He licks in circles around each of her breasts and asks, “Is that all right?” If so, he continues. He licks each of the nipples, and bites each one gently. Then he runs his tongue down to her belly button and licks around it—then slides down to her vagina. He licks around her vagina and asks, “Is that all right?” If so, he continues. He licks her inner thighs, then bites each knee, and then each elbow.

He then takes the ice bag and runs it slowly about her body. He circles her breasts, then grazes each nipple. He runs the bag up her neck and around her right temple, over her forehead, down her left temple, very lightly across her lips, down her chin, around the rims of both ears, around her breasts again, down each inner arm, across each palm, then down to the belly button, around it, then down to the pubic hair, around it, down to the vagina, around it, then gently across it, then down the inner thighs, inner calves, and over the top of each foot.

Next he takes the hot washrag and follows the same route.

Next he takes the feather duster and follows the same roate:

Next he kisses her, following the same route. Next he covers her with a comforter and gently rubs her all over.

Next he lies on top of her, holding her hands, and rubs his body against her. Then he kisses her softly on the lips. Then he asks, “Is it all right?”

If so, he asks, “Would you like an inner massage now, madam?”

If the answer is no, he stops the massage right there. If the answer is yes, he proceeds to fondle her, making sure she is wet, and then enters her. Looking at her and keeping her hands in his, he begins to have intercourse. He says, “It’s very important to have an inner massage every so often. Try to think only of the inner massage now—but if you do think of something else, then gently return to the inner massage and think of that again. If you start thinking of how glum life is, then go ahead and think about how glum life is but then return to the inner massage and think of that. If you start thinking about how meaningless your existence is, then go ahead and think about the meaningless of existence and then return to the inner massage and think of that. Are you thinking about the inner massage now? Is it all right? Are you feeling better and better? It’s all right if you want to come. I will protect you while you come.”

*73/196/1*

Players: Passive wife and aggressive husband.

Activist: Husband, without wife’s knowledge or cooperation.

Setting: Bedroom.

Aim: Resolve the defensive posture of the wife by “killing with kindness,” and change the husband by having him give up his tendency to guilt-trip or threaten.

Game Plan: This game is for the passive-aggressive couple in which the wife is the passive and the husband is the aggressive, and their sexual relations are epitomized by the “Not tonight, dear, I’ve got a headache” syndrome. Couples who get stuck in this syndrome are invariably locked in a particular kind of impasse. In this fix, the wife appears to be a kind, giving person who takes care of the husband and children—and, indeed, often treats her husband as if he were one of the kids. But when it comes to adult sexuality, she avoids it. The husband likes being pampered by the wife and feels guilty about wanting more sex. His response to being sexually frustrated is to beg, guilt-trip, and threaten his wife: “Please, I need it!” he may say—or, “I don’t know why I put up with a wife like you”—or, “Maybe I’ll have an affair.”

*48/196/1*

It can take months—even years—of therapy for such couples to break through these resistances. However, through erotic games, the wishes, fantasies, and feelings will often be prodded loose rather more swiftly as a by-product of play. The spontaneity associated with sexual play undermines rigid character defenses and hastens confrontations that would otherwise continue to fester.

Following are five games to be used by bored couples. Games 1 and 2, “Seduction Surprise (by the Wife)” and “Seduction Surprise (by the Husband),” are variations of the same game. These would be excellent starting games for the husband and wife described above. Which game should be played first depends upon who is “boring” and who is “bored.” In the case just discussed, it would probably be the husband who would be the game activist, since he would feel most sexually deprived and therefore eager to try something new. In cases where it is the wife who is feeling frustrated sexually (or otherwise), and therefore most bored, she would be the game activist.

*23/196/1*

Although the irrelevance of intrapsychic considerations to the treatment of disturbed sexual behaviors that are now blind habits is especially clear, this same behavioral perspective may be applied to all sexual disturbances. Many behavioral therapists take any sexual problem, break it down into its component behaviors, and systematically change each behavior in turn. With this approach they have achieved some excellent results.

Barlow, Reynolds, and Agras, for example, have used just such a behavior-by-behavior approach in the successful treatment of a transsexual young man, an area generally considered to be highly refractory to any kind of treatment. First the patient was trained in “masculine” motor and social behaviors. He was taught to sit, stand, and walk in a male-appropriate (as determined by community standards) role, to deepen his voice, and to converse appropriately. Next, using sexual fantasies combined with social reinforcers, he was trained to identify himself as male rather than as female. Finally, a classical conditioning method known as fading was used to establish heterosexual arousal, and aversive methods were used to decrease homosexual arousal. Through the sequential, successful modification of these component behaviors, the patient changed from a person desiring sex transformation surgery to one on the brink of leading a full heterosexual life. The power and limits of such a completely behavioral approach to complex sexual problems, what it can and cannot do, has not yet been fully tested, but it does have great promise.

In clinical practice, however, there are times when the exploration of intrapsychic processes seems necessary to identify the target behaviors. Even under these conditions, behavioral technology may be used to bring about the actual change. To illustrate this approach, we will describe the treatment of a twenty-four-year-old homosexual man who complained of compulsive masochistic sexual behavior. He was not attracted to lovers who would show him tenderness and consideration but rather to “bastards” who would mistreat and even physically abuse him. He received no pleasure from this and experienced only disgust with himself and a feeling of intense frustration. He rather quickly broke off each such relationship, only to be caught up again just as quickly in a similar one. A variety of behavioral methods was attempted unsuccessfully: desensitization to tenderness, assertive training, aversion to “bastards,” and various behavioral assignments.

A series of sessions using quasi-free association methods revealed that he had experienced similar feelings of self-disgust and frustration as a child in relation to his father. The memories of specific incidents, however, were sparse and vague and the feelings were almost conjectural. A nonsystematic desensitization (Fensterheim) to the vague memories was attempted. The first result of this procedure was more vivid memories and a heightening of the disturbed reaction to them. Eventually the disturbed reactions diminished and then disappeared. At that point, without any further behavioral recommendations or treatment, the masochistic pattern was replaced by a series of more satisfactory relationships. An almost two-year follow-up (he returned to discuss an unrelated career problem) showed this adaptive change to persist.

These illustrations have stressed the importance of identifying target behaviors. It must also be noted that the behavior therapist, as a clinician, is well aware that the sexual problem may not be primary but may derive from other problems. Depression, poor inter-personal relations, a generally high level of anxiety, physiological malfunctions – all may influence sexual behavior.

In these instances, even though the person has a sexual problem, nonsexual target behaviors may have to be selected for change. Many times the modification of these nonsexual behaviors will relieve the sexual problem; other times, further and more sexually-oriented treatment is necessary to resolve the problem.

*233/187/5*

Transvestism means cross-dressing, that is, dressing in the clothes of the other sex. On the stage, it may be done as a dramatic device, as in a play by Shakespeare. For Halloween, it may be done as a gag or joke. A professional impersonator may cross-dress for a living, but such a person is likely to have more than a salaried interest in dressing up. He may be a drag queen, or she may be a butch lesbian, or either may be a would-be transsexual. In the case of the male, he may be a clinically diagnosed transvestite; clinical transvestism has not yet been recorded in the female.

As clinically defined, tranvestism is a condition in which a male has a sexual obsession for or addiction to women’s clothes, such that he episodically experiences intolerable psychic stress if he does not dress up. In addition, he is handicapped in getting erotically aroused and performing sexually, regardless of being either heterosexual or homosexual in partnership, unless he is wearing female garments, as though wearing a fetish, or at least imagining himself as doing so. Some transvestites discover their proclivity at puberty by discovering that they can masturbate to orgasm only if wearing or handling some article or articles of female apparel. Many eventually try to find or educate a partner with whom to practice their transvestism. A few, especially as they advance in age, are erotically inert, but cross-dress permanently or as often as expediently possible. They do not request transsexual surgery, but they may take female hormones. The typical transvestite, however, wants no female hormones and no feminizing surgery. He simply dresses and wears makeup episodically as a female, and then returns to his male garb, until irritability, restlessness, and inner agitation demand relief again by impersonating a female and having an orgasm. Almost all transvestites have a female name to go with the female wardrobe. There is also a female personality. Like the male personality, it is in the literal sense unwholesome. The two personalities, if they can be put together, would make a whole. The female personality by itself is a travesty of a conventionally stereotypic woman and likewise the masculine personality.

*196/187/5*

Paternalistic legislation might seem to reach a justification of sorts in cases of rape. Although paternalism is not absent from rape legislation, the actual process of prosecuting alleged rapists and the concomitant treatment of rape victims is typically paternalism’s nemesis turned against the victim herself.

Rape often has been viewed as an almost unique crime. Among crimes of sex, it is one which is decidedly not victimless. The legal definitions of rape, interpretations of relevant statutes, and indeed the entire criminal process pursuant to a rape charge, are a myriad of practical and theoretical conundrums.

Only in a minority of cases do rape victims report the crime; rape has a bizarre “halo” effect, bestowing on the victim a sense of degradation and often an implied responsibility for the crime. Although the FBI reports 55,000 rape cases per year (Gager and Schurr) that figure—of reported rapes—is estimated to represent between five percent and twenty percent of actual rapes. Furthermore, a relatively high proportion of rapes reported to the police have been classified as false reports, as “unfounded.”

However rape may be defined in a specific, legal sense, understandings of the crime and its implications have shifted through the ages. In Biblical, as in early English law, rape was comprehended as an act akin to theft, robbing a woman’s male guardian of her virginity. Earlier assumptions and ambiguities “as to whether the crime was a crime against [a man's] own estate” (Brownmiller) have not vanished totally. The laws of rape continue to be linked with those of marriage. In most states of the United States, though not in other countries (e.g., Sweden, Denmark, the U.S.S.R.), rape by legal definition cannot occur between spouses; a woman cannot be raped by her husband, for in establishing the marital bond, she effectively gives up the legal right to withhold consent from what otherwise might be deemed rape.

The law’s and the wider society’s suppositions about what constitutes the crime of rape may be revealed in comparing rape laws with other statutes. In particular, rape bears certain similarities to incest; that comparison becomes especially striking when comparing statutory rape (rape with a victim below a specified age) to incest committed by a father or legal guardian with his young daughter. In a different sense, rape can be compared with robbery. The first comparison, between rape and incest, becomes significant in regard to dissimilar penalties tending to be exacted from the victimizer; the second comparison, between rape and theft, is important in light of differential treatment typically accorded the respective victims by police and in the courts. What is or should be implied by the victims’ consent, crucial to rape trials, and by the rapist’s use of “force” becomes the crux of the matter in both comparisons.

Consent by a rape victim is a defense to a prosecution for rape. Consent, however, is irrelevant—being legally impossible to grant or to refuse—when the victim is below a certain age (set at ten in the Model Penal Code) or is incompetent. Penalties for statutory rape of a girl presumed too young to be able to offer reasonable consent are among the severest handed down in cases of convictions of rape. In contrast, a man charged with “raping” his young daughter (termed incest) tends to be treated with more leniency by the courts than is the convicted rapist. In this regard, the effect of the law, if not its explicit intent, would seem to have a protracted history. The codes of Hammurabi, which condemned a man to death for raping a betrothed virgin, dealt with one found to have committed incest with his daughter by simply expelling him beyond the city walls (Brownmiller).

*159/187/5*

STUDIES ON COGNITIVE STYLES -I

There is a vast area of cognitive style that has been studied since Witkin’s and others’ pioneer study of adults’ field-dependent versus field-independent patterns of scanning. Studies on stable cognitive styles among individuals have been extended to children. The concept of cognitive style also has been widened to include not only field dependence-independence, but also reflection versus impulsivity (Kagan and others; Kagan and Messer), breadth of categorization (Gardner), and style of conceptualization (Kagan and others). The results of research on the nature of sex-type differences in cognitive styles among children are promising but not conclusive, for a number of reasons. First of all, children are not as verbal as adults—especially very young children. In addition, most studies on children’s cognitive styles lack methodological sophistication and therefore are usually the reflection of the investigators’ individual differences rather than the children’s.

Children are required to respond to certain limited stimuli provided by the investigator, rather than to behave autonomously and spontaneously, and except for a very few (Block and Block), most of these studies are carried out in research laboratories and do not take into consideration the actual performance of children in classrooms. Nevertheless, a general survey of the literature (Kogan) provides convincing information about the cognitive style differences among sexes. In one study Coates (as reported by Kogan) using the Articulation of the Body Concept (ABC) Test, based on the child’s ability to articulate an embedded figure, found that girls scored higher than did boys. It was concluded, with some misgivings, that not only field independence, but other cognitive styles appear earlier in females (four to five-year-olds) than in the control group of boys. In Oltman’s study, based on the responses of one hundred males and one hundred females between four and thirteen years of age to the Portable Rod and Frame Test, there was a significant increase in the field-independent functioning for both sexes as they became older. Within the preschool population of children, similar studies have detected a difference between the sexes in the developmental pattern of field-independent perceptual ability. It seems that girls are ahead of boys in this ability up to age four to five years, but boys surpass girls by the age of five to six years (Coates; Dermen and Meisner). This stability of field-independent function in boys over a period of time, as compared with its discontinuity in girls, is puzzling. It might have some relation to other variables, such as girls’ tendency to be more socially oriented and boys’ tendency to be more task-oriented, as suggested by some investigators (Coates and others).

*122/187/5*

Consensual adultery occurs with the knowledge and consent of the spouse. Smith and Smith have described three forms: adultery toleration, comarital relations, and group marriage. Adultery toleration is similar to conventional adultery except that the spouses extend to each other the freedom to engage in extramarital sex, relieving the partners of the requirement of sexual exclusivity and of the need for secrecy and deception. Such liberal arrangements are by no means new. Havelock Ellis had such an agreement with his wife, and the gynecologist, Robert L. Dickinson in 1932 described such a case among his series (Brecher). Others have been reported by Hamilton and by Lindsey and Evans. On a more contemporary level, the open marriage model proposed by the O’Neills includes absence of sexual exclusivity.

Comarital relations incorporate extramarital relations into the marital relationship. Both partners participate as a dyad, both on a couple-to-couple basis and sometimes a group basis, which is popularly called mate swapping or swinging. Although such relations may be quite impersonal and transient, the Smiths say that their studies suggest that some couples “succeed in establishing basic friendship relations which yield more enduring and more rewarding social networks”.

Group marriage does not include, strictly speaking, extramarital relations, since it consists of members of a group all of whom consider themselves married to each other. Rarer than the other two forms, it is ideologically the same as the Oneida model discussed earlier, with unrestricted sexual access of the individual members to each other.

Such forms of extramarital sex with the knowledge, consent, and sometimes the participation of the spouse are phenomena which have attracted much more attention than their prevalence in the population seems to justify. Their deviance from traditional norms in an area of behavior which more than any other has historically been rigidly defined and prescribed has attracted a high level of attention in the popular media.

Recent estimates agree that the numbers of persons participating in any of the forms of consensual adultery are quite small. No reliable data exist on adultery toleration but if they did, they would probably be higher than figures for the other two forms, simply because “toleration” is less deviant from conventional norms than is mate swapping or group marriage. Hunt found that about two percent of the husbands and wives in his sample had ever engaged in mate swapping, but Tavris and Sadd reported that four percent of the Redbook wives, a less representative sample, had tried swapping at least once. A stratified probability sample of 579 married adults drawn from a mid-western community of 40,000 found that less than two percent of the respondents had ever participated in swinging (Spanier and Cole). Smith and Smith state that the incidence of group marriage is far lower than either of the other forms. Ramey provides an interesting account of eighty upper-middle class couples who explored over a three-year period the various problems and possibilities of communal and group marriage arrangements. Only eighteen of these couples did, in fact, have any experience in such living arrangements.

Finally, in an analysis of some moral and social implications of infidelity, Bernard speculates that the conditions of exclusivity and permanence required in traditional marriage may now be incompatible: “It may be that we will have to choose. … If we insist on permanence, exclusivity is harder to enforce; if we insist on exclusivity, permanence may be endangered. The trend . . . seems to be in the direction of exclusivity at the expense of permanence in the younger years but permanence at the expense of exclusivity in the later years”.

Bernard reveals in this same paper that she has changed her views on the significance for women of extramarital relations. A few years ago she thought that women could not be casual about such relations. She sees now that there is a new kind of woman who can be casual about sex and can accept the idea of sex-as-fun without conflict. She believes that the increasing economic independence of women plays some part in this change. We have seen already that working women were more likely than nonworking (outside the home) women to have affairs, certainly in part because of more opportunities and contacts with men. At the same time, such a woman, less dependent on her husband for economic security, might be less fearful of the consequences of discovery. She also might be less frightened at the prospect of her husband’s involvement with another woman although, as Bernard rightly pointed out, economic independence is far from the whole story. The threat to one’s psychological needs can be more terrifying than the threat to one’s material security.

*85/187/5*

Deciding when a person with dementia should no longer drive a car is a very tricky problem. Not only is it usually a matter of pride for the driver, but the ability to get about by car can be of great practical importance in the everyday life of the sufferer and his or her carers. It is therefore very tempting to assume that all is well when there is no obvious risk. Driving is an automatic activity that often doesn’t require thought — until some untoward event occurs, that is. It is quite possible for a person with dementia to undertake a journey that he or she has made many times in the past without any difficulty at all. However, should something happen that requires fast and logical thought to avoid an accident, or the road layout be unexpectedly changed, major problems can ensue. Although familiar journeys will probably remain possible for some time, as the dementia progresses an attempt to make a journey that breaks new ground may well produce a crisis and, if you are unlucky, an accident.

As soon as you are aware that driving ability is even only a little impaired by dementia, it is essential that the person concerned stops driving, but if you are in any doubt, consult your doctor. There is also a legal requirement to inform the licensing authority of any disability that may impair fitness to drive, unless it is only a temporary affliction. Many insurance companies also require their policy holders to be fit to drive. It is technically possible, if an accident were to happen and the insurance company were to argue that the driver responsible was unfit through mental incapacity, that they would consider the insurance invalid. Not only could this result in their failing to make appropriate financial compensation, it may also leave the driver open to a charge of driving without insurance.

It is therefore probably a good idea to start getting a person who has early dementia used to the fact that he or she will eventually have to give up the car. This may well cause great sadness or anger. Nevertheless it will eventually be in the best interests of all concerned.

If you are unable to prevent a relative with dementia from driving by reasoning with him or her, you may have to ‘lose’ the car keys or, if necessary with the help of a friend, immobilize the car by some means. A belief that it has broken down may act as a natural break-point, enabling you to persuade your relative that it is not worth making the necessary repairs.

This is a situation that must be dealt with gently and tactfully, avoiding confrontation if possible. If you can drive yourself, you may be able to think of an excuse to do the driving on most, if not all, occasions. Remember that being able to drive a car requires physical fitness (good sight and hearing especially), coordination, and the intellectual ability to react and make decisions rapidly when this is necessary. You may find that your doctor will be able to help you if your advice to stop driving goes unheeded.

*105\138\2*

Those of us working closely with people who have dementia and who get to know well those caring for them are often told by carers that they wished they had done more, particularly after the sufferer has died or been admitted to a home or hospital for long-term care. This is very much tied up with the feelings of guilt discussed earlier. Remember that it is easy to be wise after the event. Remember also that it is very unlikely that you really could have done any more than you have, however much it may now seem that you could or should have. As already mentioned, caring for a person with dementia is a matter of compromises and there will always be room for nagging doubts and worries about the past. Even if you have made a mistake, you must remember that you will not be alone in this. Everybody makes mistakes and most people make theirs without having to cope with the very great strains that are involved in looking after someone with dementia.

You may find that you can help other carers by passing on your experiences, but it may well take a while after bereavement before this is possible. Similarly, some carers who have agreed to allow the sufferer to go into long-term care may feel too guilty to want to go on sharing their experiences with others. Nevertheless it is worth bearing this in mind and continuing to attend the support group or joining one if you are not already a member. Local voluntary organizations such as the nearest branch of the Alzheimer’s Disease Society may also be very pleased to have your help in any one of a number of ways.

Whatever happens, try not to let worries about the past prevent you from starting again with your life, and remember that looking after someone with dementia is in itself a major achievement.

*83\138\2*