sex therapy

In modern Western societies, the messages about sex are extremely contradictory and confusing. We have no traditional rites of passage nor meaningful ceremonies to initiate young people into informed adult sexuality. I hoped that my work might establish standards that could help people of all ages have less confusion about sex and intimate relationships. Much to my professional satisfaction, there were several enlightened parents who paid for a full course of sexual surrogate assisted therapy so that their sons could be initiated into the wonders of their own sexuality. How lucky to have subsequently been those young men's girlfriends or wives! I often wished that parents would take that same enlightened view toward sexual initiation for their daughters, but it was not yet the time for that. I predict, however, that this day will eventually come.

Until recently, the message was very strong that sex should be limited to marriage and monogamy. Yet everyone knows this standard is continuously being broken. But more often than not, it is broken in secrecy and with guilt. Our standards are very hypocritical. What we say and what we do just don't jibe.

Mixed Messages

We are led to believe through the incessant references to sex in the media that we live in a society that condones open sexuality, but when examined more closely, most of what is shown on TV, in the movies, or in print is labeled "X-rated" or "for adults only," which implies that the sexual activities depicted are really not OK. And, although sexual innuendo sells everything from baby lotion to trucks, the link between sex and violence is more prevalent than the seductive soft sell.

The number of children sexually abused, the number of teenage pregnancies, the spread of Aids, the high incidence of rape, and the millions of people who are unhappy in their sex lives shows that in our supposedly open and free culture things have really gotten out of hand. The authorities who shape our attitudes toward Sex attempt to make us believe that these problems are caused by too much openness toward sexuality. Just the opposite is true. It is the unwarranted sexual repression that causes sexual exploitation and aberrant behavior. Both the stifling of sexuality and the inevitable rebellion against prudery and ignorance is what puts us at the mercy of our sexual urges rather than being personally in charge of our sexuality.

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Using the argument that sex is natural and therefore need not be discussed and taught in the schools, on TV, or in sexual surrogate assisted therapy is most often just a cover for the attitude that any reference to sex is sinful. What in reality is sinful is not talking about sex, not respecting and honoring our natural sexual feelings. Condemning and preventing all attempts to learn what sex is really about is actually the root of the evil.

Sexual Surrogate Or Prostitute?

There are several major differences between what a sexual surrogate does and what we typically think of a prostitute doing. Frequently a prostitute provides only the sexual experiences that are asked of her. In many cases her job is simply to provide instant gratification. She may never see the client again.

A sex surrogate's main purpose, rather than just to provide sexual pleasure, is to educate the client in how to reverse specific sexual problems. And it is the therapist, not the sex surrogate or the client, who decides what activities are appropriate in view of the overall therapy. A course of therapy is likely to take several months or more. And, in most cases, sex (defined as genital stimulation and orgasm) is the least of it.

The fact that money is paid for the services of a prostitute, a sexual surrogate, or a sex therapist is not the issue. We live in a society where monetary exchange for goods and services is the rule. The intent of those who insist upon comparing sex surrogate assisted sex therapy with prostitution is to demean and discredit both. It is a reflection of our basically repressive culture regarding sexuality.

For The Greater Good

Nothing daunted my determination to become the very best sex therapist I possibly could. Helping people accept and respect their sexual urges as a natural part of life and helping them to have satisfying sex lives was compelling for me. As a child, I'd had several sexual experiences initiated by adult men. There had been no violence nor threats of violence. Yet I was sworn to secrecy and knew, from an uneasy place deep inside, that this was not socially acceptable behavior. The most traumatic part, however, was that I was blamed for being seductive and made to feel guilty.

From that time on, I searched for understanding about this most powerful of human energy: sex. I observed, asked questions, read everything I could get my hands on, and experimented wherever I could. In order to learn even more, I talked my husband into having an open relationship for a short while, in which either of us could, by mutual agreement, have other sexual partners. From all my searching, I could only conclude there was something radically wrong with the attitude toward sex in our culture. The most important thing I discovered was that, despite the fact that we are continually being bombarded by sexual images and sexual innuendoes, our society basically denies the value and beauty of sexuality. Therefore we are taught very little about it, being left to discover what little we can, through a great deal of fumbling and bumbling and embarrassment. What masquerades as sexual freedom is often only a rebellion against the lies, secrecy, hypocrisy, and ignorance about sex that our culture imposes upon us. We have been given the message that our sexual urges and attractions are bad. They are not. They are natural and beautiful. However, in our ignorance, how we act upon those urges is often what turns the sublime into the horrific!

Sex therapy utilizing experiential methods and surrogate partners became for me a way of making sex right both for myself and for my clients. I also hoped my work might have a redeeming influence upon some of the negative sexual attitudes in our culture. What is desperately needed are clear, unambiguous standards of sexual behavior that support the responsible and joyous expression of our sexuality. But this cannot be achieved in theory only. Such standards can only become effective through societally approved experiential learning. Surrogate-assisted therapy has proven to serve that purpose.

next: Sex Therapy with Survivors of Sexual Abuse

Depressed and Hurting

My name is Aimee and I discovered I had AIDS on my 26th birthday this year.

I had a strange bruise-like spot on my left breast that continued to get bigger and bigger. Soon, it covered my entire breast. I went to 7 different doctors and no one knew what it was. I was admitted to hospitals, specialists took pictures and yet, it was a mystery. I went to a general surgeon on December 28, 2004 and had a biopsy done. He told me I would be OK. I had to get my stitches out on Thursday, Jan. 6, 2005---my 26th birthday. He told my mom and I that it was something called Kaposi's Sarcoma. Found only in end-stage AIDS patients. As you can imagine, my head was spinning. I had had an HIV test and a Hepatitis test in December and had not received word of the results. Thinking no news was good news, I assumed it was negative. It wasn't. The doctor just never contacted me to tell me the results.

I remember thinking that it was a nightmare and I would soon wake up. My family sat around and mourned for me. We all thought I was dead. I remember my dad crying out "My precious baby girl!" That was the first night I ever saw my dad get drunk. We just couldn't cope with the news. My family cried like wounded animals, and I was in a state of shock. I put the pieces together and now understood why I had been so very ill the last year. I had been hospitalized. I had shingles 3x and my hair was falling out. I had rashes on my skin that itched sooo bad. I would lay in bed for months at a time, having no energy. It would take everything I had just to get a shower and put make-up on. Doctors told me it was stress. I knew it was something serious, but never imagined AIDS.

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I went to an incredible Infectious Disease doctor who gave me my first ray of hope. He said it was no longer a death sentence, instead, a chronic disease and with a healthy lifestyle and medication, I could very easily live to be an old woman. WHAT? I was so excited. I had blood work done and my T-cell count was 15. My viral load was 750,000. I was almost dead. I weighed 95 lbs in contrast with my usual 130lbs. I started on the medications Sustiva and Truvada along with Bactrim and Zithromax. I've been on the meds now a month and a half and my T-call count is climbing! It was 160 last week and my viral load was 2,100. My doctor believes my viral load will soon be undetectable and my T-cell count over 200 in the next few months.

I have my life back. I've enrolled in grad school, run with my two dogs, work, work out at the gym, and enjoy life again. I'm even dating. If I can be brought back from near death......emotionally, spiritually and physically, then so can you! My outlook on life is this: Love as you've never loved before, dance as though nobody's watching, be truthful regardless of the cost and trust in yourself as well and the Lord. I am lucky enough to have a supportive family, friends and a love of the Lord that gets me through this. I am not angry.... saddened, yes, but not angry. I have forgiven those that I feel have done me wrong as I know the Lord will forgive me of my sins. I look forward to keeping in touch with all of you so when I dance at my children's' weddings. I will know I HAVE LIVED LIFE!

Imagine Loving Your Child

This story was originally written at Christmastime but its message, like that of Christmas, is important to remember every day. Used by permission of the author.

by Carol

Imagine loving your child, imagine being willing to do anything you could to protect your child, and now imagine knowing that this virus lives in your child, every day, every night, you can never escape and you can't let down your guard. Imagine, if it were YOUR child.

As the holidays approach, we naturally think of children, happy, healthy children. We think of children enjoying Christmas and looking forward to many happy holidays. Unfortunately, some children, right here, children we pass every day, in the store, on the street, have AIDS. I know this because one of them is our son. He was born to a drug-addicted mother. She had AIDS and unknowingly passed the HIV virus to our child. We adopted him when he was 3 weeks old. Ten months later we found out he was HIV positive.

We live here, we worship here, we are your neighbors. And there are others, men, women and children who live here and who are in hiding. At Christmastime, with our thoughts turned to the greatest gift of all, I hoped and prayed that we could all come out of hiding and feel safe. How wonderful it would be to know that if our neighbors found out about our child, and about all the other people here who are living with AIDS, that our neighbors would still look at us the same way. Would people still smile at him if they knew?

People always smile at our son. He is a beautiful child, full of mischief and always smiling at everyone. His dignity, courage and his sense of humor shine through the nightmare of this disease. He has taught me much over the years that I have been blessed to be his mother. His father adores him. His brother loves him. Everyone who has gotten to know him is amazed by him. He is bright, he is funny, and he is brave. For a long time, he has beaten the odds.

All of us, straight, gay, male, female, adult and child are threatened by this virus. We may think that it could never affect us (I thought so too), but this isn't true. Most of us think we can reduce the risk of infection by our behavior which is true to some degree. But what is totally true is that it is impossible to reduce or eliminate the risk of affection by this disease. We can not predict which one of us will love someone that has AIDS.

When you walk down a street and see the many different houses, you can't tell if a home is inhabited by AIDS. It could be the home of one of your friends, a family member or a co-worker. Everyone is afraid to talk about it but it exists and we all need to help. The very people the most afraid to tell you, are the ones the most in need of your love, support and prayers.

We know there are others like our child in the community who face these same issues every day. They, like our child need your support in so many ways. People who are living with AIDS need, housing, emotional support, medical care, and the ability to live their lives with dignity. People with AIDS have many of the same dreams, hopes and plans that everyone else has. We certainly had plans and dreams for our child, and we still do.

In the time our child has been with us, with all the many people who have known and loved him, medical professionals, teachers, friends, countless others, not one has been infected by him, but all of us have been affected by him in wonderful ways. He has enriched our lives and taught us many lessons.

Reach out and learn about AIDS for our sake and your own. Please look into your hearts and remember us in prayer today.

About the Author

You can write Carol at MamaCinPa@aol.com. She especially welcomes mail from other parents of children with HIV/AIDS. She wrote "Imagine" in December 1996. It was first published on the web on July 31, 2000.

Andy died in Danville, Pennsylvania, Sept. 13, 2001. He was only 12 years old. Carol has written a memorial about him.

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Life with Alex

by Richard

(November 5, 1997) -- As I passed by my son Alex's bedroom on the way to bed myself, I heard him crying. I opened the door and found him sitting in his room sobbing uncontrollably. I invited Alex to lay down beside me in my bed and put my arms around him to comfort him.

After a short time, my wife came up to bed and found me holding Alex and stroking his head. When Alex finally began to calm down, we asked him what he was crying about. He told us he was scared. We asked him if he'd had a nightmare. He said that he had not even been to sleep.

It turns out that he was not scared of a dream, he was scared of reality. He told us he was afraid of his past and even more frightened by what the future held. You see, Alex deals with a nightmarish reality every day of his life. Alex lives with the nightmare called AIDS.

The Beginning of Alex's Life

This story about a child with AIDS starts at the beginning of Alex's life. When Alex was born he was delivered by C-section due to complications in the birthing process. His mother, Catherine, experienced post operative bleeding. She received a massive blood transfusion and further exploratory surgery to find the source of the bleeding. By the day's end, she was in intensive care in a coma.

During her recovery, under the advice of the pediatricians, Cathie breast-fed Alex. She had no idea that she had been infected with HIV.

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Nearly 2 years later, Cathie decided that she had a debt to pay. She had received the gift of life from those who donated the blood she had received at Alex's birth. She went to the local office of the American Red Cross to return the good will she had received. After a few weeks, we received a call from the Red Cross asking her to return to their office. They told her that she had tested positive for HIV, the virus associated with AIDS.

Subsequent testing of Alex showed that he was also HIV positive. We presume that he was infected via mother's milk, a known path of infection from an HIV positive mother to her baby.

Alex's Childhood

Alex has had a fairly normal childhood up until the last year. In his infancy, Alex was oblivious to his problem. As a toddler, he began receiving monthly immunoglobulin infusions and taking Septra as a prophylaxis against pneumocystis carinii pneumonia. Despite these inconveniences, we did our best to see to it that Alex had as normal a life as possible.

Life was not so normal for my wife and I, however. Aside from having to live with the fact that both Cathie and Alex were infected with HIV and would probably reach a premature end, we also had to deal with the ignorance and hatred of many people. We were afraid to tell even close friends and family members of our problems for fear we would loose their friendship.

Since Cathie has worked outside of the home off and on through the years, at times, Alex required day care. We were asked to remove Alex from one day care center, he was refused admission to at least two others, and has been refused admission to two different schools, one run by a Catholic church and the other at a Protestant church, all because of his HIV status.

Even the local public school asked us to delay his admission so they could do training. We had given the school board several months notice that our child, who was HIV positive, would be attending school there.

At the age of 6, Alex was diagnosed to have AIDS due to a diagnosis of lymphoid interstitial pneumonitis. As time went on, I found it increasingly difficult to remain silent about my family's problems and the ignorance we had faced in others. I'm not one to stick my head in the sand... I prefer tackling problems head on.

Going Public

With the support of my wife, I decided to go public with my family's story. I did this first by becoming a Red Cross HIV/AIDS Instructor. This, I felt would give me the opportunity to educate people of the facts concerning HIV and AIDS as well as an opportunity to share my personal story.

I took a week of vacation to attend the Red Cross course. During that week, I had to take Alex, now 7, to see his doctor at Children's Hospital. As we drove on the way to the hospital, I pointed out the Red Cross to Alex and told him that daddy was going to school there.

Alex looked very puzzled as he exclaimed, "But daddy! You're a grown-up! You're not supposed to go to school. What are you learning in school anyway?"

I told him that I was learning to teach people about AIDS. He pursued this a bit further asking what AIDS was. Apparently my explanation hit a little too close to home as I explained that AIDS was a disease that could make people very sick and they had to take lots of medicine. Ultimately, Alex asked me if he had AIDS. I have made it a point never to lie to my son, so I told him he did. It was one of the hardest things I have ever had to do. Alex only 7 years old, already was having to come to grips with his own mortality.

In the several years that have followed we have become increasingly public about our story. Our story has been reported, usually in conjunction with some fund raiser, in the local newspaper, television, radio, and even the Internet.

Alex has also made public appearances with us. As Alex got a little older we made something of a game out of learning the names of his medicines. Now Alex can be quite a ham (and a bit of a show off) in interviews. He knows AZT not only as AZT, Retrovir, or Zidovudine, but also as 3 deoxy 3-azidothymidine!

Alex has done very well so far. He is 11 now. During the last year he has been hospitalized 5 times. This sounds very grim. Of these hospitalizations, 4 were the result of side effects of drugs. Only one was the result of an opportunistic infection.

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The Community of Faith and AIDS

The community of faith plays an important role in dealing with AIDS. First of all, though many churches might find this repugnant, education about at-risk behaviors including open and frank sex education is a moral imperative. The lives of our youth are at stake. Though the education of my own family may not have prevented their infection, the education of the blood donor who was infected might have saved both his life and the lives of my wife and son.

The health and welfare of those infected and affected by the AIDS pandemic does not end with receiving the necessary medicines and medical care. An important part of their health and welfare is their mental and spiritual well being. Though the church may not be able to save the lives of these people, they certainly can provide a source or spiritual support that could lead them to an even greater gift... the gift of faith that could lead to eternal life.

This year's World AIDS Day (1997) focused on Children Living in a World with AIDS. Alex has his own perspective from the viewpoint of a child living with AIDS with both of his parents. Still other children have the perspective of living without one or both of their parents. I know several children who have lost other relatives and friends who have a difficult time understanding why and how this has happened.

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Our focus is on Children Living in a World with AIDS, so let's take a moment to consider those children living in a community of faith with AIDS. My own son and I had a conversation that went something like this:

Alex: Daddy...(pause) I believe in miracles!

Dad: Well that's great son. Perhaps you should tell me more.

Alex: Well... God can work miracles, right?

Dad: That's right.

Alex: And Jesus worked miracles and could heal people the doctors couldn't make well, right?

Dad: That's right.

Alex: Then Jesus and God can kill the HIV in me and make me well.

People of faith across the world must work together to ensure that all of God's children have the opportunity to experience faith such as this. This is especially important for those that are living a real life nightmare like AIDS.

People living with AIDS, need love and caring as much as anyone. They need something that can give them comfort and peace.

I know the inner peace that faith in Jesus Christ can bring and the emptiness that can exist in the absence of that faith. Despite all of the problems that my family has experienced (or perhaps even because of them) and a nearly 20 year absence from church, I have had my faith restored. The example set by people ministering to my family as we learned to live with AIDS, has led me back to God. I know this is the greatest gift I could receive and, I know now, that this is the greatest gift I have to offer.

Ed. note:Richard's wife died on Nov. 19, 2000, as the result of liver problems brought on by AZT, her AIDS medication. Alex Cory has not been hospitalized since just before Christmas in 2001. He is now 20 and was diagnosed with AIDS in 1996.

A Personal Journey

by Terry Boyd
(died of AIDS in 1990)

(March, 1989) -- I vividly recall a night in December of January about a year ago. It was 6:00 P.M., very cold and getting dark. I was waiting for a bus to go home, standing behind a tree for protection from the wind. I had recently lost a friend to AIDS. From whatever measure of intuition God had given me, I knew suddenly and quite certainly that I also had AIDS. I stood behind the tree and cried. I was afraid. I was alone and I thought I had lost everything that was ever dear to me. In that place, it was very easy to imagine losing my home, my family, my friends, and my job. The possibility of dying under that tree, in the cold, utterly cut off from any human love seemed very real. I prayed through my tears. Over and over, I prayed: "Let this cup pass". But I knew. Several months later, in April, the doctor told me what I had discovered for myself.

Now, it is nearly a year. I am still here, still working, still living, still learning how to love. There are some inconveniences. This morning, just out of curiosity, I counted the number of pills I have to take during the course of a week. It came out to 112 assorted tablets and capsules. I go to the doctor once a month and find myself reassuring him that I feel quite well. He mutters to himself and rereads the latest laboratory results which show my immune system declining to zero.

My last T-Cell count was 10. A normal count is in the range of 800-1600. I have been fighting painful sores in my mouth that make eating difficult. But, frankly, food has always been more important to me than a little pain. I have had Thrush for a year. It never quite goes away. Recently, the doctor discovered the herpes virus had gotten hold of my system. There have been strange fungal infections. One was on my tongue. A biopsy caused my tongue to swell and I couldn't talk for a week making many of my dear friends secretly thankful. A way had been found to shut me up and they all reveled in the relative peace and quiet. Of course, there are night sweats, fevers, swollen lymph glands (no one told me they would be painful), and unbelievable fatigue. .

When I was growing up, I literally detested grubby, down-in-the- dirt sorts of work like changing the oil, digging in the garden, and hauling garbage to the dump. Later on, a friend, who was a psychiatrist, suggested I should accept a summer job at a lumber camp in the Northwest. He chuckled with sinister glee and suggested it might be a constructive emotional experience. This last year has been that constructive emotional experience I had avoided. Parts of it have been grubby and down-in-the-dirt and other parts have been life-changing. I cry more now. I laugh more now, too.

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I have come to realize that my story is not in any way unique, nor is the fact that I will most likely die within two or three years. Like many of my brothers and sisters, I have had to come to terms with my own death, and the deaths of many of those I love.

My death will not be extraordinary. It occurs daily to others, just like me. And I have realized that death is not really the issue at all. The challenge of having AIDS is not dying of AIDS, but Living with AIDS. I didn't come to these realizations easily and, unfortunately, wasted precious time caught up in what I thought was the tragedy of my impending demise.

I still have a difficult time when someone I love is sick, in the hospital, or dies. We have all been to far too many funerals and many of us don't know how we will be able to find any more tears for the ones we continue to lose. In a story published recently about a man who lost his partner to AIDS, the man says that after Roger had died, he thought that just maybe the horror was over: that somehow it would all go away and everything could get back to the way it once was. But, just as he starts to think the horror is over, the telephone rings. I am crying as I write this because I have a very vivid picture in my mind of my partner making those same telephone calls.

We all know about the discrimination, fear, ignorance, hatred and cruelty attached to the AIDS epidemic. It sells newspapers and most of us read the newspaper and watch television. But I think there are a few things we continue to neglect.

Jonathan Mann, Director of the World Health Organization's Global Program on AIDS, recently spoke in my city. The World Health Organization (WHO) estimates that at least five million persons are currently infected with HIV. They also believe that twenty to thirty percent of those persons will go on to develop AIDS. Some medical experts at Walter Reed Hospital believe all persons infected will eventually develop symptoms.

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In Missouri, 862 cases of AIDS have been reported since 1982. If the WHO figures are applied, the number of those who are currently positive or who will go on to more serious symptoms is staggering. Our state of health reports that an average of six to seven percent of all those who are voluntarily tested test positive for the virus. Our local and state health departments are preparing for an explosion of cases in the next few years.

We often neglect those who test positive (those who are seropositive), but have no symptoms of AIDS. It does not take much imagination to envision the fear and depression that can result from learning you are infected with the AIDS virus. And, then, there are the families and loved ones of those who are sick or infected who must struggle with the same fears and depressions, often without a whit of support.

There is a major myth I would like to dispel. When we approach the AIDS crisis our first inclination is to search about for money to throw at the problem. I don't underestimate the importance of funds for services and research. But money will not solve, by itself, the problems of suffering, isolation and fear. You do not need to write a check: you need to care. If you do care, and if you have some money in your account, the check will follow naturally enough. But, first, you have to care.

The head of our local health department was quoted recently saying she believes there is a conspiracy of silence on AIDS. She reports that of the 187 deaths in this area, not one has listed AIDS as the cause of death in an obituary. It appears this conspiracy of silence involves those who have AIDS, or are infected with the virus, as well as the general public which still seems to have a difficult time discussing the subject.

Why is it, for example, that many of those actively involved in AIDS support services are the ones who have lost someone or know someone who has AIDS? I guess it is understandable. People are afraid. Another part of my constructive emotional experience has been to learn the value of honesty and straightforwardness. It is time for us to lose a lot of that useless baggage we carry around. You know the stuff ? that green bag that carries my attitude toward this person or that, or that big trunk containing my notions on this subject or that. So much useless baggage weighing us down. It's time for a new set of luggage. All we need is a small wallet and in our wallet we'll carry the really important stuff. We will have a little card that says:

Jesus answered, 'Love the Lord your God with all your heart, with all your soul, and with all your mind'. This is the greatest and the most important commandment. The second most important is like it: 'Love your neighbor as yourself'.

And once a day, we'll open our little wallet and be reminded of what really matters.

Some time ago I had the opportunity to hear Bishop Melvin Wheatley speak. He addressed the difficulties the church has in discussing sexuality. He said (as best I can recall) that the church has difficulty discussing sexuality because it has difficulty discussing LOVE. And it has difficulty discussing love because it has difficulty discussing JOY. The AIDS crisis involves the very same issues. As a church, we have our work cutout, and it is going to be grubby, down-in-the-dirt work.

I think it is important for us always to make a special effort to concentrate on the heart of the matter: being a truly Christian people. Bishop Leontine Kelly said at the National Consultation on AIDS Ministries that we must remember there is nothing that can separate us from the love of God. I understand her to mean that absolutely nothing, not sexuality, not illness, not death can separate us from the love of God. You may ask, "What can I do?" The answer is relatively simple. You can share a meal, you can hold a hand, you can let someone cry on your shoulder, you can listen, you can just sit quietly with someone and watch television. You can hug, and care, and touch and love. Sometimes it's scary, but if I (with the Lord's help) can do it, so can you.

Back when I lost the first of my friends to AIDS, I knew that one friend, Don, had been sick. It seemed like he was in and out of the hospital with this and that and didn't seem to begetting any better. Finally, the doctors diagnosed AIDS. By the time he died, he had been affected with dementia and was blind. When his friends found out he had AIDS, many of us did not visit him while he was in the hospital. Yes, that included me. I was afraid not of catching AIDS, but of death. I knew I was at risk and that in looking at Don I could be looking at my own future. I thought I could ignore it, deny it, and it would go away. It didn't. The next time I saw Don was at his funeral. I am ashamed and I know that none of us, even those with AIDS, are exempt from the sins of denial and fear. If I had just one wish, just one, it would be that none of you would have to experience the death of a loved one before you realize the extent and seriousness of this crisis. What a terrible, terrible price to pay.

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"What happens", you may ask, "when I get involved and I come to care about someone and, then, they die?" I understand the question. The wonderful part, though, is to understand the answer. I serve on my conference's AIDS Task Force. At a recent meeting I was trying to listen to several threads of discussion all at the same time when a woman (and a dear friend) spoke up. She had recently lost her brother to AIDS. She said quite directly that she was always amazed to see me and to see how well I was doing. She said she had become convinced that I was doing so well because I had been open about my AIDS diagnosis and because of the support, love and care I had received from those around me. She, then, turned to me and said she knew her brother would have lived longer if he had been able to get that same support and care, if somehow he hadn't felt so isolated and alone. She was right and I have come to realize how precious that care and support, that love, is. It has literally kept me alive.

How many people do you know who have saved a life? I tell you I know quite a few. You may ask, "What did they do, save a child from a burning building?" No, not exactly. "Well, did they pull someone out of a river?" Again, not exactly. "Well, what did they do?" When so many are so afraid, they sit next tome, they shake my hand, they hug me. They tell me they love me and that, if they could, they would do anything to make it easier for me. Knowing people like this has made my life a daily miracle. You can save a life, too. That life may only be a few months, or a year, or two years long, but you can save it just as surely as if you had reached into the river and pulled out someone who was drowning.

In my early days when I first "got religion", there were a couple of topics which fascinated me: mainly those which dealt with the presence of Christ. One of these topics was the old debate about the presence of Christ in the Eucharist. Catholics, for example, believe He is actually and physically present from the moment the elements are consecrated. I was, also, quite taken with certain passages in the Gospels, particularly in Matthew where someone asks Jesus, "When, Lord, did we ever see you hungry and feed you, or thirsty and give you a drink? When did we ever see you a stranger and welcome you in our homes?" Jesus replies, "I tell you, whenever you did this for one of the least of these, you did it for me." And again, in Matthew, the statement that: "For where two or three come together in my name, I am there with them."

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I was, and probably still am, a religious innocent. I still harbor a childlike desire to really see Jesus, talk with Him, ask Him a few questions. So, the question of when and where Christ is actually present has always been important to me.

I can tell you truthfully that I have seen Christ. When I see someone holding a person with AIDS who is crying desperately, I know I am in the presence of holiness. I know Christ is present. He is there in those comforting arms. He is there in the tears. He is there in love, truly and fully. There stands my Savior. Critics notwithstanding, He is here in the church, in the person sitting next to me in the pew on Sunday, in my pastor who has shared tears with me on more than one occasion, in the widow at church who is helping us to set up an AIDS caring network. And you can be a part of that.

But, finally, you will be called upon to grieve; yet, you will know you have made a difference, and you will realize you have gained more than you could ever have given. An old, old story really . . . about 2,000 years old.

I am reminded about a song recently released titled: "In The Real World". Part of the lyrics read: "In dreams we do so many things. We set aside the rules we know and fly above the world so high, in great and shining rings. If only we could always live in dreams. If only we could make of life what in dreams, it seems. But in the real world we must say real good-byes, no matter if the love will live, it will never die. In the real world there are things that we can't change and endings come to us in ways that we can't rearrange."

When I was asked to contribute to this Focus Paper, it was suggested that I try to make it a statement of challenge to the church. I have no idea if I've accomplished that goal or not. It sometimes seems that a challenge should not be necessary since we are dealing with the most basic and fundamental tenets of our religion. If we cannot respond to those with AIDS (at whatever stage) as Christians, what is to become of us, what is to become of our church?

In the book, THAT MAN IS YOU, by Louis Evely, the author writes: "When you think of all those poor cold hearts and the equally cold sermons that bid them perform their Easter duty! Have they ever been told that there is a Holy Spirit? the Spirit of love and joy, of giving and sharing . . .; that they are invited to enter into that Spirit and communicate with Him; that He wants to keep them together . . . forever, in a body; that that's what we call "the Church"; and that that's what they have to discover if they're really to perform their Easter duty?"

Evely also tells this story:

"The good are densely clustered at the gate of heaven, eager to march in, sure of their reserved seats, keyed up and bursting with impatience. All at once a rumor starts spreading: 'It seems He is going to forgive those others, too!' For a minute, everyone is dumbfounded. They look at one another in disbelief, gasping and sputtering, 'After all the trouble I went through!' 'If only I'd have known this . . .' 'I just can't get over it!' Exasperated, they work themselves into a fury and start cursing God; and at that very instant they're damned. That was the final judgment, you see. They judged themselves, . . . Love appeared, and they refused to acknowledge it . . . . 'We don't approve of a heaven that's open to every Tom, Dick and Harry.' 'We spurn this God who lets everyone off.' 'We can't love a God who loves so foolishly.' And because they didn't love Love, they didn't recognize Him."

As we say in the Midwest, it's time to "hitch up your britches" and get involved. The consequences of not caring, not loving are much too severe. One final story. Soon after I had discovered I had AIDS, the most important person in my life brought home a small package of seeds. They were sunflowers. We lived in a small apartment with a tiny patio with a bare patch of earth - really more of a flower box than any sort of a garden. He said he was going to plant the sunflowers in the "garden". Okay, I thought. Our luck with growing things had never been tremendous, especially such large plants as pictured on the package in such a small plot of ground. And I had much more important fish to fry. I was, after all, dying of AIDS and I had never paid much attention to anything as mundane as flowers in a flower box.

He planted the seeds and they took hold. By summertime, they stood at least seven feet high with glorious, bright yellow blooms. The blossoms followed the sun religiously and the patio became a hive of activity as bees of all descriptions hovered relentlessly around the sunflowers. Out of row upon row w of apartments which were indistinguishable from one another, it was always easy for me to spot our patio with those great halos of yellow towering high above the fence. How precious those sunflowers became. I knew I was coming home: home to someone who loved me. When I saw those sunflowers, I knew that everything, in the end, would be alright.

For those of you who do care and find yourself ready to make this kind of Christian commitment, I would like it very much if you could come to my house. We wouldn't do a whole lot. We would just sit on kitchen chairs, have some iced tea, and watch the bees in the sunflowers.

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Seeing the Face of AIDS: The Story of George Clark III

The Covenant to Care program was founded because of personal encounters with the many faces of AIDS. A compelling instance was at the United Methodist National Consultation on AIDS Ministries in November 1987. At closing worship for that gathering, Cathie Lyons, then staff of Health and Welfare Ministries, suggested some images that would bind the participants together as persons of faith as they traveled home. One of her images reflected a question raised by George Clark III (right), a participant.

Earlier in the week, in a soft voice and thought-filled manner, George had disclosed that he had AIDS. Then he asked: "Would I be welcome in your local church, in your annual conference?" On the last day of the conference, Cathie responded publicly to his question: "George, I name you Legion, because in the life of this church you are many. The question you raise is manifold in its proportions. It is a question which must be addressed to every congregation and every conference in this church."

The face AIDS wears is both many and one. The face of AIDS is women and men, children, youth and adults. It is our sons and daughters, brothers and sisters, husbands and wives, mothers and fathers. Sometimes the face AIDS wears is that of a person without a home or a person in prison. Other times it's the face of a pregnant woman who is fearful she will pass HIV to her unborn child. Sometimes it's a baby or child who has no caregiver and little hope of adoption or being placed in foster care.

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Persons Living with AIDS (PLWAs) come from all walks of life. PLWAs represent all racial and ethnic groups, religious backgrounds, and countries of the world. Some are employed; others are underemployed or unemployed. Some are affected by other life-threatening situations such as poverty, domestic or societal violence, or intravenous drug use.

We should not be surprised that the many faces AIDS wears are, really, one and the same face. The one face that AIDS wears is always the face of a person created and loved by God.

George Clark III died on April 18, 1989 in Brooklyn, New York from the complications of AIDS. He was 29 years old. He was survived by his parents, his sister, other relatives and United Methodists across the country who were moved by the challenge George put to his church at the National Consultation on AIDS Ministries in 1987.

The story of George Clark III reminds us that every day another family, friend, community, or church learns that one of its own has AIDS. George's parents were en route to New York City when he died. George had hoped that the Reverend Arthur Brandenburg, who had been George's pastor in Pennsylvania, would be with him. George got his wish. Art was there, as was Mike, a gracious and kind man who had opened his home to George.

Art Brandenburg recalls that, at death, George was wearing a World Methodist Youth Fellowship T-shirt . . . and that the birds outside George's window stopped singing. . .

The photographs are of George Clark III serving communion and the communion table at the National Consultation on AIDS Ministries in 1987. They were taken by Nancy A. Carter.

next: Teens Living with AIDS: Three People's Stories

What are the possible reasons for losing interest in sex and what to do to help

 
Have you gone off sex?

Many people go off sex for a while - especially during times of stress or after childbirth. But what if you don't regain your desire? Psychosexual therapist Paula Hall looks at the causes and solutions.

Losing interest

If you're single, or have made a conscious decision to be celibate, you may be quite happy without having sex for a while. But if you're in a relationship and you've just gone off it, not only are you missing out on the fun and intimacy sex can provide, but so is your partner. This can lead to powerful feelings of rejection and loss that can soon turn to resentment. Both partners can begin to doubt their sexuality and attractiveness.

Going off sex can be particularly disturbing for men. It's a common myth that men are always dying for it, so if you're not, both you and your partner maybe feeling left confused.

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Common causes

Low sexual desire is rapidly becoming the most common issue treated in psychosexual therapy. There are a number of reasons why someone may initially go off sex, but often what happens is that even when the original cause has long gone, couples may find it very difficult to restart their sexual relationship.

In some cases, going off sex may start as a symptom of another sexual problem. For example: difficulty reaching orgasm, impotence or painful intercourse. If this maybe the cause, read the information on those conditions too.

For a few, the problem may be physical. But in the majority of cases it's the result of negative thoughts or feelings. The most common ones are:

• Poor self-esteem. If you don't feel good about yourself you'll find it difficult to see yourself as a sexual person. Your partner will be seeing a very private side of you and that takes confidence.
• Relationship issues. If you're feeling angry, upset or in any way insecure about your relationship, you need to address these issues before you can expect to feel sexual towards your partner. Try talking things through with them or going for couple counseling. Some couples struggle to feel desire for their partner because they say they feel too close. The relationship feels too much like brother and sister and sex may feel inappropriate. Sex therapy can help these couples see each other in a new light.
• Partner problems. It's a sensitive subject, but a common cause of going off sex is a partner who turns you off. It might be a physical or hygiene issue, perhaps they have a habit that makes you switch off or they're not a very skilled lover. Honesty is the only way to get round this. (See I'd like you to... for some tips.)
• Bad experiences. An inhibited childhood or a particular traumatic experience might have left you with negative feelings about sex.
• Fears. There may be powerful fears of pregnancy or getting an infection. Talking through these things with your partner or a counselor may help.

Other possible reasons

Any illness, disability or change in your lifestyle that leaves you tired, in pain or feeling low about yourself will have an indirect affect on your sex drive. The following have a direct effect:

• depression
• childbirth
• alcohol and drug abuse
• illness or damage to testes or ovaries, which can affect hormone production
• illnesses such as some pituitary conditions, hypothyroidism, cirrhosis or stress certain prescription drugs

You may find it useful to see your GP if any of the above apply.

Tips for increasing desire

• Relax. This is the most important thing you can do. Have a bath, use deep-breathing techniques or buy a relaxation tape.
• Check your environment. Be sure there are no distractions to you becoming aroused and that the atmosphere suits your mood.
• Exercise your pelvic floor. This will increase the blood flow to your genital area and make you more conscious of any sensations of physical arousal.
• Try using fantasy. Get yourself in the mood by slipping into a favorite fantasy.
• Enjoy being sensual before you're sexual. Take your time and allow your body focus on the pleasurable sensations of touch.
• Change your view. Get sex into the forefront of your mind by reading or watching something more raunchy than you'd normally choose.
• Focus on positives. If there's something about your partner or yourself you don't like, don't think about it. Force yourself to look at and think about the positives, instead.
• Stimulate your sympathetic nervous system. Exercise, watch a scary movie, go on a roller coaster - anything that will speed up your heart rate. Research suggests that 15 to 30 minutes later your body is more sexually responsive.

See the practical exercises section for more information.

Further help

If none of the self-help techniques work for you, you might want to ask your GP for advice. Alternatively, the support and guidance of a psychosexual therapist may help.

Books

The Sex Starved Marriage, Michele Weiner Davis (Simon and Schuster UK)

Rekindling Desire: A Step by Step Program to Help Low-Sex and No-Sex Marriages

Rekindling Desire: A Step by Step Program to Help Low-Sex and No-Sex Marriages Barry McCarthy, Emily McCarthy (Brunner Routledge)

Related Information:

• Difficulty Reaching Orgasm
• Orgasms
• Sex Therapy

next: Difficulty Reaching Orgasm

Recognizing the problem in anorexia nervosa

In anorexia nervosa, family members are often the first to notice that something is wrong. They notice that you are thin and continuing to lose weight. They become worried, and may be alarmed by your weight loss. You will probably continue to think that you are over-weight and will want to lose more weight. You may find yourself lying to other people about the amount you are eating, and the weight you are losing. If you have bulimia nervosa, you will probably feel guilty and ashamed of your behavior. You will try to hide it, even if it affects your work and makes it difficult to lead an active social life. People with bulimia often find that they finally admit to the problem when their life changes, perhaps a new relationship, or starting to live with other people. It can be a huge relief when this happens.

Getting the right help for anorexia

Your general practitioner can refer you to a counsellor, psychiatrist or psychologist who has experience with these problems. Some people choose private therapists, self-help groups or clinics, but it is still safest to let your GP know what is happening. You will need to have a regular physical health check.

Assessment

The psychiatrist or psychologist will first want to talk with you to find out when the problem started and how it developed. You will need to talk frankly about your life and feelings. You will be weighed and, depending on how much weight you've lost, you may need a physical examination and blood tests. With your permission, the psychiatrist will probably want to talk with your family, (and perhaps a friend), to see what light they can shed on the problem. However.. if you do not want other members of the family involved, even very young patients have a right to confidentiality. This may sometimes be appropriate because of abuse or stress in the family.

Self-help for anorexia and bulimia

• Bulimia can sometimes be tackled using a self-help manual with occasional guidance from a therapist.
• Anorexia usually needs more organized help from a clinic or therapist. It is still worth getting as much anorexia information as you can about the options so that you can make the best choices for yourself.

Things to do

Stick to regular mealtimes - breakfast, lunch and dinner. If your weight is too low, have morning, afternoon and night-time snacks.

• If you can't manage this, try to think of one small step you could take towards a more healthy way of eating. For instance, you may be unable to eat breakfast. To start with, get into the routine of sitting at the table for a few minutes at breakfast time, and perhaps drink a glass of water. When you have got used to doing this, try having just a little to eat, even half a slice of toast - but do it every day.
• Keep a diary of what you eat, when you eat it, and what your thoughts and feelings have been every day. You can use your diary to see if there seems to be any connection between how you feel, what you are thinking about, and how you eat
• Try to be honest about what you are or are not eating, both with yourself and with other people.
• Remind yourself that you don't have to be achieving things all the time- let yourself off the hook sometimes. Remind yourself that, if you lose more weight, you will feel more anxious and depressed.
• Make two lists - one of what your eating disorder has given you, one of what you have lost by it. A self-help book can help you to do this.
• Try to be kind to your body, don't punish it.
• Make sure you know what a reasonable weight is for you, and that you understand why.
• Read about stories of other people's experiences of recovery. You can find these in self-help books or on the internet.
• Think about joining a self-help group. Your GP may be able to recommend one or you can contact the Eating Disorders Association (see overleaf).

Things NOT to do

• Don't weigh yourself more than once a week.
• Don't spend time checking your body and looking at yourself in the mirror. Nobody is perfect. The longer you look at yourself, the more likely you are to find something you don't like. Constant checking can make the most attractive person unhappy with the way they look.

• Don't cut yourself off from family and friends. You may want to because they think you are too thin, but they can be a lifeline.

• Avoid websites that encourage you to lose weight and stay at a very low body weight. They encourage you to damage your health, but won't do anything to help when you fall ill.

What if I don't have any help or don't change my eating habits?

Most people with a serious eating disorder will end up having some sort of eating disorder treatment, so it is not clear what will happen if nothing is done. However, it looks as though most people with an established eating disorder will continue with it. Some sufferers will die, but this is less likely if you do not vomit, use laxatives or drink alcohol.

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Professional help Anorexia

You need to get back to somewhere near a normal weight. To help with this, you and your family will first need information. What is a 'normal' weight for you? How many calories are needed each day to get there? You may ask, "How can I make sure that I don't become fat again ?" and "How can I be sure that I will be able to control my eating?" At first, you probably won't want to think about getting back to a normal weight, but you will want to feel better.

• If you are still living at home, your parents may get the job of checking what food you are eating, at least at first. This involves making sure that you have regular meals with the rest of the family, and that you get enough calories. Mounds of lettuce can be very deceptive! You will see a therapist regularly, both to check your weight and for support.
• Dealing with this problem can be stressful for everyone concerned and your family may need support to cope with an eating disorder. This doesn't necessarily mean that the whole family has to come to therapy sessions together (although this can be very helpful for younger patients). It does mean that your family may need help to understand and cope with the anorexia.

• It will be important to discuss anything that may be upsetting you, such as how to get on with the opposite sex, school, self-consciousness, or any family problems. Although it is important to be able to talk things over confidentially, sometimes a therapist may need to discuss things with you and your family together.

Psychotherapy or counseling

• This involves spending time regularly, probably about one hour every week, with a therapist to talk about your thoughts and feelings. It can help you to understand how your problem started, and then how you can change some of the ways you think about things. You can talk about the present, the past, and your hopes for the future. It can be upsetting to talk about some things, but a good therapist will help you to do this in a way which helps you to feel better about yourself.
• Sometimes it can be done in a small group of people with similar problems, in sessions lasting around 90 minutes.
• Other members of your family can be included, with your permission. They may also be seen separately for sessions to help them understand what has happened to you, how they can work together with you, and how they can cope with the situation.
• Treatment of this sort can last for months or years.
• Only if these simple steps do not work, or if you are dangerously underweight, will the doctor suggest admission to hospital.

Hospital treatment

This consists of much the same combination of controlling eating and talking about problems, only in a more supervised and concentrated way.

Physical health

• Blood tests will be done to check whether you have become so under-nourished that you are anaemic or at risk of infection.
• Your weight will be regularly checked to make sure that you are slowly getting back to a healthy weight.

Advice and help with eating

• A dietician may meet with you to discuss healthy eating - about how much you eat and whether you are getting all the nutrients you need to stay healthy.
• You can only get back to a healthy weight by eating more, and this may be very difficult at first. You will be encouraged to eat regularly, but also helped to deal with the anxiety this causes you. Staff will help you to set targets and to deal with the fear of losing control of your eating.
• Gaining weight is not the same thing as recovery - but you can't recover without first gaining weight. If you are starved, you won't be able to think clearly or concentrate properly.

Compulsory treatment

This is unusual. It is only done if someone has become so unwell that he or she:

• cannot make proper decisions for themselves
• needs to be protected from serious harm. In anorexia, this can happen if your weight is so low that your health (or life) is in danger and your thinking has been severely affected by the weight loss.

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How effective is the treatment?

More than half of sufferers make a recovery, although they will on average be ill for five to six years. Full recovery can happen even after 20 years of severe anorexia nervosa. .Past studies of the most severe cases admitted to hospital have suggested that one in five of these may die. With up-to-date care, the death rate is much lower if the person stays in touch with medical care. .As long as the heart and other vital organs have not been damaged, most of the complications of starvation (even bone and fertility problems) seem to recover slowly, once a person is eating enough.

Bulimia:

Psychotherapy

Two kinds of psychotherapy have been shown to be effective in bulimia nervosa. They are both given in weekly sessions over about 20 weeks.

Cognitive Behavioural Therapy (CBT)

This is usually done with an individual therapist, but can be done with a self-help book, group sessions or even self-help CD-ROMs.CBT helps you to look at your thoughts and feelings in detail. You may need to keep a diary of your eating habits to help find out what triggers your binges. You can then work out better ways of thinking about, and dealing with these situations or feelings.

Interpersonal Therapy (IPT)

This is also usually done with an individual therapist, but concentrates more on your relationships with other people. You may have lost a friend, a loved one may have died, or you may have been through a big change in your life. It will help you to rebuild supportive relationships that can meet your emotional needs better than eating.

Eating advice

The aim is for you to get back to eating regularly, so you can maintain a steady weight without starving or vomiting. You may need to see a dietician for advice about a healthy, balanced diet. A guide such as "Getting Better BITE by BITE" (see references) can be helpful.

Medication

Even if you are not depressed, SSRI antidepressants can reduce the urge to binge eat. This can reduce your symptoms in 2-3 weeks, and provide a "kick start" to psychotherapy. Unfortunately, without the other forms of help, the benefits wear off after a while. Medication is useful, but not a complete or lasting answer.

How effective is the treatment?

• About half of sufferers recover, cutting their binge eating and purging by half. This is not a complete cure, but can enable someone to get back some control of their life, with less interference from their eating problem.
• The outcome is worse if you also have problems with drugs, alcohol or harming yourself.
• CBT and IPT work just as effectively over a year, although CBT seems to start to work a bit sooner.
• There is some evidence that a combination of medication and psychotherapy is more effective than either treatment on its own. .Recovery usually takes place slowly over a few months, or even years.
• Long-term complications include damaged teeth, heart burn, and indigestion. A small number of people will have epileptic fits.

The Royal College of Psychiatrists also produces mental health information for patients, carers and professionals including: Alcohol and Depression, Anxiety and Phobias, Bereavement, Depression, Depression in Older Adults, Manic Depression, Memory and Dementia, Men Behaving Sadly, Physical Illness and Mental Health, Postnatal Depression, Schizophrenia, Social Phobias, Surviving Adolescence and Tiredness.

The College also produces factsheets on treatments in psychiatry such as Antidepressants, and Cognitive Behavioural Therapy. All these can be downloaded from this website. For a catalogue of our materials for the general public, contact the Leaflets Department, Royal College of Psychiatrists, 17 Belgrave Square, London SW1X 8PG. Tel: 020 7235 2351 ext.259; Fax: 020 7235 1935; E-mail: leaflets@rcpsych.ac.uk.

Organisations that can help

Eating Disorders Association, 103 Prince of Wales Road, Norwich NR1 1DW Helpline: 01603-621-414; Monday to Friday, 9.00 am to 6.30 pm Youth Helpline: 01603-765-050; Monday to Friday, 4.00 pm to 6.00 pm www.edauk.com. Provides information and help on all aspects of eating disorders, including anorexia nervosa, bulimia nervosa, binge eating and related eating disorders.

NHS Direct 0845 4647 www.nhsdirect.nhs.uk. Provides information and advice on all health topics.

Patient UK. www.patient.co.uk. Provides information on leaflets, support groups, and a directory of UK websites on all aspects of health and disease.

Young Minds, 102 - 108 Clerkenwell Rd, London EC1M 5SA; Parents Information Line: 0800 018 2138; www.youngminds.org.uk. Provides information and advice on child mental health issues.

Anorexia Nervosa and Related Eating Disorders, inc www.anred.com/slf_hlp.html. Website with information on eating disorders. 17

Books

Breaking free from Anorexia Nervosa: A Survival Guide for Families, Friends and Sufferers, Janet Treasure (Psychology Press)

Overcoming Anorexia Nervosa: A self-help guide using Cognitive Behavioural Techniques, Christopher Freeman and Peter Cooper (Constable & Robinson)

Bulimia Nervosa and Binge-eating: A guide to recovery, Peter Cooper and Christopher Fairburn (Constable & Robinson)

Overcoming Binge Eating, Christopher G Fairburn (Guildford Press)

Getting Better BITE by BITE: A Survival Kit for Sufferers of Bulimia Nervosa and Binge Eating Disorders, Ulrike Schmidt and Janet Treasure (Psychology Press)

References

Agras, W. S., Walsh, B.T., Fairburn, C. G., et al (2000) A multicentre comparison of cognitive-behavioural therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 57, 459-466.

Bacaltchuk J., Hay P., Trefiglio R. Antidepressants versus psychological treatments and their combination for bulimia nervosa (Cochrane Review). In: The Cochrane Library, Issue 2 2003.

Eisler, I., Dare, C., Russell, G. F. M., et al (1997) Family and individual therapy in anorexia nervosa. Archives of General Psychiatry, 54, 1025-1030.

Eisler, I., Dare, C., Hodes, M., et al (2000) Family therapy for anorexia nervosa in adolescents: the results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry, 41,727-736.

Fairburn, C. G., Norman, P.A., Welch, S. L., et al (1995) A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Archives of General Psychiatry, 52, 304-312.

Hay, P. J., & Bacaltchuk, J. (2001) Psychotherapy for bulimia nervosa and bingeing (Cochrane Review) In The Cochrane Library Issue 1.

Lowe, B., Zipfel, S., Buchholz, C., Dupont, Y., Reas D.L. & Herzog W. (2001). Long-term outcome of anorexia nervosa in a prospective 21-year follow-up study. Psychological Medicine, 31, 881-890.

Theander, S. (1985) Outcome and prognosis in anorexia nervosa and bulimia. Some results of previous investigations compared with those of a Swedish long-term study. Journal of Psychiatric Research 19, 493-508.

next: Medical Management Of Anorexia Nervosa And Bulimia Nervosa
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What happens to anorexic teenagers when they become anorexic young women?

In their twenties many fall in love, get married and try to build a life with their husbands just like other young women. The difference is that the anorexic young woman has anorexic thinking and feeling influencing every decision and action in her life. She is often very afraid.

Most people in their mid-twenties go through a kind of developmental shock as they are confronted by new and different kinds of personal challenges in their lives. The woman is only recently no longer a young girl. There are new responsibilities to understand and shoulder. She discovers that she and others people are placing new and often quite reasonable expectations on her.

Whether she accepts those expectations or not, she still has to deal with them. This is a stressful time for any young woman, but particularly so for an anorexic young woman. She can feel angry, frightened and overwhelmed.

An anorexic who for years has been doing a 'good job' at being anorexic is hiding in plain sight all the time. She's thin, but not skeletal. According to fashion dictates, she is elegantly lean in a most feminine way.

When friends and family see her, they often see an attractive, dainty and feminine young woman who, in their eyes, might be a lovely model. She is a bit on the nervous side and does overreact to a few things, they think, but, they continue to themselves, she's still young. She'll outgrow it soon.

However, she knows she has begun to build an adult life based precariously on an image of herself that is unsupported by her inner world.

Inside, the anorexic young woman is wracked with anxiety. Because her outer appearance is so different from her inner experience she has problems expressing her fears. If she makes a reference to her anxieties she is often ignored or discounted. She may even be accused of being stupid for being nervous because she appears to have a good life. She may have what appears to others to be a better life than they, and so her pain is even more difficult to accept or understand.

This makes her, already an isolated person, even more isolated. Grief, despair and anxiety become her constant companions.

If someone does see a bit through her facade, suggests that she has a mental problem and that it might be a good idea to seek psychotherapy she will often panic. The classic paradoxical thought comes through. "I don't need a psychotherapist. I just need someone to talk to honestly who will listen to me."

She yearns for genuine understanding, but that means she would have to reveal herself. This would, in her perception, destroy the adult life she is attempting to build. She knows her foundations for that life are flimsy. She is so good at creating a correct and lovely appearances that few people appreciate just how flimsy her foundations are. And, in keeping with her isolationist beliefs, she can think of no one who could listen to her. She is trapped in a bind created by her own mind.

Because she needs desperately to have people think well of her and because she thinks her appearance is the way to control other people's perceptions she strives valiantly to maintain a specific look and image.

If she publicly acknowledges her tormented inner world, she is terrified of what people will think of her. Her fear drives her to create an image of even greater perfection as she withholds her real feelings from others. She draws the anorexic trap tighter around herself.

Often, she knows she is doing this and her terror terrifies her as well. Her intelligence may tell her that this kind of thinking and behavior doesn't make sense, but it seems more powerful than any healing action she might dare.

Many anorexic women find benefits to being riddled with anxiety. Anxiety can be a powerful experience that overwhelms the possibility of feeling anything else. In the anorexic anxiety can eliminate any recognition of hunger for food. It's easier to starve. But then they can panic over that too. Too much starvation might affect their appearance so that others know something is wrong.

An anorexic can feel hunger. But her anxiety is greater than her hunger. Her fear is that is she eats a tiny bit or eats the wrong thing her hunger will overwhelm her and she won't be able to stop eating. That fear creates an overwhelming state of anxiety that floods her inner world. The flood of anxiety overwhelms her need to nourish herself and she continues living in starvation mode.

Often the anorexic woman knows she is in some kind of cycle where she recognizes a pattern to her feelings of weakness and flooding anxiety. She doesn't know what is causing it. She can't tell if it's coming from the outside world or from her inner life. If she gets more close to exploring her inner life than she can bear, she often will feel a strong burning sensation in her abdomen.

This is like a danger signal, a warning not to know more about herself. Also, since that burning sensation will prevent her from eating food, she may experience that pain as a kind of familiar protection. She may also experience it as a betrayal and become even more frightened.

The anorexic young woman wants relief from this anguish. She says she wants a normal life, but she doesn't really know what that is. She hopes there is help, but she can't imagine it. Help involves moving into exactly what she fears most, letting someone see her real inner life. It means experiencing exactly what she wants to avoid.

She is not a teenager now. She is a young woman attempting to build a life. She may have made promises to her husband, made commitments to an advanced educational program, be on a career track where others depend on her. After all, she looks good and knows how to control her appearance and what others perceive at least for a while longer.

Healing may mean that her flimsy structure will collapse. She cannot imagine the life that would remain in the debris. Despite her fear and pain she is clutching to the life she has. She tries to keep her fear and pain away from her awareness through starving, controlling her appearance and trying to control other people's behavior and perceptions. She is certain that if she surrenders control she is doomed to unimaginable horrors.

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It's difficult to convey to a woman who is anorexic that the healing process does not have to be dramatic and extreme. Healing is a gradual process where each level of experience unfolds when the person is ready for it. That's one of the many reasons a mental health professional who understands eating disorders is so helpful. Healing is painful. So is being anorexic and living with hidden pain.

One kind of pain is endless. The other is in the service of healing and living that healthy life she so years for.

The biggest and most important step in healing is that first step...making the commitment to your own healing regardless of fear and regardless of what people think. The young adult anorexic woman knows that building a life on false appearances with no solid base just makes the structure she is creating more apt to topple on its own. The consequences will impact her and people who depend on her presence.

This adds to her anxiety. But this thought can also lead her to make a decisive move toward genuine healing and a genuine life.

There are ways to recover and people to help.

U.S. Sources of Help

More help is available in urban areas than rural areas, but more resources are continually developing around the country. Specific, personal, in depth and confidential attention is available through private practice licensed psychotherapists. This is often more costly than what is available through clinics which often offer treatment at low fee by therapists in training who are supervised by licensed professionals or by HMO programs which limit number of sessions and access to psychotherapy. Some hospitals have excellent in patient and out patient treatment programs for people with eating disorders.

Twelve step programs can be a great support. Plus the people you meet at local meetings may be able to provide good local referrals to public and private resources that may be helpful to you.

Referrals are available online for therapists, out patient and residential programs around the world.

See:

EDAP (Eating Disorder Awareness and Prevention)

The Something Fishy website offers a treatment finder section.

next: Eating Disorder Education: Benefits for Parents and Teens
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sexual problems

Almost everyone, at one time in their lives, will have been attracted to a person of the same gender, but not necessarily felt sexual attraction. We all have idols, heroes or heroines during our growing years, and for many, that is where it ends. But for about 10-15% of the adult population, the feelings of attraction to a person of the same gender persist.

Trying to identify your true sexual orientation may be difficult for some, who might be distressed at the feelings of sexual attraction, and experience behavioral changes, like withdrawal, unwillingness to go out socially, mood swings, eating difficulties, and problems with concentration.

The question 'Am I gay or lesbian?' can be a cause of great pain and turmoil to many women and men alike. In particular, those who have had a strict religious upbringing can suffer very much if they find themselves attracted to a person of the same gender.

Many people suppress their true feelings and form heterosexual relationships, leading to marriage or longterm partnerships in an attempt to be 'normal' or acceptable to family, friends and society. Others suppress their feelings with alcohol, drugs, or even overwork. Sadly, a number of gifted, talented people have committed suicide, rather than face the disapproval or judgment of family members. People do not choose to be gay, they either are or are not, although to date there is no proof that it is either 'in the genes' or determined by experiences in early life.

It can be very helpful to openly discuss these feelings and attractions with someone non-judgmental and supportive, who can help you to discover who you really are.

 

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next: Male Erection: Penis Erection Problems

sexual problems

Men don't like to admit to sexual problems, especially their own.

Women are much more ready to admit ignorance, to find fault with their own behavior, and to look for ways of making things better. Compare women's magazines with men's. The women's magazines have articles on improving sex and fixing problems in virtually every issue. Playboy and Penthouse almost never have such articles. Since so much rides on a man's being good, or at least adequate, in sex, it's very difficult for men to hear they have a problem in this area.

A lot of these differences are things that both sexes have taken heat about. Women are often criticized by partners for their relative lack of interest, not initiating enough, wanting too much foreplay, and taking too long to get aroused or to orgasm. Men have been scolded for every single item on the list. I think the criticism is unfortunate and gets us nowhere. In a sense, everyone is doing what comes naturally, whether naturally be defined as what's built in or what's been learned over the years.

While it is true that we have to learn to accommodate to each other, I don't think blame and accusations or feeling guilty is going to help. We have to feel good about ourselves to have decent relationships and sex. A man should not have to feel guilty for looking at or fantasizing about younger women, for desiring sex without love, or anything else that he is or feels. But neither, on the other hand, should he denigrate his partner. It's fine if you have fantasies about the college girl next door, but it's something else if you make comments about her in front of your lover that imply your lover is inadequate. It's fine if you sometimes want a quickie -- perhaps you can arrange it with your partner -- but it is not fair to complain that you can't have them all the time or that she takes too long to turn on.

The male ways of expressing love and sex are really OK. And so are the female ways. The better we understand and feel about ourselves and each other, the more likely we will be able to make the changes we desire in our sex lives and elsewhere.

From "The New Male Sexuality" by Bernie Zilbergeld, PhD. Copyright © 1992 by Bernie Zilbergeld.

 

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next: Four Perspectives on Sex Problems

men and sex

Not many people talk about male rape and sexual assault. However, I discovered that outside of child abuse and the prison population, the gay community deals with that a lot. I would imagine that men, like women who are sexually victimized, wonder whether what happened was rape and whether they were to blame.

Rape and sexual assault can happen to anyone, including men, regardless of their race, class, age, size, appearance, or sexual orientation.

"I picked up this guy at a bar and took him home with me. He made me have a kind of sex that I didn't want. I was too scared to fight back or refuse. Is that sexual assault?"

Yes. Rape and sexual assault include any unwanted sexual acts. Even if you agree to have sex with someone, you have the right to say "no" at any time, and to say "no" to any sex acts. Rapists sometimes use threats or weapons to force a person to cooperate. It is important to remember that cooperation does not mean consent. Sometimes cooperating with a rapist is necessary to survive the situation. If you are sexually assaulted or raped, it is never your fault - you are not responsible for the actions of others.

What are rape and sexual assault?

A sexual assault is any time either a stranger, or someone you know, touches any parts of your body in a sexual way, directly or through clothing, when you do not want it. Sexual assault includes situations when you cannot say no because you are drunk, high, unconscious, or have a disability.

Rape is any kind of sexual assault that involves the forced penetration of the anus or mouth, by a penis or other object.

Rape and sexual assault are not sex, they are violent crimes. Rape and sexual assault, like any other forms of violence, are used to exert power and control over another person.

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Can men be sexually assaulted or raped by other men?

Yes. Rape and sexual assault can happen to anyone, including men. Thousands of men are sexually assaulted and raped every year, and it has nothing to do with their race, class, age, religion, sexual orientation, size, appearance, or strength. A man can be sexually assaulted by a stranger, a family member, or someone he knows and trusts. Experts estimate that 1 in 6 men are sexually assaulted during their lifetime. Even though male sexual assault remains vastly underreported, the united States Department of Justice documents more than 13,000 cases of male rape every year.

"I was walking down the street late one night and three guys jumped me and dragged me into an alley. They called me a "faggot" and a "bitch", threatened to beat me up, and forced me to give them all blow jobs. It this what I get for being gay?"

No. What you experienced was a sexual assault, a crime of violence, not sex. Attackers frequently use verbal harassment and name-calling during a sexual assault. Sexual assault has nothing to do with the sexual orientation of the attacker or the survivor. While rapists can be bisexual or gay, most of the men who rape and sexually assault other men are heterosexual. Sometimes heterosexual men use rape and sexual assault to target, humiliate, and hurt other men for being gay. A sexual assault does not make you gay, bisexual, or heterosexual.

What are typical reactions during or after a rape or sexual assault?

Sexual assault or rape is almost always a traumatic experience. Sometimes a man who is sexually assaulted or raped has an involuntary or forced erection or ejaculation. Also, muscles in the anus often relax when a man is raped. This does not mean that the survivor wanted to be raped or sexually assaulted. Involuntary erections and ejaculations are normal reactions to trauma.

Although, everyone reacts differently to surviving such an assault, there are some common symptoms and reactions.

Common Physical Symptoms:

• tears in the lining of the rectum
• swelling and abrasion of the anus
• anal warts or lesions
• stiff or sore limbs
• loss of memory and/or concentration
• loss of appetite
• nausea
• changes in sleep patterns
• stomachaches
• and headaches

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Sometimes a survivor can contract a sexually transmitted disease during the assault, but not have symptoms until months later.

Common Psychological Reactions:

• denial
• shame
• humiliation
• feeling of loss of control
• fear
• mood swings
• flashbacks to the attack
• depression
• loss of self-respect
• anger
• anxiety
• guilt
• retaliation fantasies
• nervous or compulsive habits
• change in sexual activity
• suicidal thoughts and behavior
• withdrawal from relationships or support networks.

"My boyfriend and I were having lots of problems. He was going out a lot and having sex and not using a condom. One night he got angry, hit me, stormed out of the house, and came back hours later, stinking drunk. He forced me into bed, fucked me, and refused to wear a condom. I was always careful about having safe sex, now I'm afraid of getting HIV."

Many people are concerned about HIV infection after surviving a sexual assault, and it is important to know the facts. Any contact between your bodily fluids (including blood and semen) and the bodily fluids of an HIV-positive person puts you at risk of contracting HIV. However, repeated contact with HIV is usually necessary for infection.

What should I do if I am raped or sexually assaulted?

Get medical attention as soon as possible.

Go to the nearest hospital emergency room that has a rape crisis program. Although you may feel embarrassed about your injuries, it is important to receive medical assistance. Hospital staff frequently see such injuries to the penis, anus and other body parts, not all caused by rape or sexual assault.

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Even if you do not seem to be injured, it is important to get medical attention. Sometimes injuries that seem minor at first can get worse. Also you may have been infected with a sexually transmitted disease, which may take weeks or months to appear, but may be easily treated with an early diagnosis.

If you are living with HIV/AIDS, especially if you are symptomatic, medical attention is particularly important. Exposure to another persons bodily fluids can further compromise your immune system, or trigger an opportunistic infection.

Going to the hospital can be frightening, especially after surviving a traumatic experience. Ask a friend to go with you, or call the Anti-Violence Project.

Consider talking to a sexual assault/rape crisis counselor.

Counseling is an important way to regain a sense of control over your life after surviving a rape or sexual assault. Counseling can help you cope with both the physical and emotional reactions to the sexual assault and any previous sexual assaults, as well as provide you with the information about hospital and criminal justice system procedures. A counselor can provide you with information and support necessary to help you decide whether or not you want to tell friends and family members about the assault, or report the assault to the police.

Consider reporting to the police and/or pursuing a criminal case.

Sexual assault is a serious crime. As a sexual assault survivor, you have the right to report the crime to the police. If you think you can identify the perpetrator, you have the right to look at mug shots and ride in a patrol car to look for the perpetrator.

Because police are not always sensitive to male sexual assault survivors, it is important to have a friend or advocate accompany you to the precinct to report the crime.

If you are concerned about HIV infection, it is important to talk to a counselor about the possibility of exposure and the need for testing.

next: The Basics of Sex Therapy Homepage

Discover how to deal with the pressure to have sex and why many teens are choosing abstinence.

More and more teenagers are choosing abstinence now because they want to be 100% sure of avoiding STD's (sexually transmitted diseases) and pregnancy. Even teens who have had sex before are making a commitment to be abstinent. Read on to find out more about how to deal with the pressure of having sex, whether it's still possible to get STD's, and why many teens are choosing abstinence over sex.

What exactly is abstinence anyway?

Abstinence means that you are not having sexual intercourse. Sexual intercourse means that you are having "sex" with a partner. Sex can be vaginal, oral or anal. So if someone is abstinent, it means they are not having sexual relations with anyone.

Why are teens choosing to be abstinent?

Many teens choose abstinence because they know that it is the best protection against STD's, and it is 100% effective in preventing pregnancy. Others choose abstinence because of religious beliefs or because of their own values.

Do most teens who have had sex wish they waited?

Yes! In fact 3 out of 4 girls who have had sex wish they had waited longer before having sexual intercourse.

What should I say if I feel pressured to have sex?

A good relationship is about good communication. Talk to the person you're dating and be clear about your values and what you really want. Don't be shy about what you don't feel comfortable doing. The fact is you don't really need to tell anyone why you don't want to have sex. It's good to be honest with the person you are dating early on that you plan to be abstinent. This way there will be no expectations and you both can avoid situations that could make abstinence difficult, such as going to a party where there's alcohol or being alone in an empty house.

My partner keeps telling me. "If you love me, you'd have sex with me."

Don't be fooled by this line! Loving someone doesn't just give them permission for sex. Changing your mind and having sex when you really don't want to is letting yourself down, and it doesn't guarantee that your partner will stay with you either. In the long run, if someone wants to break up with you just because you won't have sex, they really are not worth it.

How can I talk to my parents about sex?

You may think that your parents would be last on your list of people that you would talk to about sex but remember they were teenagers once too and probably faced a lot of similar issues that you are facing now. In fact, your values are based on your parent's attitude about things. Talking to a parent may help you understand your feelings. You might want to start a conversation with your parent(s) about peer pressure. You could mention that you think there's a lot of pressure on teens to have sex. Then you might ask them their feelings about sex before marriage. Parents know that growing up isn't easy. If given the chance, parents can be very helpful and supportive. The important thing to remember is to talk about your feelings with an adult or friend you feel comfortable with—someone you can trust.

Is it possible to get and STD or become pregnant without vaginal intercourse?

It is possible to get pregnant without having sexual intercourse if a male ejaculates near your vagina, since sperm can still get inside of you. If you don't have vaginal, anal, or oral sex, you can't get and STD. You should know that some STD's are spread from oral sex.

Are there any other risks involved with having sex?

Yes. Besides running the risk of getting an STD or becoming pregnant, having sex when you're not ready can cause you to feel bad about yourself and also make you question your relationship.

How will I be able to tell if I'm ready to have sex?

Knowing when you are ready to have sex can be tricky because your body may feel like you are ready. You may feel very romantic with your partner and have the urge to have sex. This is perfectly normal but you should also listen to your thoughts and beliefs to help you decide when the time is right. If you're nervous or not sure, wait until you can make a choice that you are sure of. Remind yourself that abstinence is the only 100% way to avoid pregnancy and STD's. One thing for sure to remember is: "you should never feel pressured or pushed into having sex."

Most teenagers will agree that saying "no" to sex can be hard but having sex is a serious decision that has consequences. You can make a choice to say "no" to sex and still be close with your partner. When you choose to be abstinent, it means you want to wait to have sex until the time is right for you! Talking with someone you trust will help you follow your feelings and values and stick to your decision.

South Korea Women Starving, Victims of Fashion

Thirty miles south of the border with starving North Korea, young women in the South Korean capital are starving themselves, victims not of famine but of fashion.

Dr. Si Hyung Lee has seen this dark side of affluence and modernity. He remembers best the patient who died of respiratory failure: "She was a pediatrician's daughter," said Lee, director of the Korea Institute of Social Psychiatry at Koryo General Hospital in Seoul. "Her father and mother were both doctors."

But her parents failed to realize that their teen-ager suffered from anorexia nervosa -- a disease almost unheard of in Korea a decade ago -- until it was too late to save her.

If Asia is a reliable indicator, eating disorders are going global.

Anorexia -- a psychiatric disorder once known as "Golden Girl syndrome" because it struck primarily rich, white, well-educated young Western women -- was first documented in Japan in the 1960s. Eating disorders are now estimated to afflict one in 100 young Japanese women, almost the same incidence as in the United States, according to retired Tokyo University epidemiologist Hiroyuki Suematsu.

Over the past five years, the self-starvation syndrome has spread to women of all socioeconomic and ethnic backgrounds in Seoul, Hong Kong and Singapore, Asian psychiatrists say. Cases also have been reported -- though at much lower rates -- in Taipei, Beijing and Shanghai. Anorexia has even surfaced among the affluent elite in countries where hunger remains a problem, including the Philippines, India and Pakistan.

Doctors in Japan and South Korea say they also have noticed a marked increase in bulimia, the "binge-purge syndrome" in which patients gorge themselves, then vomit or use laxatives to try to keep from gaining weight, sometimes with lethal consequences.

Experts debate whether these problems are caused by Western pathologies that have infected their cultures via the globalized fashion, music and entertainment media, or are a generic ailment of affluence, modernization and the conflicting demands now placed on young women. Either way, the effects are unmistakable.

"Appearance and figure has become very important in the minds of young people," said Dr. Ken Ung of National University Hospital in Singapore. "Thin is in, fat is out. This is interesting, because Asians are usually thinner and smaller-framed than Caucasians, but their aim now is to become even thinner."

A weight-loss craze has swept the developed countries of Asia, sending women of all ages -- as well as some men -- scurrying to exercise studios and slimming salons.

Liposuction surgeons have popped up in Seoul, as have diet powders and pills, cellulite creams, weight-loss teas and other herbal concoctions "guaranteed" to melt away the pounds.

In Hong Kong, 20 to 30 types of diet pills are in common use, including variations on the "fen-phen" combination of fenfluramine and phentermine that was banned in the United States last month for causing heart damage, said Dr. Sing Lee, a psychiatrist at the Chinese University of Hong Kong who has written extensively on eating disorders. Though the Health Ministry has asked pharmaceutical companies to withdraw the offending drugs, "I'm sure new ones will be coming out right away," Lee said.

In Singapore, where the anorexia death of a 21-year-old, 70-pound student at the prestigious National University made headlines last year, dieting itself has become a fashion statement. On Orchard Road, the city's toniest shopping district, a hot-selling T-shirt designed by "essence" bears this stream-of- consciousness essay on modern female angst:

"I've got to get into that dress. It's easy. Don't eat ... I'm hungry. Can't eat breakfast. But I ought to ... I like breakfast. I like that dress ... Still too big for that dress. Hmm. Life can be cruel."

In Japan, where dieting is less a trend than a way of life for many young women, the principle that thinner is better is now being applied to facial beauty. A recent subway flier for a young women's magazine pictured an attractive model complaining, "My face is too fat!"

Drugstores and beauty salons offer face-reducing seaweed creams, massage, steam and vibration treatments and even Darth Vader-like facial masks designed to promote sweating.

The Takano Yuri Beauty Clinic chain, for example, now offers a 70-minute 'facial slimming treatment course' for $157 at 160 salons across Japan, and reports business is booming.

South Korea is perhaps the most interesting case study since, until the 1970s, full-figured women were seen as more sexually attractive -- and more likely to produce healthy sons, said Lee. "When I was a kid, plumper-than-average women were considered more desirable, they could be a first son's wife in a good house," he said.

But standards of beauty have changed dramatically in the 1990s with democratization, as South Korea's government decontrolled TV and newspapers, allowing in a flood of foreign and foreign-influenced programming, information and advertising.

"The 'be slim' trend starts earlier now, even in elementary school," said the institute's Dr. Kim Cho Il. "They shun overweight boys and girls -- especially girls -- as their friends."

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Dieting by growing teen-agers often leads to inadequate calcium intake and weaker bones. Kim is worried about an increase in osteoporosis cases when this generation of girls reaches menopause.

"The dieting will also result in weaker physiques and lessened resistance against disease," she said.

South Korean psychiatrist Dr. Kim Joon Ki, who spent a year in Japan studying eating disorders, said the increase in eating pathologies over the past few years has been phenomenal. "Before I went to Japan in 1991, I had seen only one anorexia patient," Kim said. "In Japan they told me, 'Korea will be next, so you should study this now.' And sure enough, they were right."

Kim said he has seen more than 200 patients, about half of whom were anorexic and half bulimic, in the 2 years since he opened a private eating-disorder treatment clinic. "Lately I have so many calls that I can't even give them all appointments," he said.

But Kim said his new book on eating problems, "I Want to Eat But I Want to Lose Weight," is selling poorly. "Readers' attention is still focused on dieting, not on eating disorders," he said.

Dieting is not only trendy, it's a necessity for many South Korean women who want to fit into the most fashionable clothes _ some of which are only made in one small size which is the equivalent of an American size 4, said Park Sung Hye, 27, a fashion editor at Ceci, a popular monthly style magazine for 18- to 25-year-old women.

"They make just one size so only skinny girls will wear it and it will look good," Park said. "They think, 'We don't want fatty girls wearing our clothes because it will look bad and our image will go down."'

As a result, "If you're a little bit fatty girl, you cannot buy clothes," she said. "All of society pushes women to be thin. America and Korea and Japan all emphasize dieting."

Park said eating disorders are increasing but still are relatively rare. "If, say, 100 people are dieting, maybe two or three have bulimia or anorexia so it's not enough to worry about," she said. But in the articles she writes on how to diet, she cautions readers against excess, warning, "A model's body is abnormal, not normal."

Park said young Koreans' attitudes toward food differ from those of their elders, who remember hunger after World War II and the old greeting, "Have you eaten?" and fat as a sign of prosperity. "Now skinny (means you are) more wealthy, since everyone can eat three times a day," Park said.

Young women interviewed in Seoul's swanky Lotte department store said dieting was a necessary evil.

"Boys don't like plump girls," said Chung Sung Hee, 19, who at 5 feet and 95 pounds considers herself overweight. "I don't know whether they are serious or not but sometimes they say I'm plump.... So I try to lose weight. I go without food, and my friends use milk diets or juice diets, but we don't last that long."

Han Soon Nam, 29, an advertising company employee, said of dieting: "I don't think it's good but it is the fashion. Everything has a price. You lose your health to get skinnier."

next: Eating Disorders: The Cultural Idea of Thinness
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