain and wasting of the ridges on the brain’s surface.

As one might expect, the severity of the dementia parallels the number of areas of the brain that have been destroyed. It has been suggested that dementia only occurs after a certain amount of brain tissue has died and this threshold has been estimated to be approximately 50 ml — the equivalent of ten teaspoonfuls. In many cases, however, we come across people who have multiple infarct dementia, but in whom there is less than 50 ml of dead brain tissue. Whether or not a person develops dementia seems to depend not only upon the total amount of brain tissue that has been lost, but also upon the site of the strokes. Some brain structures are more important than others in this respect.

Smoking

It is now well established that people who smoke cigarettes are more likely to have a stroke than non-smokers and it has even been suggested that about a third of strokes or similar episodes may be caused by cigarettes. There is, however, very little specific evidence to link smoking with dementia as opposed to paralysis of the limbs or face. Nevertheless because there is no doubt about the effects of smoking on the blood vessels, it makes sense to cut down or preferably to cease smoking altogether if there is any evidence of even a single stroke, whether this is affecting mental function or the limbs.

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Like so many other conditions that mainly affect older people, there always seem to be more elderly women who are affected by these illnesses than men. This is probably a reflection of the fact that in general women live longer than men, the average woman of sixty-five having a reasonable chance of living into her early eighties whereas most men of this age have a life expectancy of approximately thirteen years — into their late seventies. The situation isn’t quite as simple as this, however, because there is a suggestion that women with Alzheimer’s disease, the most common cause of dementia, tend to live longer than men with Alzheimer’s disease. There is no obvious reason for this, but it may be that female demented patients are fitter than the men. Some of this difference in life expectancy may be a result of the earlier habits of the men who are now old, since men used to drink and smoke far more than women. It will be interesting to see whether contemporary changes in these habits will even out the difference in the length of life expected by normal old men and women, and those with a dementing illness.

There is no unequivocal evidence that dementia strikes any particular social class or professional group more than others. Certain types of illness that cause dementia occur more frequently in certain groups; people who drink too much alcohol are more likely to have dementia, caused either by the brain damage that results from the excess drinking or because of the associated vitamin deficiencies that many alcoholics suffer from. However, as the commonest cause of dementia is Alzheimer’s disease which does not show a particular affinity for any specific group of people, dementia in general would appear to affect men and women in roughly equal measure and not to be associated with any other particular sub-group. The socio-economic group to which a person with dementia belongs does, however, have one important effect upon the progression of the illness, since those from lower socio-economic groups are more likely to be admitted to hospital or an alternative institution for prolonged periods of care and for the management of intercurrent illness.

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