Dear Ann Landers,
y hus-band has been impotent for the past five years-which means no sex what-ever. Being a loyal and highly prin-cipled woman, I could not bring my-self to cheat on him. So I haven't had any sex either. Will you please educate your male readers who are in the same boat as my husband? A wife can live without sex, if her man can't perform, but she cannot live without affection. The very least a hus- band can do is hold his wife in his arms and tell her he loves her. I have never made one unkind re-mark to him about his inability to per-form. I know it must bother him terri-bly and I don't want to add to his unhappiness. But don't you think I am entitled to some consideration? It would take so little for him to make me feel wanted and loved. I have asked my husband to go to a doctor, but he refuses. He comes home THE ANN LANDERS ENCYCLOPEDIA 689 from work, eats dinner (reading a newspaper at the table) and proceeds to get drunk. This goes on seven nights a week. I need some help. WITHER-ING ON THE VINE

DEAR W.,
You sure do, honey. Why did it take you five years to write? My advice is talk to a counselor and learn the relationship between male impotence and alcoholism. There's a definite link. Next join Al-Anon and get a new outlook on YOUR life. Al- Anon is as near as your phone book. Many impotent husbands make their wives feel wanted and loved. Yours could, too, if he didn't get bombed every night. That's the problem. Surgical Treatment of Impotence No one knows how many men are afflicted with the problem of impotence- the inability to have an erection and to complete the sex act. Estimates by health care experts run into the millions. There are many causes for this problem, both physical and psychological, and there is no one treatment method appropriate for all cases. A surgical procedure, however, offers new hope to many of these impotent patients-particularly those whose impotence is caused by a medical condi-tion. The procedure calls for implanting a prosthesis, or artificial device, to produce an erection in the penis. The device is called the inflatable penile prosthesis. It operates like a miniature hydraulic system and is totally implanted within the body to remain there permanently. To date, more than one thousand impotent men have received the device. I implanted the first such device in Feburary 1973, in Houston, Texas. The device had its beginnings several years ago, when a collaborative study was initiated by myself, a neurologist at the University of Minnesota and a bio-medical engineer affiliated with the American Medical Systems, Inc. This study concerned the development of an implantable artificial sphincter (ring of muscles) to help people who could not control urination. From the beginning, our attempts were to simulate the natural process of erection. This process depends upon the expansion of two cylindrical bodies of spongy tissue in the penis, enclosed within a thin and strong elastic tissue. 690 THE ANN LANDERS ENCYCLOPEDIA In the normal male, sexual excitement causes the spongy tissue to fill with blood until the surrounding elastic tissue becomes tense. The penis is then hard and erect. In the impotent male, the flow of blood to the erectile bodies within the penis is impaired. The process of erection by the inflatable penile prosthesis also depends upon two cylindrical bodies, but constructed of elastic silicone rubber (a medical-grade silicone rubber similar to that used for breast augmentation, facial reconstruction, heart valve replacement, etc.). These silicone rubber cylindrical bodies are surgically implanted so they lie within the erectile bod-ies. Since these silicone cylinders lengthen as well as expand when filled with fluid, they fill the same space that would be occupied by blood in a natural erection. Since inflation of the cylinders causes the elastic covering around the spongy tissue to become tense (as with a natural erection), the penis becomes hard and rigid. The size of the penis and the degree of hardness when erect is quite comparable to that of a natural erection. The pump for a natural erection is, of course, the heart, which provides the force to pump blood into the penis. The pump for the prosthesis is constructed of silicone rubber and is implanted inside the scrotum (the sac containing the testicles). This small bulb-shaped pump is connected to the penile cylinders by silicone rubber tubing, and hangs loosely inside the scrotum in a manner similar to the testicles. It is invisible but can be felt with the hand. The act of squeezing the pump with the fingers through the skin of the scrotum forces fluid into the silicone rubber cylinders. Repeated squeezing makes the penis harder, until sufficient for natural sexual inter-course. The reservoir for the blood of a natural erection is the body's circulatory system. The reservoir for the erectile prosthesis is constructed of silicone rubber and is filled with a fluid that is compatible with the body's tissue fluid. This fluid can be made radiopaque so it will show up on an X ray. This reser-voir (also connected to the pump by silicone rubber tubing) is implanted underneath the muscles of the abdomen, where it is invisible, the patient is unaware of its presence and it lies in a protected position. After intercourse, the fluid inside the penis is released, and moves from the penis back into the reservoir until the penis becomes soft or flaccid again. To release this fluid, a release valve located in the same pump inside the scrotum is opened by pressure over a button-like spot on the pump. Steady pressure in this area for a few seconds causes the penis to go limp. The surgical procedure is a meticulous technique, but is well tolerated by the patient since there is little loss of blood, no incisions into major organs THE ANN LANDERS ENCYCLOPEDIA 691 and minimal tissue disturbance. Usually through a single incision about one inch long, the cylinders are inserted into the penis, the pump is inserted into the scrotum and the reservoir is implanted beneath the abdominal muscles. These components are connected and put in place using special surgical in-struments and techniques. The sizes of the components selected are deter-mined at the time of the procedure and will differ according to the build of the patient The duration of the operation will vary, ranging from less than one hour to as many as three. Since the operation does not require dangerous deep stages of anesthesia, the surgeon need not feel rushed. Implantation of the device allows the patient to achieve an erection; it does not produce orgasm or climax. If the patient could have a climax even with a soft penis before, then he can also expect this after surgery. Some patients who were unable to reach a climax can do so after surgery, because they can now have natural sexual intercourse. In evaluating patients for this procedure, the physician must first determine whether or not the patient is indeed impotent, and if so, what is the reason. Usually a team of physicians works together to evaluate each patient Some patients require more extensive evaluation than others. The patient must be able to withstand the stress of surgery and anesthesia. He must be emo-tionally stable, and he must have realistic expectations as to the purpose of the surgery. (For example, the prosthesis is not implanted unless the patient has, or expects to have, a sexual partner.) Goals are to help the patient lead a normal sex life, which may or may not require this surgical treatment The cause of impotency varies and is determined whenever possible so that the treatment is appropriate. The majority of patients do not require surgical testing and laboratory studies. Normal diagnostic evaluation of the patient includes a routine medical and sexual history, a physical examination, psychiatric interviewing, psychological testing and laboratory studies. To properly determine treatment, the physician needs to know whether the impotence is physical or psychological. In a case of severe psychogenic impo-tence, the patient would be referred for therapy before the implant would be considered. The monitoring of nighttime erections-called "nocturnal penile tumescence"-has contributed significantly to making a valid diagnosis. This diagnostic technique involves the use of a special machine that records erec-tile activity while the patient is sleeping, on a recording similar to an elec-trocardiogram tracing. Patients selected for the procedure at our medical center have included those whose impotence is related to diabetes, trauma (such as pelvic fracture), cancer surgery, neurological disease, ar-teriosclerosis, Peyronie's disease and psychological factors. 692 THE ANN LANDERS ENCYCLOPEDIA More than 250 patients have received the device at our medical center. Of these, over 230 or over 90 percent are now functioning successfully. The re-mainder have had the device removed for various reasons, some unrelated to the device. A decreasingly small percentage of patients require minor revision surgery following the original implant. Time required for the procedure is usually seven to ten days in the hospital for work-up, surgery and recovery. Sexual intercourse is not advised until at least three weeks after surgery. It should be noted that temporary failures are possible; however, they can be corrected. (1) Sometimes the prosthesis is rejected if the man has an in-fection at the time of the surgery. However, when the infection clears, the de-vice can be reimplanted. (2) Sometimes an occasional leak is discovered. Minor surgery can replace the part that is malfunctioning, or the entire prosthesis can be replaced if necessary. Some cases of "failure" are due to poor candidate selection (1) when the husband or wife cannot get used to the device for some psychological reason and therefore it isn't used, or (2) in a case where a man has psychogenic im-potence to begin with, the device will not necessarily help the psychological problem. In these cases, the men are referred for therapy and are not good candidates for the surgery. (They should not have been selected in the first place.) Also, if a man has a severe congenital malformation or has had previous penile operations, he may not be a good candidate for the surgery since the device may not be insertable. However, in most cases this can be rectified. The only cases where the device cannot be implanted would be where there is gangrene of the penis, or an extremely severe deformity. In summary, the device can malfunction temporarily as with a leak, or it can be rejected in case of an infection, but these problems can be corrected. If there is a psychological problem, the device should not be implanted and the patient should be referred for therapy. If the man discovers that he is able to have a normal erection following surgery, the device can be removed if the man so wishes, but there is no reason for this. In a few rare instances the device may interfere with a normal erection. In a small percentage of cases, the device would make no difference whatsoever in the man's normal erection. (It could be in a case of psychogenic impotence, the man discovers that actually having an erection [even mechanically] helps solve his original impotence, in which case the device may be removed. This has never happened so far, however.) Since this procedure is relatively new, not all physicians are aware of it. However, information is readily available to a physician who is interested in THE ANN LANDERS ENCYCLOPEDIA 693 learning about it. He should contact a urologist in his area or write to the au-thor of this article, who will put the inquirer in touch with implanting physi-cians at any of the more than one hundred medical centers throughout the country where the implants have been performed. Although the prosthesis implant operation is being done at over one hun-dred medical centers, I am listing twenty of the best-known. If you are inter-ested and do not live in the vicinity of any of these hospitals, you may write to American Medical Systems, Inc., attention: Graeme Thickens, 3312 Gorham Avenue, Minneapolis, Minnesota 55426, and he will inform you of the hospital nearest you. St. Luke's Episcopal Hospital (Texas Medical Center) Houston, Texas 77030 Mayo Clinic, St. Mary's Hospital Rochester, Minnesota 55901 Pennsylvania Hospital Philadelphia, Pennsylvania 19107 Stanford University Hospital Palo Alto, California 94304 St. Louis University Hospital St Louis, Missouri 63104 Loyola University Medical Center Chicago, Illinois 60153 Walter Reed Army Medical Center Washington, D.C. 20012 Lackland Air Force Base, San Antonio, Texas 78236 University of Colorado Medical Center Denver, Colorado 80262 Latter Day Saints'Hospital Salt Lake City, Utah 84102 Cleveland Clinic Cleveland, Ohio 44106 Boston University Medical Center Boston, Massachusetts 02118 White Memorial Medical Center Los Angeles, California 90033 University of Iowa Hospital Iowa City, Iowa 52242 Northwestern Memorial Hospital Chicago, Illinois 60611 694 THE ANN LANDERS ENCYCLOPEDIA Morristown Memorial Hospital Morristown, New Jersey 07960 Lucerne General Hospital Orlando, Florida 32801 Baylor University Medical Center Dallas, Texas 75246 New York University Medical Center New York, New York 10016 El Cajon Valley Hospital El Cajon, California 92021 Address inquiries to the Urology Department in each of the above hospi-tals. ANN LANDERS' APPRAISAL I have checked out this device with several leading urologists in addition to the authorities at Loyola University Medical Center and Northwestern Me-morial Hospital in Chicago and their consensus is: This prosthesis works but it may be too expensive for the average person. It also requires a training period that many doctors find too time-consuming. Other devices less com-plicated and less costly are now being developed. Interested parties should check with their own urologists for further investigation and write to Dr. F. Brantley Scott credit: F. Brantley Scott, M.D., Professor of Urology, Baylor College of Medi-cine, Houston, Texas. Incest Illicit Sex in the Immediate Family Incest is defined as sexual intercourse between people related so closely that they may not legally marry. This definition, simple as it seems, is so loaded with loopholes that anthropologists and sociologists, lawyers, theologians and philosophers have puzzled over the issue for thousands of years. THE ANN LANDERS ENCYCLOPEDIA 695 To begin with, dose kinship is defined differently by various sodeties, so that people who might legally marry in one culture may not do so in another. Sexual intercourse, too, is defined differently by different cultures; simple vaginal penetration is only one of a vast variety of sexual activities that might be considered incestuous if done with the wrong relative. Even in our modem United States, where the legal structure is fairly con-sistent concerning most matters, the laws defining and punishing incest vary from state to state. Some states, for example, permit first cousins to marry; others do not. The penalties for incest range from a $500 fine and/or twelve months in prison in Virginia to a prison term of one to fifty years in Califor-nia. In general, modem societies prohibit sex between blood-related people: between a person and his/her brothers, sisters, parents, grandparents, uncles, aunts and cousins. THE INCEST TABOO The mere mention of sexual feelings within the family or any hint of sexual activity between close blood relatives is sure to bring out feelings of fascina-tion, anxiety, fear, anger or avoidance. This is particularly true when the sexual partners are parent and child. Throughout the centuries, incest has served as a major theme for mythol-ogy, religion, law, literature and psychology. Its prohibition has been called "the universal taboo," and for good reason: with very few exceptions, every human society, past and present, primitive and modem, has banned incest in one form or another. Among those few societies that have permitted incest, most have permitted it only in special rituals or between certain privileged or holy members of the society. Generally speaking, incest has never been socially acceptable. How and why did this powerful taboo originate? This question has been debated for many years by biological and social scientists, and still no one has come up with an answer that will satisfy everyone. One theory is that successive inbreeding leads to genetic weakness, so incest must be forbidden for the health of the species. Another theory is that exogamy (marriage out-side the kinship group) is beneficial to the nuclear family, the extended clan and society in general. The first theory doesn't hold together, because we know that primitive peo-ple were ignorant of biogenetics and in fact weren't even aware of the con-nection between intercourse and pregnancy. The second theory makes more sense, since it is reasonable to assume primordial human families were sure to learn that extended sexual relations within the family-except between 696 THE ANN LANDERS ENCYCLOPEDIA husband and wife, and especially between parent and child-blurred the familial roles and led to jealousy and family disintegration. Primitive families were also bound to discover that marital contracts between families helped replace rivalry with co-operation and enhanced the ability of kinship groups to survive. For example, when Margaret Mead asked men of the Arapesh, a New Guinea tribe, why they didn't marry their sisters, they responded, "What is the matter with you anyway? Don't you want a brother-in-law? Don't you realize that if you marry another man's sister and another man marries your sister, you will have at least two brothers-in-law, while if you marry your own sister you will have none? With whom will you hunt? With whom will you garden? Whom will you go to visit?" Thus many social scientists have con-cluded that human society began and flourished as a result of the incest taboo. One other thing we can say about the incest taboo is that it has never completely prevented incest from happening. If the incest taboo is "the universal taboo," then incest itself is "the universal crime." Incestuous be-havior has cropped up in virtually every society ever studied. Nor is it the rare phenomenon it was once believed to be. Until recently, the incidence of reported incest in the United States and other modem nations was believed to be one or two in a million inhabitants. In Santa Clara County, California, in 1971 about thirty cases of incest were referred to the Child Sexual Abuse Treatment Program, which serves a population of just over a million. This year we have been contacted by more than five hundred families troubled by incest. Even this figure is but the tip of the iceberg. Sexual tension in various degrees exists in all families. This tension is of course more serious when it is acted out, but many children develop sexual problems from seductive parents who send subtle sexual messages and even from parents who deny them affection because they are afraid of arousing sexual feelings. FATHER-DAUGHTER INCEST IN AMERICA Perhaps the most common form of incest is sexual experimentation be-tween young members of a family. But the most damaging and certainly the most frequently reported form of incest in America today is that between fa-thers and daughters. It is a myth that incest occurs only in lower-class families or that the daughter is a Lolita, the mother is a doormat and the fa-ther is a tyrant. The problem can and does exist at every social and economic level of society, among all races. Many men who have incestuous relationships with their daughters do not THE ANN LANDERS ENCYCLOPEDIA 697 drink, have never been in trouble with the law ("not even a parking ticket" as one father put it to me during a therapy session). He was in the $40,000-a-year income bracket. The average child-victim of father-daughter incest is about ten years old when the affair begins, and the sexual activity involved can include anything from fondling and exposure to oral sex to full intercourse, usually at puberty. Occurring, as this often does, just as the girl is beginning to develop sexu-ally, it can be an intensely bewildering experience. She receives from her fa-ther attention that should suggest pleasure, closeness, approval, warmth and security but instead translates into guilt, anxiety and anger when she dis-covers that she is being used. At a time when she needs the warmth and guid-ance a father can give her, the father instead uses his position of authority to force her into sexual acts far too mature for her years or her understanding. The familial roles become terribly confused. Her father is both parent and lover. Her mother also becomes "the other woman." What leads to this tragic breakdown in the family structure? As Tolstoy said, "Every unhappy family is unhappy in its own way." But experience with hundreds of incestuous families leads me to believe there are few recurrent themes. Often the father is going through a period of intense boredom and low self-esteem. He is unhappy in his marriage, disappointed with his career and discouraged about his future. In the midst of all this despair, the one bright spot in his life is his daughter. Usually his first approaches to her are tender, but slowly they become sexual. His guilt is soon sensed by his daugh-ter and she finds his attentions intolerable. The effects of father-daughter incest are nearly catastrophic. If the situa-tion is detected and reported and the case handled along traditional punitive lines by the criminal justice system, the whole family can expect to suffer even more. The girl is often removed from her home and placed in a juvenile shelter. The father is more often than not placed in jail to await trial. The mother is stuck with the problem of raising enough money to cover legal costs and maintain the family. The family often ends up separated, humili-ated and bankrupt and the child is forced to endure the ordeal of the courts. Even when the incestuous situation goes undetected and unreported the danger of harmful effects is high. Denied her right to a normal social and sex-ual development, the girl is in danger of psychological aftereffects. A number of studies have shown a high percentage of former incest victims among women and girls with such problems as truancy, promiscuity, prostitution, drug abuse, sexual dysfunction and poor marriages. 698 THE ANN LANDERS ENCYCLOPEDIA CHILD SEXUAL ABUSE TREATMENT PROGRAM In midyear of 1971 I was invited by the Juvenile Probation Department to provide family counseling to the increasing number of families being referred to the department for father-daughter incest. There was grave concern re-garding the inadequate treatment these cases were receiving. I felt strongly that family therapy was needed. At the time we had no idea full-fledged pro-grams would develop, or that in the next six years the current referral rate of thirty cases per year would jump to over five hundred per year. I started with the idea that the principles and methods of humanistic psychology would be used in the treatment of these families, similar to the approach I had been using with other relatively "normal" families I had been treating. What are the basic premises of this humanistic approach? First, we start with the simple assumption that a person's strongest drive is to feel good. To feel good our needs must be met These needs include the biological needs of food, clothing and shelter; they also include a need to belong, to be re-spected, to connect, to care and be cared for by other people. If our needs are not met, we feel bad, and if we feel bad we must find a way of discharg-ing that agony, through hostile acts toward ourselves or toward others. Peo-ple with unmet needs become social problems, and a society that doesn't pro-vide for the needs of all its people will in time be overwhelmed with casualties. Many have pointed with alarm at the high cost of violence in our country, but little has been said about the subtler products of alienation: sui-cide and alcoholism, ulcers and heart failure. Another key premise of the humanistic viewpoint is that people are what they are. We persist in our ways until we are taught better ones. Insults do not motivate us to change for the better. The father-offender already knows he has betrayed his daughter, wife and family. One of our tasks is to teach him to develop self-worth and how to meet his needs in a productive rather than a damaging and self-destructive way. It was with these lofty notions that I began the Child Sexual Abuse Treat-ment Program. My humanistic convictions were quickly put to the test by my first case. Before our first appointment I read the police report: fondling at age five, oral copulation and sodomy at eight, full vaginal penetration at thir-teen. I was overwhelmed with a picture of pain on the young girl's face and my first feelings toward the father were violent outrage. I was surprised by this reaction and felt like dropping the whole thing. But it didn't take long to realize that there must be repressed incestuous feelings in myself that needed attending to. THE ANN LANDERS ENCYCLOPEDIA 699 I spent a week in deep self-exploration of sexual feelings I might have felt and repressed toward my mother, sisters and daughters. Although I knew I had just begun this investigation I was able to calm down enough so that I could face the offender. This turned out to be far less difficult than I had thought For one thing, the man's raw feelings of despair, confusion and help-lessness needed to be examined. What's more, my own hang-ups were tem-porarily set aside. My sessions with the girl and her mother were far easier because the mother's primary interest was for her daughter. I'm convinced that to be an effective child advocate you must be a family advocate. If you are really concerned with the child's well-being, you will do your best to get the family together. We begin by concentrating on the mother-daughter relationship. With few exceptions most child victims wish to return to their mothers, who in turn want them back. This may not be apparent at first because the child often feels she has betrayed her mother and family and suffers from shame and guilt just as she feels anger for having been betrayed. The mother too usually feels let down by her daughter, not to mention her husband. So the child and mother normally have to be treated separately before they can be treated together. The aim here is to convince the child that she was indeed a vic-tim-a victim of inept parenting and of a poor marital relationship. She must hear this not only from the counselor but more importantly from the mother before she will be ready to return home. The mother too must tell her that her father has assumed full responsibility for the sexual activity. While we are working with the mother and daughter we also work with the father, who comes to us as soon he is free on bail or on his own recog-nizance. We continue to treat the father even after he is given a jail sentence, by special arrangement with the county jail. In addition to individual therapy, the family members usually receive mother-daughter, marriage and eventu-ally family counseling. There are also two self-help groups-Parents United and Daughters United-which meet weekly for group therapy sessions and to assist one another through family and personal crisis. In addition to individual and group counseling, the CSATP and Parents United provide practical assistance in the form of advice on financial and legal problems, help in finding housing and jobs, etc. But most important, the CSATP offers troubled families a supportive, caring environment where they can find hope and assistance during this the crisis in their histories and where family members can learn to lead more self-satisfying lives. The CSATP can point to a number of successes during its first six years. No offenses have been repeated among the more than six hundred families that have been treated and formally terminated (the over-all repeat rate is 700 THE ANN LANDERS ENCYCLOPEDIA less than 1 percent). About 95 percent of the girls have been returned to their homes. About 90 percent of the marriages have been saved, many cou-ples reporting they have never been happier. The self-abusive behavior of the victimized children (promiscuity, drug abuse, etc.) has been reduced dramat-ically. The criminal justice system seems to recognize the value of our pro-gram, as evidenced by the increasing number of referrals each year and by the suspended or lighter sentences given to offenders who have agreed to par-ticipate. Parents United has grown from 3 mother-members to over 125 members, of which half are father-offenders. Daughters United has also grown substantially. The most satisfying result to me and the staff of the CSATP is that the child is returned to a family which can now provide a healthy, nurturing environment for her. Finally, I am gratified to see that the idea of a caring way of treating families troubled by incest is transferable to other communities. In early 1977 the Child Sex Abuse Therapy Program was established as a treatment and training center for the state of California. Our training program, like the treatment program, is guided by the principle and methods of humanistic psychology. At this writing, six months after the training project began, about ten communities are in various stages of developing their own therapy programs. It is our hope that the practical, per-sonal and compassionate help offered to families in trouble will be made available in all American communities. IF INCEST HAPPENS . . . One last word for children who are being molested or who are suffering from the effects of past molestation. If you are a victim, please confide in your mother or someone you can trust Anyone suspecting a child molest sit-uation should contact the Child Protective Services Agency, or the police in his/her community. Also, most states have child abuse hotlines which can offer immediate help. A good general source for information and assistance is the National Center on Child Abuse and Neglect, Washington, D.C. Phone: (202) 755-0590. Above all, the worst thing anyone can do is ignore or try to cover up father-daughter incest. If you are a mother who is afraid of the consequences to your husband, child and family if you report the problem, make an anonymous phone call to your Child Protective Services Agency. The person answering your call will explain what is apt to happen to your family if you place your problem in the hands of the agency. Ifre chances are that your husband will be treated far less harshly by the authorities if he turns himself THE ANN LANDERS ENCYCLOPEDIA 701 in than if they hear about the situation from other sources. But most impor-tantly the situation will stop once and for all and both your child and your husband will receive help. credit: Henry Giarretto, Ph.D., Director of Treatment and Training Center Child Abuse Treatment Program, Juvenile Probation Department, Santa Clara County, California. The word "indigestion" is a term rarely used by physicians; the synonym "dyspepsia" is used instead. However, dyspepsia, which comes from the Greek (dys+peptein, to digest), means a disturbance of the function of digestion. It should be emphasized that what patients call indigestion and physicians dyspepsia usually has no relationship to the inability to digest food. INDIGESTION AS "GAS" When a patient says he has indigestion one must ask what his specific symptoms are. What does this person mean by indigestion? One of the most frequent replies is, "I have gas." This is a poor answer since the hollow por-tions of the gastrointestinal tract-the stomach, small bowel and large bowel or colon-invariably contain gas. The normal person is quite unaware of its presence. People may become aware of "gas" normally present due to its marked increase in quantity. One might then describe this as bloating, or an apparent enlargement or bulging of the abdomen. Another reference to "gas" may be defined as expulsion of gas either by belching (eructation) or by passing of flatus via the lower opening of the in-testinal tract. Either way, it is never a sign of any organic disease. It may be a bad habit and is most commonly seen in nervous people or during a period of anxiety. A single eructation may expel a small quantity of gas from the stom-ach. This is normal after drinking carbonated beverages. However, the repeated "belching" or "eructations" do not expel gas from the stomach-on 702 THE ANN LANDERS ENCYCLOPEDIA the contrary, they are accompanied by swallowing of air without relief, and increase bloating. This act of swallowing air is called aerophagia and is seen in nervous people, or people who actively swallow more air as they belch. It is a bad habit and should be treated as such. People who eat rapidly fre-quently swallow more air than food. Therefore, a change in eating habits is necessary to rectify this situation. A small amount of flatus is natural, but socially unacceptable. The flatus of air swallowers does not have an especially offensive odor. If the flatus has a very offensive odor and is accompanied by frequent, foamy, watery stools (true indigestion), malabsorption may be present. Such individuals may be unable to digest and absorb a variety of substances including carbohydrates, proteins and fats. The intestinal bacteria break down the unabsorbed food into foul-smelling by-products. In this condition weight loss is the rule despite a good appetite. This is called steatorrhea, which means diarrhea with un-digested fat in stools. The proper treatment can be instituted only if the exact cause is determined. ACID INDIGESTION This term has been popularized by TV commercials. The patient may also say, "I have acid" or "too much acid." Hydrochloric acid is a normal secre-tion of the stomach. The normal individual does not feel that he has add in his stomach because acid itself produces no symptoms. On the contrary, com-plete absence of acid secretion by the stomach is abnormal. Normally the capadty of the stomach to secrete acid is reduced with advancing age. "Heart-burn," a burning sensation under the breastbone, may be due to the abnor-mal location of hydrochloric add in the esophagus. This is produced by reflux of add into the esophagus, also referred to as reflux or peptic esophagitis. This is due to weakness of the muscle which separates the stomach from the esophagus. This condition may be accompanied by a hiatus hernia, or diaphragmatic hernia. If the burning sensation is below the dia-phragm it may be due to a gastric or duodenal ulcer. All of the above- described in this paragraph are reduced or relieved by antacids. These are simple drugs that neutralize hydrochloric acid. THE NERVOUS STOMACH If this burning or other discomfort in the upper abdomen (pit of the stom-ach) is not readily relieved by antacids and is brought on by nervous tension or anxiety, there may be no organic cause for it The stomach and esophagus THE ANN LANDERS ENCYCLOPEDIA 703 are quite normal in such situations. It may be brought on by spasm of the stomach muscle at the outlet of the stomach (pylorus). This is not serious or detrimental to health, but may be quite annoying. SPASTIC COLON Abdominal discomfort in the lower abdomen is usually due to disturbances of the large bowel or colon. Indeed too much "gas" in the colon may be the cause of discomfort and relieved by passage of gas. The air swallowing de-scribed above may cause the accumulation of this excessive gas in the colon: A person with an irritable or spastic bowel becomes aware of normal amounts of gas because the muscles of the colon contract excessively, and unnecessarily, because of the nervous impulses brought on by tension. These individuals may be constipated or have frequent stools. This condition is not serious and does not lead to any serious organic disease. It is not caused by specific food; "it's not what they eat but what they meet." It is no longer thought that dietary restrictions will cure these people. If constipation is the chief problem, a low-fiber diet is considered harmful but high-fiber (residue) diets, including bran, should be helpful. LACTASE DEFICIENCY Lactose or milk sugar has to be split into two primary sugars by the en-zyme lactase before it can be absorbed. Most Orientals and many black adults, as well as many Jews, but only about 1 percent of Scandinavians, have deficiency of this enzyme. When people with this deficiency drink milk or eat milk products, such as ice cream, they develop bloating, abdominal discomfort, passage of flatus, as well as diarrhea. This is a true form of indi-gestion of milk sugar and the treatment consists of avoiding foods that con-tain a large amount of milk sugar or lactose. After such restriction of diet the condition may improve, and the person may gain the ability to digest these foods in small amounts. credit: Mitchell A. Spellberg, M.D., M.S., F.A.C.P., F.A.C.G., Clinical Profes-sor of Medicine, the Pritzker School of Medicine, University of Chicago; Acting Chairman, Department of Gastroenterology, Michael Reese Hospital, Chicago, Il-linois. 704 THE ANN LANDERS ENCYCLOPEDIA Infatuation Emotional involvement-that almost crazed and confused experience of ab-sorption in another person's life, feelings and whereabouts-has been experi-enced by everybody. Not many of us like to talk about it because even its rec-ollection causes us to smart with pain. We are generally glad we finally came out on the other end of it-and we promise ourselves that we will never let ourselves get involved that way again. And yet emotional involvement of this anguished sort is a necessary expe-rience in our journey of development. It is a hazard at the stage of learning something of the world, a problem that goes along with the wonder of dis-covering friendships, an almost inevitable component of first love. It seems powerful enough to destroy us and yet most of us survive and if we have been open to the experience we have grown a little and we know a lot more about ourselves. Such involvement should not be regretted. We won't recog-nize real love unless we experience the pain of discovering that we mistook something else for it at another time. We start out filled with our own needs. The business of day-to-day living bums away the fatty tissue of self-concem and, as we mature, we begin to make room for other people and their needs. In other words, we break out of ourselves and respond to others for their sake rather than for our own gratification. That chink in the armor of our narcissism allows love to find a place in our hearts. We turn outward, in necessary vulnerability, toward others. Infatuation, like a bad detour, occurs at the earliest stage of that journey. It is the experience we have before we have grown beyond concern for or un-derstanding of our own needs. The pain of infatuation can, in fact, help to free us from these needs. Infatuation in itself is the product of these needs. It is an exciting and sometimes dizzying state, but it is not based so much on our accurate perception of and response to others as it is on a view of them that is notably distorted and distended by our emotional hunger. There is no getting outside of ourselves without these stirrings and all the THE ANN LANDERS ENCYCLOPEDIA 705 bittersweet disharmony of the soul which they generate. But the passage can be made safely because basically healthy people do survive infatuation. They learn from it, and go on to real love. credit: Eugene C. Kennedy, Ph.D., Professor of Psychology, Loyola University, Chicago; author of Living with Everyday Problems and A Time for Being Human (published by Thomas More Association Books, Chicago). About 85 percent of the couples who want children manage to get pregnant within the first eight months of trying. Approximately 15 percent of the couples who want children have some sort of problem. Sixty percent of the time the inability to conceive lies with the female. The other 40 percent of the time, it's the male. Seventy percent of the couples who have trouble eventually manage to conceive. The other 30 percent need special evaluation and help. About half of the group will even-tually succeed. If the couple is thirty years of age or younger, and a wanted pregnancy has not occurred within twelve months of trying, medical help should be sought If a couple is over thirty, help should be sought after six months. (Time be-comes more valuable.) Absolute infertility must be accepted as an irreversible fact, if the testicles of the male or the ovaries of the female were removed surgically or were not properly developed because of an inherited condition or an illness. Relative infertility can be present in one or both of the partners. Some of these problems can be corrected easily, others require more patience. The most common problems are a lowered sperm count, pituitary or ovar-ian disease resulting in infrequency or lack of menstrual periods, a blockage of the Fallopian tubes or an incompatibility between sperm and cervical se-cretions. When both partners have been checked out and declared "fertile" and no The Inability to Have Children 706 THE ANN LANDERS ENCYCLOPEDIA pregnancy occurs, it must be suspected that there may be psychological problems-usually anxiety, overeagemess or a mental block of some sort. Such couples need counseling. In some cases, adoption is recommended. THE EMOTIONAL ASPECTS OF INFERTILITY IN THE FEMALE A rather wide scope of personality profiles can describe the woman who has trouble becoming pregnant. There is no one special type. Some are extremely shy, sexually inhibited, high-strung, immature, unable to cope with daily stresses or angry with themselves or the world. Others have been described as not really wanting a family, in spite of well- circulated claims to the contrary and repeated insistence that they would "give anything" to have a child. Some of these women have unresolved conflicts with their mothers or deep-seated conflicts about accepting the re-sponsibilities of motherhood. Others may be afraid of pregnancy or labor. On the other hand, many are quite normal emotionally. It is sometimes difficult to separate the emotional factors from the physical when conception does not occur. For example: A woman who is in a state of anxiety may have muscle spasms of the tubes which cause temporary obstruc-tion. If the sexual interaction is poor, or the woman is frustrated by a partner who experiences frequent premature ejaculation, organic obstacles may be set up. Depressions can influence the hormonal output and interfere with fertili-zation. Since the state of infertility can produce anxiety, frustration and depression, a vicious cycle may develop. Therefore, some women need coun-seling in order to help them conceive. A major danger signal is the tendency to reach for pills or alcohol in an attempt to relieve depression. Extreme anger or envy of women who are pregnant is another danger signal. WHAT SHOULD THE INFERTILE COUPLE DO? A couple who want a child and have been trying for well over a year with no results should seek the help of a physician who specializes in infertility. Ask your family doctor, or call the County Medical Society. If they live in a small community, it may necessitate a trip to a larger city. Expensive, per-haps, but certainly worth it The average sperm count for impregnation is approximately three hundred million. It is possible (though rare) to impregnate a female with a sperm count as low as one million. THE ANN LANDERS ENCYCLOPEDIA 707 Fertility specialists often recommend that men with a low sperm count who want to father a child (1) stop smoking marijuana, (2) abstain from drink-ing alcohol, (3) discontinue the use of non-prescriptive drugs. Men whose occupations subject the testicles to undue heat, such as driving a truck or operating a blast furnace, may have to change jobs in order to father a child. TESTING THE MALE Tests for the male are painless and quite simple. Three separate specimens of semen are required to ascertain whether the sperm cells are of the quality and quantity to result in a pregnancy. In addition to the analysis of the sperm count, a sample of the sperm is taken from the female immediately after sexual intercourse, along with the mucus from her cervix in order to determine the compatibility of the two. TESTING THE FEMALE There are many tests to determine whether or not a female is fertile. Most of the tests can be performed in a physician's office. First it must be learned if the passages are free of inflammation and if the reproductive structures are fully developed and free from obstruction. The blowing out of the Fallopian tubes, which may be blocked, has been de-scribed as slightly uncomfortable by some women and extremely painful by others-depending on their threshold of tolerance. There may be bloating and shoulder discomfort. Ovulation, or egg-cell production, must be ascertained and the exact time of ovulation in the menstrual cycle determined. It varies according to the length of the cycle. (Some women menstruate for three days, others for as many as eleven.) The best time to conceive is in the center of the month. For example, if a woman's menstrual cycle is twenty-eight days in length, and she begins on January 10, the best time to get pregnant would be from January 20 to the 27. AN EXCELLENT ALTERNATIVE Artificial insemination with a donor. In cases where the husband is completely sterile, a woman can get the sperm of an anonymous donor. Selection can be made from a large number 708 THE ANN LANDERS ENCYCLOPEDIA of donors, choosing from males who have the same hair and eye coloring, height* skin color and other physical characteristics of the husband. Also, a woman can choose the sperm of a male who has no inheritable diseases or in-compatible blood types. SPERM BANKS The sperm for donor insemination can be obtained fresh or frozen from a sperm bank. Although the concept of human sperm banks dates back to 1866, the first human pregnancies resulting after insemination of frozen sperm cells occurred only in 1956. However, freezing destroys some of the cells so that the rate of successful pregnancies, even when using donor semen, is somewhat lower when frozen sperm is used as opposed to fresh sperm. There are three commercial sperm banks in the United States-one in Minneapolis, another in Atlanta and a third in New York. The university banks usually get their semen from medical students. A donor is paid about $20 (this can vary). In general, the banks do not engage in widespread advertising, although the commercial banks do sometimes take ads in medical journals, aimed at gynecologists who are looking for sperm for infertile couples. There is some controversy about the testing of donors. While the banks are usually quite good on hair, eye and skin color, blood type, RH factor and family health background (looking for sickle cell anemia among blacks and Tay-Sachs among Jews), there are inconsistencies. Some banks do a chromo-some check. Others do not. There are no laws at this moment (1978) that govern sperm banks, so the opportunity for fraud is great. If infertility is caused by the husband's low sperm count, it has been suggested that he deposit several of his semen samples in the sperm bank, where they will be frozen. At the proper time (the woman's most fertile pe-riod) the sperm deposits will be thawed out, combined and deposited in the wife's vaginal tract. However, once again, too many of the sperm are injured by freezing and thawing, and this procedure has not been too successful. The other use of sperm banks is to store sperm for future use. In recent years, since vasectomy has become popular, many males have deposited large quantities of their sperm in these hanks for freezing in the event that if they and their wives might want a child in later years, the sperm will be available to them. THE ANN LANDERS ENCYCLOPEDIA 709 FREEZING AND THAWING SPERM CELLS A brief description of the actual method begins with the collection of the ejaculate from the donor or husband, who has been asked to refrain from sexual activity for three days. An evaluation of the ejaculate is made to deter-mine motility, volume measurement and sperm count. Glycerol is added to the semen to prevent the formation of ice crystals during freezing. The container, or ampul, is sealed and placed in the cold vapor coming from liquid nitrogen for about fifteen minutes. The ampul is then submerged in liquid nitrogen for storage at -196� C (-320.8� Fahrenheit). Thawing is accomplished by immersing the ampul in a water bath at body temperature (37� C). The motility, or percentage of forward-swimming sperm cells, is checked under a microscope, and the semen is ready for insemination. This is done in the office through a vaginal speculum-depositing the semen in the entrance of the womb. At present, the number of spermatozoa exhibiting good motility is usually reduced 30 percent or more by the freeze-thaw process. Variation in the storage temperatures of the sperm cells is highly detrimental to their survival, therefore exacting techniques are demanded of the specialists managing sperm banks. Research has revealed numerous requirements for a good survival after thawing, including such things as a rapid freeze rate, a perfect seal on the ampul, upper and lower limits of glycerol concentrations, as well as the time when the glycerol preservative must be added. Some factors, such as the time between adding glycerol and freezing, and the thawing method, have been shown to be non-critical. Human ejaculates contain a number of abnormal sperm cells and these forms appear to survive just as well as the normal sper-matozoa. CHILDREN FROM FROZEN SPERM Already, dozens of children have resulted from inseminations with frozen human spermatozoa. At the present time, no form of genetic damage due to frozen semen has been detected among these children. Considerable confidence in regard to genetic safety is derived from the dairy cattle industry, which has led the way with frozen semen and artificial insemination. No genetic damage has been established after production of more than one hundred million calves by this technique. 710 THE ANN LANDERS ENCYCLOPEDIA Recently, a child was bom after artificial insemination with sperm cells that had been frozen ten years. Usually inseminations are done with sperm cells stored less than a year, since research has shown some decline in sperm motility after long-term storage. There are presently fifteen human sperm bank facilities in the United States, with several additional under way. Records and identification of semen samples are meticulously kept, and the use of such facilities is strictly confidential. These banks of human seed may be viewed as technological achievements, but for many deserving couples, they are the means of fulfilling a missing part of their lives. credit: American Fertility Society. Checked for accuracy by Melvin L. Taymor, M.D., New England Fertility & Gynecology Associates, Boston, Massachusetts. Additional information supplied by Peter Kovler, Washington, D.C., free-lance writer. In-Laws In 1961 I wrote my first book. It was called Since You Ask Me. In that book, I dealt with the problems that produced the greatest number of letters. Chapter Six of that book was called, "Must We Outlaw the In-Law?" Today, many years later, in-law problems still figure prominently as one of the major causes for marital bust-ups. I am often asked, "How serious is an in-law problem? Has it been exagger-ated? Has the American mother-in-law earned her black eye or is she the in-nocent victim of gag-writers?" My mail provides daily evidence that the in-law problem is no myth. Ex-perts say in-laws figure in two out of five divorces-somewhere. Social critics insist the American matriarchy has crowded Dad so far out of the picture that he isn't important enough to make trouble. This may be more than a lame joke. My mail indicates that the mother-in-law is at least fifty times as troublesome as the father-in-law. And in most cases, it is the mother of the husband who causes the problem. THE ANN LANDERS ENCYCLOPEDIA 711 When it is the wife's mother who creates marital discord, the problem be-comes extremely complicated. The Mama-dominated wife never gets over feeling like a naughty child when she bypasses Mama and puts her husband first. The most troublesome relative, after the mother-in-law (his or hers), is the sister-in-law (usually his sister). The brother-in-law (his brother) is close on her heels, and the father-in-law (hers) comes straggling in-a poor fourth. The trite phrase, "I'm marrying him (or her), not the family," is unreal-istic. In most instances it is virtually impossible to steer clear of all relatives. But even when physical separation is accomplished, it is difficult to sever emotional bonds. Family ties are like roots. And roots lie ever present, be-neath the surface. The classic mother-in-law problem is caused by the woman who refuses to let go of her son. The young wife who understands her mother-in-law's need to cling feels less threatened and maintains a calm center. I have suggested repeatedly that married couples who are plagued with in-law prob-lems visit a clergyman or a marriage counselor and verbalize their feelings. A third party who is unbiased and trained in dealing with family problems may give them both a fresh look at the other side. The daughter-in-law should be tuned in and sympathetic to a mother of three or four adult children who finds herself with an empty nest. For the past twenty years she has been busy with her children. One by one, they leave. Her interests are frequently limited to club or church groups. Suddenly life becomes empty and sterile. She has nothing important or demanding to occupy her time and energy, so she turns to "helping" her married children. She means well, but a young bride who wants to do things her own way may consider it meddling. When a mother-in-law offers suggestions to Betty on what to do about Ted's cold (after all, who knows better than a boy's mother?) Betty inter-prets it as "butting in." A marriage counselor or a clergyman can point out that a mother's interest in her son is normal and that a mother-in-law can be useful to a daughter-in-law who is willing to accept gracefully a few well-in-tentioned suggestions. The following letter from Virginia illustrates a problem which is more complex because it involves two gravely neurotic people-a mother and her son: