Все о мигрени – All about migraines

Often heart disease runs in the family, and sometimes large numbers of family members die at a relatively young age of this condition. Our genes affect how high our LDL cholesterol is because they determine how fast LDL is made and removed from the blood. You are two to five times more likely to have a heart attack if a first degree relative has died of coronary heart disease before the age of 60.

There is a genetic condition called familial hypercholesterolemia (FH). It is an autosomal dominant disorder that produces severe elevations in total and LDL cholesterol. The DNA in our cells is packed into chromosomes, which occur in pairs. Autosomal comes from the word “autosome” which means all chromosomes other than the sex chromosomes. Dominant means that only one parent needs to contain the defective gene to pass it on to their offspring.

Heterozygous familial hypercholesterolemia occurs in approximately 1in 500 people worldwide, and it causes an approximate doubling in LDL cholesterol levels.

Heterozygous means that only one defective gene is present for a condition, so it usually produces a less severe case of the disease. In other words only one parent passed the condition on, rather than both parents. FH is especially common in French Canadians, Lebanese, South Africans and Ashkenazi Jews.

In FH the LDL receptors are either missing or deformed. These receptors are required in order for the liver to take up LDL that has been floating in the bloodstream, process it and remove it from the bloodstream. If the liver can’t take up LDL particles, blood levels quickly rise. Also, if LDL is not able to get into liver cells, it can’t suppress the production of more cholesterol, therefore greater amounts of cholesterol are produced, and blood levels rise. In people with heterozygous FH, only half the normal number of LDL receptors is present. Commonly, levels of LDL cholesterol will be between 5.1 and 10.3 mmol/L. In normal healthy people LDL cholesterol should be no higher than 3.5 mmol/L. People with heterozygous FH typically develop premature coronary artery disease; men typically in their forties, and women 10 to 15 years later.

Homozygous familial hypercholesterolemia is a much more severe case of the disease, as both genes are defective. It affects approximately one in one million people. In people with this condition sudden death due to a heart attack occurs as early as age 1 to 2 years.

High blood levels of LDL cholesterol in people with FH means that various cells in the body that do not require LDL receptors, take up and absorb cholesterol. This includes monocytes and macrophages, which can turn into foam cells and lead to the production of fatty plaques in the arteries.

People with familial hypercholesterolemia often display telltale signs on their bodies called xanthomas. The word xanthoma is derived from the Greek word xanthos, which means yellow. Most xanthomas have a yellowish appearance, but this isn’t always the case. They are basically deposits of fat, connective tissue and blood vessels in and under the skin which grow on various sites of the body. People with familial hypercholesterolemia typically develop xanthomas on their Achilles tendons and tendons on the hands. Sometimes a xanthoma develops on the inner side of the eyelid; this is called a xanthelasma. An iridologist looking in the iris of a person with FH will usually see an arcus senilis, this is a cloudy ring on the outer border of the iris. There are several other genetic conditions besides FH which produce severely elevated levels of LDL cholesterol.

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Mobility is important because it affects your sense of control and independence. Whatever your circumstances – whether you are in bed or using a wheelchair much of the time or simply not as energetic as usual – you need the right level of support to ensure a good level of comfort and the ability to do as much as you reasonably want to for yourself.

If you experience more difficulty than usual getting around the house you might consider making up a temporary ‘bedroom’ downstairs, as climbing stairs uses a lot of energy. If your bathroom is upstairs, then this may be less practical although you may be able to borrow equipment to solve this problem. The district nurse at your doctor’s surgery will be able to advise you, perhaps in conjunction with an occupational therapist (who will know about specialist equipment or useful aids to make practical tasks easier for you).

There may be other equipment or small changes at home which would make a big difference to you. An adapted lavatory seat, a special cushion to sit on, the installation of handles to help you out of the bath, a new stair-rail or a walking frame to give you extra confidence are some examples. These may all be temporary measures, but can help you to feel less physically confined.

Experiencing reduced levels of energy is very common, and it will make a big difference if you are able – and willing – to rely on others more than usual. Getting up to fetch a book or make a cup of tea or prepare a snack may be more difficult than before, and although you may hate to feel like an ‘invalid’, it is often a relatively short-term problem. This does not mean that others will be constantly running around for you, nor that you should worry about ‘being a burden’ to them. Remember that you are undertaking this journey through your treatment together, and by working together you can vastly improve the quality of your life. Small measures can make a big difference.

Driving may be another activity you have always taken for granted. It is obviously foolish to drive if you are not fit to do so, and you also may need to consider the implications of any physical limitations caused by your cancer on your motor insurance. This may make no difference at all, but again, it would be foolish to be caught out.

If driving is not possible for you for a while, you may need to arrange for someone else to be available to drive you to your hospital appointments. Taxis or public transport may be a possibility for you, but you are likely to find that friends or family members are more than happy to save you the money or the time and trouble by driving you. Don’t be afraid to ask! After all, you’d do the same for them.

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Even if you normally regard yourself as a ‘strong’ person, it is natural in these circumstances to turn to your wife or partner or a member of your family for extra support. At heart you will want to remain in control as much as possible, but you are unlikely to want to handle all the practical details of, say, hospital appointments and your treatment single-handed. You may look to, for example, your wife to be strong and capable in communicating with your hospital and doctors. Initially, this can present difficulties on two counts. First, it can be hard to accept that you want to opt out of a degree of control of your situation. Second, it may be that the person from whom you are seeking that support finds it difficult to give because they are also profoundly affected by your diagnosis. They too may want to be strong for you, but simply feel incapable of taking charge in the very early days. Tensions can result from the resulting sense of helplessness you might feel at first, but do allow yourselves time to absorb what has happened before trying to adapt your lives to include your cancer treatment.

Frustration can also arise from your own wish to be physically strong, while knowing that this is not possible all the time. This can be hard for your family and friends too – you may feel that people are walking on eggshells around you, trying not to offend you by treating you as an invalid while at the same time making sure you have all the support you need. It is a difficult balance to strike, and there will inevitably be times when you or other people make the wrong judgement. There will be moments when you will feel like shouting, ‘Why doesn’t someone help me?’ or at the other end of the scale, ‘I really don’t need your help with this.’ Similarly, those around you will be wondering whether an offer of help will be welcomed or considered an insult. The only way to find out is to keep all the lines of communication open and to be as flexible as you can. It will take time to reach the right balance – and just to make matters more complicated, the balance may change, from day to day or week to week or gradually over time.

It will be tough for your close family to adjust too, however supportive they are. While they will be doing their utmost to help you practically and emotionally, those who are closest to you will also be going through a period of shock and fear for the future. If you have previously taken pride in your emotional strength and ability to support others, remaining calm and strong at times of crisis, you may feel that it is incumbent upon you to do so now. And yet you may feel unable to, and need to draw on the support of others. Your family will not look to you to be the ‘strong’ party, but it can be difficult to shake off old habits. This can lead to a sense of emotional confusion for all concerned, and you will all need to allow time for relationships to reach a new balance.

This will have different effects for different people, some practical and some emotional. For example, there may be certain tasks which you have always carried out but which you are not capable of at the moment. Handing over responsibility for these can feel like a failure on your part, and might initially cause some upheaval as your family or friends adjust their own routines to accommodate you. It is sometimes more difficult to be the recipient than the giver of help, and you may find it hard to sit on the sidelines and take a less active role, especially if people don’t do things ‘your’ way.

After my first four-week stay in hospital, it was wonderful to be home but difficult at first to accept that I had had no part in tying up the loose ends following the sale of our business nor in dealing with any domestic matters which had cropped up. Helen had been keeping me up to date with what was happening, but had obviously had to take complete control, make decisions and deal with things on a day-to-day basis herself. I would probably have done things no differently, but needed to quibble at times just to feel that I still had an opinion which mattered! My parents too had been very supportive in helping us sort out practical issues at home, and I’m sure I was less than gracious at times in accepting their help simply because it was so hard to accept that we needed it. I desperately needed to feel part of all that was going on around me and to assert my independence in some way – it was as if after being in a relatively helpless state as a ‘patient’ for so long, I needed to regain my status as a functioning human being with a brain.

It is not easy to be a spectator while other people continue with their lives, and this can emphasize your situation painfully. Allow time and keep talking – relationships do reach a new state of equilibrium.

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The hours and days immediately after your cancer diagnosis has been confirmed are in some ways the most difficult because it is now that your world is turned upside-down. This is the point at which the transition into new and frightening territory begins and the time when the sense of shock is at its most raw. You may already have experienced the considerable stress of tests to establish whether or not you have cancer and the sense of being in limbo as you await the results. Receiving a cancer diagnosis, however sensitively the news is given to you, represents the confirmation, of your worst fears. You may be unwell and in pain or you may be physically able to continue your normal life. In either case, the period between diagnosis and the beginning of treatment can be a time of great upheaval, both practically and emotionally. Everybody reacts differently, but gradually you will need to find your own way of coming to terms with your cancer and working out how to live with it.

In the early days, the overwhelming emotion experienced by many people is shock. It can leave you feeling numb and dazed and can make absorbing information or taking decisions difficult. Some people start to feel that dealing with anything practical is completely superfluous, and just want someone to magic away their cancer and return their life to normal. Others are galvanized into action, and want to sort out the aspects of their life which will be affected by their cancer and treatment, such as their job or other regular commitments. Shock affects everybody differently, and there is no ‘right’ way to react to your cancer diagnosis. It will take time to accept it and the changes it will bring to your life, and this process cannot be rushed.

Neil’s diagnosis had been made during the course of a single day, and he made an immediate and conscious decision not to allow this momentous event to impose on him the passivity which is often associated with being a hospital patient.

So that was it then. I was now back at home in a physical state which was exactly the same as when I left home to visit the hospital some eight hours earlier. There was the knowledge however that I had cancer and we had better start thinking about getting a few things sorted out. I think that this is probably the moment at which it is easiest for the patient either to empower themselves by becoming totally involved in the ghastly process or to abdicate responsibility by letting events run away from you. The decision is very often in the hands of the patient and his family and friends. Do not underestimate the importance of this point!

You may feel very alone and isolated after being told you have cancer. Your doctor or GP may try to reassure you with anecdotes about the effectiveness of treatment for your type of cancer or about other patients’ experiences, but these can seem completely irrelevant to your particular situation. You might feel like the only person in the world who has ever been in such terrible circumstances. Some hospitals provide support for patients immediately after their diagnosis, such as a Macmillan nurse (who will be specially trained in helping cancer patients) or specialist counselling. You might think that talking further about your cancer cannot possibly help. After all, talking makes no difference to your diagnosis. In fact, talking to a medical professional other than the doctor who made your diagnosis can help you to start voicing your questions and fears: this in itself is a hurdle to be crossed. If the hospital has no such support system, then your GP should be happy to talk to you at short notice.

For some men, beginning to talk about a cancer diagnosis is not so easy in practice. If you are not in the habit of discussing such personal and private matters, your instinct may be that your cancer is nobody’s business but yours. A temptation to feel that you must be strong and ‘pull yourself together’ is prevalent in many men, together with a sense that the need to seek outside help is a sign of weakness. These may be entirely unconscious reactions, born of habit, and it would be unreasonable to expect any man newly diagnosed with cancer to develop new ways of coping overnight. What is important is for both men and those close to them to be aware of the support available at this stage (it may not be widely publicized), and not to feel reticent about drawing on it whenever it is needed.

After your diagnosis has been made, simply leaving the hospital and getting through the rest of the day can feel impossibly difficult. What are you to do now? It can feel as if your entire world has just collapsed around you. You know that somehow you have to go home or back to work, and that the world around you is exactly as it was before your diagnosis – but for you it has changed irrevocably.

How you react at this time will be driven less by conscious decision than by instinct and the effects of shock. Returning to your normal routine might deflect the impact of your diagnosis for a short time. It is as if the action of going back to work or to the supermarket can push your diagnosis into the background for a while. You might need to spend some time alone to absorb the news and to think quietly about it before telling anybody. If your wife or partner or a close member of your family was with you when you heard your diagnosis, you might spend time alone with them, until you feel able to start passing on the news to others. Neil found he needed time for the news to sink in, but then some issues started to become clearer:

There is a moment which seems to go on for ever on the first evening of ‘C-Day’ which is me and my partner sitting on our sofa just holding hands in absolute silence with nothing that we could possibly say. I do remember that it was that evening that we made what I am certain was the most important decision of this whole ‘voyage’: to take control in whatever ways we could. The need to attempt to regain some control over these events was the secondary emotional reaction after the trauma of the diagnosis.

The need for some sense of control is not uncommon, born of a fear that if you do not actively take control of what events you can, then events will surely take control of you. It is certainly not the only common reaction though; withdrawal into oneself can be hard to avoid too, especially if you are inclined not to talk openly about your feelings. “I really don’t want to talk about it’ may be your overriding feeling, through a combination of shock and the difficulty of seeing a way forward through the treatment and uncertainty ahead.

Getting through the day is tough. Around you, all is normal – but your world has changed. You may be capable of little but sitting at home thinking through your consultation and diagnosis. You might need to use ‘normal’ activities to prevent yourself going over the same ground again and again in your mind, taking refuge in seemingly trivial tasks – walking the dog, cutting the grass, cleaning the car. This may seem odd behaviour to an onlooker, but can feel like the only way to cope with the immediate effects of shock as you try to come to terms with your diagnosis.

It is extremely important to find and use some support at this stage and especially so if you are alone. You may feel that you can cope on your own and neither need nor want to talk to anybody. Maybe you can manage, but you are likely to cope more effectively if you feel able to ask for support, and particularly someone to talk to at this early stage. Sitting at home on your own, worrying about your cancer and treatment and the future is a natural reaction, but ultimately it will not benefit you either physically or emotionally. You need to conserve all your strength to fight your disease and deal with your treatment, so now is not the moment to assert that you don’t need any help from anybody. Even if you don’t feel like talking, just the presence of a good friend or close family member can help to dissipate the sense that you are the only person in the world facing this problem.

Even if your thoughts are not very clear at this time, talking will help you more than bottling up your questions and fears. It may take some time before you can start to think clearly. You might find your thoughts go around in circles, stuck in a loop in which you can’t get your diagnosis out of your mind, and simply don’t know what to do with yourself. Perhaps you can’t stop thinking ‘Why me? What have 1 done to deserve this?’, and want nothing more than for life to go back to normal, as it was yesterday or last week or last month. Talking will help to provide a release.

It is not always easy to find the right person to talk to, and you might feel awkward at first discussing your situation with those closest to you. Some people prefer to talk to a professional counsellor or a nurse or doctor about their disease in the first instance. If you are not offered counselling, your GP or your hospital should be able to help with this – and should also be able to advise you about other forms of practical and emotional support available to you.

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The degree to which radiotherapy affects your daily life will depend very much upon the nature of your radiotherapy and how you respond to it. It is very important to remember that there is no ‘right’ way to live through this process, and that both the emotional and the physical effects will vary from person to person. Some people prefer to continue with as normal a routine as their radiotherapy schedule and physical energy will allow, as this helps them to retain some sense of control over their lives. For others, this may not be physically possible, or they may decide to make quite dramatic changes to their lives so that their time and energy is focused around their treatment. Most people will fall somewhere between the two. It will take time to adjust as the radiotherapy progresses, and you will need the support of family and friends. Don’t be afraid to accept offers of help, either at home or driving you to your hospital appointments, for example.

Following surgery, Gary underwent an intensive course of radiotherapy for a tumour which had recurred in his brain. His treatment was given twice a day, morning and afternoon, as an outpatient on Monday to Friday over four weeks.

As I lived some distance from the hospital, I stayed with a friend for the duration of my treatment, going home only at weekends. The radiotherapy made me very tired and lethargic, and I had to make the journey to the hospital by public transport twice a day -I was not allowed to drive because of the possible effects of my tumour. Friends helped out by driving me to or from the hospital when they could, but it was hard to stay motivated and believe that the treatment would be worth all the effort. I didn’t suffer too badly from other side-effects, although eating sensibly, keeping myself occupied (other than sleeping) and generally looking after myself were hard work. The point of relating this is not to put other people off, but to emphasize that sometimes you need more support and encouragement than you appreciate at the beginning of your treatment. You just have to keep remembering (and it helps if other people repeat it) that it is just too important not to see it through. Against the odds, I have been completely clear of cancer for over a year now.

Coping with your cancer and its treatment is discussed in more detail later in the book.

When your treatment has finished, your progress will be monitored via regular check-ups. It is extremely important for you to attend these appointments, as it is your main means of contact with your doctors. The knowledge that you will be attending check-ups on a long-term basis can be very reassuring. These appointments are a good opportunity to talk about any worries or queries which have arisen and you should never feel afraid to contact your doctor between appointments if you have a specific problem.

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Bladder cancer is roughly twice as prevalent in men as in women and, as with prostate cancer, it is more likely to occur with increasing age. It is believed to be more common in people who smoke, as the chemical products of smoking travel via the lungs and bloodstream into the bladder before being passed out of the body. It is also more common in those who have worked in the dye or rubber industries.

Bladder cancer can be non-invasive or invasive. The non-invasive form does not grow deep into the wall of the bladder. The invasive form can cover a large area of the inner surface of the bladder as well as invading deeper into the bladder wall. If this occurs, the cancer can also spread to the lymph nodes and later progress to distant sites such as the lungs, liver and bones.

The symptom you are most likely to notice is blood in your urine (haematuria). You may also be aware of a need to pass urine more often than usual and experience discomfort or pain on passing urine (dysuria). It’s important to remember that both symptoms can often be caused by a non-cancerous problem – such as a readily treatable infection – but this is no reason to delay a check-up with your doctor.

You will undergo various tests to establish whether cancer is present, and these may include urine tests and an internal examination of the bladder with a cystoscope. This is a means of looking inside the bladder with a thin tube containing a type of telescope and may be done under either general or local anaesthetic. You may also have X-rays and scans of the kidneys, abdomen and the pelvis.

The treatment for the non-invasive type of bladder cancer involves cystoscopy, with cauterization or removal by laser of any tumour and then regular follow-up cystoscopy. Drugs may also be instilled into the bladder. The more invasive type of cancer may involve more extensive surgery, possibly with the removal of the whole bladder (cystectomy). This also involves the requirement to reconstruct the bladder or to divert the flow of urine, and you will need to discuss this in detail with your doctors so that you fully understand the impact that the surgery will have on your life. Radiotherapy may be an option to consider instead of surgery, but this will depend upon your particular circumstances. Chemotherapy may be proposed. Although its role is not yet fully defined, bladder cancer (including secondary disease) can respond well to chemotherapy.

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Getting expectations clear and discussing them in detail with the therapist and your partner is an essential part of sex therapy. If you can get erections in some situations but not others, it’s realistic to explore what is happening in the situations when you don’t become erect. For example, a man who feels he “should” have sex whenever his partner is willing may discover that just removing that requirement solves the problem. If you have a physical illness which plays a role in your potency, your expectations of what constitutes success must, of course, be defined with those facts in mind. A sex therapist will probe and help you define what constitutes success for you. It’s important to get this clear before you embark on a program of therapy, so everyone knows the goals and objectives of the program.

Sometimes a couple comes in for one problem, and in the process of defining the man and woman’s expectations, different concerns emerge. Harry’s announced reason for wanting sex therapy was his inability to consistently maintain an erection. This 57-year-old man suffered from high blood pressure and had to take medication for this condition. He also had been diagnosed recently as diabetic, a fact he found very difficult to accept.

Harry’s first marriage had ended in divorce. In discussions with the therapist it became clear that Harry blamed his erection problem for the breakup of this relationship. He was convinced that the same thing might happen again with his second wife, Shirley, a vivacious 54-year-old who also had been married before. For the most part, Harry and Shirley considered themselves a happy couple. But increasingly, Harry was fixated on his “sexual failures.” He was convinced that Shirley would reject him just as his first wife had—and that his erectile problems were to blame.

Harry felt an erect penis was necessary to satisfy a woman, and he was quite surprised when the therapist explained in detail that this was not true. He was even more surprised when Shirley, encouraged by the therapist, explained that she was not overly concerned with Harry’s erection problem.

When Harry lost potency, Shirley’s usual comment was, “Don’t worry about it.” Harry interpreted this remark as a well-intended solace for his failure. But Shirley meant her words, and more. Her first husband had been, she explained, a “slam-bam thank you ma’am” kind of guy, and Shirley was quite happy to be cuddled, kissed and caressed. She wanted to be physically close to Harry, but she did not feel especially deprived by Harry’s loss of potency. What she did want was physical affection. Harry’s preoccupation with intercourse as the only “real” sex was troubling her.

What Harry and Shirley learned in sex therapy helped their fundamentally sound relationship. They learned to communicate more clearly and directly. Each learned to say what was wanted without confusing the other. Relieved of the self-induced pressure to always produce an erection, Harry relaxed and found his erections improved. He also began taking better care of himself, because he could accept more easily the changes his diabetes required in his life.

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If you thought that stress couldn’t tamper with your life any more than it already has, consider this. Stress can dampen sexual arousal. An action that includes the surging of blood, increased heart rate, and erection, arousal depends, to a great extent, on a number of various hormones to spark specific reactions in the body.

But there are other hormones discharged from the adrenergic system—epinephrine and norepinephrine, especially—that can effectively shut down sexual response. Whenever you are under stress, no matter what the source is, these hormones begin to course through your veins, directing blood flow to the heart and major muscles and, therefore, away from the genitals, in both men and women. This results in increased heart rate and blood pressure, two physical factors that can contribute to lowered libido and performance.

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Based on extensive research by scientists, as well as my own experience, I have put together a list of seven supplements which can improve penile health. These substances have other wide-ranging effects. Not only can they decrease the risk of ED, they also offer increased protection against cardiovascular diseases such as atherosclerosis.

The seven are vitamin E, vitamin C, Pycnogenol, ginkgo biloba, coenzyme Q (also called Co-Q-10), ginseng, and saw palmetto. You may already be taking one or two of them. If so, see my recommendations to ensure that you are taking a high enough dosage to make an impact on your health. Keep in mind that you can try any or all of these supplements. But as is always the case with new remedies, consult with your doctor before you decide which to take, and in what dosage. Five out of the seven substances listed have powerful antioxidant effects (ginseng and saw palmetto have other properties). Utilizing them to your best advantage can help to ward off—or significantly diminish —the effect of one of the body’s great enemies: free radicals.

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But what about those anxiety-related situations that most men can relate to? Job performance, concern over finances, problems with teenagers at home, relationship issues with a partner—the list goes on and on, changing each day. Problems stemming from daily life are universal.

Consider the example of a thirty-four-year-old patient of mine whose job as a Wall Street trader gives him more than his share of high anxiety. It so happened that Eric’s third wedding anniversary coincided with the day of a stock market freefall. That night he went home, trying to put the awful day behind him, anticipating a sexual celebration. Only, it didn’t happen. There was no way that he could circumvent his worry over the events of that afternoon and the result was a disappointing evening.

When he called me the next morning, I understood why his erectile failure had occurred; so did he. Then he wanted to know if he could have a prescription for the pills for those times when he might need them. He is healthy and doesn’t smoke. His drinking is limited to an occasional glass or two of wine and he exercises regularly. His ED is solely anxiety-related. Why shouldn’t a man with his profile, in a loving relationship, have the fallback support he may need? Isn’t his quality of life being compromised otherwise?

For Eric, and the millions of men like him who will—if they haven’t already—experience anxiety-related ED, the pills can relieve worry and offer substantial piece of mind. Isn’t that a valid function of medicine?

I do feel, however, that the decision to provide the medication to males who are already performing at the highest sexual levels, and who have never experienced any kind of ED, must be made on a case-by-case basis. Presently, there is a lack of scientific data to support any preventive use of the oral drug. Although controlled medical studies are being planned to measure the benefits of prophylactic use—some experts are predicting that, in the near future, the drug will be taken two or three times a week, even when a man is not engaging in sex, to ensure erectile health—we may not have definitive answers for several years.

Based on my own experiences and on the extensive reports of my fellow medical colleagues, I’m extremely pleased with the profile of the medication. With the information on hand, I can weigh the merits of the drug on a risk-to-benefit ratio on a patient-by-patient basis.

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Before I provide a man with the ED medications, I have a serious discussion with him about the importance of understanding how the pills work. I make it very clear that the erection pill will allow him to I unction sexually within a relatively large window of opportunity. It does not, however, mean that the medications can cure the condition i hat caused ED in the first place. I also reiterate that more is not better. I doubling a dose will not make a belter lover. In fact, it might bring on some undesirable side effects, such as plummeting blood pressure, light-headedness, and a racing heart.

When a Patient Doesn’t Want Medication

For some people, the idea of having to take medication is less than thrilling. It signifies getting older, losing control of their bodies, and facing their mortality. Even though the ED drugs have proven to be so successful, some of my patients are still reluctant to use them. Or they use them for a while and suddenly stop. I think this is linked to the unspoken desire to feel “normal” and in control. But if a patient stops taking the drugs, thinking that he is cured permanently, he is going to subject himself to another, potentially more devastating round of failure, deflated self-confidence, and embarrassment.

Using ED medication is hardly a sign of weakness or inadequacy. On the contrary, taking it means that a man is dealing with his problem and, in fact, overcoming it in the most painless, practical way possible. It basically comes down to this: Without the drugs, junction is going to remain impaired. With them, it will be corrected.

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One group that has been largely ignored by researchers is the group of men and women who identify themselves as bisexual. That means that they are sexually attracted to both men and women. The ultimate choice of a longterm partner may well come down to broader social factors. Pauline and Sally had known each other for a few months before they decided to travel abroad together. Sally recalled, ‘Our friendship became more and more intimate over the time we were traveling. We spent twenty-four hours a day together and so we got to know everything about each other. The closeness that comes from having to rely totally on each other in a foreign country was just incredible. We had both dated only men in the past, but after it became sexual with us it added a whole new dimension. We both thought this was the most wonderful relationship we could imagine. That was until we got back home. Pauline couldn’t cope with the reactions of some of her friends and she started pushing me away, but she refused to talk about it. Eventually I just pleaded with her to tell me why. She told me she was in love with me and that I was everything she could possibly want in a partner but I wasn’t a man. The only way I could cope was to leave the country and just distract myself. About a year later I heard that she was engaged. It hurt like hell, but I hope she is happy.’

When asked if any of his clients were married men, one male prostitute answered, ‘Yeah, heaps. They open their wallets to pay me, and there are the photos of the wife and kids.’

Woody Allen looked on the positive side when he said, ‘I can’t understand why more people aren’t bisexual. It would double your chances for a date on a Saturday night.’ But the reality is not so easy. In fact it may even be more difficult to establish a sexual identity than for a person who is exclusively heterosexual or homosexual. One of the problems for people who identify as bisexual is that they may not be entirely accepted by either gay people or the ‘straight’ people. One gay man told me, ‘A lot of people who say they are bisexual are confused. They just don’t want to admit they are gay so they fool themselves.’

Oscar Wilde, the English writer Vita Sackville-West, Eleanor Roosevelt and Marlene Dietrich were all known to have had relationships with both men and women, but high profile bisexual role models were relatively scarce until Madonna decided to make a career out of it. The explicit details of her celebrated and varied exploits made it almost socially necessary to have some ambiguity of sexual preference.

Wendy identifies herself as bisexual. ‘I can have a strong physical attraction to a man or a woman but I feel more of an emotional intensity with a woman, so those are the relationships that seem to work best for me. Trouble is, because I have the physical need for both but the emotional energy for only one, I feel I am constantly having to make a compromise. Some people ask me why I can’t be satisfied with just choosing one or the other. It’s hard to describe, but it’s like you have two quite separate libidos, each with needs of its own, and satisfying one makes no difference to the other.’

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The term ‘heavy petting’ was once in common use but it is so ambiguous that it is meaningless. It is supposed to mean any sexual activity up to but not including the penis crossing the entrance of the vagina. Unfortunately, without more detailed information it could be taken to mean kissing with

your mouth open, touching your partner’s genitals with your hands or even massaging each other without your clothes on none of which will result in pregnancy. ‘Heavy petting.’ It sounds so serious! When you think of ‘heavy’ you think of cumbersome, unwieldy, bulky, awkward, clumsy. Now while this may be a very accurate description of the early grope sessions of adolescence, it does nothing to help young people work out safe and unsafe activities, or to improve the attractiveness of non-intercourse options. It is more useful to talk about ‘outercourse’, referring to a number of ways of satisfying your physical needs, even to the point of orgasm, without the disadvantages of intercourse.

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Conflict arises when a young person’s actions go against parents’ beliefs, and this is particularly so in the context of sexuality. Parents may have to ask themselves, ‘Is it really worth declaring war?’ One area where parents’ attitudes may clash with their children is on a sexual activity with a traditional image problem. Although attitudes to masturbation have progressed a lot in the past twenty years or so, there are still some people who see it as a sin with dire consequences. However, it is now widely recognized as a natural form of sexual expression.

Around puberty both boys and girls become aware that masturbation is a sexual activity and it is an opportunity to explore your sexual responses in privacy. This is probably the first time we become aware of the ability to orgasm. One friend recalls the first time he ejaculated. T remember I was masturbating in the shower one day when I was about thirteen. I saw this white stuff coming out of the end of my penis and my erection disappeared faster than it had ever done before. I had no idea what k was. I thought I had burst something, so I spent the next hour or so checking all my bits and pieces, and nothing seemed to have dropped off. After it happened a few more times I figured it must be okay, so I stopped worrying. Then I heard a few of the boys at school joking about it, and I realized I wasn’t the only one!’

It is a frequent cause of battles within families. A friend, now in her thirties, has bitter memories of the time her mother found out she was taking the Pill. ‘I was about nineteen and I had been going out with Rick for over two years. He was a bit younger than me, but we knew we were both ready for a sexual relationship. My mother always had this expectation that I would be a virgin when I got married. That was about all she ever said about sex at all. Although I never challenged her about it, it had never been my plan. I think I’d been sexually active for about four months. I came back from a weekend away at a girlfriend’s house and Mum found my packet of contraceptive pills when she was looking through my bag for washing. Well, I couldn’t have imagined a worse reaction if she’d found out I had a terminal disease! She cried, she yelled, she called Rick all sorts of terrible names and said I was ruined and all that. I felt guilty, like I’d really let her down. For ages afterwards I had trouble having sex, like every time Rick and I got close I felt like I was hurting Mum or something. It took me years to forgive her for it, and we still never talk about anything really personal.’

The issue here is clearly one of permission to make your own choices. One of the biggest difficulties about being a parent is the ability to accept that we cannot dictate every thought, belief or action of another person, even if it is our own child. The achievement is in equipping our children to make responsible decisions for themselves.

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For some people, their earliest sexual experiences are synonymous with fear and betrayal. These people have been sexually abused in childhood and nothing in life can equal the damaging impact of this abuse on self-esteem and on the ability to enjoy lasting relationships.

Every parent needs to have power. Try getting a three year old to bed on time or negotiating a teenager’s curfew time without it! This position of authority is necessary if parents are to be able to teach, discipline, and establish trust and security for their children.

The physical relationship between parents and children is necessarily sensual. The kisses and cuddles, tickling each other, the comforting stroking of their hair when a child wakes frightened in the night by a nightmare. This is how we learn about affection, the appropriate expression of love and caring for another person that is so necessary to our emotional development. But there is a difference between appropriate expressions of affection and ‘abuse’.

What we need to try and figure out is this: At what point is the line crossed?

By abuse we mean an adult or someone bigger than the child using their power or position of authority to take advantage of that child’s trust or respect to involve the child in sexual activity. Now that might sound a bit long-winded but there are two key points — the betrayal of the child’s trust, and the sexual gratification of the adult.

In some cases the distinction is absolutely clear. Any adult coercing a child into intercourse, for example, is abusive beyond a shadow of a doubt. But there’s a huge gray area that would need to be taken case by case. Take the example of ‘exposure’. In many families, it is quite usual to keep the bathroom door open while you shower or dress. There is no sexual intention and it causes no distress. This would not be considered abusive but it is one of those sexual matters that depends on your perception. Sally is twenty-nine. ‘In my family when I was growing up, it was perfectly normal for everyone to share the bathroom. When we were little we often showered with one of our parents. When I married Jim and we had children of our own it just seemed to be the most practical way to get the kids clean. You know how much fuss they can make having their hair shampooed in the bath! We thought nothing more of it than that. But Jim’s father saw it differently. He thought it was really strange that we would shower with the children. Mind you, he’d never even undressed in front of his wife and they had been married for over forty years! He really tried to make us feel guilty about it.’

On the other hand, if the exposure was designed as a sexual turn-on for the adult then it would be abusive, as in the case of an uncle drawing a child’s attention to his erect penis. A child does not have to be physically touched to be sexually abused.

Take the example of sexually explicit language. What is appropriate in one context is quite out of line in another. When we talked about sex education for children, I pointed out how important it is to use the right words … a penis is a penis and so on. The information needs to be straightforward and honest to that extent. Answering a child’s questions about sex in a way that is understandable for their age group and sensitive to their need for information is an essential part of parenting. If the child is exposed to explicit sexual language or behavior that is forced upon them to the point of distress or goes well beyond their comprehension at that age, there is a problem. This is particularly the case if the adult derives sexual pleasure from it.

So whether a situation is abusive or not will depend on its context.

Some people will not realize the effect of abuse until later in life when they are confronted with a situation that somehow triggers a delayed reaction. A teenage girl became very upset and embarrassed when she started to hear about sex at school. She remembered that, when she was about five, a family friend easily coerced her into a ‘game’ during which she drew pictures on his penis with a felt pen. She said she thought nothing of it at the time and didn’t think of it as ‘sex’. Now that she was finding out about sex and starting to discover her own sexual feelings, she realized that the game was ‘sexual’ and she said she felt very angry and bad about it.

So it is clear that not all cases of sexual abuse involve physical force or violence. One of the very confusing aspects about looking back at sexual abuse is that it is not always a totally terrifying experience for the child at the time. There are even some sensations that they find pleasant, yet at the same time may recognize as ‘wrong’. These mixed emotions can make a survivor of abuse feel guilty that somehow they were responsible for the abuse and that they must have encouraged or seduced the perpetrator. However, on this point one truth is irrefutable: Children do not fantasize or lie about sexual abuse and they do not seduce adults.

The estimates of child sexual abuse are astonishing. One in four females and one in ten males has been sexually abused in childhood. The reasons that these figures can only be estimates is because so many cases still go unreported. Even today sexual abuse counsellors say that the numbers reported are the tip of the iceberg. One estimate puts the reporting rate at only five percent — only one in twenty — so the real facts about sexual abuse can come as quite a shock. It is vital for us all to know these facts so that we can fully understand its impact on a survivor, emotionally and sexually, and so that we can do something about protecting those who are at risk or suffering now.

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This book is the result of countless requests from my viewers, patients, colleagues, friends and students, who want to know more about sex. Not just the mechanical ins and outs of how to do it. Not just bare facts on how babies are made or how not to catch a sexually transmitted disease, but more complex issues about the way we relate to each other sexually, sensually and emotionally. These are the issues that both fascinate and confuse us.

In the enlightened nineties, when America is considering a city in space, the environment is under threat and the world is in recession, there is an even more fundamental problem, which is just as intimately linked to our very survival.

An enormous number of people are frightened of a basic function which has been around since the world began — their own sexuality.

Sex is a unique subject that can, almost in the one breath, give people great joy and great anguish. It is probably the one thing in our lives that gives us the most feelings, the most emotions across the whole spectrum.

Judging by the reaction to the television series SEX, it’s clear that the whole subject is a hornet’s nest of fears, beliefs, misconceptions, legends, ignorance and plain hypocrisy. As I see it, a lot of this stems from one false assumption — at some point in our lives we should know all there is to know about sex, and if we are parents of teenagers we should be able to answer all their questions. It can be pretty hard to admit that we don’t have all the answers. Traditional sex education was woefully inadequate. It left people with more questions than answers. ‘So what makes Dad want to put his penis in Mum’s vagina?’; ‘How long does he have to leave it there?’ The emphasis on reproduction and morality left out some absolutely vital issues … like specific genital anatomy, sexual technique, relationships and sexual orientation. The truth is, we need never stop learning.

However, making any changes to the way we teach about sex is a struggle every step of the way. At times it feels like a highwire balancing act.

The reaction of some groups, mainly religious fundamentalists, would have us return to the dark ages, when sex was a taboo subject. Their argument, that sex is a private matter between a married man and woman and should not be discussed, is fundamentally flawed.

Firstly, by denying people the right to openly discuss sex, we deny them the vocabulary to talk about any problems they might have. At the same time we deny them the knowledge and the skills they need to protect themselves against the results of ignorance and secrecy — sexual abuse, unwanted pregnancy, unhappy relationships, sexually transmitted diseases.

Many of our sexual decisions are made for us throughout our lives, but we each have the power to control our own sexual destiny. The choices we make will be influenced by the attitudes and the spoken and unspoken messages we get from our parents, teachers, peers, religious and political leaders, and the media. But to make informed decisions we need information, not a conspiracy of silence. Where sex is concerned, ignorance is not bliss, it’s not a form of contraception and it certainly isn’t a protection against sexually transmitted diseases.

Secondly, the emphasis on ‘shoulds’ and ‘musts’ is a real barrier to effective communication. These have to be two of the most overworked words in the English language. I’ve heard it called ‘musturbation’. By dictating what someone else ‘must’ or ‘should’ do, we deny them the right to come to their own conclusions and at the same time we invite rebellion. The more we appear to judge, the less likely we are able to get in touch with the way the other person is really feeling. This is particularly true of adolescents, but the same goes for any age group. That’s not to say that young people don’t need ‘spiritual guidance’. Of course they do, but they don’t need to be beaten about the ears with dogma. That just closes the subject. It is also very easy to lose sight of the fact that there is more than one belief system out there. What suits one group of people doesn’t work for others. Just as an example, some people believe you ‘should’ be celibate until you are married. Others believe that this is a recipe for marital disaster.

Some will criticize any discussion of the sheer pleasure of a good sex life. The fundamental reason for our sexual urges may be the survival of the species, but why should we make excuses for it being fun? Why should that be such a big secret? The human species is set apart from all others in that the female gets pleasure from sex, unlike any other animal. It would be a very cynical Creator who would design women with a clitoris and the ability to have multiple orgasms, and then expect her not to enjoy the experience. Yet why do so many of us deny ourselves permission to play? Traditional thought maintains that the clitoral orgasm exists to make women more receptive to vaginal intercourse and conception. Maybe it’s quite the opposite — the clitoris evolved as a natural contraceptive device so that women could satisfy their sexual needs as often as they liked without vaginal intercourse and the prospect of unwanted pregnancies.

In so many cases, fear and misconceptions about sex cause unhappiness and guilt. This gets in the way of something that is our fundamental right: a right to give and receive pleasure through a basic function. Instead of a mutual expression of love and delight, too often I see needless despair and barriers to fulfillment. Our sexuality, whatever our gender, our choice of partner, or our preferences, can be a joy to explore, rather than a burden to carry.

From the moment we take our first breath through to life’s final conclusion, our sexuality is a series of personal exclamation marks. We start to learn about it the moment we emerge from the womb and feel the softness of our mother’s breast, the warm strong touch of our father’s hand.

SEX: Confronting Sexuality outlines the fears and dilemmas confronting men and women at each stage of their physical and emotional development. During each stage of life, sexuality is either faced or ignored.

SEX: Confronting Sexuality deals with the moments in your life when sexuality must be confronted. It takes you sensitively, but openly and honestly through problems and their solutions.

With a subject as emotive and as controversial as sex, you’ll never get everyone to agree. The very least we can do is reassess our attitudes and beliefs and talk to each other. Perhaps more importantly than that, we might find new ways of listening to each other.

Exploring our sexuality is like taking a long journey. It’s a continuum, a winding country road with curves and hills, blind corners, hairpin bends and a few pot holes; then there are the long straight stretches when you can relax behind the wheel, enjoy the scenery and stop once in a while to smell the flowers. We all make the journey, no matter who we are, and we remember the important landmarks we pass along the way. SEX is a guided tour of those landmarks.

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