As we grow through our teens and early twenties we may think at various times that we are in love with or even ‘love’ several members of the opposite sex. Sooner or later we realise that we and this particular person are not right for one reason or another, and we part.

This causes real grieving on occasions and certainly most of us feel unhappy or depressed, at least temporarily.

It is a vital part of growing up and maturing psychosexually that we do not marry our first love object after puberty – it would usually be disastrous if we were to do so. This then implies that we have to be able to accept the loss of a loved one and live to fight another day. This, of course, applies not only to love-sex objects but also to the loss of relatives, parents, or even pets. Throughout life people’s love-objects are withdrawn from them (by death or divorce for example) and most grieve their loss. At this time the affected person says to him- or herself, ‘I’ll never have another husband/dog daughter/ mother like that again’, and of course they are right because each person and animal is unique. However, Nature heals this wound over some years – depending on the individual’s personality and the nature of the relationship involved – and they are soon on the way to investing their love in someone else.

In a sense the original love for the love-object is displaced on to the new one, because, as we have seen, we all need to love and be loved. This primitive, instinctual drive leads many people to rush into the search for a new love-object after the loss of their original one and such people often choose someone very similar to the last one. In this way the lost love-object never dies (or disappears, in the case of divorce) – they live on in the remaining person’s memory, yet may be related to through the ‘new’ love-object.

Those who have invested an enormous amount of love in a person who subsequently dies or leaves often tell how they never really get over the loss but simply put on a brave face for the world and even to a new partner. Such a reaction can become troublesome to some people because they hanker after one perfect love-object (even if during the object’s time with them things were far from perfect), idealise the past and they cannot step into the future because they fear that no one will ever match up to the lost love-object.

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A mastectomy (removal of one or both breasts) is a major blow to most women’s sexuality but the negative psychosexual effects can be greatly reduced by careful psychological preparation before the operation. With modern trends in the treatment of breast cancer fewer women are having their breasts removed so the problems associated with mastectomy are likely to be seen less frequently.

Once the operation and its immediate after-effects are over, worries about sex and sexuality often dominate a woman’s emotions about mastectomy. Many women say that they feel less of a woman and the natural reaction in the early days is to feel unsexy and undesirable. Some women even feel strongly enough to say that they would rather have kept their breast and lived a few years less.

The one key factor to emerge from the large amount of research into this subject is that the role of the woman’s partner is absolutely crucial. This is true of women of all personalities and of all levels of intelligence and education. Ideally, the woman’s husband should be actively involved through the whole process right from the time when the lump is discovered. In this way the woman feels she has the support she needs and so fares much better.

There is no reason why sexual intercourse should not be resumed the day the woman gets home. There is no such thing as too much sex after a mastectomy and as long as the wound area is not hurt there are no problems. It is a matter of trial and error to find a position that is comfortable for the woman and then to use it until healing is complete.

Some women are afraid that their partners will leave them – the underlying fear being that a woman with one breast is not able to attract and keep a man. The facts are that men are no more likely to leave their partner after a mastectomy than otherwise and that most worry a lot about how to be supportive and helpful. Although most women try to hide their chests from their partners (especially in the early days), most men are not as upset by the loss of the breast as their women think they will be.

Some couples approach mastectomy with considerable existing psychosexual and relationship problems and for them the mastectomy may be the last straw. That this is unusual can be seen from one study which found that two-thirds of post-mastectomy women judged their emotional state to be excellent or very good. Women who fared best had been married longer, had found their partners (and doctors) more supportive and were pleased with the response from their children and the hospital staff.

Strange though it may seem, most women say that the worst time emotionally is immediately after the lump is discovered. Only one in seven women in one study found the immediate

post-operative period the most difficult. Although most women have thoughts about mutilation, loss of femininity and death, several studies have found that the good news outweighs the bad. One study, for example, found that 71 per cent of women rated their husband’s reaction to the mastectomy as extremely or very understanding; 76 per cent felt that the loss of the breast made no difference or had a positive effect on their sexual satisfaction or their ability to be orgasmic; and 60 per cent rated their overall post-mastectomy adjustment as ‘very good’.

Many women have married after a mastectomy. If you are still having periods, you may find you will get the same sort of discomfort on your mastectomy side as you previously had at this time of the month.

Remember that talking about it with your husband, family and friends is bound to help. Slowly they will all come to terms with your new condition.

Stages of breast self-examination:

1) Stand in front of a mirror with your breasts bare. Look carefully to see if there is any change from your normal appearance.

2) Raise your arms and see how your breasts move. Are there any dimples or bulges that change their outline? Does each nipple point in the same axis as its breast? Is there any puckering of the skin?

3) Gently squeeze the nipples. If more than a drop of colourless fluid emerges, see your doctor.

4) Lie down on your back with a small pillow or towel under the shoulder of the breast you are feeling and work slowly round the breast, section by section, feeling with the tips of your fingers for lumps.

5) Don’t forget to feel at the very edge of the breast tissue which can extend high up on the chest and

6) Under the arm

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Various arguments are put forward against prostitution. Some of them are listed here:

• It is sinful, immoral and promotes fornication. It may lead to divorce.

• It degrades and misuses women solely to satisfy male lusts.

• It is an exploitation of the weaknesses of men by women and would not occur if women did

not offer the temptation.

• It tends to be associated with crime and criminals.

• It affects certain areas of cities reducing property values and making life miserable for non-

prostitute residents. (The Sexual Offences Act 1985 aimed at preventing curb crawling has

done something to help in this respect.)

• Due to ignorance or lack of care, the prostitute may harm the performance especially of young

men by, for example, hurrying them and so conditioning them to become premature

ejaculators.

• It spreads disease. This does not appear to be particularly true, at least for London prostitutes, and similar reassuring reports have been published from Copenhagen.

In the main, London prostitutes now insist that new clients wear a condom. The main concern there is the tendency for condoms to burst. Fifty prostitutes examined in 1985 were all clear of HIV. Women working in the San Francisco sex industry are no more likely to be HIV-positive than other sexually active women there. Elsewhere, especially in Africa and Haiti, prostitutes are a source of HIV. However, there are grounds for concern. One in five London prostitutes allows regular customers to have unprotected intercourse and nearly all fail to use condoms with their boyfriends and pimps. A more recent survey found 3 HIV-infected London prostitutes in a group of 150 but two were also drug abusers. Furthermore, several had infections with gonorrhoea and chlamydia probably caught from boyfriends. Although customer sex with London prostitutes is fairly safe they could become a source of spread of HIV in the future.

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This used to be an extremely common disease until the coming of penicillin in the 1940s, but is happily less common today. In the past, when treatment was poor, the long-term effects (both physical and mental) were atrocious. Today such effects are extremely rare.

About a month after having sex with an infected person (often a homosexual man) the contact gets a chancre (pronounced shanker) at the site of the infection. This can be on the penis, vagina, nipple, finger tip, or lip. A woman may not know that she has it because it could be deep inside her vagina. The sore goes away after a few weeks. This stage is called primary syphilis.

The second stage starts with a copper-coloured skin rash produced as the germs spread through the body in the blood-stream. There is also a fever, sore throat, swollen glands and loss of hair. These symptoms go away too.

The third stage is a hidden one that can last for years. There are no symptoms but the germs are working their way into almost every organ of the body.

The fourth stage of syphilis which affects about a third of all cases is the one described in historical records with such horror. This stage damages the nervous system, along with most of the other organs of the body, and the person can be paralysed, go blind, go mad and eventually die.

A woman who is pregnant and has syphilis can pass the disease on to her baby who will be born dead or diseased. This disease can be detected easily by taking a swab from the sore and blood tests can help too. Treatment with antibiotics is effective, especially in the early stages. Any long-term changes that have occurred in various organs cannot, of course, be reversed.

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How do we handle the dirty jokes from school?

When children are about six or seven they start to giggle at ‘dirty’ words like ‘underwear’, ‘penis’ or ‘naked’. Early dirty stories do not necessarily have a sexual component but the child gets a kick out of telling them. The next stage is to find excretion and sexual functioning hilariously funny. There are now some sexual overtones. Swear words become incorporated in the stories and even the unfunniest of stories causes the child to fall about with laughter. It is interesting how little dirty jokes have changed over the years. Today’s nine year old laughs at exactly the same things as his grandparents did and for the same reasons. Dirty jokes are an early sign of the child’s growing independence and preparation for the adult world. Sometimes the jokes are defiant and rebellious but most often they are geared to shock the ‘stuffy’ adults around him. Often they laugh because everyone else is laughing (it is simply a social pursuit) even though they may not really understand the joke. All of this is a part of growing social confidence and enjoyment and acceptance of becoming part of a peer group.

With all this in mind it is possible to stay calm and to put dirty jokes into perspective. By all means enjoy a joke with your young children, if only to show them that you know what they are on about and that you are not dead from the waist down. Dirty jokes, if they are not actually harmful or worrying your child, are simply a passing phase and will do no harm.

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When to start treatment and which treatments to start are the topics of much research and discussion. Different health care providers have different approaches to using these medications, mostly because information about them and studies of their effectiveness are being disseminated so rapidly.

Many specialists believe that the new drugs ought to be prescribed only by health care providers who know the latest guidelines for how and when to prescribe them, because prescribing them incorrectly, or taking them in the wrong way, can lead to resistance and so limit treatment options in the future. Studies have shown that the providers who care for larger numbers of patients with HIV infection will often offer the best care, because they are more up to date with newer developments in treatment options. If your provider does not have the time to treat you and listen to you, you may want to consider working with another provider who does, relying on a specialist to act as a consultant for certain decisions.

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Carriers. Although 95 percent of people who are infected with hepatitis B go on to clear the infection and then have lifelong protection against ever becoming infected again, about 5 percent of them become carriers. A carrier is a person whose immune system was not able to clear the infection from the body, so the virus persists and the carrier remains infectious to others throughout his or her lifetime. People with impaired immune systems, such as those with HIV infection, are more likely than others to be carriers. Those who develop symptoms of hepatitis B infection are also more likely to become carriers than those who do not.

There are two kinds of carriers, with different prognoses. About one-third of carriers develop chronic active hepatitis, in which the virus continues to cause destruction of the liver. This chronic destruction can lead to scarring of the liver, known as cirrhosis. These people are the most infectious to others through the types of contact listed in the next section, on transmission. They are also at risk of developing liver cancer [hepatocellular carcinoma). The risk of developing liver cancer is about one hundred times higher in those people who have been infected with hepatitis B than in the noninfected population, and about 1-2 percent per year for someone with chronic active hepatitis B infection.

Both cirrhosis and hepatocellular carcinoma can be fatal. Hepatocellular carcinoma usually takes years to develop after someone acquires a chronic infection, although occasionally the tumor can be seen after a shorter time, and it is sometimes seen in childhood among children who had been infected at birth. It is more common in populations in which the rate of chronic infection and transmission to newborns is higher, such as in Asian countries. There is as yet no cure for hepatocellular carcinoma, although surgery and chemotherapy may have some success, depending on the person and the stage of the cancer.

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Some studies have tried to replace the Lactobacillus in the vagina and eliminate the “bad” bacteria through a diet containing yogurt or nutritional supplements (such as acidophilus-containing milk, yogurt, or pills). So far this strategy has been unsuccessful, because the Lactobacillus in yogurt is different from the Lactobacillus in the vagina. Currently, there is no effective way to replace this type of Lactobacillus in the vagina by simply putting it there, although studies continue.

Another “treatment” often prescribed to women, or initiated on their own, is douching. Douching should absolutely be avoided by all women. Not only does douching put women at higher risk for pelvic infections, it only masks symptoms and thus prevents many women from seeking health care for potentially serious problems.

Male partners of women with BV do not need to be treated. There is no evidence that treatment of male partners changes the course of the infection in women, nor does it prevent recurrences of BV If a woman with a male sexual partner is diagnosed with By however, it is reasonable to test both the woman and the man for other sexually transmitted infections, such as chlamydia, since a chlamydia infection can trigger BV in women, as mentioned previously.

A case can be made for treating female partners of women who have BV especially if there is evidence of the infection in the partner. Among women who have sex with other women, BV may be considered a sexually transmitted infection, since female partners of women with BV have a high rate of infection themselves. This may occur through vaginal fluid transmission from the sharing of sex toys.

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After the examination, blood tests for infections such as HIV, syphilis, hepatitis, or herpes may be performed. A health care provider will explain all the tests, what a positive or negative result means, and how much they cost and will decide with you which tests need to be done.

Depending on when your last sexual contact took place, you may want to wait to have some of these tests done. For example, the most common blood test for HIV is unlikely to show an accurate result immediately after a person has been infected. It may take up to three to six months after infection to show a positive blood test for HIV. Your health care provider should explain this, so a decision can be made about which tests are appropriate at this time. You may decide to come back at a later time for these tests so that they will be more accurate, or you may want to test now and retest at a later time.

Make sure you know how you are going to find out the results of your tests. Are you supposed to call or is your health care provider supposed to call you? Do you need to return to the office or clinic to learn the results of your tests? If you don’t get a telephone call, don’t assume that everything was normal. Sometimes offices and clinics are understaffed, and making even important phone calls can be overlooked. Be sure to find out your results.

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Mucopurulent cervicitis is an infection of the cervix that may be caused by several bacteria, including chlamydia and gonorrhea. Other infections, such as herpes and trichomoniasis, may also cause irritation of the cervix. The most common symptom of MPC is a discharge, which can range in color from clear-white to yellow-green. Occasionally, there may also be spotting of blood between periods, or after sexual intercourse, because the cervix is inflamed and bleeds very easily.

Herpes. Although the typical symptom of herpes is sores or breaks in the skin, discharge may be the only symptom if there is an outbreak on the cervix that is causing irritation. The discharge is usually white to yellow in color, and it maybe accompanied by external sores or irritated areas on the skin. Occasionally lymph nodes in the groin may become swollen, the person may have pain in the back of the legs, and flu-like symptoms may occur, especially with a first infection.

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