Toxoplasmosis. Toxoplasmosis is an infection caused by the parasite Toxoplasma gondii. Approximately 80 percent of all adults have been infected with T. gonda at some point in their lives, and most healthy people experience no symptoms or problems from this infection. However, in people with AIDS this infection can reactivate and cause problems in the central nervous system, such as encephalitis and pockets of infection in the brain. A blood test can tell whether or not someone has been infected and therefore whether he or she is at risk of the T. gondii infection reactivating as the HIV infection progresses.

Trimethoprim/sulfamethoxazole is the medication of choice; alternatives are pyrimethamine and dapsone.

Tuberculosis. Skin testing for tuberculosis will tell if a person has been exposed to the disease in the past. This is a particularly good idea for HIV patients, because a reactivation of the tuberculosis can occur as the immune system declines. If a skin test is positive, the medication isoniazid is recommended to kill the bacterium and prevent the disease from occurring.

Mycobacterium avium Complex Infection. When the T-helper-cell count falls below 50, about 30 percent of people with AIDS will develop infection with this organism. Symptoms include fever, night sweats, weight loss, and stomach pain. Three medications that have proven effective in treating this infection are clarithromycin, azithromycin, and rifabutin.

Fungal Infections. Fungal infections are very common among persons with AIDS, and they include cryptococcal meningitis and fungal infections of the esophagus and mouth. Fluconazole has been shown to prevent these infections; however, because it interacts with other medications that are commonly used to treat HIV infection, it is recommended that fluconazole be used only to treat active infections and not to prevent potential infection.

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The hepatitis C virus is the most common cause of what used to be called “non-A, non-B” hepatitis, a term formerly used to describe viral hepatitis that was not caused by hepatitis A or B. Hepatitis C is a major health concern in the United States and around the world, and it is the most common cause of chronic liver disease in the United States.

The hepatitis C virus has only recently been recognized as a cause of viral hepatitis, and a test to screen blood for it has been available only since 1990. Because it has been identified only recently, hepatitis C is not clearly understood in the way that hepatitis A and B are. Much research is currently under way, however, and new information is emerging rapidly.

Several types of hepatitis C virus have been recognized so far, each with a slightly different genetic makeup. A person may have infection with one or several types. Although the symptoms the viruses cause are similar, their response to treatment with medication (alpha-interferon) differs, and their degree of infectiousness may also differ. The most common types in the United States are hepatitis C types 1 (a and b), 2, and 3. Type 4 is more common in northern and central Africa and the Middle East, whereas type 5 is seen in South Africa and types 7, 8, and 9 in Vietnam.

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Chlamydia infection of the eye usually produces redness, itching, and pain in the lining of the eyelids, this infection is called conjunctivitis.

A man or woman who becomes infected with chlamydia in the anal area after receiving anal intercourse from someone who is infected may develop a mucous rectal discharge, rectal bleeding, diarrhea, and pain with bowel movement. Or there may be no symptoms.

Finally, the throat can also be a site of infection with chlamydia, usually in someone who performs oral sex on a man who is infected. Men who perform oral sex on women are usually not at high risk, since there is no direct contact with the cervix, which is the usual site of infection in women. Kissing is not a risk factor for chlamydia. Although throat irritation can occur with chlamydia throat infection, when someone has a chlamydia infection of the throat.

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Talking about sex can be very difficult, so many people—regardless of their gender, age, or sexual orientation—avoid the subject altogether. For example, a recent American Social Health Association survey of women attending college showed that although 81 percent, on entering into a sexual relationship, asked their partner how many partners he had had in the past, only slightly more than half asked if he had ever had a sexually transmitted infection or had ever had unprotected sex. Fewer than a third asked whether their partner had ever had a same-sex partner or had ever used intra- venous drugs. And these are the findings on how women behaved when they knew their partner. fairly well before entering into the sexual relationship. When women were entering into a new sexual relationship with a casual partner, even fewer of them asked these important questions. Finally, although about 85 percent of the women in this study were sexually active, fewer than half of them used any method to protect against sexually transmitted infections, and about a quarter had never had a pelvic examination.

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Lice. Pubic lice, also known as “crabs,” are tiny bugs that infect the pubic hair and sometimes the hair under the armpits and the eyelashes. They can but do not always cause itching. A person with lice may also notice tiny blood spots on their underwear, resulting from the openings in the skin where the lice have bitten.

Scabies. Scabies causes itchy bumps and small lines (which are the burrows of the mites that cause the infection) on the body in a characteristic pattern. Most often, these are seen in the genital area, around the beltline, in the armpits, and in the webs between the fingers. The itching is usually worse at night and after a shower.

Trichomoniasis. The itching resulting from a trichomonas infection can range from mild to severe. The discharge is usually thin and yellow-green in color. There may also be a strong, fishy odor.

Warts. Warts are usually small, hard, flesh-colored bumps that can occur anywhere in the genital or anal area. They may also be cauliflower-like in appearance. Although warts usually don’t produce any accompanying symptoms, about 20 percent of people with warts experience itching, which is usually mild.

Yeast. Yeast infections—usually caused by the fungus Candida albicans—can occur at any time of the year, but they occur more often in the warmer months. Often there is itching, which can range from mild to severe, as well as a thick, white, clumpy discharge. If the inflammation is severe or if a woman scratches in the genital area, there may be breaks in the skin as well. A woman who has recently taken an antibiotic is more likely to develop a yeast infection, since the antibiotics temporarily diminish the quantity of the normal vaginal bacteria and allow yeast to overgrow.

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Sexual law is a highly political issue. Some argue for more restrictive sexual laws and harsher enforcement. Others argue for more personal freedom. The sexual laws currently being debated across America include laws about:

• marriage and domestic partnerships

• divorce, child custody, and child support

• sexual health and safer sex

• sexuality education in the schools

• teenage pregnancy

• abortion and contraception

• civil rights for people who are gay, lesbian, bisexual, or trans-gender

• sexual assault

• sexual abuse of children

• sexual harassment

• pornography

• HIV/AIDS discrimination

Marriage and Domestic Partnerships

Each of our states has its own marriage laws. Each can decide who can marry, set the legal age for marriage, and state requirements for blood tests and marriage licenses. As of this writing, marriage can be legalized only between a man and a woman.

Bigamy

Bigamy—to have more than one spouse—is against the law in all states. There are two forms of bigamy. “Polygamy” or “Polygyny” means having more than one wife. “Polyandry” means having more than one husband. Polygamy is legal in some societies. Polyandry is no longer legal anywhere.

Domestic Partnerships

In the past, many states considered women and men who lived together for a significant period of time (different time requirements in different states) and who publicly described themselves as “husband and wife” to be common-law spouses. This gave them certain benefits held by other couples who had been married in an official way.

There are now more single people in our country than at any other time in history. Many never marry. Many divorce and do not remarry. Many singles live together in long-term, sexual relationships. This is called cohabitation. Increasing numbers of cities, states, corporations, and insurance carriers recognize these relationships and confer on couples some of the benefits otherwise available only to couples who are legally married. In some cases, same-sex couples also receive these benefits. These relationships, when recognized in this way, are sometimes called domestic partnerships.

Gay Marriage

In 1967, the U.S. Supreme Court overthrew all miscegenation laws in its decision Loving v. the Commonwealth of Virginia. The Supreme Court ruled that laws against marriage between persons of different races violated the right of equal protection. As we go to press, similar arguments are being used in the state of Hawaii, where legalized gay marriage is being debated. So many people are against gay marriage, however, that the U.S. Congress recently passed a new law, the Defense of Marriage Act, that allows states to disregard gay marriages recognized in other states. Some people think this law is a violation of the full faith and credit clause of the U.S. Constitution—which makes the official acts of one state valid in all states.

The Defense of Marriage Act also allows the government to withhold certain federal benefits from the spouses of gay marriages. These benefits include Social Security, veterans benefits, and federal pensions. President Bill Clinton signed this law in 1996.

Many states already ban same-sex marriage, and other states are considering similar laws.

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Men who report being sexually assaulted by women were pressured by guilt or threat of breakup. Some described being too drunk or incapacitated to be able to control the situation. Others report being threatened with physical violence, blackmail, or demotion.

Sexual assault against men by women is much less common than sexual assault against women. There are more than 9,000 cases of sexual assault by women against men reported each year, but sexual assault against men is often unreported. Men encounter disbelief when reporting a woman as a rapist. They may fear public and private humiliation. They may feel that they have failed to be masculine enough to defend themselves. Some fear they will be perceived as effeminate or homosexual.

The emotional effects of sexual assault for men are anger, fear, shame, guilt, and disruptions in sexual, social, and family relationships, as well as in sleeping and eating. Professional counseling can help relieve these effects. Rape-crisis centers assist men as well as women.

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Adolescence in American society is generally viewed as a period of change, friction, and problems. It is a period during which the individual is no longer a child and yet not quite an adult. The adolescent is encouraged to be independent and to be assertive, but with regard to sexual expression there are varying degrees of prohibition depending on gender and social status. More restrictive sexual standards are applied to women than to men, blacks are more sexually permissive than whites, and lower social class people are generally more permissive than other social groups. The sexual restrictions imposed by society on adolescents at a stage when the physiological need for sexual expression increases creates many conflicts. The period of conflicts is now longer than it ever has been, because there has been a prolongation of adolescence both biologically and socially. The mean age at menarche in the Western European populations declined from about age sixteen in 1870 to age fourteen by around 1930 and went down to about age thirteen years during the 1950s. The present mean age at menarche in the United States is about age twelve. Socially, there have been changes in the life cycle. The median age at marriage for United States women increased from 20.3 years in 1960 to 21.6 years in 1977, and the proportion of unmarried adolescent women has increased dramatically. In 1960, 60 percent of nineteen-year-old women were single compared to 74 percent in 1977 (Current Population Reports). Also, adolescents are exposed to sex to a much greater degree than ever before, both through the mass media and through personal experiences. Under these circumstances, the restrictive standards of society with respect to sexual behavior are likely to be violated. There seems to be a greater tolerance now of the violators of the sexual code than there was a few decades ago, but this tolerance is not usually extended to the young woman who becomes pregnant before marriage. The social, psychological, and economic consequences of an out-of-wedlock birth are grim for both the young mother and her child.

Most earlier studies on adolescent sexual behavior have dealt not with the consequences of sexual behavior but with different types of sexual outlets in the context of sexual standards, interpersonal relationships, attainment of orgasm, and marital happiness. For example, Kinsey studied the correlation between premarital patterns of various types of sexual behavior and subsequent sexual adjustments in marriage, based on the sexual histories of females of all ages; Reiss analyzed premarital sexual standards and premarital sexual permissiveness: Ehrmann examined premarital sexual behavior in terms of sex codes of conduct and the love relationship; Burgess and Wallin analyzed factors influencing engagement and marriage adjustments; Kirkendall studied premarital intercourse and interpersonal relationships based on experiences of 200 college-level males; and Locke dealt with premarital sexual intercourse and marital sexual adjustment among 525 divorced and 404 happily married persons.

We will examine adolescent sexual behavior from the viewpoint of the consequences of sexual behavior, for example, out-of-wedlock pregnancy. Our focus will be on premarital sexual behavior and more particularly on the social aspects of premarital intercourse (heterosexual coitus) among women fifteen to nineteen years of age. Our findings are based largely on data from two national surveys of women aged fifteen to nineteen. In the first study, conducted in the spring and early summer of 1971, interviews were obtained from a national probability sample of 4,611 adolescent women fifteen to nineteen years of age living in households and in college dormitories in the continental United States. The sampled population included young women of all marital statuses and races (Zelnik). A similar but independent study was carried out in the spring and summer of 1976, with a national probability sample of 2,193 adolescent women fifteen to nineteen years of age, who lived in households in the continental United States. Again, the sampled population covered women of all marital statuses and races (Zelnik).

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Affectional-sexual development, in comparison with other aspects of development, motor and language, for example, has been more often repressed than encouraged by most families in the United States and throughout most of the Western world. In the United States, sex is seldom treated as a strong and healthy force in the positive development of personality. Infant sexual behavior, in the eyes of many, is negative, perverse, and destructive. Some see infant sexual-affectional potential as related to excesses—addictions that control the individual and weaken reason. That infants have erotic capacity has been pointedly ignored or overlooked. After an asexual infancy and childhood, sex is supposed to burst out in full bloom at puberty or, better, later. Sexual innocence has been assumed to be normal and appropriate. Still earlier, infants were considered depraved if they masturbated, asked sex-related questions, or showed any sexual interest or curiosity. Ignorance was and is deemed best to keep dormant any precocious sexual feelings. It has been taken for granted that other aspects of physical and mental growth would proceed gradually from birth to full maturity, but knowledge about sexual capacity and interest has been either consciously or unconsciously suppressed even in the community of social and behavioral scientists. This is an enigma, for as early as the turn of the century, Bell, Freud, and Moll were reporting that in infants of suckling age, various parts of the body could give pleasurable sensation and romances did develop in childhood, and it was known that “unscrupulous nurses” had found that they could calm crying babies by stroking their genitals. Freud observed that sexual behavior of the infant and child not only was ignored but “the educators consider all sexual manifestations of the child as an ‘evil’ in the face of which little can be accomplished”. To find sexuality suppressed in the schools is perhaps understandable; to find it largely overlooked in the behavioral and social sciences is more difficult to understand and to accept.

What would be the outcome of a concerted effort to give infants the opportunity to develop fully their capacity for sensory and affectional response? We do not know because we have not wanted to know. Those who argue that the individual, to be fully human, must have the opportunity to develop all his or her capacities argue that this principle should apply to sexual capacity as well as to intellect and motor skills. Those who argue for discipline, self-control, and the curbing of harmful or socially disruptive human tendencies, argue that only the minimum of stimulation and no erotic experience should characterize the personal encounters of infants. Those who opt for restriction of erotic expression in infancy and childhood are in the majority in the United States at the present time.

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In micropenis, the penile corpora are underdeveloped. They may be so small that the penis looks like a clitoris. Unlike a clitoris, however, the micropenis has a median raphe, a covered urethra, a foreskin, and a glans in which the urethral meatus is normally placed. It may or may not be erectile, dependent upon the amount of corpora cavernosa and corpus spongiosum present. The scrotum is present and fused. The testes may be descended or either unilaterally or bilaterally cryptorchid. The etiology of micropenis is unknown.

In the two cases of micropenis compared here, the sex of assignment, rearing, and rehabilitation (surgical and hormonal, as required) was male and female respectively. In the male case, the boy differentiated a masculine gender identity/role, but not without difficulty. As a child, he did not join in rough-and-tumble play. He played more with girls than he did with boys. At the age of ten, he revealed to an interviewer that he had often thought about changing his sex. He already had made up his mind, however, that he would not bother with a change of sex unless he could be guaranteed to have children by his own pregnancies. Despite application in childhood of testosterone cream to his penis and, in adolescence, injections of androgen (given primarily to induce a masculinizing puberty since his testes were vestigial and defective) the micropenis remained excessively minute. Consequently, its use in both heterosexual and homosexual relationships was grossly impaired. Maintenance of intromission was, in fact, impossible.

At the present time, despite surgical and/or hormonal treatments for micropenis, there is no evidence that such treatments produce a fully functioning penis of adult size.

The other micropenis infant was surgically rehabilitated as a girl during the fourth month after birth. This consisted of bilateral gonadectomy and feminization of the external genitalia. At age twelve, feminizing puberty was exogenously induced by means of oral estrogen. Vaginoplasty was performed at age seventeen.

In childhood, this girl played with boys and girls. Although she did prefer outdoor activities, it was not to an intense or one-sided degree. With adolescence, she began to be interested in boys and had experiences with necking and petting at age thirteen, even though girls in her family were not officially permitted to date. At age eighteen and a half, she had intercourse for the first time with her steady boyfriend.

Three years later they married. Her gender identity/role is unquestionably female.

The fact that the testes of the infant assigned and reared male were defective and did not produce pubertal androgen, and that the testes of the infant assigned and reared female were removed before the age of six months, might eventually prove important in relationship to the differentiation of their erotic gender identity/role. In normal XY infants there is an increase in plasma testosterone from birth until the second or third month of life, followed by a gradual decrease. By the seventh month, the level of plasma testosterone diminishes and stays at the low, pre-pubertal level of boyhood. Perhaps the high postnatal level of plasma testosterone is needed to complete the job, initiated prenatally, of setting in the brain thresholds for the release of certain types of sexually dimorphic behavior later in life. This hypothesis is currently only speculative. In any event, the lesson of the matched pair of micropenis individuals teaches the same lesson taught by individuals matched for various diagnoses of hermaphroditism. It is that, in the differentiation of an individual’s gender identity/role, the determinants are prenatal as well as postnatal. It is possible for postnatal determinants to override prenatal ones, just as it is possible for prenatal determinants to intrude on postnatal ones. The various possible permutations and combinations still need to be clarified.

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