Vaginal thrush is more common in diabetic women and this can cause uncomfortable sex or even an avoidance of sex altogether.

Some diabetic women find that their insulin requirements are raised when they become sexually active.

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Exhibitionism becomes a perversion when it is a person’s preferred sexual activity, leading to his greatest sexual pleasure. It is most common in timid young men who frequently best enjoy the activity if the selected victims, usually pubescent girls, look at them just as their masturbation has reached the point of ejaculation. Such acts are not intended to be seductive and if the man has a partner of his own, (some are married) he does not usually want intercourse. Such men are basically harmless but other types of exhibitionists certainly are not. Some alcoholics, psychotics, criminally sadistic paedophiles and brain-damaged people may exhibit themselves occasionally but this may not be the limit of their activities. Similarly, disturbed women may exhibit their genitals and perhaps masturbate in public. Some mentally deficient people exhibit themselves too, probably to attract attention rather than for any overt sexual pleasure.

Survey evidence suggests that nearly a half of all girls and women can expect to be the victim of male exhibitionism or, as it is called, indecent exposure. A third or so of these will tell no one, but if they are under the age of sixteen or so they can be very upset by the episode. The young girls who are subsequently most disturbed are those who tell their parents who then over-react, perhaps involving the police, as happens in a fifth of cases.

Few members of either sex would fail to watch nude members of the opposite sex or a couple having intercourse if the opportunity presented itself, especially if there were little chance of detection. Inhibited people of either sex who have been fitted with an eye-camera, and who therefore know that the experimenter knows what they are looking at, will look anywhere except at the nude body of a member of the opposite sex with whom they are confronted. When looking is allowed, as at strip shows, which are now available for both sexes, or on nude beaches, the inhibition recedes. Probably we are all reared, by others if not by our parents, to believe that it is ‘dirty’ to look at the genitals or sexual behaviour of others.

Whilst this is voyeuristic behaviour it is not really voyeurism in the true sense of the word. Voyeurism is a condition in which the person usually, but not invariably, takes deliberate steps to watch others undressing or copulating and so gets his or her kicks from witnessing ‘realistic pornography’. Some conceal themselves in bushes, creep on knee pads, drill holes in walls, or climb ladders in pursuit of their peeping-Tom activities. Some homosexuals spy on their own sex ‘and some specialist voyeurs concentrate on watching women urinate. An occasional voyeur such as a psychopath may assault the woman he is watching but the vast majority of peeping Toms are harmless.

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Insurance companies calculate that a 30 year old man can expect to live another 47 years if he is not in an at-risk group for AIDS and is not HIV infected. If he is in a risk group he can, on average, expect to live 27 years. If actually HIV infected this falls to 8 years and if he has developed AIDS it is only one and a half years.

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Over thousands of years people have considered various sexual practices ‘immoral’ but it was not until the coming of Christianity that all such practices were forbidden. Throughout history, societies have usually condemned adultery; have sometimes condemned homosexuality and abortion; and have never condemned masturbation. The Christian Church declared all these pursuits to be immoral and, what is more, sinful. Not only did they, it was agreed, have adverse effects on society but they also offended God and cut the offender off from his maker until he repented. In the first few centuries after the death of Jesus, early Christian thinkers virtually outlawed any form of sex other than that within marriage for the procreation of children. Some of the greatest Christian proponents of these ideas could hardly bear to accept that men and women had to have intercourse to keep the race going, so fervently anti-sex were they. Most of these moral rulings had little or nothing at all to do with the teachings of Jesus, but were an embellishment of basic Judaeo-Christian thinking by over-enthusiastic authorities such as St Jerome, St Augustine and, to a lesser extent, St Paul.

Jesus, perhaps surprisingly, said very little about sex (though he specifically condemned adultery and divorce) and was loving and forgiving to those who broke the moral codes of the day. The Church over the years since his death has reinterpreted much of what He said, often to suit its own ends. This has resulted in the Church having basically negative and prohibitive views on sex and sexuality, though views vary considerably from sect to sect within the Christian Church world-wide. Even among members of some Christian denominations (for example Catholics) there is a considerable breadth of interpretation among both clergy and laity.

This had led to a situation in which Western cultures usually discuss morality solely in relation to sex. A woman can be a wonderful mother, never steal, cheat or lie and be a good housekeeper, but if she is unfaithful to her husband, then she is immoral. On the other hand as long as she is faithful to her husband, she can be a slut, a spendthrift, a poor mother and never out of the courts, yet she will not be labelled ‘immoral’.

The earliest moral rules were aimed at providing four main things. First, they were aimed at maintaining and increasing the numbers of the nation. From this real need arose rules that forbade any form of sex that did not result in children (such as homosexuality, masturbation and, of course, contraception). By going against these rules the person not only did himself ‘harm’ but also damaged the group or the race.

The second aim of traditional sexual morality was to strengthen the family unit because the family was the main structural unit of society. Marriage developed as a way of giving the children resulting from sexual intercourse a secure base from which to grow up and this tended to have a stabilising influence on society generally. At this time, most women died in their thirties or forties, not long after their procreative function had ended (the menopause was earlier in pre-Christian times). This meant that women saw their sexual role as inextricably linked with childbearing from when they were sexually mature until they died. This led to the view that all forms of sex that did nothing to promote family and marriage were ‘wrong’. Sex outside marriage was therefore ‘wrong’ as were all types of sex (such as homosexuality) that took men away from their main duty in life-that of supporting women within a family.

The third area of traditional morality is not so practically or socially based but involves the philosophical concept of asceticism. The argument runs as follows: given that sex is so pleasant, is it not ‘better’ in moral terms to prove to yourself that you can do without it and that it does not rule you? The acceptance of this principle led quite understandably to the state of affairs we have already discussed in which sex was ideally to be avoided at all costs. The early Christians were particularly influenced by this line of thought because they had seen the sexual excesses of the Roman empire which, they argued, had led to its downfall. After such a libertarian system people all over Europe were ready for something more sober. As a result Judaeo-Christian asceticism over sex came at the right time and the seeds fell on fertile ground. People had seen the terrible problems of libertarianism and did not want to pay the price themselves. The emerging Christian Church, like any other clever political institution, saw the advantages of taking this line, latched on to it and promoted it.

The fourth aspect of Christian sexual morality has occurred more recently in Christian and Marxist writings. It is suggested that too great an emphasis on sex is bad in a purely practical way because it takes people’s eyes off the production of material things for the community (in the Marxist version) or God (in the religious version). So either way sex ‘gets in the way’ of the real business of living and is therefore to be avoided.

For hundreds of years these attitudes were so ingrained in society that they became accepted as essential for all human beings – a view which is patently nonsense. Other societies all over the world have developed very different sets of morals, all of which are perfectly acceptable to them, yet many of their ‘norms’ are quite unacceptable to societies based on Judaeo-Christian principles. Clearly, then, morality in sexual matters in any one society is not necessarily based on concepts of absolute ‘rights’ or ‘wrongs’. Sexual morality, like all morality, is based on practical considerations, the origins of which are often forgotten as the centuries pass. New codes of behaviour are constantly emerging and in a highly complex society such as ours in the West today there are many sub-groups whose concepts of sexual morality are developing at a different rate from those of others.

What then is happening today in the Western world? Quite simply, although we live in a notionally Christian society, few people adhere co Christian principles to any degree and as a result a secular collection of ‘morals’ has developed by common consent. This in itself would be fine but unfortunately things are not as clear-cut as one might think because, although most people do not follow Christian precepts, they have an uncomfortable feeling, deep down, that they should do, because our culture is inextricably tied up with individual religious affiliations. The problems arise when new or different concepts of morality, no longer based on the traditional ones, start to conflict with what we have been brought up to believe are unshakeable truths. If for all of your life you have been brought up to think of masturbation as immoral or sinful (for the historical reasons we have outlined), it is not going to be easy to unlearn this programming and suddenly to accept it as OK.

We live in a changing world in which many traditional morals are being questioned. This does not mean that the new morals are necessarily right, or that we are necessarily any happier because of this questioning, but it is undoubtedly happening and if producing all kinds of problems. The old objectives of traditional morality seem mainly irrelevant to many today, when population growth is, if anything, anti-social; when marriage is frequently a short-lived undertaking with a decreasing success rate; and when asceticism is a very unfashionable concept. Today’s moral principles seem to be based more on the increasing of pleasure for the majority and, perhaps even more important, on the right of each individual to express him- or herself in the best way he or she can. Because sex is an important form of self-expression it has become a very important part of this way of thinking.

These ideas have taken root and grown all the more quickly because we live in a world in which we no longer need so many children and in which we have effective contraception and abortion. These changes have freed us to have intercourse without worrying about what was, until very recently in human evolutionary terms, the inevitable outcome – children. Now that babies are no longer the inevitable outcome of intercourse, sex has taken on a new function which traditional moralists did not have to face. Add to this the fact that in today’s society women (perhaps with the help of the state) can support themselves and it becomes relatively unimportant for them, to marry men in order to be supported. This has led to concepts of more temporary support and even to a reversal of the roles with some women supporting their partners.

Only a tiny minority of even so-called ‘religious’ people today adhere strictly to traditional Judaeo-Christian morality in all its detail, and the law of the land certainly no longer upholds such morals as being essential for the maintenance of the fabric of society. Adultery, homosexuality and prostitution, for example, are not illegal, even in so-called Christian countries. What we see is a situation in which even religious people (a small minority of the whole population) adhere only to those parts of traditional morality that they choose. Clearly the average man and woman in the street are running their lives according to a set of moral codes that they have to some extent defined for themselves individually. Morality has thus become ‘privatised’ to a great extent. But even such a private system of morals is passed from generation to generation.

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Even a woman who really wants a baby may become anxious and depressed early in pregnancy. Most husbands today are willing to understand and help their wives during pregnancy but the majority do not do as well as they could because they are not sufficiently well informed about the real fears and anxieties of pregnant women. Virtually all men regard the pregnancy as very much their concern and nearly all want to learn how to help. Unfortunately, they are often excluded by health professionals and have only fairly recently been admitted to the labour ward, for example.

About one in ten expectant fathers produce symptoms during pregnancy for which no physical explanation is found. These include abdominal pain, nausea and vomiting, toothache, and so on. These problems are psychosomatic, though no less real, and are known as couvade. The symptoms occur most in the early months but recur at the end of pregnancy and end with delivery.

As the birth approaches most women seem to regress psychologically to a child-like state of dependence. Whether this is natural or a result of the way the culture and health professionals treat them is hard to say. If a woman is adequately prepared psychologically her understandable anxieties will be under control by now, which will help to reduce any pain or distress during labour. Obviously, expectations are important and here again both the culture to which she has been exposed since childhood and the professionals around her have an effect.

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A shot of ceftriaxone or a single dose of such oral medications as ofloxacin, cefixime, and ciprofloxacin will treat gonorrhea. Recently some gonorrheal resistance to ofloxacin has been reported in certain areas of the country. Other treatments are available if these are not well tolerated.

If more extensive infection—such as epididymitis, prostatitis, or PID—is suspected, then a longer course of antibiotics is necessary (see the sections on epididymitis and prostatitis and on pelvic inflammatory disease). For gonorrhea of the throat, either ceftriaxone or ciprofloxacin is usually given, since these antibiotics are more effective than the other choices. Talk with your health care provider about which treatment is best for you.

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Unfortunately, many women experimenting with their first sexual experiences in young adulthood are not adequately informed about STDs and how to keep safe. It is young people, and young women in particular, who suffer the brunt of the consequences of the STD epidemic. Young women are more vulnerable to becoming infected with bacterial STDs such as gonorrhea and chlamydia because of the anatomy of the cervix, which makes it more susceptible to infection in adolescence and the twenties than later in adulthood. Even though women may not be thinking about pregnancy at that point in their lives (in fact, they may be trying their best not to get pregnant), what about five or ten or twenty years later? The actions taken by a young woman now could affect her chances of getting pregnant later, when she wants to.

Many women are becoming sexually active at earlier ages but are delaying marriage and childbirth until later—a life choice that leaves them with more time for sexual activity, and more opportunity to acquire a sexually transmitted infection. Education can equip young people with the tools to protect their fertility for later in life, and getting regular STD screens will help to detect most infections early, while they are still treatable and reversible.

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1. When was your last sexual contact with a partner? With your steady partner? With a casual partner?

2. What kind of sexual contact have you had? Oral? Anal? Genital? (Knowing where on the body you have had sexual contact will help the health care provider know where to look for evidence of infection.)

3. How many sexual partners have you had in the last two months? In the last twelve months? In your lifetime?

4. For heterosexual persons: Do you use any type of birth control, such as a condom, diaphragm or cervical cap, or birth control pills? For all sexually active persons: What method do you use to prevent STD transmission, such as condoms, spermicides, or dental dams? Did you use this method during your last sexual contact?

5. Are your partners male, female, or both? (Certain health care providers may use terms that label people in terms of their sexual orientation, such as gay or homosexual for those who have sex with same-sex partners, straight or heterosexual for those who have sex with opposite-sex partners, or bisexual for those who have sex with both male and female partners. This approach may make some people less willing to answer this question. Certain health care providers make assumptions; in other words, they may assume that if you are male, you only have sex with females. You must make clear what type of sexual practice you have engaged in, so that your health care provider will have accurate information.)

6. Are you concerned that your partner may be having sex with other partners?

7. Are you having any symptoms in the genital area?

8. Have you had a history of a sexually transmitted infection in the past, and if so, when? Have you ever been tested for STDs?

9. Do you use injection drugs? Do you have a sexual partner who uses injection drugs?

10. Have you ever had a blood transfusion?

11. Do your partners (or partner) have a history of sexually transmitted infections? Are they having symptoms now?

You will also usually be asked about your understanding of sexually transmitted infections—what causes them, how they are transmitted, and so on—and be given a chance to have all your questions answered.

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