becomes engorged with blood during arousal,

causing it to increase in sizeand a glans, a

highly sensitive tip, about the size of a pea
I
the urethra, the opening through which urine
passes from the bladder to the outside
I
the vestibule, or entryway to the vagina
I
the perineum, the area between the vestibule and
the anus (the opening from the rectum and
bowel)
I
the hymen, a ring of tissue that partially covers
the vaginal opening. The hymen contains small
blood vessels that may bleed the rst time the tis-
sue is broken: at rst intercourse, rst insertion
of a tampon, during masturbation, or as a result
of some accidental injury. The main internal
structures of the female reproductive system are
the vagina, the cervix, the uterus, the fallopian
tubes, and the ovaries (see Figure A.1).
The vagina is the passageway from the uterus to
the external genitalia. It is a potential space within a
womans body. Usually, the vaginal walls touch one an-
other, but the vagina is elastic and capable of opening
wide enough to allow a baby to pass through during
birth. Such stretching would be extremely painful if
the vagina had the same number of nerve endings as
many of the structures of the vulva. Therefore, the
vagina is not so sensitive to feeling.
At the top of the vagina is the cervix: the neck of
the uterus (cervix means neck in Latin). The uterus,
I
f you are to understand sexual rela-
tions between individuals, you need to be
aware of both the anatomy and physiology of
sex and the attitudes and emotions that shape peoples
feelings about their own sexuality and that of others.
In Appendix A we will consider the rst of these ele-
ments, the anatomy and physiology of sex. We will
look at female and male sexual anatomy and describe
the genitalia, or external reproductive parts, and then
the internal reproductive systems of each sex.
I
Female Genital Structures
I
The external genitalia of a woman are technically re-
ferred to as the vulva. The vulva is composed of the
following structures:
I
the mons veneris, or pubic mound: an area of
fatty tissue above the pubic bone
I
the labia majora (Latin for greater lips): two
rounded folds of skin and, within them, the labia
minora (or lesser lips)
I
the prepuce, or clitoral hood: a fold of skin that
covers the clitoris when it is not erect and is
formed where the labia minora join
I
the clitoris, which consists of an internal shaft
composed of erectile tissuetissue that
A p p e n d i x
A
Human Sexual
Anatomy
or womb, is a cavity whose purpose is to cradle a fetus
until birth. Leading from the uterus are two passage-
ways, called fallopian tubes, that connect a womans
uterus to her ovaries.
Ovaries are female gonads, or sex glands.
Women have two ovaries, one on each side of their
bodies. They produce reproductive cells (ova, or eggs)
and two female sex hormones: estrogen and proges-
terone. Ordinarily, the ovaries alternate in producing
one ovum per month, in a process called ovulation.
1
The egg released in ovulation then travels along the
fallopian tubes to the uterus.
In preparing to receive the egg, the lining of the
uterus, called the endometrium, thickens with a layer
of tissue and blood (see Figure A.2). This tissue can
nourish an embryo during the early stages of preg-
nancy if the egg becomes fertilized during its passage
from the ovaries. When fertilization does not occur,
the egg and the unused endometrial tissue and blood
are discarded during menstruation.
2
A-2 Human Sexual Anatomy A P P E NDI X A
Fallopian
tube
Ovary
Uterus
Bladder
Urethra
Clitoris
Mons veneris
Labia majora (greater lips)
Labia minora (lesser lips)
Vaginal orifice
Hymen
Vagina
Cervix
FIGURE A.1
Female urogenital system
1. Sometimes, women produce more than one egg at a time. This is
one way that twins or higher multiples are conceived.
2. Menstruation occurs in monthly cycles, ranging from about
twenty-one to thirty-ve days. Travel, anxiety, illness, extreme ath-
letic activity, or change in diet can make menstrual periods more or
less frequent.
F E MA L E GE NI TA L S TRUCTURE S A-3
Fallopian tube
Ovary
Mature ovum
Immature ova
Uterine lining
Uterus
Vagina
Vagina
Blood and other fluids
Uterine lining thickens
Vagina
Blood and other fluids
Vagina
Disintegration of
unfertilized ovum;
Menstruation occurs
(uterine lining sloughs
off and is discharged from
body in menstrual fluid)
Lining continues to thicken
a
b
c
d
Ovum is released (ovulation)
Ovums journey through tube
FIGURE A.2
The menstrual cycle: (a) During the early part of the cycle, an ovum matures in an
ovary; the endometrium, or uterine lining, begins to thicken. (b) About fourteen days
after the onset of the last menstruation, a mature ovum is released; the endometrium
is thick and spongy. (c) The ovum travels through one of the fallopian tubes; blood
and other uids engorge the uterine lining. (d) If the ovum is not fertilized, the endo-
metrium breaks down and sloughs off in a form of bleeding (menstruation).
I
Male Genital Structures
I
The external male genitalia are the penis and the scro-
tum (see Figure A.3). Like the female clitoris, the penis
is composed of an erectile shaft and a sensitive tip, or
glans. The glans is especially sensitive to touch at the
corona: a crownlike ridge at its base. If a male has not
been circumcised, the glans is covered by a thin mem-
brane, the foreskin, when his penis is not erect. In cir-
cumcision, this foreskin is removed.
3
On the side of
the penis, which rests against the scrotum, is the
frenum, the place where the foreskin is or was con-
nected to the penis. The frenum, even more than the
corona, is sensitive to tactile stimulation.
When a man is not sexually aroused, his penis
is accid. When erect, penises vary somewhat in size
and are usually about six inches in length and about
an inch and a half in diameter. The urethra runs
through the penis and carries male reproductive cells
and urine, though never at the same time.
4
This open-
A-4 Human Sexual Anatomy A P P E NDI X A
Bladder
Penis
Urethra
Corona
Scrotum
Glans
Meatus
Frenum
Perineum
Seminal vesicle
Prostate gland
Testis
FIGURE A.3
Male urogenital system
3. In the United States, circumcision is commonly performed and the
procedure is done shortly after a male babys birth. For somepar-
ticularly Jews and Muslimscircumcision is an important religious
or cultural ritual.
Conclusions about whether there are signicant health or hy-
giene benets to circumcision have varied over the years (Haas and
Haas 1993, p. 99; Greenberg, Bruess, and Haffner 2002, pp. 143
145). Current thinking is that the medical benets arent as com-
pelling as once believed (Blecher 2001). Also, beginning in the
1970s, the circumcision of male babies has been challenged by
those who arguewith some research evidencethat there is
enough pain to pose a psychological trauma to the infant (Green-
berg et al. 2002, pp. 142145; Blecher 2001).
In 1999 the American Academy of Pediatrics ceased recom-
mending circumcision as a medically advantageous routine proce-
dure. Instead, it is AAP policy that parents should determine what
is in the best interest of the child. Parents should be given accurate
information and then make an individual decision based on their
assessment of the advantages and disadvantages of circumcision.
It is legitimate for the parents to take into account cultural, reli-
gious, and ethnic traditions, in addition to medical factors, when
making this choice (American Academy of Pediatrics 1999).
As circumcision has become less routine, rates have declined. In
1999, only 65 percent of male infants were circumcised, compared
to 90 percent in the 1970s. White rates, which had been much
higher than those of other racial/ethnic groups, have almost con-
verged with black rates now (66% of white baby boys and 64% of
black babies were circumcised in 1999). Circumcision is less com-
mon for Latino or Asian babies (Blecher 2001; Rubin 2001; U.S.
National Center for Health Statistics 2002). Some Jews have
adopted a substitute circumcision ritual in which there is no actual
surgery performed (Blecher 2001).
4. A mans urethra cannot carry urine while his penis is erect because
erection automatically blocks the opening from his bladder to his
urethra.
ing at the tip of the penis is called the meatus, Latin
for passage.
Behind the penis hangs a sac, the scrotum, which
holds the two male gonads, the testicles. One testicle
is usually lower than the other. Testicles, sometimes
called testes, are the male counterpart to the female
ovaries. They produce the male reproductive cells,
called sperm, as well as male hormones such as testos-
terone. Unlike ovaries, however, testicles are external
structures. That is because they must be maintained at
a temperature lower than the body temperature in
order to produce living sperm. Between the scrotum
and the anal opening is an area called the perineum.
As in women, this area is sensitive to the touch.
The internal male reproductive structures are also
shown in Figure A.3. Above the testicles, near the in-
ternal surface of the rectal walls, are two glands, the
seminal vesicles and the prostate. These glands pro-
duce semen, the milky uid that carries the sperm
through the urethra and out the meatus. There are
usually between 200 million and 500 million sperm in
a teaspoonful of semen. Sperm are ejaculated, or
ejected, during the rhythmic contractions of orgasm.
If they are ejected into a womans vagina, sperm
move toward her fallopian tubes. Sperm can live in the
fallopian tubes from two to ve days. If a sperm cell
fuses with a females egg, fertilization occurs, and a
fetus is conceived. There are a number of methods
that may be used to prevent conception, and these are
discussed in Appendix F.
The structures described above make up the male
and female reproductive systems. Their reproductive
functions are discussed in Appendix E. Appendix B
describes the physiology of human sexual response
and sexual expression. (See also The Boston Womens
Health Book Collective. Our Bodies, Ourselves for the
New Century. New York: Simon and Schuster, 1998.)
MA L E GE NI TA L S TR UCTUR E S A-5
of stimulifantasy, sights, sounds, smells, touches
can cause sexual excitement.
1
Women and men share
several responses during the excitement phase, includ-
ing an increase in blood pressure and pulse rate and
faster breathing. There is a heightened feeling in and
awareness of the genitals. This is caused by engorge-
ment, or congestion, of the genital blood vessels,
which causes the affected tissue to swell and, often,
coloration to deepen. Another effect of excitement is
mytonia: increased muscle tension, especially in the
abdominal region and in the long muscles of the arms
and legs. A measleslike rash, called a sex ush, appears
on the abdomen and chest in about 75 percent of sexu-
ally excited women and 25 percent of aroused men.
In women, sexual excitement is marked by the
onset of vaginal lubrication, or sweating of uid
from the inner walls of the vagina. In men, sexual ex-
citement is characterized by erection of the penis,
caused by congestion.
The excitement phase can be stopped intention-
ally by removing the sexual stimulus. It can also be
stopped or interrupted unintentionally through dis-
tractions, such as babies crying, phones ringing,
changes in lighting and temperature, or feelings of
anxiety or guilt. Once interrupted, the excitement
phase can be resumed.
A
ppendix a describes human sex-
ual anatomy; here we examine the
physiology of sexual response.
I
The Four Stages of
I
Human Sexual Response
Through carefully controlled laboratory observation
over a period of eleven years, sex researchers William
Masters and Virginia Johnson (1966) recorded in de-
tail the bodily changes that take place as a consequence
of sexual arousal: the awakening, stirring up, or
excitement of sexual desires and feelings in either
ourselves or others. Masters and Johnson described
four phases of human sexual response: excitement,
plateau, orgasm, and resolution. These phases charac-
terize both mens and womens responses and take
place in sex with partners of the same or the opposite
sex. Specic stimulation and sexual movements may
vary with the presence or absence of a partner and the
sex of the partner, as well as with individual preference
and spontaneity on any given occasion. However, the
underlying physiological response is the same.
Excitement
When people begin to feel sexually aroused, they enter
the excitement phase of sexual response. Many forms
A p p e n d i x
B
Human Sexual
Response
1. For a detailed review of mens and womens responses to sexual
stimulation, see the Boston Womens Health Book Collective
(1998).
Plateau
The plateau phase involves an intensication of
processes begun during the excitement phase, with
several marked bodily changes. The color of the penile
glans and the labia minora becomes a deeper red or
reddish-purple. There is increased tension in both in-
voluntary and voluntary muscles. Pelvic thrusting,
which begins voluntarily, grows more rapid and be-
comes involuntary, especially among men. Heart rates
may nearly double, and blood pressure continues to
rise. If the sex ush appeared on a woman during the
excitement phase, much of her body will now be
ushed. A man may now show the rst signs of a sex
ush, which begins under his rib cage and spreads over
his chest, neck, and face.
In men, the corona becomes more swollen. Sev-
eral drops of uid, which is not semen but which may
contain some sperm cells, may emerge from the mea-
tus.
2
Late in this phase, a womans clitoris pulls deeply
underneath the clitoral hood. This, along with the
marked change in color in the labia minora, is evi-
dence of her impending orgasm.
The plateau phase may be intentionally prolonged
by decreasing the stimulation, returning to the excite-
ment phase, and then increasing stimulation. If stimu-
lation is withdrawn and not restored, sexual tensions
will decrease only very gradually. This can be an un-
comfortable process, with feelings of fullness and pres-
sure in the pelvis, cramps, lower back pain (Masters
and Johnson 1973, p. 119), and general physical and
emotional frustration.
Orgasm
In orgasm, or climax, sexual tension reaches its peak
and is suddenly discharged. This extremely pleasur-
able and totally involuntary response, the orgasmic
phase, lasts a few seconds and is accompanied by pro-
nounced physiological changes. Heart and pulse rates
peak. Breathing becomes deeper and faster than in the
plateau phase, so an individual may sometimes mo-
mentarily experience a shortage of oxygen. The senses
of smell, taste, hearing, sight, and feeling (except for
genital sensation) are temporarily diminished. The sex
ush is brightest at this point. Muscles in the neck,
legs, arms, buttocks, and abdomen may contract spas-
modically, and hand and foot muscles often contract
strongly. Involuntary rhythmic contractions in the
vagina and penis also occur, though their strength
varies from person to person and from orgasm to
orgasm. In adult men, orgasm is almost always ac-
companied by ejaculation, the rhythmic discharge of
seminal uid containing sperm. Once these contrac-
tions begin, a man cannot voluntarily stop ejaculation.
Men normally experience a single orgasm; however,
women can be multiorgasmic, experiencing several
orgasms successively during one sexual encounter.
About 15 percent of women regularly have multiple
orgasms (McCary 1979, p. 109). In women who expe-
rience multiple orgasms, each successive orgasm is
often more intense than the preceding one.
Resolution
During the resolution phase of sexual activity, partners
bodies return to their unstimulated state. The genitals
resume normal size and color, the sex ush disappears,
muscles relax, and erect nipples soften. Heart rate, blood
pressure, and respiratory rates revert to normal.
Return of the penis to its accid state begins
quickly, then proceeds more slowly. During this stage,
men experience a refractory period: a time during
which they cannot become sexually aroused. The re-
fractory period usually lasts at least twenty minutes
and may be considerably longer, particularly as a man
grows older. For women, the resolution phase lasts
about ten to fteen minutes and occasionally as long as
a half hour. During this time, women may remain sex-
ually aroused and, with continued or renewed stimula-
tion, can experience subsequent orgasms.
THE F OUR S TAGE S OF HUMA N S E XUA L RE S P ONS E A-7
2. If this uid is discharged while the penis is in the vagina, a woman
can be impregnated. Thus, interrupting intercourse before ejacula-
tion (coitus interruptus) is not a reliable birth control method.
B
ecause aids has taken center
stage, we sometimes overlook other sexu-
ally transmitted diseases (STDs) and
sexually related diseases (SRDs)
1
that also threaten
comfort, health, reproductive capacity, and sometimes
life. Public health ofcials have become very aware in
recent years of the serious impact of some STDs that
were previously unknown or thought to be relatively
trivial. The effects of STDs may extend to infants born
to infected mothers. Not including AIDS, around
nineteen million Americans become infected with a
sexually transmitted disease each year; almost half are
youth between the ages of fteen and twenty-four
(U.S. Centers for Disease Control and Prevention
2004l).
STDs are named according to the bacterium or
virus (e.g., syphilis or herpes) that produces them, or
they may be dened by their symptomatic effects.
Such terms as vaginitis and pelvic inammatory dis-
ease, for example, refer to inammations or infections
of the vagina or reproductive organs in the abdomen.
Well rst describe some common sexually trans-
mitted diseases (not including AIDS); then talk about
protective practices; and conclude by discussing the
connections between AIDS and other sexually trans-
mitted diseases.
Common Sexually Transmitted Diseases
Table C.1 describes the nature, symptoms, complica-
tions, and treatment of STDs other than AIDS. These
include: syphilis, gonorrhea, chlamydia, human papillo-
mavirus (HPV), genital herpes, cytomegalovirus (CMV),
chancroid, Hepatitis B, pelvic inammatory disease
(PID), and bacterial vaginosis and trichomoniasis.
Rates of syphilis, a bacterial disease, peaked in 1990
and then began to decline. By 2000 they had fallen 90
percent. In 2001 syphilis rates began to increase again,
but only among men. There have been outbreaks of
syphilis among men who have sex with men, and
syphilis in that population is often associated with HIV
infection (U.S. Centers for Disease Control 2004k).
Gonorrhea is also a bacterial disease. Rates have
undergone a long decline; the 2003 rate was the lowest
ever reported. Rates vary widely by state, ranging from
5 cases per 100,000 people in Idaho to 264 per 100,000
in Louisiana. Gonorrhea rates vary by race and ethnic-
A p p e n d i x
C
Sexually Transmitted
Diseases
1. Sexually related diseases are diseases of the reproductive tract that
occur in both sexually active and sexually abstinent individuals.
These can be caused by organisms that live in the healthy body but
under certain conditions, such as stress, diabetes, drug use, and
other health-related problems, affect the delicate chemical balance
of the body and cause disease conditions of the sexual organs. . . .
A sexually related disease can sometimes be transmitted to a sexual
partner (Greenberg, Bruess, and Hafner 2002, p. 462). Bacterial
vaginosis is an example of a sexually related disease.
Sexually related diseases are often grouped with and discussed
as sexually transmitted diseasesas we have done herein order
to inform sexually active individuals about disease conditions asso-
ciated with sexual activity. When tissue becomes irritated or bro-
ken or germs are transferred from their normal site in the body to
elsewhere in the reproductive, urinary, or digestive systems, an in-
fection can occur that is not strictly speaking a sexually transmitted
disease, but which is produced by or related to sexual activity.
S E XUA L LY TR A NS MI TTE D DI S E A S E S A-9
Ta bl e C. 1
Sexually Transmitted Diseases
DISEASE NATURE, SYMPTOMS, AND COMPLICATIONS TREATMENT
Chancroid
Chlamydia
Cytomegalovirus (CMV)
Genital Herpes
Gonorrhea
continued
Penicillin or other antibiotics. There are
now penicillin-resistant strains, making
gonorrhea riskier than it had been and
turning treatment into a search for the
right antibiotic. At risk people should be
tested routinely, and certainly if they de-
tect possible symptoms.
Gonorrhea is a bacterial disease, transmitted through
sexual contact, including oral contact. It can also be
transmitted from mother to child during delivery.
Symptoms include genital irritation, discharge, and
painful urination, although gonorrhea in women may
be symptomless. Gonorrhea can lead to pelvic inam-
matory disease in women, which can, in turn, lead to
infertility. Infertility is possible in men also. Newborns
of infected, untreated mothers are at risk of serious
complications. In adults gonorrhea may spread to the
blood and joints and become life threatening.
Antiviral drugs such as acyclovir can con-
trol outbreaks of symptoms, although
the infection cannot be cured. Taking
care of general health and avoiding
stress may help prevent outbreaks.
A viral disease that produces lesions on the genitals
that are similar to cold sores that appear on the mouth.
May be asymptomatic, but symptoms often take the
form of a general malaise (tiredness, depression, low
energy, not feeling right). Frequently recurs, but the
rst episode is usually the worst. Genital herpes can be
transmitted to sex partners or infants even when symp-
tomless. Can cause blindness, hearing problems, or
death of infants born to infected mothers, although
this last is a rare occurrence.
Contact CDC for latest developments.
Immunosuppressed adults with serious
symptoms are treated with antiviral
drugs. Drug use is being tried with
infants on an experimental basis.
A virus that is part of the herpes family. It produces
mononucleosis-like symptoms in an active infection.
CMV can be transmitted through sexual contact, but in
other ways as well. This virus is present in a majority of
the American population, but is usually latent; that is, no
symptoms are manifested. For people with impaired
immunological systems, the effects of CMV are more
severe and include gastrointestinal problems or blind-
ness. When a newly acquired infection is transferred to
a fetus during pregnancy, especially when it is a rst
infection for the mother, a possible result is retardation
or death.
Antibiotics Genitourinary tract bacterial infection. Chlamydia can
cause pelvic inammatory disease in women, which
can lead to infertility and is potentially life-threatening.
Can also lead to infertility in men. Can cause prematu-
rity, eye disease, and pneumonia in infants born to in-
fected mothers. Frequently asymptomatic, so screening
is important. Screening is recommended for women
under the age of twenty-six and for older women who
are with a new partner or who have multiple sexual
partners.
Antibiotics Bacterial infection that causes genital ulcers sometimes
accompanied by enlarged, painful lymph nodes in the
groin. Screening for chancroid is technically difcult,
but the disease has now become relatively rare.
A-10 Sexually Transmitted Diseases A P P E NDI X C
Ta bl e C. 1 continued
Sexually Transmitted Diseases
DISEASE NATURE, SYMPTOMS, AND COMPLICATIONS TREATMENT
Hepatitis B (HBV)
Human Papillomavirus
(HPV)
Pelvic Inammatory
Disease (PID)
Syphilis
Trichonomiasis, Bacterial
Vaginosis, and Vaginitis
Sources: Greenberg, Bruess, and Haffner 2002, Chapter 14; Rosenthal 2003; Syphilis through Oral Sex 2004; U.S. Centers for Disease Control and
Prevention 2002; 2004a; 2004b; 2004c; 2004d; 2004e; 2004f; 2004i; 2004j; 2004k; 2004m.
Various prescription and over-the-
counter medications are used to treat
these commonand often persistent
conditions. Male sex partnerswho may
be asymptomaticalso need to be
treated to avoid reinfection. Womens
health books such as Our Bodies,
Ourselves for the New Century (Boston
Womens Health Book Collective 1998)
provide useful advice on diet, clothing,
hygiene, and so on, which can help pre-
vent some forms of vaginitis or prevent
recurrences.
Bacteria, fungi, and other infectious organisms,
allergens, or physical irritation can cause inammation,
discharge, and itching of the vagina and genital area.
Trichonomiasis is caused by a microscopic parasite,
while bacterial vaginosis is not sexually transmitted, al-
though it is associated with sexual intercourse. Vaginitis
is the term used for nonspecic vaginal and genital irri-
tations of uncertain cause. Male sex partners may de-
velop urethritis (inammation of the urinary tract) or
penile lesions. Vaginitis from some causes can result in
an oral infection in newborn infants and trichonomiasis
and bacterial vaginosis are associated with premature
or low-birth-weight babies.
Syphilis is diagnosed by a blood test.
Early diagnosis is important because
syphilis can be cured by antibiotics if
caught early enough. Syphilis can some-
times be asymptomatic, so it is
important that people at risk be
regularly screened. Later-stage syphilis
cannot be successfully treated.
A bacterial disease that is transmitted through vaginal,
anal, or oral sex; transmission through oral sex is in-
creasingly common. Syphilis develops in stages. In the
rst stage, a genital sore appears. It disappears but is
followed in a few weeks by fever, swollen lymph nodes,
and rash, which also recede. May be in remission for
some years, but arrival of the last stage involves dam-
age to heart, nervous system, brain, and other organs.
In infected pregnant women, can cause stillbirth or
birth defects.
Treat the causal STD with antibiotics be-
fore PID develops. Sex partners should
be treated as well to prevent reinfection.
A condition that may develop when other STDs go
untreated. Can result in chronic pelvic pain in women
and/or harm to the reproductive organssuch as dam-
age to the fallopian tubeswhich causes infertility.
HPV is often symptomless, and this viral
infection usually resolves on its own. But
serious complications are possible, no-
tably cervical cancer. Pap smears can de-
tect precancerous or cancerous lesions
caused by HPV, and these can be
treated. Genital warts can be removed
surgically, chemically, or cryogenically
(freezing of tissue).
Also termed genital warts because one possible symp-
tom of this viral disease is wartssometimes painful
on genital organs or rectum. Can increase the risk for
cervical cancer, and more rarely for penile and anal
cancer.
Treatment consists of certain medications
used to prevent or retard liver damage.
There is now a vaccine for hepatitis B,
recommended for individuals at high risk
in terms of their sexual behavior or ex-
posure to the disease in their household
or work and routinely given to children.
Also recommended for overseas travelers
to countries where HBV is prevalent.
This viral disease, contracted primarily through sexual
contact or infected blood or needles, is a liver disease
similar to other forms of hepatitis. Symptoms are gen-
eral, such as nausea, vomiting, pain, malaise, loss of ap-
petite, and jaundice, but HBV can be asymptomatic.
HBV can cause short-term liver inammation that sub-
sides after the active phase, or chronic infections that
can lead to such life-threatening conditions as cirrhosis
and liver cancer. It can also be passed from mother to
child during birth.
ity, with African American rates much higher than
those of other groups. Men and women are equally
likely to have gonorrhea. A current concern is the
growing resistance of gonorrhea to antibiotic drugs
that were previously effective in curing the disease
(U.S. Centers for Disease Control and Prevention
2004j; 2004l).
While syphilis and gonorrhea have long been
known and regarded as serious health threats, some
more recently identied STDs, chlamydia and human
papillomavirus (HPV), are the most commonly occur-
ring STDs today. Reported cases of chlamydia have in-
creased in recent years, but some of the apparent
increase is due to better reporting after screening
programs were introduced in the 1980s. Chlamydia
is a risk factor for pelvic inammatory disease, a
signicant cause of infertility, and PID can be life-
threatening as well. Chlamydia is asymptomatic and
often not recognized. Thus, it is important for sexually
active women under twenty-six and older women at
riskthose with new or multiple partnersto be tested
periodically (U.S. Centers for Control and Prevention
2004b; 2004j; 2004l).
Human Papillomavirus (HPV) affects at least 50 per-
cent of sexually active men and women at some point
in their lives. Most will not have symptoms, and in
many instances the disease will recede on its own. But
HPV is a family of viruses. Some strains are high
risk, implicated as a causal factor in cancer of the
cervix and, more rarely, other cancers of the genital
area. Low risk HPV viruses can produce genital
warts (U.S. Centers for Disease Control 2004d). Re-
searchers are experimenting with vaccines that might
prevent development of cervical cancer, the most seri-
ous complication of HPV (Grady 2002).
Genital Herpes is a viral disease transmitted
through genital or oral sex. Genital herpes increased
30 percent from the 1970s to the 1990s, but declined
17 percent in the 1990s, perhaps as a consequence of
the decline in risky sexual behavior among teens. Still,
approximately 20 percent of American adolescents and
adults are infected. Women have slightly higher rates
of infection, while African Americans have rates of
genital herpes that are substantially higher than those
of whites. In part, this has to do with differential re-
porting. But part of the difference is real, attributed to
poverty, drug use, sexual networks in which STDs are
prevalent, as well as less access to health care (Altman
2004a; Rosenthal 2003; U.S. Centers for Disease Con-
trol and Prevention 2001c; 2004c).
Chancroid is a bacterial STD similar to genital her-
pes, found primarily in men. However, from a high
point of around 5,000 cases in 1987, chancroid has de-
clined to almost the point of extinction; only 54 cases
were reported in 2003 (Rosenthal 2003; U.S. Centers
for Disease Control and Prevention 2004j).
Cytalomegavirus (CMV) is a viral STD that infects
a majority of adults by the time they reach age forty.
Symptoms of active CMV resemble mononucleosis. In
most individuals the disease is latent, with no symp-
toms or health effects. However, immunosuppressed
adults and infants exposed during their mothers preg-
nancy are at risk of serious health damage if they be-
come infected with CMV (U.S. Centers for Disease
Control and Prevention 2002).
Hepatitis B is a liver disease caused by infection
with the hepatitis B virus (HBV). It is spread from one
person to another by contact with blood, semen, or
vaginal uids, most commonly through vaginal, oral,
or anal sexual contact. There is now a vaccine for HBV
that is routinely administered to children. New infec-
tions have decreased from about a quarter of a million
annually in the 1980s to fewer than 80,000 today.
Pelvic Inammatory Disease (PID) is an infection of
the reproductive organs (uterus or fallopian tubes) that
symptomatically causes abdominal pain, but may also
be symptomless. PID often occurs as a complication of
such sexually transmitted diseases as chlamydia or gon-
orrhea, although it may also be caused by other infec-
tions that invade the reproductive organs through the
vagina and cervix. More than a million women have an
episode of pelvic inammatory disease each year, and
100,000 cases of infertility are attributed to PID annu-
ally (U.S. Centers for Disease Control 2004i).
Trichonomiasis, Bacterial Vaginosis, and Vaginitis are
grouped together because their symptoms are simi-
larvaginal discharge and itchingand so are their
complications. These diseases increase the risk of trans-
mission of HIV and other sexually transmitted dis-
eases, and they are associated with premature delivery
and low birth rate babies. But they do differ as to na-
ture and cause.
Bacterial vaginosis is a sexually related disease of
women that results from a disruption of the normal
balance of bacteria in the vagina. The specic cause of
bacterial vaginosis is not well understood. It may or
S E XUA L LY TR A NS MI TTE D DI S E A S E S A-11
A-12 Sexually Transmitted Diseases A P P E NDI X C
HIV/AIDSSome Precautions
AIDS has changed the context of
sex, relationships, and life choices.
Readers will want to keep updating
their information, but here are some
precautions that at present seem
reasonable:
1. Safer sex (no precautions
can make sex completely risk-
free). For sexually active individu-
als who are not in long-term,
securely monogamous relation-
ships, this means the use of latex
condoms (or plastic condoms for
those who are allergic to latex,
but do not use animal skin
because it is permeable and will
permit transmission of the HIV
virus).
Unless it is possible to know
with absolute certainty that nei-
ther you nor your sexual partner
is carrying the HIV/AIDS virus
you must use protective behav-
ior. Absolute certainty means not
only that you and your partner
have maintained a mutually
faithful monogamous sexual re-
lationship, but it means that nei-
ther you nor your partner has
used illegal intravenous drugs
(Koop n.d., p. 16).
2. For heterosexuals as well as
those in the gay community,
safer sex also means the limit-
ing of partners in number and
selectivity. It would be prudent
to conne sexual activity and re-
lationships to those worth the
risk. This can mean decisions
about individuals, or it can mean
categorical decisions about mul-
tiple partners or sex with mem-
bers of high-risk groups such as
men who have sex with men,
individuals who have multiple
partners, intravenous drug users,
or people known to have AIDS
or HIV.
Inquiring about a potential
sex partners health, HIV status,
and previous partners is useful.
However, it is entirely possible
that a prospective partner will
not be honest. Large propor-
tions of men and women with
HIV have sex without telling
partners that they are infected
(Large Proportions 2003,
p. 235). Many people are un-
aware and untested (Altman
2002) It is also the case that anti-
bodies to HIV do not develop
for up to six months or longer
after infection with the virus, so
an infected person may appear
virus-free in early tests and may
report the possibly erroneous
results in good faith. Conse-
quently, experts argue that the
use of latex or plastic condoms
with any partner is the most pro-
tective approach.
3. Deciding to take risks may in-
volve others: your current or fu-
ture sex partners, your children,
and your family. A responsible
sexually active individual con-
cerned about risk to others will
be voluntarily tested and, if the
test is positive, will either refrain
from sex or inform the partner
beforehand and use latex or
plastic condoms during sex.
Responsible sex also includes
telling prospective sex partners
about past sexual activity
with infected or high-risk
individuals.
4. Women planning to become
pregnant or not taking precau-
tions against pregnancy should
be sure that they are free of HIV
by being tested and perhaps
retested over a six-month period
of time. If they are infected and
become pregnant, they should
seek medical help; with that,
they are likely to prevent passage
of the HIV virus to their child.
5. Health care workers should
take the precautions recom-
mended by guidelines for their
occupation.
6. Citizens should support sex
education designed to prevent
the spread of AIDS. Appropriate
AIDS education should be en-
couraged for children (because
even young children can be ex-
posed to AIDS through sexual
abuse), as well as for teenagers
and adults. Videotapes intended
for home viewing are available
from schools, libraries, public
health departments, and com-
mercial sources.
Keep yourself informed by
consulting your local public
health department, physicians,
clinics, reproductive health ser-
vices, student health services,
churches, gay/lesbian activist
groups, and/or media sources.
A good source for comprehen-
sive and updated information
and links to other websites is
the National Library of Medi-
cine information website:
http://sis.nlm.nih.gov/HIV. The
Centers for Disease Control and
Prevention website is also an im-
portant resource: www.cdc.gov.
As We Make Choices
may not be associated with sexual activity, but having a
new partner or multiple partners does seem to increase
the risk. Trichomoniasis is clearly a sexually transmitted
disease, caused by parasites. Both men and women can
get trichomoniasis, though it is more common among
women, and the itching/discharge symptomology is
more pronounced in women. Vaginitis is a nonspecic
irritation or infection of the female genital tract.
Protective Practices
Because many STDs can be asymptomaticthat is,
have no visible symptoms to indicate the presence of
the diseaseit is important for people at risk to have
frequent screening for STDs. At risk in this context
includes anyone with multiple sex partners or a partner
who has a history of multiple partners. Individuals
whose general health makes them vulnerable to in-
fection are also at risk. In truth, any sexual relation-
ship that is not long term and not known to be
monogamous should be considered risky. Sexually ac-
tive individuals, particularly women who have regular
gynecological checkups, might wish to make STD
screening a normal part of their health care.
Latex condoms
2
provide some but not absolute pro-
tection from STDs. Condoms are clearly effective in
the prevention of HIV infection, gonorrhea, chlamy-
dia, and trichomoniasis. These are discharge STDs,
spread by the discharge of semen or vaginal secretions,
and condoms prevent these uids from entering the
body. Condoms provide some unknown degree of pro-
tection from genital herpes, syphilis, and chancroid
(all genital ulcer STDs) and human papillomavirus.
Those STDs are transmitted by contact with skin and
mucous membranes, and condoms do not cover all of
the vulnerable areas (U.S. Centers for Disease Control
and Protection 2003). Vaccines exist for Hepatitis B
(U.S Centers for Disease Control and Protection
2004f ). Efforts are under way to develop vaccines for
some other STDs.
To be effective, condoms must be used always, and
used correctly. A survey of 1,155 adults eighteen
through thirty-ve years old conducted by the Ameri-
can Social Health Association found that one-quarter
of single, sexually active individuals said they never use
condoms in vaginal sex; 71 percent in oral sex (Oglesby
2004).
Many mistakes are made by users. A study of 158
male students at Indiana University found that 43 per-
cent waited too long, putting the condom on after sex
began; 30 percent put the condom on upside down,
and 15 percent removed it before the sex act was com-
pleted. Broken or slipped condoms were also reported
(Webster 2002). A study of almost 800 sexually active
young women between the ages of eighteen and
twenty-four found that 44 percent of the women who
used condoms in a sexual encounter waited too long
(after rst penetration) and 19 percent reported slip-
page or broken condoms (Brody 2003c). Condom
users should check condoms for intactness and cur-
rency (not past expiration date) and should carefully
read directions about usage, best done beforehand.
Early treatment can often prevent the most severe
outcomes of STDs. CDC guidelines recommend
these principles regardless of the STD being treated:
1. Refrain from sex while infectious and while under
treatment.
2. Inform sex partners so they can be treated.
3. Continue treatment as long as recommended and
return for follow-up visits.
4. Use condoms to minimize future transmission, as
many STDs tend to recur. Successful treatment of
STDs may require a great deal of trial and error
on the physicians part and considerable patience
from the patient.
5. Seek the advice of a physician before becoming
pregnant.
AIDS and Other Sexually
Transmitted Diseases
Sexually transmitted diseases other than HIV/AIDS
are important health risks in their own right. But many
STDs are also signicant risk factors for transmission
of HIV/AIDS. Genital ulcers (open sores) or other
bodily vulnerabilities produced by STDs make infec-
tion by the HIV virus much more likely. In fact, many
HIV-infected people are found to have other STDs as
well (Kaiser Family Foundation 2003).
While HIV/AIDS is in a class by itself in terms of
threat to life and health, precautionary guidelines
against the risk of HIV/AIDS are also useful for sexu-
S E XUA L LY TR A NS MI TTE D DI S E A S E S A-13
2. Polyeurathane (plastic) condoms are available for people allergic to
latex, but they have not been tested for effectiveness against STDs.
Condoms made out of lambskin, or other natural materials, are
known to be ineffective (Brody 2003c).
ally active individuals who wish to avoid other sexually
transmitted diseases. See As We Make Choices:
HIV/AIDSSome Precautions.
The Division of Sexually Transmitted Diseases at
the Centers for Disease Control and Prevention
(CDC) in Atlanta is a central resource for information
and research on HIV/AIDS and other STDs. The
STD hotline number is 1-800-227-8922 and the AIDS
hotline number is 1-800-342-2437. The CDC website
is: http://www.cdc.gov. You can nd material on sex-
ually transmitted diseases by clicking on the diseases
and conditions link on the home page and then
choosing HIV/AIDS or Sexually Transmitted Dis-
eases. Alternatively, go to Health Topics AZ, and
nd HIV/AIDS and Sexually Transmitted Dis-
eases or search for a particular STD.
A-14 Sexually Transmitted Diseases A P P E NDI X C
A
sexual dysfunction may be de-
ned as a specic chronic disorder
involving sexual performance (Green-
berg et al. 2002, p. 515). But the concept of sexual dys-
function has been rethought in recent years, to give
priority to whether or not an individual or couple nds
a particular condition or situation to be troublesome.
In these terms, a sexual dysfunction is a chronic in-
ability to respond sexually in a way one nds satisfy-
ing (p. 515). Research indicates that 43 percent of
women and 32 percent of men report that they experi-
ence sexual problems (Laumann, Paik, and Rosen 1999).
Sex experts identify these dysfunctions: premature
ejaculation, retarded ejaculation, and erectile dysfunc-
tion in men; female sexual arousal disorder, female or-
gasmic dysfunction, and vaginismus among women;
and dyspareunia as a sexual dysfunction that may be
experienced by either men or women (Kaplan 1974;
Greenberg et al. 2002). See Table D.1 for an outline of
common sexual dysfunctions, their symptoms, and
treatment.
1
In addition, there are situations of absent or mini-
mal sexual desire that are not considered sexual dys-
functions per se, but that mean a sexual life that an
individual is not happy with and wishes to change.
Technical terms are inhibited sexual desire, dissatisfaction
with sexual activity frequency, and sexual aversion.
Inhibited sexual desire may occur only in the con-
text of particular relationships or situations (such as
lack of privacy). Dissatisfaction with sexual frequency
is very common. Partners as individuals often differ in
their preferences, and men typically prefer more fre-
quent sexual activity than do women.
Sexual aversion refers to a distaste for sex that can
have quite different origins: parents who were very
negative about sex; a traumatic experience of rape or
abuse; too much pressure from partners; or gender
confusion (Kaplan 1995; Greenberg et al. 2002).
It may be hard to determine in measurable terms
whether or not a person has a sexual dysfunction. For
one thing, virtually all sexually active people will have
some instances of unsatisfactory sexual experience or
nonperformance. And couples and individuals vary in
their expectations of sex. It is for this reason that ther-
apists would rather rely on the individuals or couples
denition of the situation in considering the need for
treatment (Greenberg et al. 2002).
Sexual dysfunctions, along with the more general
situation of decreased sexual desire, may result from
certain physical disabilities and chronic diseases. Thus,
the rst step in sexual therapy needs to be a medical
review and examination. Some surgical and chemo-
therapy treatments for cancer can cause sexual dys-
function. Various medications are related to sexual
difculties: drugs for hypertension and some heart con-
ditions, antidepressants, anti-anxiety drugs, and street
narcotics, for example (Kaplan 1974; Forman 1996;
Hellstrom 1997).
A p p e n d i x
D
Sexual Dysfunctions
and
Therapy
1. By and large, general information on sexual dysfunction is pre-
sented in most sources in the context of heterosexual relationships,
often presuming marriage.
A-16 Sexual Dysfunctions and Therapy A P P E NDI X D
Ta bl e D. 1
Common Sexual Dysfunctions
DYSFUNCTIONS SYMPTOMS USUAL TREATMENT
Premature Ejaculation Inability of a man to control ejaculatory
reex or if one or both partners are
dissatised.
Retarded Ejaculation Inability of a man to trigger orgasm;
may be situational or a general
dysfunction.
Erectile Dysfunction Inability of a man to produce or
maintain an erection.
Female Sexual Arousal Sexual unresponsiveness: inability of a
Disorder woman to derive erotic pleasure from
sexual stimulation.
Female Orgasmic Difculty of a woman in reaching
Dysfunction orgasm.
Vaginismus Involuntary contraction of vaginal walls
that prevents intercourse.
Dyspareunia Painful sexual intercourse.
Sources: Kaplan 1974, 1995; Greenberg et al. 2002.
Note: Treatment is preceded by a complete physical examination to identify any physiological causes for the disturbance.
Treatment of any relevant medical conditions; edu-
cation about hygiene. For women, education of
self/partner about stimulation in foreplay, similar to
therapy for orgasmic difculties.
Correction of possible physical conditions; counseling
plus exercises to recondition muscles.
Focus on helping woman learn to reach climax by
herself, then with partner in sexual exercises not ini-
tially aimed at intercourse.
Education about arousal techniques, creation of re-
laxed, sensuous environment free from pressure to
have intercourse. Efforts to nd a pharmaceutical
treatment for female sexual arousal disorder or other
female sexual dysfunction has thus far proven
unsuccessful.
For medical conditions or other erectile dysfunction,
pills such as Viagra, Levitra, or Cialis stimulate erec-
tion (new drugs may come on the market after this
book goes to press). Alternatives include another
drug, which is injected into the penis, or penile
implant or vacuum pump. For psychosocial factors,
sexual exercises combined with therapeutic counsel-
ing, with focus shifted away from performance aspect
of sexual interaction.
Sexual exercises combined with therapeutic counsel-
ing; temporary avoidance of intercourse and use of
other means to elicit ejaculation.
Repeated stimulation to the point just before
ejaculation.
Some 40 percent to 90 percent of sexual problems
have psychological aspectsif that term is broadly de-
ned to include relational and cultural issues (Green-
berg et al. 2002, pp. 515; 529). Women with female
sexual arousal disorder and men with erectile dys-
function, for example, were more likely to be generally
unhappy with their lives than those not reporting
sexual problems. Of course, what is cause and what
is effect are often unclear (Laumann et al. 1999); sex-
ual difculties would be likely to dampen ones life
satisfaction.
The general state of a couples relationship will in-
teract with their sexual relations. Typically, womens
sexual problems are more closely tied to relationship
issues than mens (Bancroft, Loftus, and Long 2003).
Married men and women have fewer sexual problems
than nonmarried individuals. The highly educated
have fewer sexual problems, and people experience
more sexual dysfunction or disinterest as they age
(Laumann et al. 1999).
The cultural climate regarding sex is relevant to
sexual attitudes and experiences. Women in a culture
that maintains a double standard may be less free sexu-
ally, while mens gender-related cultural issues would
typically center on performance pressure (Greenberg
et al. 2002, p. 527).
I
Premature Ejaculation
I
Premature ejaculation, the inability to control the
ejaculatory reex, is one of the most common male
sexual complaints, reported by around 30 percent of
men (Laumann et al. 1999). A man might ejaculate
after several minutes of foreplay or just after entering
his partners vagina. In contrast, a man who has good
ejaculatory control can continue to engage in sex play
while in a highly aroused state.
The expectations of the man and woman play a
role in dening whether or not there is a premature
ejaculation problem. Some sexual experts, especially in
the past, would look at the actual time a man can main-
tain sexual thrusting without ejaculation. More re-
cently, partners satisfaction is used as a diagnostic
criterion by some therapists, while others would focus
on the mans inability to control ejaculation. One way
therapists deal with premature ejaculation is to teach a
couple an exercise through which the man can gradu-
ally learn to control his orgasm. Therapists report that,
in most cases they have treated, premature ejaculation
eventually ceases to be a problem (Mulcahy 1997).
I
Retarded Ejaculation
I
A man aficted with retarded ejaculation, or ejacu-
latory inhibition, cannot trigger orgasm. Less than
10 percent of men report this dysfunction (Laumann
et al. 1999), although it may be more prevalent as an
occasional experience. In mild form, ejaculatory in-
hibition is conned to specic anxiety-producing situ-
ations, such as when a man is with a new partner or
when he feels guilty about the sexual encounter. In
more severe cases, a man may seldom experience or-
gasm during intercourse but may be able to achieve it
by masturbation or by a partners fondling or oral
stimulation.
Once physical or drug-related causes are ruled
out, treatment consists of couple counseling sessions
along with a series of progressive sexual exercises de-
signed to relieve the man of his latent fears about in-
tercourse. The rate of success with therapy is fairly
high (Mulcahy 1997; Hellstrom 1997).
I
Erectile Dysfunction
I
A man suffering from erectile dysfunction is unable
to produce or maintain an erection.
2
Although he may
become aroused in a sexual encounter and want to
have intercourse, he cannot. Virtually all men of what-
ever age occasionally experience an episode of erectile
dysfunctionperhaps in response to over consump-
tion of alcohol or circumstances in which either the
environment or feelings about the partner are not
conducive to good sex. As a more chronic condi-
tion, estimates are that some thirty million American
men experience erectile dysfunction, a problem that
increases with age: 7 percent of men aged eighteen
through twenty-nine, 9 percent of men in their forties,
and 40 percent of men in their eighties experience
erectile dysfunction.
Physicians estimate that 70 percent to 80 percent
of the erectile dysfunction cases they see have at least
partial physical causes. Diabetes, certain medications,
spinal cord injury, and nerve damage from prostate
cancer or other surgery are just few of the many health
conditions that may affect a mans erection (Greenberg
et al. 2002). Today, there are several medical treat-
ments for chronic erectile dysfunction, including Via-
gra and other medications designed to sustain an
erection. Surgical insertion of an inatable implant
into the penis is another option (Leland 1997), though
somewhat displaced now by pharmaceutical treat-
ment. Newer drugs have been developed to assist men
who do not respond well to Viagra.
Nonmedical factors that may affect erectile func-
tion are usually situational rather than deeper psy-
chological problems: fear of sexual failure, pressures
created by an excessively demanding partner, or guilt.
Because our society tends to equate the capacity to
have an erection with adult masculinity, even transient
E RE CTI L E DY S F UNCTI ON A-17
2. Impotence is the term by which erectile dysfunction was known
until very recently. Sex therapists now reject the term because of its
implication of a more general powerlessness.
impotence may cause a man to feel anxious. As with
other sexual dysfunctions, the anxiety produced by one
otherwise insignicant and transitory failure may initi-
ate a downward spiral in which anxiety retards sexual
responsiveness, leading to more anxiety about perfor-
mance, less sexual success, and so on.
Depression or relationship discord may accom-
pany erectile dysfunction, and, if so, these symptoms
must be at least somewhat relieved before a therapist
can treat the sexual dysfunction itself. Therefore, ther-
apists combine sexual exercises at home with therapeu-
tic counseling. The exercises are designed to free the
man from pressures to perform and let him simply
enjoy his sexual feelings. Essentially, the couple is in-
structed to caress each other during sexual play but not
to have intercourse. Permission to enjoy himself with-
out having to perform allows the man to relax without
worrying whether his body will respond. Paradoxi-
cally, the more he relaxes, the more likely his body is to
respond. This same philosophy lies behind much of
the treatment for female sexual dysfunction.
I
Female Sexual Arousal
I
Disorder
Women who experience female sexual arousal dis-
order
3
derive little if any erotic pleasure from sexual
stimulation and do not evidence such physiological re-
sponses as vaginal lubrication. About 30 percent of
women (compared to 15 percent of men) report that
they lack interest in sex (Laumann et al. 1999). Some
women have never experienced erotic pleasure; others
have at one time but no longer do. Often they enjoyed
petting before marriage but became unable to respond
when intercourse was the expected goal of sex.
Besides giving the couple basic information, ther-
apists encourage them to create a relaxed, sensuous
atmosphere at home, one that allows for the natural
unfolding of sexual responses. In one exercise, the in-
dividuals take turns caressing each other, but they do
not progress to sexual intercourse and orgasm. Freed
from the pressure to have intercourse, a woman can
often experience erotic sensations, and the couple can
gradually build on this sensation of pleasure until they
are eventually ready for intercourse.
I
Female Orgasmic
I
Dysfunction
About a quarter of women have difculty in reaching
orgasm, termed female orgasmic dysfunction (Lau-
mann et al. 1999). A few women cannot reach a climax
under any circumstances. More often, a woman can
reach orgasm, but only under specic conditions.
Many women with this dysfunction enjoy sex; they just
get stuck at the plateau phase and cannot proceed to
a climax (Masters and Johnson 1970; Masters, John-
son, and Kolodny 1994). As in erectile dysfunction,
anxiety about performance may feed back to further
inhibit a womans sexual responsiveness. Only about 5
percent of orgasmic dysfunction is believed to have or-
ganic causes (Greenberg et al. 2002).
Treatment for women who have never experienced
orgasm usually begins by focusing on the woman. The
therapist asks her to masturbate at home alone, stress-
ing that the environment should be free from distrac-
tions and interruptions. Another approach for women
who have never experienced orgasm is group educa-
tion. Women meet together to learn about their bod-
ies; they are then encouraged to masturbate at home
until they become familiar and condent with their
own response cycles (Masters, Johnson, and Kolodny
1994). Research conrms the effectiveness of both
masturbation and various forms of talk therapy, includ-
ing general couple therapy (Konner 1990; Kaplan
1974; 1995).
Once a woman can stimulate herself to climax, her
partner enters the treatment program. The couple is
told to make love as usual, except that after the man
ejaculates, he stimulates his partner to orgasm. The
woman is told to be utterly selsh, not to monitor her
progress toward orgasm but to simply enjoy her sensa-
tions. Women are cautioned that watching ones own
response to see if its rightthat is, headed toward
orgasmtends to inhibit physical responsiveness and
to contribute to tension that sometimes develops into
long-term sexual problems (Masters and Johnson
1970; Masters, Johnson, and Kolodny 1994). Instead,
each partner is to enjoy the pleasurable sensations pro-
duced by the caresses of the partner.
A-18 Sexual Dysfunctions and Therapy A P P E NDI X D
3. Frigidity has been replaced as a term for female sexual dysfunc-
tion because of its negative aura and the implication that a woman
who has a sexual response problem is emotionally cold or hostile
to her partner.
This treatment is helpful in letting couples see be-
yond the myth of the simultaneous orgasmthe erro-
neous idea that true love or really great sex means that
both partners must always reach orgasm at the same
time. Sometimes partners do climax simultaneously,
but not usually. The belief that they should can leave
the woman, who is typically slower to become aroused,
frustrated; it may even encourage her to fake it. It may
be better to take turns in being pleasured to orgasm.
Direct Clitoral Versus
Vaginal Stimulation
One reason that it may be better to take turns is that
many women report they do not reach orgasm
through vaginal stimulation in intercourse. As Appen-
dix A points out, there is a much greater concentration
of nerve endings in the clitoris than in the vagina itself.
One possible pattern is for the husband to stimulate
his wifes clitoris until she reaches orgasm and then to
enter her vagina to attain his own climax.
Research indicates that of those women who expe-
rience orgasm, only about 30 percent to 44 percent do
so without clitoral stimulation (Greenberg et al. 2002,
p. 522). Most experts and therapists see the need for
direct clitoral stimulation as normal to female sexual-
ity. The best strategy, it would seem, would be for the
individual woman to be aware of and make her partner
aware of her own response pattern.
Some women never achieve orgasm with a partner
even with direct clitoral stimulation, although they are
able to climax by masturbating. Typically, this situa-
tion reects a womans anxiety, ambivalence, or anger
about the relationship. Treating this type of inorgasm
typically involves individual or marital therapy or
both.
I
Vaginismus
I
Vaginismus is relatively rare. A woman with this
dysfunction is anatomically normal, but whenever her
partner attempts to penetrate her vagina, the vagi-
nal muscles involuntarily contract so that inter-
course is impossible. Typically, vaginismic women are,
at least unconsciously, afraid of vaginal penetration
and intercourse.
After any physical conditions have been corrected,
therapists treat vaginismus by seeking in counseling
sessions to uncover the basis for the womans fear of
vaginal entry. Then progressive exercises are used to
recondition the muscles at the entrance to the vagina.
The length of the treatment varies, but therapists re-
port excellent results (Kaplan 1974).
I
Dyspareunia
I
Dyspareunia refers to recurrent pain that men or
women may experience during sexual activity. For
men, pain may localize in the penis or testes or be felt
internally. For women, pain may take the form of
burning or cramping felt in the vagina or pelvis. A
little more than 20 percent of women aged eighteen
through twenty-nine experience dyspareunia; rates de-
cline as women get older.
There are a variety of possible physical causes for
dyspareunia in either men or women, and these call for
appropriate medical treatment or improved hygienic
practices. Women may experience pain during inter-
course if their vagina has not become sufciently lu-
bricated before penile insertion. Here the solution
seems to be education about sexual anatomy and re-
sponse, and changed practices regarding foreplayas
well as ensuring the most anxiety-free setting for inter-
course. If relationship issues underlie problems in
physical responsiveness, they need to be addressed.
In all of the dysfunctions we have described, a
common thread is the emotional climate of a couples
relationship. As therapists help a couple to overcome
their immediate sexual difculties, they also try to help
partners recognize and avoid alienating practices that
may become obstacles to mutually pleasurable sex.
Maintaining and enhancing the total couple relation-
ship is an important part of the therapeutic process.
I
Sex Therapy
I
The number of people seeking treatment for sexual
dysfunction has increased in recent years. This is
probably due to increased openness about sexuality
and willingness to admit a problemperhaps former
Senator Bob Dole has led the way in his acknowledg-
ment of erectile difculties in advertisements for Via-
gra (Hitt 2000). Viagra exemplies the development of
more effective sex therapies in recent years, whether
S E X THE R A P Y A-19
medical or involving new forms of psychological or re-
lationship therapy (Greenberg et al. 2002).
In traditional approaches to treating sexual dys-
function, therapists looked for subtle and profound
psychological sources, such as unresolved emotional
conicts from childhood or severe marital power
struggles. These causes and therapies still exist, but
today most therapists focus on more immediate and
obvious reasons for the dysfunction. These include not
only health conditions (in a population whose median
age is increasing) but also anxieties about sexual failure
or the partners satisfaction. These fears can create var-
ious sexual defenses and inhibit people from abandon-
ing themselves to the experience. One important
feature of Masters and Johnsons therapy is its attempt
to remove performance pressure by insisting that
the couple not strive for orgasm or even have inter-
course but rather focus on all-over body pleasure and
pleasuring.
Masters and Johnson laid down some ground rules
for sex therapy in their book Human Sexual Inadequacy
(1970). They said that therapists should work in
malefemale teams and with both partners in the rela-
tionship. They stressed that the team should be com-
fortable with their own sexuality and nonjudgmental
about the full range of human sexual activity. Since
then, some respected therapistsHelen Singer Kap-
lan, for examplehave successfully treated couples
without a co-therapist (Kaplan 1974). Many contem-
porary therapists continue to follow the Masters and
Johnson guidelines, however.
Therapy normally begins with a physical and psy-
chological examination of both partners. The last
decade has witnessed a signicant return to a consider-
ation of medical problems and physical treatments for
male sexual dysfunction. New hormonal products are
also envisioned for the treatment of female sexual dys-
function (Riordan 1999; Hitt 2000; Leland 2000).
A legitimate therapist will give a couple a clear
picture of what to expect during treatment and will
probably make a therapeutic contract with them that
clearly establishes the couples responsibility for their
treatment. They will also scrupulously follow profes-
sional ethical guidelines that prohibit therapists be-
coming sexually involved with clients. Sensitivity to
racial/ethnic cultural differences and religiously based
values is also important.
One way to check sex therapists qualications is
to nd out whether they belong to a professional asso-
ciation. An important national organization is the
American Association of Sex Educators, Counselors,
and Therapists. This group publishes the Journal of
Sex Education and Therapy and maintains a web site that
offers a state-by-state listing of certied sex therapists.
A sex therapists code of ethics is posted on the web
site: http://www.aasect.org.
There are also regional professional associations.
In the absence of membership in a professional associ-
ation, therapists are more likely to be legitimate if they
are accountable to a community agency, teaching hos-
pital, medical school, or university. Some states license
or certify therapeutic professionals of various kinds.
One might also seek recommendations from trusted
friends who have had experience with sex therapists.
A choice for couples is to recognize that sexual
problems often reect their relationship and to seek
help from a qualied marriage or relationship coun-
selor. Individuals might also address sexual problems
in a general therapeutic context. A womans group ap-
proach to sex therapy is another option (Barbach 1980,
1991 [1975]).
For more information, see Jerrold Greenberg
et al., Exploring the Dimensions of Human Sexuality
(2002); Kamal Hanash, Perfect Lover: Understanding
and Overcoming Sexual Dysfunction (1994); Judith
Heiman and Joseph Lopiccolo, Becoming Orgasmic: A
Sexual and Personal Growth Program for Women (1992);
Helen Singer Kaplan, The Sexual Desire Disorders: Dys-
functional Regulation of Sexual Motivation (1995); and
Bernie Zilbergeld, The New Male Sexuality (1999).
There are also books available in bookstores and li-
braries that address sexual dysfunctions associated
with various health and disability conditions or that
address sexual problems in gay and lesbian relation-
ships. In evaluating books on sexual dysfunction, check
the credentials and afliation of the author as one
would do in choosing a therapist.
I
The Medicalization
I
of Sexuality
A sharp departure from the model of relationship-
oriented sex therapy is a growing tendency to focus
solely on medical solutions to sexual dysfunctions or
sexual dissatisfaction. The acceptance of Viagra and its
success in remedying many mens erectile dysfunction
problems has set off a search for a pharmaceutical cure
A-20 Sexual Dysfunctions and Therapy A P P E NDI X D
for other sexual dysfunctions, including those affecting
women.
Research and development for a female equivalent
of Viagra to treat female sexual arousal disorder has
been in progress for almost ten yearswith little suc-
cess, however. Women, the maker of Viagra has
found, are a lot more complicated than men. . . . The
problem . . . is that men and women have a fundamen-
tally different relationship between arousal and desire
(Harris 2004, p. C-1). There is a disconnect in many
women between genital changes and mental changes,
said Mitra Boolel, leader of Pzers sex research team
(p. C-1). Pzer has given up on marketing Viagra to
women because company researchers have found that
when physiological arousal is stimulated by drugs, that
does not lead to a womans desire, or even willingness
to have sex. Viagra may, however, help women whose
sexual desire levels were previously normal, but have
fallen because of medications such as anti-depressant
pills.
The Federal Drug Administration has refused to
approve another approach, a testosterone patch, as
presently too risky (Pollack 2004). Pzer has begun to
explore yet another approachchanging focus from
a womans genitals to her head, i.e., drugs that might
affect brain chemistry. As one professor of clinical
medicine at Columbia University put it, facetiously,
What we need to do is to nd a pill for engendering
the perception of intimacy (Harris 2004, p. C-1).
A New View of
Female Sexual Disorder
The point is that womens sexual feelings are very
much connected to relationships and they are shaped
by the cultural climate as well. Daily pressures are
another factor affecting womans sexual desire: [A]ny-
one affected by FSD [female sexual dysfunction] might
do better to claim some leisure in her life and work on
rekindling the romance (Ehrenreich 2004, p. 154).
A more formal reconceptualization of female sex-
ual dysfunction has been developed by a working
group of psychiatrists, sex therapists, feminists, and so-
cial scientists. A New View of Womens Sexual Prob-
lems (The Working Group on a New View of
Womens Sexual Problems; Karshak and Tiefer
2002)their manifestocategorizes female sexual
dysfunction in terms of socio-cultural, political, or
economic factors; sexual problems relating to part-
ner and relationship; sexual problems due to psycho-
logical factors; and sexual problems due to medical
factors. The New View group is opposed to the as-
sumptions behind the development of pharmaceuti-
cal treatments. They argue that this approach labels
women as sexually decient; does not address womens
real problems; and may pose medical risks besides.
This new view of female sexual issues is sup-
ported by current research on heterosexual womens
sexual response (Bancroft, Loftus, and Long 2003).
John Bancroft, director of the Kinsey Institute, resists
labeling women dysfunctional if they lack desire or fail
to have organisms. Dysfunctional for whom? Ban-
croft asks. If a woman is stressed or has children and a
job, she might put sex on the back burner for good rea-
son. It could be adaptive for her. . . . It doesnt mean
theres anything wrong with her response system or
that shes dysfunctional (in Elias 2003, p. A-1).
Medicalization and Men
The assumption that most often mens sexual prob-
lems and their solution are physiological has been
widely accepted (Leland 1999). That model has given
men Viagra. While Viagra is not effective for all men
and has some drawbacks in terms of lack of spontane-
ity, newer drugs have been added to the pharmaceuti-
cal roster, and many men have seen their sex lives
resume or improve. It is still the case that medical con-
siderations prevent use of these erectile dysfunction
drugs by some men, or that they are deterred by side
effects.
Now some sexuality professionals and activists are
beginning to question whether the new tight link be-
tween drugs and sexual performance has gone beyond
remedying specic medical/sexual problems that have
impaired sexual satisfaction toward redening mens
sexuality in almost entirely physiological terms.
[T]heres something deeply creepy about the med-
icalization of sexuality, male and female, says social
critic Barbara Ehrenreich (2004, p. 154). Concern has
also been expressed that drugs intended for men who
have sexual problems due to surgery or health condi-
tions are being used by men who have no sexual dys-
function, but who believe the pills will enhance sexual
experience, or perhaps provide insurance against the
occasional failure to achieve erection. Some ads for
erectile dysfunction drugs now emphasize their recre-
ational use (Harris 2003; Kirby 2004).
THE ME DI CA L I ZATI ON OF S E XUA L I TY A-21
There are several ways to think about this. Ehren-
reich would prefer to see individual choice in the use
of sex-enhancing erectile drugs rather than make a
sharp distinction between recreational and therapeutic
usefor that in essence requires labeling individuals
as either sexually functional or dysfunctional.
Some sex therapists are concerned about the dis-
appearance of the partner and of the psychological
context of sexual expression when the focus is entirely
on producing an erection. Physicians in the eld of
sexual medicine believe a trend that ignores the psy-
chological and relational factors that also enter into
sexual satisfaction is not ultimately conducive to sexual
happiness. Individual psychology and couple fac-
tors remain important causes [of sexual dysfunction
or satisfaction] says an article, Viagra and Broken
Hearts, in the Canadian Family Physician (quoted in
Stamler 2004, p. 10).
We see that new issues have emerged out of the
medicalization of sexual dysfunction, including that of
the essential meaning of sex. Discussion appears to
have just begun.
A-22 Sexual Dysfunctions and Therapy A P P E NDI X D
I
n appendix e, we present some of the
basic facts of conception, pregnancy, and child-
birth, as well as some issues in the management
of pregnancy and birth by parents and doctors. Appen-
dix F discusses contraception, while Appendix G pres-
ents information on reproductive technology.
I
Conception
I
A womans ovaries alternate in releasing one egg, or
ovum, each month, in a process called ovulation.
Ovulation takes place about fourteen days before a
menstrual period; thus, a womans most fertile time is
usually midway between menstrual periods, when the
ovum is traveling through the fallopian tubes to the
uterus.
When sperm enter a females vagina during coitus
(sexual intercourse), they move into the fallopian tubes
and can live there from two to ve days. Conception
takes place upon fertilization, or the joining of the
sperm cell with the ovum. If this takes place in the
fallopian tubes, the fertilized egg, or zygote, moves
down to the uterus, where it embeds itself in the thick-
ened lining, or endometrium (see Figure E.1), a
process called implantation. Until an umbilical cord
is formed during about the fth week, the endometrial
tissue provides nourishment for the developing fetus.
I
Pregnancy
I
The fertilization and implantation processes just de-
scribed take place during the germinal period, or rst
two weeks of pregnancy.
1
During this early period, the
woman usually isnt aware that she is pregnant. By the
fourth week, however, she may begin to notice some
changes.
The rst signs a woman often notices are a cessa-
tion of menstruation (because the endometrial tissue
will not be sloughed off ), nausea (a physical reaction to
the zygotes embedding itself in the uterine wall),
changes in the size and fullness of the breasts, dark-
ened coloration of the areolae around the nipples, fa-
tigue, and frequency of urination, a result of pressure
on the bladder from the expanding uterus. Not all of
these signs, including nausea and cessation of men-
struation, are always present, so a woman who suspects
she is pregnant should have a pregnancy test even if
she does not detect all of these indicators of pregnancy.
The Embryonic Stage
The embryonic stage of pregnancy lasts from the sec-
ond until about the eighth week. During this stage, the
A p p e n d i x
E
Conception,
Pregnancy,
and
Childbirth
1. Pregnancy is often thought of in terms of three three-month
trimesters that do not correspond to the germinal, embryonic, and
fetal periods. The embryonic and germinal periods take place in
the rst trimester; the fetal period of development begins in the
rst trimester and continues through the second and third
trimesters.
head, skeletal system, heart, and digestive system begin
to form. Also during this time a sac of salty, watery uid
called amniotic uid surrounds the fetus to cushion
and protect it. In later stages of pregnancy, doctors can
detect some fetal defects by withdrawing a tiny portion
of this amniotic uid through the mothers abdomen
with a syringe and testing it in a laboratory. During this
period, the placenta develops inside the uterus. It is an
organ that holds the fetus in place and provides nour-
ishment and oxygen through the umbilical cord,
which links the fetus to the mother; waste is expelled
through the cord. (The placenta will be discharged in
the nal stage of childbirth.)
The Fetal Stage
The fetal period of development lasts from about
eight weeks until birth. During the fetal period, the
organs and structural system that budded during the
embryonic stage rene themselves and grow. Some of
the changes that take place up to fteen weeks are il-
lustrated in Figure E.2.
In the third month, the facial features become dif-
ferentiated. The lips take shape, the nose begins to
stand out, and the eyelids are formed, although they
remain fused. The ngers and toes are well developed,
and ngernails and toenails are forming.
During the fourth month, most of the fetuss
bones have formed, although they are still soft carti-
lage and will not be completely hardened into bone
until after birth.
In the fth month, the fetal heartbeat can be heard
through a stethoscope. Around this time, too, the
quickeningthe rst fetal movements apparent to
the mother herselfprogresses from a mild uttering
to solid kicks against the side of the mothers abdomen.
Any nausea that the mother may have experienced
usually disappears by now, and she is in the most com-
fortable period of her pregnancy.
In the sixth month, the fetus grows to a foot in
length and about twenty ounces in weight. The fetus
now has eyelashes, it can open and close its eyes, and it
may even learn to suck its thumb. By the end of this
month, its essential anatomy and physiology are al-
most complete; further development consists largely
of an increase in size and renement and stabilization
of the organs functions. A fetus born or aborted at this
time is likely to emerge alive and may live several
A-24 Conception, Pregnancy, and Childbirth A P P E NDI X E
Zygotes journey
through fallopian tube
Uterine lining
Oviduct Two-cell stage Fertilization
Ovum is
released
Follicle
Immature
ova
Corpus Iuteum
Implantation
Ovary
FIGURE E.1
Ovulation, fertilization, and the germinal period of pregnancy.
hours. Survival beyond that will require constant med-
ical attention, and the chances for survival are slim.
2
By seven months, the fetus weighs about two and a
half pounds. If born now, it will have a substantial
chance of survival with the aid of specialized attention
and equipment. A baby born in the eighth month of
pregnancy has a very good chance of survival because
its development is virtually complete.
In the eighth and ninth months of pregnancy, the
fetus grows very rapidly, gaining an average of a half
pound per week. At this time, the mother is likely to
feel generally healthy but may also be uncomfortable
because of the crowding in her expanding uterus and
because weight increases may disrupt her equilibrium
and her ability to get around. Toward the end of preg-
nancy, the fetus usually changes its position so that the
head is in the lower part of the uterus. This marks the
beginning of preparation for birth. The normal length
of gestation, or development of a pregnancy into a
full-term baby, is forty weeks.
P RE GNA NCY A-25
14 days
18 days
24 days
4 weeks
6
1
2 weeks
7
1
2 weeks
9 weeks
11 weeks
15 weeks
FIGURE E.2
Prenatal development.
2. The survival of very small babies is not unknown and is becoming
more common. An infant weighing only 8.6 ounces at birth is
thought to be the smallest surviving baby. She was born in 2004 at
Loyola Hospital in Chicago, which has cared for some 1,700 new-
borns weighing less than two pounds. Ninety percent of babies
born at Loyola who are of twenty-eight weeks gestation have sur-
vived (normal length of pregnancy is forty weeks) (Worlds Small-
est Baby 2004). Loyolas record is unusual, however, as 41 percent
of babies who are premature at twenty-eight weeks or fewer do
not survive the rst year (Martin et al. 2003, p. 16).
I
Monitoring Fetal
I
Development
Recent years have seen extraordinary scientic advances
in monitoring fetal development. Here we look at sev-
eral such advancesultrasound, amniocentesis, chori-
onic villus sampling, and the newer blood screening
techniques for assessing a fetuss risk of abnormality.
Ultrasound
In ultrasound, sound waves are bounced off the ab-
domen of the pregnant woman to determine the shape
and position of the fetus. Ultrasound is now widely
and routinely used; ultrasound monitoring was used in
the pregnancies of 68 percent of the women who gave
birth in 2002 (Martin et al. 2003). Doctors say that it
helps to predict the date of birth within two weeks,
that it can detect twins 90 percent of the time, and that
it shows whether the fetus is maturing as it should. Ul-
trasound can also reveal several different kinds of birth
defectsespecially malformations of the skeleton
early enough for a legal abortion if parents choose to
have one. In other cases, defects or problems revealed
by ultrasound have led to corrective surgery that takes
place before birth ( Jones 2001).
The use of ultrasound has implications beyond di-
agnosis, however. Sonograms permit prospective par-
ents to do something they have never been able to do
beforeobserve the fetus; they are often given pic-
tures or videotapes of the fetus to take home. This
technology is pushing back parental bonds to before
birth: You just feel like you already know him (in
Kempley 2003, p. C-01).
3
Amniocentesis, Chorionic Villus Sampling,
and Other Prenatal Testing
While ultrasound can assess the overall structural nor-
mality of a fetus, amniocentesis and other prenatal
testing provide more information to parents about
their risk of having a child with a birth defectthat is,
a condition substantially lowering the quality of life or
leading to premature illness and death. Common con-
cerns of parents are Downs syndrome and spina bida,
a neural-tube defect in which the spinal covering fails
to close, which may lead to severe mental and physical
disability and early death. Cystic brosis is another
health condition that is testable prenatally. The risk of
genetically or gender-linked diseases such as Tay-
Sachs disease or hemophilia may be assessed through
such testing. In some cases, there is the potential of
fetal surgery to correct problems discovered by pre-
natal testing.
In amniocentesis, a physician inserts a needle
through the abdominal wall into the uterus, withdraw-
ing a small amount of amniotic uid. Cells and other
substances that the fetus has cast off oat in this uid,
which technicians can examine for clues to fetal health
and the presence of the most common birth defects.
When doctors suspect that a woman might give birth
to a child with a particular disorderoften because she
carries a recessive gene for this disorder or because she
has already given birth to a child with the disorder
scientists can examine the uid for those conditions,
including nearly 100 rare genetic diseases. As women
postpone child bearing to older ages, they have more
concern about the risk of such birth defects as Downs
syndrome; the risk increases with age. Pregnant
women over thirty-ve are usually advised to have am-
niocentesis or chorionic villus sampling.
When performed by experienced medical person-
nel, amniocentesis appears reasonably safe, but the
technique is not without risks. Hazards include sponta-
neous abortion and risk of premature birth, with fetal
damage occurring in 0.5 percent of cases (Amniocen-
tesis 2004)a slight risk, but one that concerns par-
ents. Moreover, amniocentesis cannot take place until
the second trimester, when sufcient amniotic uid is
present. This timing is a major drawback. The prospect
of a second-trimester abortion is more emotionally
troubling, and a later abortion heightens the physical
risk to the woman. Amniocentesis is also costly.
Chorionic villus sampling (CVS) can provide infor-
mation earlier in pregnancy by testing tissue from the
fetal membrane. This technique carries some risk and
uncertainty as well. CVS seems to cause miscarriages
in 0.5 percent to 1.0 percent of cases (Chorionic Vil-
lus Sampling 2004). Moreover, CVS cannot detect
neural tube defects.
A-26 Conception, Pregnancy, and Childbirth A P P E NDI X E
3. Some commercial rms now offer elective ultrasound, not for med-
ical diagnosis but to provide an early baby picture for the parents.
These rms use 3-D machines that produce very realistic images.
This type of ultrasound is controversial, with the FDA (Federal Drug
Administration) and some physicians groups opposed to what
they see as an unnecessary use of expensive technology that might
carry some unknown risk. But the FDA has not prohibited these
practices, and some doctors believe such ultrasounds are a harm-
less concession to those parents who want them (Lubell 2004).
The use of amniocentesis and CVS declined 50 per-
cent between 1991 and 2002, as many women now
have blood screening instead. This kind of testing can
be performed in the rst trimester for the detection of
Downs syndrome and brain, spinal, or abdominal wall
defects. Initial screening is done by combining tests
for certain substances that reveal the presence of a fetal
problem with a sonogram into a formula taking into
account the mothers age. Only if tests suggest the pos-
sibility of a fetal deformity are CVS and amniocentesis
done as a follow-up (Brody 2004b; Weise 2003).
Social scientists working in this eld nd parents
to be troubled when testing reveals the likelihood of a
serious problem. Virtually all testing programs include
genetic counselors who can advise parents as to the
signicance of their test results and help them work
through their decisions and their emotions. Because
detection of an abnormal fetus gives prospective par-
ents the chance to knowledgeably choose abortion,
anti-abortion groups have objected strenuously to
prenatal screening and genetic counseling. But some
parents who would reject abortion under any circum-
stances have had prenatal screening done with the
thought that should testing reveal an abnormality, they
would have time to prepare to care for their infant.
Prenatal testing and the accompanying abortion deci-
sion remain ethically and personally difcult choices.
We turn now to the childbirth process.
I
Childbirth
I
The process of childbirth takes place in three stages:
labor, delivery, and afterbirth (Figure E.3).
Labor
Labor is the process by which the baby is propelled
from the mothers body through a series of contrac-
tions of the muscles of the uterus. Labor usually begins
with mild contractions, at intervals of about fteen to
twenty minutes. The contractions increase steadily
over the rst phase of labor (usually from six to eigh-
teen hours for the rst birth, shorter for subsequent
births). They also increase in intensity and duration
until by the end of labor each contraction lasts a
minute or more.
During labor, some other changes usually take
place. The cervix dilates from its normal size (about
CHI L DB I RTH A-27
a
b
c
FIGURE E.3
Events in the childbirth process. (a) Early stages of labor:
cervix is dilating; babys head starts to turn. (b) Babys head
begins to emerge. (c) Afterbirth.
one-eighth inch) to approximately four inches in
preparation for the babys passage. A second occur-
rence is the expulsion of a bloody plug (sometimes
called show) from the base of the uterus through the
vagina. During pregnancy, the plug helped prevent in-
fectious bacteria from entering the uterus through the
cervix. And third, the amniotic membrane (often
called the bag of waters) ruptures, and amniotic uid
ows from the vagina. Show and breakage of waters
are usually signs of imminent delivery. Together with
these, full dilation of the cervix marks the beginning of
the second, or delivery, stage of childbirth.
Delivery
The second phase of childbirth is the delivery of the
baby. This phase extends from the time the cervix is
completely dilated until the fetus is expelleda
process that may last from fewer than twenty minutes
to (rarely) more than ninety minutes.
The mother can often speed the birth process at
this stage by tightening the muscles in her diaphragm,
abdomen, and back so that the uterine muscles are
aided in pushing the baby through the cervix. Her ac-
tive participation at this point may also help reduce
pain. Childbirth preparation classes, offered by many
hospitals, provide information and practice in these
techniques. What husbands or other birthing partners
can do to support the mother during labor and deliv-
ery is typically a part of childbirth education.
When the baby appears at the vaginal opening
(crowning), its head usually turns so that the back of its
skull emerges rst, as is shown in Figure E.3. After the
head emerges, the infant usually turns again to nd the
path of least resistance. This kind of delivery, in which
the babys skull emerges rst, occurs in about 95 per-
cent of births. The remaining 5 percent of deliveries
are more difcult: if the babys buttocks, shoulder,
foot, or face emerge rst (breech presentation), the
baby will not be able to take as compact a shape as it
passes through the vagina.
Oversized babies (the average newborn weighs
7.5 pounds) can also cause problems because the babys
head must pass between the bones of the mothers
pelvic arch. If the baby is too large, or if the mothers
or babys physical condition makes the stress of child-
birth dangerous, a physician may decide to deliver the
child by cesarean (or Caesarean) section, so called after
Julius Caesar, who was supposedly born in this way.
A cesarean section is a surgical operation in which a
physician makes an incision in the mothers abdomen
and uterine wall to remove the infant.
Another source of complications may be weak
uterine contractions (perhaps caused by anesthetics). If
contractions are not strong enough to expel the baby, a
physician may use forcepstongs that t around the
babys headto draw the baby out through the vagina.
However, this procedure is risky, for the inaccurate
placement of forceps, along with the force necessary to
pull the infant free, may cause disgurement or brain
damage. There is a newer process using vacuum-
assisted delivery devices, which also carries some risk
(Gilbert, 1998).
Afterbirth
The third and nal stage of childbirth takes place be-
tween two and twenty minutes after delivery. It con-
sists of the expulsion of the afterbirth: the placenta,
the amniotic sac, and the remainder of the umbilical
cord. The cord must be cut and tied to complete the
babys separation from the mother.
I
Issues in Pregnancy
I
and Childbirth
Early prenatal care has become more widespread for
pregnant women in the last ten years. Almost 85 per-
cent of pregnant women had medical care in the rst
trimester of pregnancy in 2003, up from 76 percent in
1990. While black, American Indian, and Hispanic
women are less likely than non-Hispanic white women
or Asians to see a physician in the early months of
pregnancy, there have been increases in early prenatal
care for all racial/ethnic groups since the 1980s (Mar-
tin et al. 2003; Hamilton, Martin, and Sutton 2004).
Tobacco use in pregnancy has declined, and alcohol
use, while more difcult to measure, seems also to
have declined.
Greater access to prenatal care, hospital delivery,
and a doctors assistance in childbirth contributed
greatly to the sharp decrease in infant and maternal
death during childbirth throughout the twentieth cen-
tury. The overwhelming majority of babies (99 per-
cent) are now born in hospitals. In 2002, 91 percent of
births were attended by physicians; 8 percent by mid-
wives (Martin et al. 2003).
A-28 Conception, Pregnancy, and Childbirth A P P E NDI X E
Natural Childbirth
The reliance on hospitals and doctors that developed
in the latter half of the twentieth century gave rise
to a counter-trend toward natural childbirth. Reac-
tion against the treatment of childbirth as a medical
problem rather than a natural event (Rothman 1982,
1989) included criticism of the usual practices of mid-
twentieth-century pregnancy and birth: heavy anes-
thesia, the authority of the doctor (not the mother)
in management of pregnancy and birth, barring the
father from the labor and delivery rooms, electronic
fetal monitoring throughout labor, the limited contact
of mothers with their newborn infants, and lack of
encouragement for breastfeeding. Infants born under
heavy sedation are less responsive and alert; they also
have somewhat reduced chances for surviving a med-
ical emergency. When infants are kept in sterile isola-
tion, the parentchild bond is less easily established.
Things began to change as parentsand health
care providerscame to value a more natural child-
birth process. Beginning in the 1950s and gaining
momentum in the 1960s and 1970s, the natural child-
birth movement came to inuence not only parents
preferences, but also physician and hospital practices
regarding birth. The underlying philosophy of the
movement was that natural methods of delivery are
more emotionally satisfying to both mother and father
and often better for the infant (Korte 1995).
Educational and support groups provide training
for parents so that mothers might deliver with minimal
anesthesia and fathers could assist them in the labor
room. Physicians, nurses, and expectant mothers ac-
cepted a labor process that was not articially hurried
by incising vaginal tissues (episiotomy) or by the use of
forceps, or by a too quick decision to do a cesarean sec-
tion. In natural childbirth, the baby may be given to
the mother for nursing or affectionate contact even
before the umbilical cord is tied. These practices are
now virtually standard practice in birthing, except that
anaesthesia is not precluded.
Cesarean Section Births
and Induced Labor
A related concern about the medicalization of child-
birth is the trend toward more frequent delivery of ba-
bies by cesarean section. An unprecedented 25 percent
of the nations infants were born by cesarean section in
1988, compared to 5 percent in 1970 (Public Interest
1994). Reasons offered for this high rate include the
now common practice of fetal monitoring (done in
85 percent of labors in 2002Martin et al 2003, p. 14),
which may trigger unnecessary intervention. Physi-
cians and hospitals fears about liability, if they failed to
intervene surgically and the infant suffered some dam-
age, were also a factor in the increase (Gilbert 1998).
Of course, difcult births may require surgical in-
tervention, and there is no question that cesareans are
often lifesaving procedures for both mothers and in-
fants. But experts express alarm at the high rates of ce-
sarean births because they are riskier for mothers and
infants. Moreover, a cesarean section also deprives a
mother of the experience of normal childbirth. Cost is
also a factor, as they cost much more than a normal
vaginal delivery.
4
Public health concerns led the Department of
Health and Human Services to set a goal of reducing ce-
sarean sections to no more than 15 percent of births by
2000 (Gilbert 1998). Cesareans did decline for a while,
to 21 percent in 1996. Women who had had cesareans
were encouraged to try a vaginal delivery in subsequent
pregnancies (Stolberg 2001), and the increase in vaginal
birth after cesarean (VBAC) accounted for a substantial
portion of the decline in cesareans.
5
But C-sections have recently increased again, and
the goal was not reached. In 2003, 28 percent of births
were by cesarean section (Hamilton, Martin, and Sut-
ton 2004). A study suggests that at least one-quarter of
the increase is due to cesareans in situations of no indi-
cated medical risk (Declercq, Menacker, and MacDor-
man 2004).
Mothers and Medicalized Childbirth
Ironically, a major reason for the increase in cesareans
has been a change in the views of pregnant women
about how they want to do childbirth. Against the rec-
ommendations of the public health establishment and
their own physicians, women are asserting a right to
control over the birth process. What many women
I S S UE S I N P RE GNA NCY A ND CHI L DB I RTH A-29
4. While cesarean births are more expensive than uncomplicated
vaginal births, lengthy vaginal deliveries are also costly.
5. Some research indicates that vaginal birth after cesarean (VBAC) is
riskier than another cesarean (Stolberg 2001). The most recent re-
search suggests that the risk is minimal (Rubin 2004). However,
some hospitals will not accept patients who plan to have a VBAC,
so those women do not have that option (Grady 2004). For what-
ever reason, vaginal births after cesarean have declined by 63 per-
cent since 1996 (Hamilton, Martin, and Sutton 2004, p. 8).
seem to be demanding is a movement away from natu-
ral childbirth.
Birthing mothers are requesting more pain med-
ication. In larger hospitals in the late 1990s, 66 percent
of mothers giving birth received spinal or epidural in-
jectionscompared to 22 percent in 1980s (Chivers
1999; Talbot 1999). There are also more elective ce-
sarean births and inductions of labor (that is, instead of
waiting for birth to occur naturally, a woman is given a
drug which will make labor begin). In 2002, 20 percent
of births were induced, compared to 9 percent in 1989
(Martin et al. 2003, p. 14). The latest trend is to book
your induction or your caesarean months ahead, a
strategy that seems just right . . . for two-career par-
entsand doctorswho dont want nature to disrupt
their busy schedules (the comments of nurse-midwife
Penny Simkin, summarized in Brockman 2000).
Mothers seek control over the birth process now,
not to enhance birthing as a life experience, but to get
through it with minimal discomfort and inconven-
ience (Springen 2000b). They are rejecting what is
seen to be an ideological invocation of pain as a moral
experience or character test (Talbot 1999)focusing
on the parenthood that follows birth rather than the
birthing experience. Moreover, some women who
have been through childbirth argue that pain kept
them from an awareness of the birth process anyway.
Dr. Fredic Frigoletto, head of obstetrics at Massachu-
setts General Hospital, says: I think theres a trend
away from the culture of a few years past, when natural
childbirth was important to women. . . . [Now patients]
dont want pain with their baby (quoted in Pan 1999,
p, 106; also Brockman 2000).
There is some medical support for these choices.
Some physicians are themselves coming to think that
natural childbirth may have been over-sold. In part,
anesthesia has now evolved so that dosage is much
smaller and wears off quickly, so it has less effect on the
newborn. There are medical arguments to be made for
elective cesarean section. While the risk of an infection
for mother or child is higher with a cesarean, as is the
risk of death (though small), vaginal births carry a risk
of damage to pelvic tissue that may compromise blad-
der control and sexual responsiveness and there is a risk
of cerebral palsy for the child, however small (Gilbert
1998; Springen 2000). Some experts would argue that a
vaginal delivery using vacuum extraction might not be
superior to a cesarean section in its risks and effects.
The American College of Obstetricians and Gy-
necologists has declared that elective C-sections are
ethical if the best choice in the judgment of the physi-
cian. Reasons for an elective cesarean might be prag-
matic, for example, a substantial distance from the
patients home to the hospital or her tendency to de-
liver quickly, which would make it difcult to reach a
hospital when labor begins. Or a physician may believe
that she or he can do the best job when time of delivery
is chosen rather than occurring in the middle of the
night after a long day of medical practice.
Still, the risk-benet balance is seen to favor vagi-
nal birth where there is no apparent medical indication
for a cesarean. There is much concern about the high
cesarean rate and especially about elective C-sections
(Brody 2003a; Stein 2003; Villarosa 2002a). Obstet-
rics has become very consumer-driven, commented
one physician (in Brody 2003a, p. D-7).
Midwives
Paradoxically, at the same time that natural childbirth
is receding in popularity and practice, the use of mid-
wives is growing. Midwives delivered more than 8 per-
cent of babies in 2002 compared to less than 1 percent
in 1975 (Martin et al. 2003, p. 15). This trend seems
also to be driven by the preferences of parents.
Midwives are birth attendants who are not physi-
cians. They may be nurse-midwivesnurses with addi-
tional specialized training, who are credentialed as
CNMs, or certied nurse-midwives. Or they may be di-
rect-entry midwives, who are not nurses, but who may
be certied professional midwives or certied midwives
(Pew Health 1999). A third category is the doula, a
birthing coach without medical claims, operating in a
long folk tradition of lay women who assist at birth.
Some women may combine a physician-managed
pregnancy with the presence of a midwife or doula at
birth. The legal status of these birthing choices and
state supervision of these professions vary by state.
6,7
A-30 Conception, Pregnancy, and Childbirth A P P E NDI X E
6. State laws vary as to the certication and training required, the
physician afliation required, the legal status of home births, etc.
The American College of Nurse-Midwives maintains a web site
(www.midwife.org) that provides information and a registry of ap-
proved nurse-midwives in each state.
The Midwives Alliance of North America site, www.mana.org, is
sponsored by an organization of direct-entry midwives. The Doulas
of North America web site is www.dona.org.
An important and comprehensive source of information on mid-
wifery is The Future of Midwifery, a report of the Taskforce on Mid-
wifery, a joint venture of the Pew Health Professions Commission
and University of California-San Francisco Center for the Health
Professions (Pew Health 1999): http://futurehealth.ucsf.edu.
7. Health plans vary in whether or not they will pay for a midwife-
assisted delivery (Dower 1999).
Some women may have home births in conjunc-
tion with a midwifery approach to childbirth. The vast
majority (97 percent) of certied nurse-midwife-
attended births took place in hospitals in 2002, while
55 percent of births attended by other midwives took
place in the home (Martin et al. 2003, Table 38).
Nurse-midwives attend births much more fre-
quently in European countrieswhich have very low
rates of maternal and infant mortality. Midwives pro-
vide emotional support as well as professional exper-
tise, and they recognize that the baby belongs to the
family, not the medical establishment (Korte 1995):
The midwifery model of care views childbirth
and well-woman care as normal processes that
do not require medical intervention unless there
are signs of pathology or deviations from the
normal. . . . The midwifery model of care in-
cludes observational (nontechnological) moni-
toring of the physical, psychological, and
social well-being of the mother throughout
the child-bearing cycle; providing the mother
with individualized education . . . and prenatal
care; continuous hands-on assistance during labor
and delivery, and post-partum support; minimiz-
ing technological intervention; [but] referring
women who require [a physicians] obstetrical at-
tention. . . . This effective collaboration between
the midwife and the physician, where the exper-
tise of both professions is valued, is the key to en-
suring optimal outcomes for women and their
infants (Pew Health 1999, pp. 56).
To summarize this section regarding pregnancy
and childbirth in the United States at the beginning of
the twenty-rst century, we see a dominant preference
for medicalized childbirth, with a vocal minority
(Dr. David Birnbach, in Chivers 1999) committed to
natural childbirth and/or midwifery. Both groups are
able to exercise more choice and control over the
birthing process than in the past.
Some Concerns:
I
Premature Births and
I
Low Birth Weight Babies
There are some concerns about the welfare of babies
despite the increased use of prenatal care and im-
proved infant mortality. The rate of preterm births has
risen since 1990. Premature birth (fewer than thirty-
seven weeks gestation) is a leading cause of infant
deaths and of almost half of congenital neurological
disabilities such as cerebral palsy (Martin et al. 2003).
Low birth weight (fewer than 2,500 grams or about
ve and a half pounds) is a related predictor of mortal-
ity and disability. There has been an increase in low
birth weight babies, reaching the highest level in three
decades. The reasons for these trends are not clear,
save for the recent increase in multiple births, which
are more likely to be premature and low birth weight
(Martin et al. 2003).
Premature and low birth weight babies are at risk
of physical and learning disability, but the latest re-
search has found better than expected outcomes. Pre-
mature babies are almost as likely to complete high
school as full-term babies. And they engage in less risky
behavior in adolescence and young adulthood. Re-
searchers have also found that the cognitive abilities of
these at-risk children improve from infancy to middle
childhood. It may be that worried parents become
more involved with their children in a way that offsets
their physiological disadvantage (Stolberg 2002; Ver-
bal and IQ Scores 2003).
For a more detailed treatment of conception,
pregnancy, and childbirth, see The Boston Womens
Health Book Collective, Our Bodies, Ourselves for the
New Century, 1998, Chapters 1322, and Greenberg
et al. 2002, Chapter 9.
S OME CONCE R NS : P R E MATUR E B I RTHS A ND L OW B I RTH WE I GHT B A B I E S A-31
C
ontraceptive use in the united
States is virtually universal among
women of reproductive age (Mosher,
Martinez, Chandra, Adma, and Willson 2004, p. 1).
According to the 2002 cycle of the National Survey of
Family Growth, more than 98 percent of a sample of
7,643 women who have ever been sexually active with
a male have used at least one method.
Some sixty-two million women are in their child-
bearing years (dened as fteen through forty-four).
Of all women of reproductive age, 31 percent do not
need contraception because they are medically infer-
tile, currently pregnant or post-partum, trying to be-
come pregnant, or not sexually active. Of sexually
active women of reproductive age who do not want to
become pregnant, 89 percent are using some form of
contraception, while 11 percent are not (Mosher et al.
2004, p. 7).
Contraceptivestechniques and methods to pre-
vent conceptioncan be divided into four groups:
chemical methods, barrier methods, surgical methods,
and natural methods.
1,2
Table F.1 describes some com-
monly used contraceptive methods and outlines the
requirements for appropriate and successful use. It
also advises against the use of certain methods for
some women.
We provide information on contraception as edu-
cational background. But keep in mind that there are
likely to be changes over time in what contraceptives
are available and in medical assessment of particular
contraceptive methods. Ours is just a brief sketch, not
intended to be taken as medical advice on family plan-
ning for a particular woman. For that you should con-
sult your personal physician or a family planning
center in your community.
A p p e n d i x
F
Contraceptive
Techniques
2. We have not included one means of controlling fertility: abortion.
Abortion differs from the contraceptive methods to be discussed
because it does not prevent conception but terminates the devel-
opment of the fetus after conception.
Another form of fertility regulation termed menstrual extraction
is difcult to classify as to whether it is contraception or abortion.
In menstrual extraction, the contents of the uterus are suctioned
and scooped out at about the time of the expected menstrual pe-
riod, whether or not a pregnancy has occurred. If performed regu-
larly and under the assumption that there is no pregnancy, it can
be viewed as a measure for health or convenience (avoiding debili-
tating periods), not as abortion. However, it could abort a zygote if
intercourse and fertilization have occurred, and menstrual extrac-
tion may be performed with that purpose in mind.
1. Much of the discussion of these four types of techniques is based
on Weeks 2002, pp. 179190, but with modications and integra-
tion of information from other sources, primarily the Planned Par-
enthood Federation of America (2004a) and Information and
Knowledge for Optimal Health (INFO) Project at Johns Hopkins
University (2005).
CONTR ACE P TI VE TE CHNI QUE S A-33
Ta bl e F. 1
Do You Know Your Family Planning Choices?
a
COMBINED ORAL CONTRACEPTIVES (ESTROGEN AND PROGESTIN)
Effective and reversible.
Take every day for best protection.
Especially in the rst few months, some users have side effects such as upset stomach, bleeding between periods or spotting,
weight gain, mild headache, or moodiness. Not dangerous.
Safe for almost all women. Serious side effects are rare. Some research suggests increased risk of blood clots in legs especially for
obese women.
Can be used by women of any age, whether or not they have children.
Help prevent certain cancers, anemia (low iron), menstrual cramps and irregular bleeding, and other medical conditions.
Can be used as emergency method after unprotected sex.
DMPA INJECTABLE CONTRACEPTIVE (DEPO-PROVERA)
Very effective and safe.
One injection every three months.
Bleeding changes are normalspotting, light bleeding between periods, and, after one year, often no periods. Some weight gain
or mild headaches can occur.
Private. Others cannot tell that a woman is using it.
Can be used by women of any age, whether or not they have children.
Women who stop using DMPA take an average of four months longer than usual to get pregnant.
Safe during breastfeeding, beginning at six weeks after childbirth.
Helps prevent uterine tumors and pregnancy outside the womb.
NORPLANT IMPLANTS
No longer available to new users in the United States, but women who are using Norplant may continue to do so.
Six small capsules placed under the skin of the upper arm.
Very effective for up to ve years (and perhaps longer).
Can be used by women of any age, whether or not they have children.
A woman can have the capsules taken out any time.
A woman can get pregnant once the capsules are taken out.
Changes in vaginal bleeding are normallight bleeding between periods, spotting, or no periods. Mild headaches can occur.
Safe during breastfeeding, beginning at six weeks after childbirth.
Help prevent anemia and pregnancy outside the womb.
PROGESTIN-ONLY ORAL CONTRACEPTIVES (POPS)
Good choice for nursing mothers who want pills, beginning at six weeks after childbirth. Very effective during breastfeeding.
If used when not breastfeeding, bleeding changes are normalespecially spotting and bleeding between periods.
Can be used as emergency method after unprotected sex.
CONDOMS
Can prevent some sexually transmitted infections (STIs),
b
including AIDS, and prevent pregnancy.
When condoms are needed to prevent STIs/AIDS, many couples use them along with other family planning methods.
Easy to use with a little practice.
Effective if used correctly every time. However, usually only somewhat effective because some men do not use condoms all the time.
Some men object that condoms interrupt sex, reduce sensation, or embarrass them.
continued
A-34 Contraceptive Techniques A P P E NDI X F
Ta bl e F. 1 continued
Do You Know Your Family Planning Choices?
a
IUD (INTRAUTERINE DEVICE)
Small device that a specially trained family planning provider places inside the womb.
Very effective, reversible, long-term method.
T 380A IUD lasts at least ten years.
Menstrual periods may be heavier and longer, especially at rst. Brief discomfort after IUD is put in.
No effect on breastfeeding. A specially trained provider can put in an IUD after childbirth.
Pelvic infection is more likely if the user gets a sexually transmitted infection. Serious complications are rare.
Can come out, especially in rst month, so checking for the strings is important.
VAGINAL METHODS
Spermicide, diaphragm, and capmethods a woman controls and can use when needed.
Must be placed in the vagina each time before sex. Can do that ahead of time instead of interrupting sex.
Can be effective when used correctly every time. However, often not very effective because some women do not use them correctly
every time.
Bladder infection is more likely.
FEMALE STERILIZATION
Permanent method for women who are sure that they will not want more children. Think carefully before deciding.
Safe, simple surgery. Usually done without putting the woman to sleep. Local anesthetic blocks pain.
Very effective.
No known long-term side effects. Brief discomfort after procedure. Serious complications of the procedure are rare.
No effect on sexual ability or feelings.
VASECTOMY
Permanent method for men who are sure that they will not want more children. Think carefully before deciding.
Safe, simple, convenient surgery. Done in a few minutes in a clinic or ofce. Local anesthetic blocks pain.
Very effective after at least twenty ejaculations or three months. Need another method until then. No known long-term side effects.
Brief discomfort after procedure.
No effect on sexual ability or feelings.
FERTILITY AWARENESS-BASED METHODS
A woman learns to tell the fertile time of her monthly cycle.
Knowing this, a couple avoids vaginal sex, or they use condoms, a vaginal method, or withdrawal during the fertile time.
Can be effective if used correctly. Usually only somewhat effective, however.
Usually need close cooperation between sex partners. Avoiding sex for a long time can be difcult.
No physical side effects.
Certain methods may be hard to use during fever or vaginal infection, after childbirth, or while breastfeeding.
CHE MI CA L ME THODS A-35
Ta bl e F. 1 continued
Do You Know Your Family Planning Choices?
a
SOME METHODS ARE NOT ADVISED FOR CERTAIN HEALTH CONDITIONS
CONDITION METHODS NOT ADVISED
Smoker and also age thirty-ve or older Combined oral contraceptive pills (COCs)
c
Known high blood pressure COCs. If severe high blood pressure, DMPA
d
Obese COCs
Breastfeeding in rst six months COCs
Breastfeeding in rst six weeks DMPA, implants, progestin-only pills (POPs)
Certain uncommon serious diseases of the heart and blood COCs, POPs, DMPA, implants. Ask your provider.
vessels, and a few other uncommon diseases; certain active
liver diseases.
Migraine headacherecurring severe head pain, often on one COCs, but use of COCs is limited for only two categories of
side or pulsating, that can cause nausea and often is made women: (1) women age thirty-ve and older; and (2) women
worse by light and noise or moving about. at any age if their vision is distorted or they have trouble speak-
ing or moving before or during these headaches.
STI or pelvic inammatory disease (PID)now or in last three IUD. Use condoms even if also using another method.
months. High STI riskfor example, you or your sex partner (Unusual vaginal bleeding may be a sign of STIs.)
has any other partners.
Certain uncommon conditions of female organs. IUD. Ask your provider.
Known pregnancy IUD. COCs in rst twenty-one days after childbirth.
a
This table will not be accurate indenitely, as new contraceptive methods enter the market periodically. Some current methods may be discontinued
or new information about risks may become known. Consult your birth control provider when making your personal choice.
b
STI = Sexually transmitted infectionsalso termed sexually transmitted diseases (STDs).
c
Also applies to combined (monthly) injectables throughout.
d
DMPA = DMPA injectable (Depo-Provera); also applies to NET EN injectable (Noristerat) throughout.
Source: Adapted from The Essentials of Contraceptive Technology Wall Chart, with additional information from Planned Parenthood Federation of Amer-
ica 2002; 2004a;c and Venous Thromboembolism 2004.
The Wall Chart is a project of the Information & Knowledge for Optimal Health (INFO) Project, 111 Market Place, Suite 310, Baltimore, MD 21202.
The Wall Chart was made possible through support from G/PHN/POP/CMT, Global, United States Agency for International Development, under the
terms of Grant No. DPE-A-00-90-0014-00. Courtesy of the Information & Knowledge for Optimal Health (INFO) Project. Johns Hopkins University.
Bloomberg School of Public Health. Center for Communication Programs. Accessed Jan. 4, 2005. www.infoforhealth.org.
I
Chemical Methods
I
One approach to contraception uses various chemical
substances (hormones) to alter the body so that con-
ception does not take place. Chemical means of con-
traception are very effective when used as directed (see
Table F.2, which provides data on contraceptive effec-
tiveness). Among these is the most popular nonsurgi-
cal form of birth control, the pill. Taken daily, it is a
sequence or combination of the hormonesestrogen
(which suppresses ovulation) and progestin (sometimes
specied as progesterone)that renders the uterine
tissues unreceptive to implantation. There are also
progestin-only pills (POPs) or mini-pills that can even be
safely used by nursing mothers six weeks after delivery.
In addition to the pill form, contraceptive hor-
mones can also be delivered in implants (Norplant),
3
in-
jectables (Depo Provera), patches (Ortho Evra), rings
(NuvaRing), and IUDs (Paragard, Mirena; see barrier
methods). All these methods must be used on the re-
quired schedule, in advance of intercourse.
3. Norplant is no longer available for new users in the United States;
current users may continue. A newer implant, Lunelle, was briey
available, but is no longer on the American market.
There are also emergency contraceptive pills,
4
which
are simply larger dosages of regular contraceptives
that are taken within 72-120 hours (preferably even
earlier) after coitus to prevent conception. Emergency
contraception can be used when birth control was in-
adequate (condom broke; pill wasnt taken; withdrawal
didnt happen; no birth control was used) or when a
woman has been raped (Planned Parenthood Federa-
tion of America 2004a).
Chemical methods of contraception also include
spermicides: chemicals that kill sperm before they can
fertilize an ovum. They are delivered in the form of
foam, cream, jelly, lm, or suppositories inserted into
the vagina before intercourse. They are often used in
conjunction with other contraceptive methods, no-
tably the diaphragm. While not so effective alone, the
combination of spermicides with a diaphragm is quite
effective (Weeks 2002).
I
Barrier Methods
I
Barrier methods of contraception are mechanical de-
vices that place a barrier between sperm and ovum.
The (male) condom (placed over the erect penis) is
a barrier method, as are the diaphragm, cervical cap,
5
female condom, and sponge
6
devices that cover a womans
cervix to prevent sperm and ovum from making con-
tact. Some barrier methodsnotably male and female
condomshave the advantage of providing some pro-
tection against STDs as well as pregnancy. Use of the
male condom has increased since the 1980s, while the
newer female condom has yet to see widespread use.
The IUD (intrauterine device) is a small device that
is inserted into the uterus by a health care professional.
By some unknown mechanism, the IUD prevents
pregnancy. As a foreign object, it may prevent implan-
A-36 Contraceptive Techniques A P P E NDI X F
Ta bl e F. 2
How Effective Are Contraceptive Methods?
PERCENTAGE OF WOMEN WHO BECOME PREGNANT
DURING FIRST METHOD
a,b
YEAR OF METHOD USE
Perfect Use
c
Typical Use
No Method 85.0 85.0
Spermicide 15.0 29.0
Withdrawal 4.0 27.0
Fertility Awareness
d
1.0/9.0 25.0
Female Condom 5.0 21.0
Cervical cap 9.0/26.0
e
16.0/32.0
Diaphragm 6.0 16.0
Condom (male) 2.0 15.0
Pill
f
0.3 8.0
Injectable (Depo-Provera) 0.3 3.0
IUD
Paragard Copper T 380A 0.6 0.8
Mirena 0.1 0.1
Female Sterilization 0.5 0.5
Vasectomy (male sterilization) 0.1 0.15
Implant (Norplant) 0.05 0.05
a
Data are for the method used alone. Methods are sometimes
combined for greater effectiveness
b
Data on the effectiveness of hormonal contraceptive delivery by
NuvaRing (ring) or Ortho Evra (patch) or the barrier methods Fem
Cap and Leas Shield are not adequate at present for inclusion in the
table.
c
Theoretical effectiveness of the method. In reality, users sometimes
forget, make mistakes in usage, or do not use the method consis-
tently. Typical use is a more realistic estimate of the results that will
be obtained with a particular method.
d
There are a variety of techniques grouped under this heading. Theo-
retical effectiveness ranges between 1 and 9 percent depending on
the technique. The calendar method has a perfect use pregnancy rate
of 9 pregnancies per 100 women, while the post ovulation method
(1.0), symptothermal method (2.0), and cervical mucus (ovulation)
method (3.0) are more effective when used by highly motivated
couples.
e
Method effectiveness varies according to whether or not the woman
has borne a child previously. It is less effective for women who have
had children already than for those who have not.
f
Data include the progesterone only pill (POP).
Source: Adapted from Planned Parenthood Federation of America 2004b.
4. The currently available brand is Plan B. Plan B is available only by
prescription, and this means a woman who needs it may not be
able to arrange to get it in time. Family planning advocates had
hoped that it would be approved for over-the-counter purchase in
2004. But the Federal Drug Administration declined to act favor-
ably on its professional advisory panels recommendation for such
approval. Another alternative for those seeking emergency contra-
ception is timely insertion of a copper IUD (Brody 2004c).
5. Newer versions are FemCap and Leas Shield, both made of silicone
(Planned Parenthood Federation of America 2004a).
6. The Today Sponge returned to the American market in 2003, hav-
ing been discontinued in 1995 by its manufacturer (Zernike 2003a).
tation, destroy the egg, or prevent egg and sperm from
connecting. The IUDs developing popularity, begin-
ning in the 1960s and continuing into the 1970s, was
cut short by the dangers posed by one brandthe
Dalkon Shieldwhich caused infections and some
deaths. The Dalkon Shield was removed from the
market in 1975. Lawsuits and potential liability, how-
ever, discouraged other manufacturers, and by 1986 no
IUDs remained on the market (Weeks 2002, p. 181).
In recent years several new types of IUDs have be-
come available (Paragard and Mirena). These newer
IUDs contain hormones, thus are chemical as well as
barrier methods.
Spermicides may be considered a barrier as well as
chemical method. They are often used in conjunction
with male or female barrier methods.
I
Surgical Methods
I
A third method of contraception is the surgical sterili-
zation of either the male (vasectomy) or the female
(usually by tubal ligation). A vasectomy involves tying
the tubes between the testicles (where sperm is pro-
duced) and the penis (through which the seminal uid
is ejaculated). The procedure can be done in a doc-
tors ofce and is safe. Following a vasectomy, the male
will be able to have erections, enjoy sex, and ejaculate
as before the sterilization, but he will not be able to
cause pregnancies because there will be no sperm in
his ejaculate.
7
A tubal ligation involves cutting, scarring, or oth-
erwise blocking the fallopian tubes between a womans
ovaries and her uterus so that eggs cannot pass
through the tubes to be fertilized. Tubal ligation must
be done in a hospital and is more expensive than a va-
sectomy, but it is also safe.
8
Sterilization is a one-time
procedure that is virtually 100-percent effective and
usually permanent. It has become the most-used form
of birth control; surgical sterilization is the contracep-
tive method of choice of almost 30 percent of U.S.
women.
Unlike many other contraceptive techniques, ster-
ilization is virtually irreversible. Microsurgical tech-
niques to restore fertility have been developed but are
not always successful. Individuals should be certain
about their decision to give up the capacity to have
children before undergoing sterilization. One study of
women who underwent sterilization in the 1980s found
that only 7 percent had regrets; 2 percent requested re-
versal. Women were more likely to regret sterilization
if they were under twenty at the time of the procedure;
if their husband or partner had wanted the procedure
more than they; or if they were in a conicted relation-
ship at the time (Five Years After 2002).
Family planning experts note that women now
spend a greater part of their lives outside of marriage
and so may make the decision about sterilization on
their own. One thing to consider is that the single (or
cohabiting) situation may change. A woman who does
not want to become pregnant now might enter a mar-
riage or relationship later and wish to have children
then (Godecker, Thomson, and Bumpass 2001); men
might change their minds as well.
I
Natural Methods
I
The fourth type of contraception avoids all surgery,
chemicals, and devices and is instead natural in its
approach to controlling fertility. It is based on control-
ling sexual behavior in conjunction with the timing of
ovulation. One such method, the fertility awareness
method (sometimes called periodic abstinence or natu-
ral family planning), relies on the couples awareness of
the womans ovulation cycle and on avoidance of inter-
course during the fertile periodseveral days before
and after the woman ovulates.
The effectiveness of this technique depends on
how correctly and diligently it is used. An old joke
What do you call users of rhythm? Answer: par-
entsis now outdated. The calendar method to
which this joke referred involved a simple count of
days elapsed since the last menstrual period and was
often wrong about the time of ovulation. Now ovula-
tion can be more precisely ascertained by tracking
basal body temperature or by monitoring changes in
genital mucous, orfor greatest accuracyboth,
NATURA L ME THODS A-37
7. A new method of surgical sterilization for men has just been devel-
opedVasClip. This is a device the size of a grain of rice which is in-
stalled in the testes to block sperm delivery (The Quest Is On
2004).
8. Another method of female sterilization developed recently is Es-
sure, a springlike device placed in the fallopian tube. It expands,
and tissue grows around it that will block the tube after about
three months. (A woman must use another form of birth control
until blockage is conrmed.) An advantage of this method is that
Essure can be inserted through the vagina and the uterus, so no in-
cision is necessary (Berger 2002).
termed the symptothermal method (Weeks 2002). Physi-
cians are not always aware of the potential effective-
ness of fertility awareness or of the instructional
programs essential to effective use of the method
(Feel Like 2000). Prospective users need to be re-
sourceful in seeking help.
Fertility awareness may be used with some effec-
tiveness by a motivated couple. It probably works best
to space births, not to limit them. For couples whose
religious teachings preclude other forms of birth con-
trol, it is the only optionand one they are usually
quite committed to. Home urine tests to detect the oc-
currence of ovulation are available in Europe but not
in the United States (Weeks 2002, p. 188).
Another natural method, withdrawal, was of some
importance in the historic fertility decline in the West
at a time when modern forms of contraception did not
exist. It depends on the males withdrawing his penis
from the womans vagina before he experiences or-
gasm. This technique is not very effective for several
reasons: the male is tempted not to withdraw, and even
if he does, the few drops of seminal uid that are emit-
ted before orgasm may contain sperm, making it pos-
sible for the woman to become pregnant. In modern
societies where there are other choices, withdrawal is
not recommended.
Another natural method is Lactational Amenorrhea
Method (LAM), or breastfeeding. Like withdrawal,
breastfeeding, which can delay the return of ovulation,
can have an impact on fertility rates in a large popu-
lation. Moreover, it was added to the list of modern
contraceptive methods by a conference of experts in
the 1980s. However, to be effective contraceptively,
breastfeeding must take place within certain parame-
ters: breast milk is the only food taken in by the infant,
and nursing occurs on demand around the clock. Few
American mothers are likely to attain effective control
over conception in this way, and we do not maintain it
on our roster of contraceptive methods. Moreover, the
outer limit of effectiveness even under perfect condi-
tions is about six months after childbirth (Population
Information Program 1999; Weeks 2002, p. 186).
Finally, reported as theoretically possible meth-
odsbut difcult in realityare complete abstinence
from sexual activity and outercoursea term coined
to refer to sex play without vaginal intercourse. Even
here, pregnancy is possible if sperm is accidentally
spilled into the vagina (Planned Parenthood Fed-
eration of America 2002). Of course, the sexual rela-
tions of gay and lesbian couples or the oral or anal sex-
ual contacts of heterosexual couples do not lead to
conception.
We have covered all natural methods in the inter-
est of a comprehensive and historically accurate pic-
ture of contraceptive activity. But the only one of the
natural methods considered to be a reasonable choice
in the twenty-rst century is fertility awareness.
I
Choosing Methods
I
of Birth Control
In order to choose which alternative or alternatives to
use, people need to consider how each method works,
how effective it is, its advantages and disadvantages, its
side effects, its health implications, its long-term ef-
fects on the ability to have children, and its moral and
philosophical acceptableness to the user.
Also of importance in choosing a method is the
social and relationship context of the sexually active
person. For a couple who is dedicated to natural family
planningand highly motivated religiouslythe sex-
ual abstinence required for part of the month can be
managed. In fact, a belief structure has grown up
around this form of contraception that supports the
choice. Women claim that it gives them more control
over sex in the relationship than they might otherwise
have if sex could take place at any time. On the other
hand, a partner relationship may limit contraceptive
choice if a woman is uncomfortable communicating
with her partner about birth control or if the womans
preference is not accepted by her partner. Moreover,
[e]conomic inequalities, violence, and power imbal-
ances in many sexual partnerships restrict womens
abilities to negotiate male condom use (Minnis and
Padian 2001, p. 28).
One interesting study of low-income women in
Miami explored womens ease of communication and
their choice of methods. Hispanic women were less
comfortable discussing the topics of sex and condom
use, but also had high condence in their condom ne-
gotiating skills. They were more likely to reach joint
decisions with their partners. Hispanic women, along
with African American women, were more likely to
consistently use condoms as a birth control method
than were non-Hispanic white women (Soler et al.
2000).
A-38 Contraceptive Techniques A P P E NDI X F
Attitudes or religious beliefs can constrain
choices. Yet many Catholics do not accept church
teachings on contraception. A 1995 survey found that
68 percent of Catholic women fteen through forty-
four chose sterilization or the pill as their birth control
methodboth prohibitedwhile only 3 percent used
the natural family planning method accepted by the
church (Febring and Schmidt 2001). Moreover,
women whose religion prevents them from using the
pill as an intentional contraceptive have sometimes
found medical reasons to take it regularly.
Women who are reluctant to acknowledge that
they are sexually active or may have sexual intercourse
nd it difcult to use methods that must be used in ad-
vancemost of the effective methods. Compliance with
a chosen contraceptive regime is often imperfect. Many
women nd it difcult to be regular in taking the pill
and when not used regularly, this method is ineffective.
A study of women using barrier methods found that
one-third report not using their method every time they
have intercourse (Alan Guttmacher Institute 2000).
Newer means of delivering hormonal contraceptives
that require only infrequent maintenancee.g., Depo-
Provera injections, the ring, or IUDswould solve that
problem. But they are not widely used.
Table F.3 shows the contraceptive choices that
Americans, in fact, make.
9
You can see that steriliza-
tionfor those who consider that they have com-
pleted their childbearingand the pill are the most
commonly used contraceptive methods. Taken to-
gether, users of these two methods are a majority of
those who are contracepting. Choice of methods
varies by age, with female sterilization a less signicant
method for younger women (under thirty) but used by
50 percent of women in their forties. The pill, on the
other hand, is the method used by more than 50 per-
cent of women twenty through twenty-four and al-
most 40 percent of women twenty-ve through
twenty-nine. A male partners vasectomy is the contra-
ceptive method relied upon by about 20 percent of
women in their late thirties and forties but is mini-
mally relevant to the sexual lives of younger women
(Mosher et al. 2004, Table 6 and Figures 6 and 7).
The remainder of women use a variety of other
methods. Some quite effective methods of contracep-
tioninjectables and IUDshave few users. Barrier
methods are important, especially the male condom
(approaching 20 percent), favored as a means of pro-
tection against sexual transmission of diseases as well
as pregnancy. But the female condom and diaphragm
are used by fewer than 1 percent of women, and the
IUD by only 2 percent. Finally, male withdrawal (not
effective) and fertility awareness (can be effective) are
natural methods that are used by fewer than 5 percent
of women surveyed.
I
New Developments
I
in Contraception
Still newer forms of contraceptiondirected toward
males as well as femalesare bound to be developed
and on the market in the future. Various experimental
NE W DE VE L OP ME NTS I N CONTR ACE P TI ON A-39
9. The table is titled What Contraceptives Do American Women
Use? Women are surveyed about contraceptive use much more
often and extensively than men. Moreover, women could be using
methods of which a male partner is not aware. Generally experts
rely on surveys of women in compiling statistical proles related to
fertility and contraception.
Ta bl e F. 3
What Contraceptives Do American Women
Use?
a,b
METHOD PERCENTAGE OF USERS
Pill 30.6
Female sterilization 27.0
Condom (male) 18.3
Male sterilization (vasectomy) 9.2
Three-month injectable (Depo-Provera) 5.3
Withdrawal 4.0
Intrauterine device (IUD) 2.0
Fertility awareness 1.6
Implant or patch 1.2
Other
c
0.9
Diaphragm 0.3
a
These data are based on women surveyed about contraceptive use by
self or partner. Some of the contraceptive methods are male methods.
b
Based on the 62 percent of American women currently using contra-
ception. Thirty-one percent of American women fteen through forty-
four are not using contraception because they are sterile, pregnant or
post-partum, seeking pregnancy, or not sexually active. Another 7.5
percent are sexually active, but not using contraception.
c
Includes the Today Sponge, cervical cap, female condom, and other
methods.
Source: Mosher et al. 2004, Tables 4 and 5.
male contraceptivesprimarily injectionshave shown
promise in animal research. But aside from the still
formidable technical problems remaining, there may
be strong psychological barriers to their use by both
men and women. Men may be uneasy at hormonal ef-
fects that they may take as threats to masculinity, or
simply not willing to take injections on a regular basis.
Women may be afraid to trust the responsibility of
contraception entirely to men, especially if not in a
marriage or strongly committed relationship (Berger
2002; Male Contraceptive 2003; The Quest Is On
2004; Szabo 2004).
Updated information may be obtained from the
Planned Parenthood Federation of America web site:
www.plannedparenthood.org or the companion Alan
Guttmacher Institute website: www.agi-usa.org. Also
see Weeks (2002, pp. 79190) for general background
and Greenberg et al. (2002, Chapter 8) for details
about features and uses of various methods of contra-
ception as of that books publication date.
A-40 Contraceptive Techniques A P P E NDI X F
T
echnology has come to concep-
tion and pregnancy, as modern science
continues to develop new techniques to
enable couples or individuals to have biological chil-
dren. About 2 percent of American women used infer-
tility services in one year, 13 percent over a lifetime,
according to a 1995 survey (U.S. Center for Chronic
Disease Prevention and Health Promotion 2003).
Among the less dramatic and more common infertility
interventions are microscopic surgical procedures to
repair fallopian tubes. Fertility drugswhich stimu-
late ovulationhave been used by about 3 percent of
American women (U.S. Census Bureau 2000, Table
101).
More dramatic and widely publicized are the as-
sisted reproductive technologies (ART) such as ar-
ticial insemination, in vitro fertilization, surrogate
motherhood, and embryo transfers. Women older
than thirty, who are married, and who are college
graduates are the most frequent users of ART (U.S.
Census Bureau 2000, Table 101). Use of assisted re-
productive technologies has increased 66 percent be-
tween 1996 and 2001. The live birth success rate has
also increased (U.S. Center for Chronic Disease Pre-
vention and Health Promotion 2003).
Infertility and its treatment, as well as the ethical,
legal, relational, and social implications of assisted re-
productive technologies, are discussed in Chapter 10.
Here we describe the technologies.
I
Articial Insemination
I
This procedure may be indicated when a woman is
presumably fertile but her husband or male partner is
not. In articial insemination, a physician injects
sperm into a womans vagina when she is ovulating.
Articial Insemination
by Husband (AIH)
In cases in which the husbands sperm count is low, the
physician may accumulate several of the husbands
ejaculations (which are preserved by refrigeration) so
that a greater quantity of semen introduced into the
vagina overcomes the low sperm count.
Articial Insemination by Donor (DI)
Should AIH fail, or when no husband or male partner
is involved, sperm from a donor may be obtained.
When donor sperm is used and the woman is married,
the physician may attempt to match the donors physi-
cal characteristics with those of the husband. The hus-
bands sperm may be mixed with the donors, which
means the womans egg could be fertilized by her hus-
bands sperma possibility that may be psychologi-
cally important to the couple.
The articial insemination procedure is relatively
simple (compared to those described below) and can
even be done by an individual or couple themselves.
Single women or lesbian couples have increasingly
used donor insemination to create families. Sometimes
that insemination takes place at home, using donor
sperm that has been supplied by a known donor or
purchased. There are now sperm banks specically for
a lesbian clientele (Bergstein 2002).
Donor insemination involving a sperm bank has
always been treated as an anonymous process. But in
1983, a sperm bank in San Francisco began to ask
donors if they would be willing to have their biological
child(ren) make contact with them after twenty years.
A p p e n d i x
G
High-Tech Fertility
Such contacts have begun to occur, and some clinics
now offer open sperm donation. The donor will be
known and is willing to provide family medical history
information or perhaps even to meet with the resulting
child (Bergstein 2002; Talbot 2001).
I
In Vitro Fertilization
I
The rst in vitro baby was born in England in 1978
and the rst American baby in 1981. There are now
some variations on in vitro fertilization.
In Vitro Fertilization
With in vitro fertilization (IVF), an embryo is con-
ceived outside a womans body (in a laboratory dish or
jar) but is then placed within a womans uterus to de-
velop. The process can be used when a woman with
diseased or blocked fallopian tubes wants to give birth.
An egg is surgically removed and fertilized in the labo-
ratory with sperm from her husband or male partner.
If he is infertile, sperm from a donor is used. The fer-
tilized egg or eggs (usually multiple eggs) are im-
planted in her uterus after two days as multi-celled
embryos. Pregnancy and childbirth follow the natural
pattern.
Fertilized embryos can be frozen in liquid nitro-
gen for implantation later if the couple anticipates
wanting to have more children. Excess frozen embryos
are sometimes donated to infertile couples.
The success rate of in vitro fertilization was 33
percent in 2001 (success being a live birth after
transfer of the frozen embryo to the womans uterus).
Success rates vary by whether the egg is fresh or
frozen, is the womans or a donors egg, and by the age
of the mother-to-be (Wright et al. 2004). The cost is
now $12,500 to $25,000 for a single cycle of IVF using
the womans egg; for IVF with a donors eggs, the cost
ranges from $20,000 to $35,000. These costs are for
the urban Northeast; costs vary by geographic area
and by fertility center (Kolata 2004).
GIFT
In an IVF process known as gamete intrafallopian
transfer (GIFT), eggs are collected from the ovaries
and put into a catheter outside the body. Sperm are put
into the same catheter but are kept apart from the eggs
by an air bubble. The eggs and sperm are then placed
in the womans fallopian tubes. If fertilization subse-
quently occurs, the fertilized egg then travels to the
uterus, as is the case in a natural pregnancy.
ZIFT
A related process is zygote intrafallopian transfer
(ZIFT). In this procedure, the fertilized egg is im-
planted in the womans fallopian tubes after only one
day, as a zygote (still a single cell) (U.S. Center for
Chronic Disease Prevention and Health Promotion
2003).
Donor Egg IVF
In vitro fertilization with a female donor egg has be-
come an option, used for women who have experi-
enced early menopause; whose eggs are damaged; or
who are known to be carriers of a serious hereditary
disease. In this procedure, either a woman or a fertility
clinic nds another woman willing to donate her eggs,
which are then fertilized and placed in the uterus of
the woman who wants to become pregnant. Donor
eggs are also used by lesbian couples. One member of
the couple may donate an egg while the other is the
birth mother; thus, both will have a biological connec-
tion to the child. We are beginning to see the use of
donor eggs by older postmenopausal women (Donor-
egg Pregnancies 2002).
I
Surrogate Motherhood
I
When a woman cannot carry a child to term and her
husband is fertile and wants a child biologically his
own, they can turn to a surrogate mother. Here a
husband fathers a child with another woman by arti-
cial insemination. This woman, the surrogate mother,
carries the child to term and then turns the baby over
to the couple. Note that the term surrogate, or substi-
tute, is inaccurate because she is in fact the childs bio-
logical mother.
Embryo Transfers
In addition to this form of regular surrogacy, in which
the surrogate mother is also the genetic mother of the
child, there is the newer gestational surrogacy, involv-
ing women who contribute no egg but carry the infant
to term. Here an embryo or ovum transfer occurs, in
A-42 High-Tech Fertility A P P E NDI X G
which fertilized eggs (not the receiving womans) are
transferred into the uterus of the woman who will be
the gestational mother. Embryo transfer may occur
when a woman who will rear the child cannot herself
carry it to term. Her fertilized eggs are transferred to
the uterus of a gestational surrogate mother, who will
bear and deliver the baby, then relinquish it to the so-
cial parents.
Embryo transfer may also occur when the mother
who will carry the infant and plans to keep and rear it
does not have healthy eggs or does not want to use her
own eggs because of a genetically transmitted disease.
In that case a pregnancy is generated by her receipt of
the fertilized egg of another woman.
I
New Developments
I
We will tell you now about a few promising new devel-
opments, some only experimental at this point.
Microsurgery for Male Infertility
For the 40 percent of infertility attributed to male
problems, doctors now have some solutions. Sperm
count may be affected by varioceles (varicose veins) in
the scrotum. Scar tissue from various common sexu-
ally transmitted diseases (notably chlamydia and gon-
orrhea) or hernia surgery may cause damage or
blockages of the epididymis (the organ where sperm is
stored in the testes) or vas deferens (the tube which car-
ries the sperm into the mans penis). Microsurgery can
remove these impediments and restore or improve
sperm count and thus fertility (Ehrenfeld 2002).
Intracytoplasmic
Sperm Injection (ICSI)
With this technique, sperm are directly injected into
the center of the egg to fertilize it. The benet is that
with this procedure, a man with a low sperm count
may successfully fertilize his partners egg. There is
some risk of minor genetic malformations.
Ovary Transplant
An American woman began ovulating and then be-
came pregnant after receiving a transplant of ovarian
tissue from her twin sister. An ovary transplant be-
tween sisters in China was also successful (Vig 2003;
Wittenauer 2004). While few women will have the
close genetic match a twin will offer, future work may
be able to expand the use of ovary transplantation be-
yond close relatives.
An ovary self-transplant may be done using the
womans own ovary when a woman has to undergo
chemotherapy or has another health condition or
treatment that will damage fertility. The ovary may be
removed in advance and then reimplanted. A Belgian
woman had an ovary removed and frozen and success-
fully transferred back after the ve-year mark of recov-
ery from her lymphoma. Two years later she gave birth
to the rst baby conceived after an ovary transplant
(Wittenaeur 2004).
Oocyte Cryopreservation
Oocyte cryopreservation simply means egg freezing. This
procedure has usually been limited to research settings
involving young women who need chemotherapy or
have some other fertility-damaging condition. Now,
however, commercial services offer oocyte cryopreser-
vation to women who are simply hopeful of becoming
mothers when they meet Mr. Right at whatever age.
Unlike sperm, which can easily be frozen, de-
frosted, and used to inseminate, eggs are technically
difcult to preserve. A spokesman for the American
Society of Reproductive Medicine stated that ASRM
feels its premature to openly market this now, but
these technologies are quickly evolving and the limited
body of evidence we have is encouraging (in Wadyka
2004, p. D-5). Researchers report a 20 percent success
rate, though the number of cases is small. About 100
babies have been born using oocyte cryopreservation
world wide, the majority in Italy. This procedure is ex-
pensive: about $13,000 for the initial egg harvest and
$40 a month for storage.
In Vitro Fertilization Innovations
In some IVF procedures, transfer of the newly created
embryo may be deferred until the blastocyst stage (ve
to seven days after fertilization, when the embryo has
about 100 undifferentiated cells). This has the advan-
tage of permitting careful selection of the most prom-
ising embryos, although it also seems to generate
multiple birthsconsidered undesirable because of
the risk of higher mortality or other problems.
There are some improvements in the technique
for drawing eggs out of the ovary and in the medium
NE W DE VE L OP ME NTS A-43
for culturing embryos. Researchers and clinicians have
also experimented with removing some eggs before
they have matured and maturing them in the labora-
tory. This permits more eggs to be harvested without
requiring the woman to take fertility drugs to stimu-
late egg maturation. Reproductive medical science
now offers the possibility of preimplantation genetic di-
agnosis, or PGM, to search for abnormalities and elim-
inate those embryos which seem likely to produce
unsuccessful pregnancies, i.e., miscarriages. Of course,
this is also a technique that is ethically troubling in
that it suggests the selection of embryos according to
perceived social value or gender (Duenwald 2003).
Nuclear Transfer
To address the problem of healthy eggs for older
women who wish to have biological children, reproduc-
tive scientists have experimented with nuclear transfer.
This refers to the process of taking a cell from an older
woman (over forty, that is) from a non-reproductive
part of the body, perhaps a skin cell, and placing it into
the nucleus of an egg of a younger woman, after
removing that womans DNA. Experimentation with
nuclear transfer has halted for the moment, as the
FDA has decided to regulate this process. It is also very
costly, perhaps not commercially viable.
A reverse process, cytoplasmic transfer, involves tak-
ing some cytoplasm from a younger womans egg and
placing it into the older womans egg to see if that will
give her egg more youthful qualities (Duenwald 2003).
Development of assisted reproductive technology
is ongoing, and there are bound to be new forms of in-
fertility treatment that become available after publica-
tion of Marriages and Families, 9th edition. These are
usually reported in the media, and interested parties
may consult their physician or infertility clinic about
the possibilities. Some new developments may raise
troubling ethical questions; for example, experimental
work has produced embryos of mixed gender (Weiss
2003b). Prospective users of reproductive technology
may want to consult religious or other ethical advisers
as well as medical specialists.
For more detailed treatment of assisted reproduc-
tive technology as presently available, see Our Bodies,
Ourselves for the New Century, by The Boston Womens
Health Book Collective, 1998, Chapter 18. For back-
ground, and for reports on usage of assisted reproduc-
tive technology and on success rates of fertility clinics,
see the Centers for Disease Control and Prevention
website (go to www.cdc.gov and search reproductive
health or assisted reproductive technology). Anthropolo-
gist Gay Beckers book The Elusive Embryo (Berkeley:
University of California Press, 2000) is a useful por-
trayal of couples experiences as they go through infer-
tility treatment. It offers a great deal of detail about the
procedures from the patients point of view.
A-44 High-Tech Fertility A P P E NDI X G
M
arriage and close relation-
ship counseling is a professional
service dedicated to helping indi-
viduals, couples, and families gain insight into the ac-
tually or potentially troublesome dynamics of their
relationship(s) and to teaching clients more effective
and supportive communication techniques (Gladding
2004). Experts have suggested that couples or families
should visit a counselor when communication is typi-
cally hostile or conict goes unresolved, when they
cannot gure out how to resolve difculties them-
selves, when a partner is thinking of leaving a commit-
ted relationship, or when a problem in the relationship
appears to be linked to a personality disorder in one or
more family members (such as chronic drinking, drug
abuse, severe depression, or deep feelings of insecurity
and inadequacy). But counseling is also appropriate
and perhaps more effectiveas a preventive tech-
nique, undertaken at the onset of a family crisis or
when a couple or family sees a potentially troublesome
transition ahead. Today people go to counselors for
help in working through premarital and engagement
issues, as well as same-sex-couple, cohabitation, mar-
riage, divorce, remarriage, and stepfamily issues
(Gladding 2004; Long and Serovich 2003; Means-
Christensen, Snyder, and Negy 2003).
Qualications of Counselors
The qualications of marriage counselors vary. A
counselor who is a member of the American Associa-
tion for Marital and Family Therapy (AAMFT) has a
graduate degree (in either medicine, law, social work,
psychiatry, psychology, human development and fam-
ily studies, or the ministry) in addition to special train-
ing in marriage or family therapy or both and at least
three years of clinical training and experience under a
senior counselors supervision.
Not all those who practice counseling are so well
qualied, however, and some have, in fact, taken on
the responsibility of training themselves. The majority
of statesbut not alllicense marriage counselors.
Some states require counselors to pass oral and written
tests in order to practice. The safest way to choose a
qualied counselor is to select one who belongs to the
AAMFT. To do so, check the organizations website:
http://www.aamft.org. Personal references from fam-
ily members and/or friends may also be helpful.
It is important to have a counselor you like, trust,
and feel is sympathetic to you. It is also important that
the counselor respect your religious and personal val-
ues. If after three or four sessions you do not feel com-
fortable with the counselor or dont believe she or he is
effective, it might be a good idea to try someone else
(Ambroz 1995).
A p p e n d i x
H
Marriage
and
Close Relationship
Counseling
Marriage Counseling Approaches
Marriage/close relationship counseling may be either
a short- or long-term arrangement. A difculty might
be cleared up in a few weekly sessions. In other cases,
counseling might last a year or more. Or a couple or
family might work through a problem in a few visits,
then quit with the understanding that theyll return if
conicts once more begin to go unresolved. In all
cases, counseling should have denite goals and should
aim at termination instead of becoming an indenite
program.
Qualied counselors have widely varying ap-
proaches to their work (Gladding 2004). For example,
counselors whose primary training is in psychiatry or
psychoanalysis may view problems in relationships as
the result of at least one family members personal neu-
rosis. Such counselors would believe that restoring each
individual to emotional health is the rst and most im-
portant step in improving the relationship and so would
probably suggest seeing each family member individu-
ally. Other approaches include choice therapy (Glaser
2001) and cognitive-behavior therapy (Freeman and
Carlson 2004). People would do well to inquire about
various techniques before engaging a counselor.
A widely accepted approach to marriage counsel-
ing is conjoint marital or relationship counseling, ac-
cording to which the counselor sees the partners
together. In such an approach, counselors help the
couple learn to interact more constructively. A related
approach is family systems therapy, in which as many
family members as possiblesometimes even ex-
tended kinare engaged together in therapy.
Despite its substantiated benets, the extent to
which counseling saves a union that is headed for a
divorce or break-up is difcult to measure (Corliss and
Steptoe 2004; Sprenkle 2002). For one thing, all weve
said about counseling is based on the presumption that
partners are willing to cooperate. It is entirely pos-
sible, however, that ones partner may not be willing.
No counselor can or will attempt to change a person to
a partners liking without active cooperation from all
involved (Ambroz 1995).
I
References
I
American Association for Marital and Family Therapy.
<http://www.aamft.org>
Corliss, Richard, and Sonja Steptoe. 2004. The Mar-
riage Savers. Time. January 19.
Freeman, Arthur, and Jon Carlson. 2004. Cognitive-
behavioral Couples Therapy. Washington, DC:
American Psychological Association.
Gladding, Samuel T. 2004. Counseling: A Comprehen-
sive Profession, 5th edition. Upper Saddle River,
NJ: Pearson/Merrill/Prentice Hall.
Glasser, William. 2001. Counseling with Choice Therapy,
the New Reality Therapy. Alexandria, VA: American
Counseling Association.
Long, Janie K., and Julianne M. Serovich. 2003. In-
corporating Sexual Orientation into MFT Train-
ing Programs: Infusion and Inclusion. Journal of
Marital and Family Therapy 29 (1): 59-67.
Means-Christensen, Adrienne J., Douglas Snyder, and
Charles Negy. 2003. Assessing Nontraditional
Couples. Journal of Marital and Family Therapy
29 (1): 69-83.
Sprenkle, Douglas. 2003. Effectiveness Research in
Marriage and Family Therapy. Journal of Marital
and Family Therapy 29 (1): 85-96.
A-46 Marriage and Close Relationship Counseling A P P E NDI X H
A
mericans think of their spend-
ing power in terms of how much
money they make. But many Ameri-
cans can considerably increase their real incomethe
amount of goods and services their money will buy
just by planning (Brock 2005; Rich 2004).
Steps in Planning a Budget
Here are some general tips for planning a budget. You
may adapt them to your own interests and needs.
1. Assess the situation. You must rst know where
you stand. Prepare a balance sheet showing all of
your nancial assets and liabilities.
2. Set your goals. Decide on your priorities and goals,
whether they may be paying off your college loan
in two years, saving for a house down payment, or
simply paying off your credit-card debt.
3. Estimate your income. Make as accurate an esti-
mate as you can, including such income as
salaries, gifts, commissions, and bonuses. Dont
be overly optimistic about raises or projected
commissions and prots. Unrealistic estimates
can result in overspending.
4. Compile a spending inventory. To get an accurate
picture of current expenses, keep track of every-
thing you spend for at least a week. Your spending
habitsand knowledge of themmay surprise
you. If youre skeptical and dont see a reason to
keep track, be aware that some overweight people
insist they never eat; when they keep a daily rec-
ord of the calories they take in, they are amazed.
In a similar fashion, you may nd, for example,
that you spend $35 on lunches, not the $20 you
had thought.
5. Prepare the budget. You might create a budget
from various worksheets that you can nd on the
Internet. Two helpful sources are the Economic
Policy Institute (http:www.epinet.org/content.
dfm/datazone_fambud_budget) and the Univer-
sity of Florida Extension Service (http://edis.ifas.
u.edu). These web sites offer guidelines for
spending as well as free worksheets for creating
a budget. (If you go to the University of Florida
web site, search on the site for Show Me the
Money Lesson.)
6. Follow through. This involves keeping daily
records of expenditures in a convenient notebook
or in an account book bought for that purpose.
At the end of each month, you should total daily
expenditure gures for each item, then compare
them with the amounts planned in Step 4. If
January had more food expenditures than were
budgeted, either this expenditure would have to
be cut back in February or more money allocated
for food by taking it from some other category. If
excessive expenses show up in successive months,
you may decide to eliminate some expensive
purchases. If expenditures for one account con-
sistently fall below what was planned, the budget
may be revised.
A p p e n d i x
I
Managing
a
Family Budget
About Saving
Being able to save regularly is highly unlikely (if not
impossible) for low-income and poverty-level families.
But middle-income people need to consider it seri-
ously (Turner 2001, Lesson 5). Financial advisers rec-
ommend regularly saving 10 percent of your gross
income. If that seems too difcult, start with less
even just 1 percentand work up. Employed people
can usually save automatically by setting up payroll de-
duction plans at work. In this case, a xed percentage
of your salary is regularly deposited into a credit union
or bank savings account. The value here is that the
amount is deducted before you receive your check so
that after a few paychecks you may not miss it. An-
other way to save automatically is to have your bank
regularly withdraw a xed amount from your checking
account and deposit it into a savings account (Toohey
and Toohey 2001).
About Credit
In our country, credit cards and time purchases have
become a way of life in recent years. Yet credit costs
money, and it should be considered a purchase in its
own right. The late nancial writer Sylvia Porter
(1976) offered some right and wrong reasons for bor-
rowing. Right reasons include establishing a house-
hold or beginning a family, making major purchases,
taking advantage of seasonal sales, nancing college or
other educational expenses, and genuine emergencies
(Sander 2003).
Wrong reasons include buying to boost morale, to
increase ones status, or on impulse. People misuse
credit when they use it to maintain an adequate cash
reserve. Another misuse is nancing purchases against
an uncertain but hoped-for raise or future nancial
windfall (Porter 1976; Sander 2003).
SOURCES OF CREDIT People borrow money from
many different sources. Some turn to their parents or,
less often, to brothers and sisters; in such cases, inter-
est is likely to be low. Sometimes, relatives help each
other by putting up security or cosigning bank loans.
Family borrowers need to consider psychological as
well as monetary costs of intrafamilial transactions.
Another source of credit is public lending agen-
cies: credit unions, banks, nance companies, and
pawnshops. Interest rates vary widely among the dif-
ferent types of agencies. One of the most highly adver-
tised sources of credit is the small loan company,
which specializes in lending to borrowers who have
little or no security. These sources serve a purpose, for
without them many people with no security or poor
credit ratings could not legally borrow money. But be-
cause of the risk small loan companies take, they
charge extremely high interest rates and are best
avoided in favor of other sources of credit.
Another way to borrow money is by arranging re-
tail installment nancing, in which people contract
with a dealer to pay for major purchases over a period
of time. The dealer receives the markup on the mer-
chandise and the interest on the unpaid balance. When
making major purchases, people should study install-
ment contracts with care and ask questions about any-
thing they dont understand. Find out how much the
item will really costthat is, the price of the item plus
the hidden cost of nancing. Compare interest rates
and consider whether a personal bank loan would be a
less expensive way of paying for the item (Turner 2001,
Lesson 3).
It is important to shop for credit as carefully as for
any other major purchase. Furthermore, people
should try to pay off one installment obligation before
taking on a new one. Moreover, consumers need to re-
member that using credit cards is the same as borrow-
ing money, and credit-card purchases need to be
budgeted the same way cash purchases are. Statistics
on credit misuse are high. A good rule is to limit bor-
rowing so that debt payments, excluding mortgage
payments, account for no more than 15 percent to 20
percent of take-home pay.
FINANCIAL OVEREXTENSION AND WHAT TO
DO ABOUT IT Optimally, families pay their install-
ment and other loans monthly, along with other regu-
lar expenses, and set some money aside for savings.
Some advisers suggest that a family is overextended if
it has less than three months take-home pay in savings
for emergencies.
If an individual or a couple is nancially overex-
tended, the rst step in solving the problem is to make a
conscious choice to change things. Plan a budget jointly
with a spouse or other family member who shares the
budget responsibility (Hunt 2003). Look for places to
cut expenses. Resolve not to use credit cards or take out
new loans until your situation has improved.
If necessary, cut up all your credit cardsthe rst
action credit counselors take for many of their clients.
A-48 Managing a Family Budget A P P E NDI X I
Ask your creditors if they will agree to spread pay-
ments over a longer period. Usually, they will be will-
ing to work out some temporary arrangement.
If you feel its necessary, consult a credit-counseling
service, but be careful as some of these charge high
rates for their advice and may offer you their own
high-interest loans, an extremely unwise solution to
your problems. To begin your search for a trustworthy
service, check the web site of the National Foundation
for Credit Counseling (www.nfcc.org). In general you
will be better able to trust the advice and information
that you nd on government (sufx=.gov) or educa-
tional (sufx=.edu) institutions.
Budgeting Resources
You can nd a variety of budgeting resources in your
local library, by browsing in your local bookstore, by
searching online, and/or by investigating computer
software. Resources range from those that present the
basics of nancial management and budgeting (for
example, Jason Richs e-book, Make Your Paycheck Last:
How to Create a Budget You Can Live With, 2004),
to those that stress saving and investing (for example,
the e-book Budget & Save: Six steps to Help You Make
the Most of Your Income, 2003), to those that focus
on recovering from debt (for example, David and
Debbie Bragoniers Getting Your Financial House in
Order, 2003), to those that address living on reduced
income due to circumstances beyond ones control
(for example, Michelle Eagles From Heaven to Earth:
Soft Landing Your Family Budget: 14 Steps to Manage
Downsizing Family Finances in Downsizing Times,
2002), to books that place budgeting within the mar-
riage and family context (for example, Mary Hunts
Debt-Proof Your Marriage, 2003, or Bill and Mary
Tooheys The Average Familys Guide to Financial Free-
dom, 2001).
. . . . In addition to the online sources mentioned
earlier, there are various online sources that charge a
fee. For example, for a monthly fee Personal Mvelopes:
the Simple, Smarter Budgeting System (http://www.
mvelopes.com) offers online access to budget infor-
mation and planning as well as ways to track your
spending. Software available online or at your local
computer store offers a similar service.
I
References
I
Bragonier, David, and Debbie Bragonier. 2003. Getting
Your Financial House in Order: A Floorplan for Man-
aging Your Money. Nashville, TN: Broadman &
Holman.
Brock, Fred. 2005. Live Well on Less Than You Think:
The New York Times Guide to Achieving Your Finan-
cial Freedom. New York: Times Books.
Budget & Save: Six Steps to Help You Make the Most of
Your Income. 2003. Washington, DC: Kiplinger.
Eagles, Michelle. 2002. From Heaven to Earth: Soft
Landing Your Family Budget: 14 Steps to Manage
Downsizing Family Finances in Downsizing Times.
New York: Writers Club Press.
Economic Policy Institute. <http://www.epinet.org>
Hunt, Mary. 2003. Debt-proof Your Marriage: How to
Achieve Financial Harmony. Grand Rapids, MI:
Fleming H. Revell.
Personal Mvelopes: The simple, smarter budgeting
system. http://www.mvelopes.com.
Rich, Jason. 2004. Make Your Paycheck Last: How to
Create a Budget You Can Live With. Franklin Lakes,
NJ: The Career Press.
Sander, Peter J. 2003. The Everything Personal Finance
Book: Manage, Budget, Save, and Invest Your Money
Wisely. Avon, MA: Adams Media Corp.
Toohey, Bill, and Mary Toohey. 2001. The Average Fam-
ilys Guide to Financial Freedom: How You Can
Save a Small Fortune on a Modest Income. New
York: Wiley.
Turner, Josephine. 2001. Show Me The Money: Lessons
1 Through 5. University of Florida Extension: In-
stitute of Food and Agricultural Sciences. <http://
edis.ifas.u.edu>
R E F E R E NCE S A-49