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When to start the medications is also a topic of much discussion and controversy. Before the development of protease inhibitors, initiation of antiretroviral medications was considered when the T-helper-cell count fell below 500. Use of medications was not recommended earlier in the course of the infection for fear that once they were necessary (when the T-helper-cell count began to fall and the consequent risk of opportunistic infections began to rise), they might no longer be effective. AZT, ddl, and ddC, when used as monotherapy, often become ineffective after six to twelve months because of the development of resistance. Combination therapy offers longer suppression of the virus and can decrease the likelihood that resistance will develop. Combining 3TC with AZT will prevent resistance to the AZT from developing, so that combination is now preferred over the use of either drug alone. The protease inhibitors are even more effective in combination with the anti-retrovirals in maintaining T-cell count and decreasing viral load. The use of two antiretrovirals with a protease inhibitor (a strategy called triple therapy) has also been tried, and it is now the preferred regimen for many patients because of its increased effectiveness.

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For a child born to a mother who is infected with hepatitis B, the same combination of vaccine series and immune globulin is given, usually within twelve hours of birth. This treatment has a high rate of success in preventing the child from becoming infected with hepatitis B, decreasing the likelihood of infection from 80 percent to 5-15 percent. All pregnant women should be tested to determine their hepatitis B status, so that their newborns can be tested and treated if they have been exposed.

Besides vaccination, the other method to help prevent the transmission of hepatitis B through sexual contacts is to use condoms or other barriers for oral, anal, and genital intercourse if a partner’s status for hepatitis B (and other STDs) is not known. However, since condoms can break or may be used improperly, they should not be relied on as the sole means of preventing infection. Women who have sex with other women can transmit the virus through oral sex and exchange of vaginal secretions. Dental dams or plastic wrap may decrease the risk of infection in such cases.

All partners of these found to be infected with hepatitis B should be immunized.

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Chlamydia is the most common bacterial sexually transmitted disease in the industrialized world. Estimates are that between four and six million people are infected each year with chlamydia in the United States, but this may be an underestimate. Many people are symptom free and are never diagnosed or reported. Studies have shown that between 3 and 5 percent of men and women in general medical clinics and about 15-20 percent of men and women attending STD clinics are infected. Studies of symptom-free people in various areas of the country have found that between 5 and 50 percent of those tested are infected with chlamydia. About half of those infected are teenagers, and about one-third are between twenty and twenty-four years old.

Even though chlamydia is a common infection of adolescents and young adults in the United States, any sexually active person can become infected. Younger women are more likely to become infected with chlamydia if exposed because the anatomy of the cervix makes them vulnerable.

Because many people have chlamydia without experiencing any symptoms, it is an infection that is frequently passed between sexual partners unknowingly. People of any sexual orientation can become infected with chlamydia, although it appears to be more common among those who have opposite-sex partners. Women who have sex with other women may be the least likely to become infected, although there is a small possibility of infection if they share sex toys. Routinely screening those at high risk for chlamydia is the only way to halt the spread of this epidemic.

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Most studies have found transrectal ultrasound to be a rather mediocre predictor of the presence of cancer that has penetrated the prostate wall, and to be downright poor in finding cancer that has reached the seminal vesicles. In two studies, only 30 percent of tumors that had spread to the seminal vesicles could be found by ultrasound. One investigation, of thirty men undergoing radical prostatectomy, found ultrasound’s sensitivity in spotting cancer that had worked its way beyond the prostate wall was a measly 5 percent. Another study, comparing ultrasound and pathological staging in 121 men, found ultrasound’s overall accuracy in staging was only 66 percent—better, but still not reliable enough. And a multicenter study of 230 men found that ultrasound correctly staged 66 percent of locally advanced cancer and only 46 percent of the cancers confined to the prostate.

Ultrasound’s main difficulty is its inability to “see” microscopic cancer spread. So, to sum up: No definitive decision about a man’s course of treatment should be made on the basis of ultrasound alone, and ultrasound readings shouldn’t be the cause of a man’s exclusion from surgery that could potentially cure his disease.

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Now, let’s take a quick look at the reproductive system:

Sperm and testosterone, the male hormone, are made in the testicles. Testosterone is the substance that makes the prostate grow at puberty; it also stimulates the prostate to manufacture its secretions. Sperm travel from the testicles to the twisting, winding epididymis, a convoluted “greenhouse” where they mature.

The epididymis connects to the vas deferens, a hard, muscular cord that winds all the way from the scrotum into the body and down to the back of the prostate. At this point, the seminal vesicles, which produce 70 percent of the fluid for semen, connect to the vas deferens to form the ejaculatory ducts, which run into the center of the prostate. When a man ejaculates, sperm rocket from the epididymis through the vas deferens and out of the ejaculatory duct, where they’re mixed with the fluids from the prostate and seminal vesicles.

To make sure that the semen doesn’t “back up” into the bladder, a muscular valve slams shut in the bladder neck, forcing the semen out the urethra in the penis. Soon after ejaculation, the semen coagulates. A substance called prostate-specific antigen (PSA), which is made by the prostate, then acts on the semen, causing it to become liquid again.

To understand what can go wrong with the prostate, it will probably help to study the illustrations in this chapter and the rest of the book (the illustration in the Glossary shows the male urinary and reproductive systems together). The prostate encircles the urethra like a fist holding a straw—therefore, when its transition zone enlarges, in benign prostatic hyperplasia (BPH), this compresses the urethra and causes urinary problems. Finally, by understanding how PSA is secreted from ducts in the prostate, you’ll be able to see why PSA levels increase when these ducts become obstructed, as they do in prostate cancer.

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Sexual values are often shaped by economic need. For example, so many French citizens died in World War II that the government needed to rebuild the population. It encouraged large families by lowering a family’s taxes each time a child was born. Families with eight children paid no taxes.

When motherhood and large families became economically important in the ancient world, contraception and abortion became illegal. These and other sexual values that are shaped by economics become part of a culture’s traditions. Often a tradition survives long after its economic roots are forgotten. As a result, contraception and abortion may remain illegal long after the economic need for large families has passed. This is one reason that women without children are traditionally stigmatized in many cultures.

Ever since the earliest agricultural times, women were expected to fulfill key roles in the economy. They were to provide labor and give birth to laborers or legitimate heirs for their families’ fortunes. Traditions that developed from these economic conditions placed a higher value on the sexual freedom of men than it did on that of women.

This double standard continues today. Social judgments about women’s sexual behavior continue to be more severe than judgments about the same behavior in men. For example, a man who has many sex partners may be admired as a “stud.” A woman who has as many may be considered a “slut.”

The double standard is the basis of sexism. Sexism is a bias held against a certain gender. Historically, most societies have favored men and boys and have been biased against women and girls. Women and girls have been given fewer privileges and opportunities than men and boys. In many cultures, they are not allowed to be educated or own property.

Sexist values are being challenged by women and men around the world. The idea that women and men have equal social, economic, sexual, and political rights is called feminism.

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• Show that you can listen to whatever your child needs to say without getting angry.

• Help your child understand sexuality by having open, easy, and frequent conversations about it.

• Talk with your child every day and take time to become acquainted with your child’s activities and feelings.

• Encourage your child to share concerns and problems with you.

• Teach your child that children’s bodies belong only to them.

• Help your child learn that no one has the right to touch children without their permission. And help your child learn to make decisions and choices by offering alternatives instead of commands as often as possible.

• Let your child know that some adults may want to do things with children that may hurt them or make them feel uncomfortable.

• Let your child know that adults who want children to keep secrets from their parents are doing something wrong. Children must not keep such secrets from their parents or other people that they trust, even if an adult threatens to hurt a child or the child’s parents.

• Explain that it is wrong for adults whom children know and trust, even adults in their own families, to do things with children that may hurt them or make them feel uncomfortable.

• Be sure to keep from frightening your child. Children should know that most grown-ups will not sexually abuse them and that most adults are deeply concerned about protecting

children from harm.

• Make sure that your child knows that you must be told as soon as possible if someone does something confusing such as talking about secrets, touching, giving gifts, or taking naked pictures.

• Reassure your child that children are not to blame for anything that adults do to them.

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The diagnosis of idiopathic delayed puberty is as much a matter of convention as the definition of idiopathic precocious puberty. Most clinicians seem to agree that the onset of puberty two or three years after the median age justifies concern and the label “delayed puberty.” Many boys aged fifteen or sixteen who are not yet in puberty are unhappy, and many of them seek professional help. Just by statistical definition, there must be the same percentage of girls with delayed puberty, but relatively fewer of them seek medical attention, because they do not seem to suffer as much as boys do. Although there are many physical conditions that may cause delayed onset of puberty, the most common is idiopathic or constitutional. Again it is not quite clear whether the hormonal pattern of constitutionally delayed puberty is identical with normal puberty, except for timing, or whether there are also some characteristic endocrine differences.

The delayed adolescent boy has many disadvantages. Compared with his peers, he falls behind in size and strength, and faces teasing and sometimes physical harassment by peers. If he is not able to keep up with his peers in some way, he may withdraw, which usually implies missing out on all the typical experiences of one’s age group and having less of an opportunity of acquiring the teenage skills of same-sex socializing and heterosexual contact and bonding. These transient developmental deficiencies may have long-term effects. Several longitudinal studies in which late maturers were compared to early (not precocious) or normal maturers, like the classical California Adolescent Growth Study, found not only the described disadvantages of late pubertal development during adolescence but also relative delays in their career status and “organizational leadership” as well as in marriage and number of children in adulthood. Unfortunately, information on the sexual behavior of these subjects was not published. Clinical studies of severe forms of delayed puberty show both psychological and psychosexual delay to be present, though it is difficult to disentangle the influence of pubertal delay per se from other contributing factors, especially the short stature resulting from the delayed growth spurt.

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Infant-infant sexual encounters are fairly uncommon, partly because of the infant’s lack of mobility. However, the older infant who is one or two years of age and old enough to crawl or walk is capable of initiating various encounters. It was reported of Louis XIII’s carefully observed permissive infancy, for instance, that “he throws down little Marguerite, kisses her, throws himself on her . . .” (as reported in Hunt). The Israeli kibbutz is a setting which allows for intimate encounters (Kaffman). The kevutza is a bisexual children’s peer group that has common living and sleeping quarters—boys and girls who are one through five years of age sleep in the same room, shower together, go to the toilet together, and often run around together before getting dressed in the morning or after being undressed in the evening. Intimate encounters include different activities. In a group of children with a mean age of two years, it was found that the most frequent expression consisted in a simple embrace of one child by another, followed in frequency by stroking or caressing, kissing, and touching the genitals. In some previously unpublished data, Kinsey records instances of cuddling and kissing encounters between infants two years of age or less.

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It has been suggested that the way a boy’s parents relate to each other provides his first and most important model of heterosexual relationships and therefore notably influences his sexual orientation. Thus, if his parents appear to have a warm, loving, and satisfying relationship, a boy may be likely to believe that basic human needs can best be fulfilled in a heterosexual relationship. On the other hand, if their relationship seems hostile and unrewarding, the boy might be discouraged from developing heterosexual interests and thus be predisposed toward homosexuality.

Psychoanalytic theory posits additional ways in which the interparental relationship might affect a boy’s sexual orientation It maintains, for example, that there is an “Oedipal period” during which a young boy experiences strong sexual attractions to his mother and hostile feelings toward his father; during this period, it is thought, he hopes to displace his father. When a strong parental coalition exists, according to this theory, the boy concludes that his mother is content with the way things are. He then gives up the hope that he can take his father’s place, identifies with his father, and eventually seeks another female to whom he can feel close. This sequence is thought to explain the development of heterosexuality in males.

Conversely, the same theory has posited that a weak interparental bond may predispose a boy toward homosexuality. Such circumstances, it is thought, lead the boy to believe that his “Oedipal” fantasies are actually being fulfilled and that he is, in fact, responsible for the tension between his parents. In this view, the boy might feel pleased about his apparent victory but also feel unequal to the role he has won; this feeling of inadequacy may later be transferred to his relationships with other females. According to this theory, the boy would also be likely to anticipate punishment from his displaced father, to perceive his father as hostile, and to have difficulty identifying with his father.

There is some empirical evidence that the parents of prehomosexual boys have less-satisfactory relationships than do those of preheterosexual boys. For example, studies have found that, compared with their heterosexual counterparts, homosexual men are more likely to describe their parents as unhappily married; physically or verbally fighting with each other; or weakly allied. The mothers of homosexual men have been described as cold toward their husbands, preferring their sons to their husbands, and allying with their sons against their husbands.

Other researchers have found that a relatively high incidence of marital dissolution (through death, divorce, or separation) exists among the parents of homosexual males. In the same vein, several studies have concluded that prehomosexual boys are more likely than their heterosexual counterparts to grow up in fatherless homes. Such a state of affairs is thought to contribute to a “confused” gender identity on the part of boys whose fathers are absent during their formative years and thus, indirectly, to a homosexual orientation.

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