WOMENSSEXUALHEALTH

SEXUAL ASSAULT: FIRST REACTION:
Immediately after the attack, you'll probably feel confused and extremely afraid. A few hours later, these feelings will give way to depression, exhaustion, and restlessness. In about two weeks, you'll begin to feel better emotionally; but three weeks later, your symptoms may worsen again.

You may experience severe bouts of fear and depression and have problems with self-esteem, social adjustment, and sexual dysfunction for up to 18 months after the assault. These symptoms will probably last at least 6 years. Women who were raped as children may repress the memory, only to have it resurface full-force years later.

It's important to talk with a professional about your assault and your reactions to it. A psychiatrist, therapist, or counselor specially trained to work with rape victims can help you understand that you really are the victim and are not to blame for what happened. Vent your anger, fear, desperation, even guilt—and discuss how you feel about the attack at the present time. In that way you can learn how to deal with your emotions and get on with your life.

EXAMINATION:
Next, a doctor will examine your vagina and treat anything that needs attention. He or she will also look for semen or other signs of sexual intercourse and take samples of secretions from all areas involved in the attack.

A doctor, nurse, or technician will trim and comb your pubic hair to check for foreign tissue or fluids. You may be asked for a blood sample to test for the presence of alcohol or other drugs and a urine sample to find out if you were pregnant before the assault.

AT THE EMERGENCY ROOM:
You will probably speak to a nurse or other emergency room personnel before the doctor sees you. First they will ask routine questions about your vital statistics, medical insurance, allergies, and the type of birth control you use. They also need to know whether you're in pain, when you last had sex before the rape, and the date of your last period. By finding out how recently you menstruated, they can determine how likely it is that the attacker made you pregnant.
They will also ask questions about the assault; for example, whether the rapist used a condom, whether he bled or had an ejaculation, and whether you scratched him. Tell the doctor or nurses everything you recall. If you're not sure of the details, simply say you don't remember. The answers you give to their questions may become part of the record if you go to court.

A nurse may also take pictures of your visible injuries. (Sometimes it takes several days for bruises and other injuries to appear, so you will want to ask a friend to take instant photographs of anything that shows up after your hospital visit.)

FIRST PRIORITY:
Even if you think you're all right, see your own doctor or go to the hospital emergency room as soon as possible after the rape. The assault may have left you with undetected injuries that need prompt treatment. After examining you thoroughly, the physician will perform tests for sexually transmitted diseases and pregnancy and will collect evidence you'll need if you decide to prosecute the attacker. Since some of this evidence is lost after 36 hours, it's especially important to get immediate medical attention.

Do not shower, douche, change clothes, or otherwise try to clean up before going to the emergency room. Bring along a change of clothes; the ones you were wearing during the attack will be kept for evidence. You may want to take a trusted friend, a family member, or a rape crisis worker with you for support.
Kelly seemed to have it all. A loving mother of three and a public-relations executive in Manhattan, she had a handsome and charming partner who was a successful entrepreneur. They jetted off for vacations in the Caribbean and dined in the finest restaurants. But their relationship floundered in one intractable area.
"After a while," Kelly says, "he just stopped wanting to have sex. He'd go months without even touching me."

It's a subject that's full of shame: low sex drive. When your partner has no interest in sex despite your best efforts, it's easy to become perplexed. And without guidance, partners may characterize the problem in ways that can destroy the relationship.

In a society saturated with sexual imagery, it seems strange that some people have no desire for sex. But it is a startlingly common problem. Millions of people suffer from a condition known as hypoactive sexual desire (HSD), about 25 percent of all Americans, by one estimate, or a third of women and a fifth of men. Sex researchers and therapists now recognize it as the most common sexual problem.

In recent years, experts have turned their attention to the causes of HSD, and sex therapists are working on strategies to treat it. Although there is a 50 percent positive outcome in treatment, many of those who have HSD don't seek help. This is usually because they don't realize it's a problem, other issues in the relationship seem more important or they feel ashamed.

Many couples in conflict may have an underlying problem with sexual desire. When desire fades in one partner, other things start to fall apart.
How Little Is Too Little?

For Pam, happily married and in her forties, her once healthy sexual desire simply disappeared about six months ago. "I don't know what has happened to my sexual appetite," she says, "but it is like someone turned it off at the switch." She and her husband still have sex, maybe once every few weeks, but she does it out of obligation, not enthusiasm.

"I used to enjoy sex," Pam says. "Now there's a vital part of me that's missing."

Ordinary people aren't in a constant state of sexual desire. Everyday occurrences "fatigue, job stress, even the common cold" can drive away urges for lovemaking. Usually, however, spending romantic time with a partner, having sexual thoughts or seeing stimulating images can lead to arousal and the return of a healthy sex drive.

Yet for some people, desire never returns, or was never there to begin with. Frequently, even healthy sexual fantasies are virtually nonexistent in some people who suffer from HSD.

Just how little sex is too little? Sometimes, when a partner complains of not having enough sex, his problem may actually be an unusually high sex drive. Experts agree that there is no daily minimum requirement of sexual activity. In a British survey, published in the Journal of Sex and Marital Therapy, 24 percent of couples reported having no sex in the previous three months. And the classic study, Sex in America, found that one-third of couples had sex just a few times a year. Although the studies report frequency of sex, not desire, it's likely that one partner in these couples has HSD.
One Tiny Pill

Years ago, another sexual problem "erectile dysfunction" received a sudden burst of attention when a medical "cure" hit the shelves. Before Viagra came along, men with physically based problems suffered impotence in silence, and without much hope. Now many couples enjoy a renewed reservoir of passion.

Obviously, any pill that relieves hypoactive sexual desire would be wildly popular. Unfortunately, the causes of HSD seem to be complex and varied; some sufferers might be treated with a simple pill, but most will likely need therapy—not chemistry.

One common source of reduced desire is the use of antidepressants known as selective serotonin reuptake inhibitors. SSRIs have been found to all but eliminate desire in some patients. Antidepressants such as Prozac and Zoloft are among the most widely prescribed drugs for treating depression. Yet one distressing side effect is a drop in sex drive. Some studies indicate that as many as 50 percent of people on SSRIs suffer from a markedly reduced sex drive.

Researchers believe that SSRIs squash the libido by flooding the bloodstream with serotonin, a chemical that signals satiety. "The more you bathe people in serotonin, the less they need to be sexual," says Joseph Marzucco, MSPAC, a sex therapist practicing in Portland, Oregon. "SSRIs can just devastate sexual desire."

Fortunately, researchers are studying antidepressants that act through other channels. Bupropion hydrochloride, which enhances the brain's production of the neurotransmitters dopamine and norepinephrine, has received extra attention as a substitute for SSRIs. Early studies suggest that it may actually increase sexual desire in test subjects. A study reported last year in the Journal of Sex and Marital Therapy found that nearly one-third of participants who took bupropion reported more desire, arousal and fantasy.
It's All In Your Head

Physiological problems can also lead to a loss of sexual desire. Men with abnormal pituitary glands can overproduce the hormone prolactin, which usually turns off the sex drive. As reported in the International Journal of Impotence Research, tests of a drug that blocks prolactin found it increased the libido in healthy males.

In women, some experts believe that one cause of weak sexual desire is, ironically, low testosterone levels. Normally associated with brawny, deep-voiced men, testosterone is a hormone with a definite masculine identity. But women also make small amounts of it in their ovaries, and it plays an important role in their sexual lives. Without a healthy level of testosterone in the blood, some researchers believe, women are unable to properly respond to sexual stimuli. Furthermore, there is anecdotal evidence that testosterone supplements can restore the sex drive in women.

Rosemary Basson, M.D., of the Vancouver Hospital and Health Sciences Center in British Columbia, however, cautions that too little is known about the role testosterone plays in women. "We don't even know how much testosterone is normal," Basson says. "The tests designed for men can't pick up the levels found in women."

In one study suggesting that HSD is more psychological than physiological, Basson and her colleagues tested the effects of Viagra on women who reported arousal problems. Basson found that while the drug generally produced the physical signals of sexual arousal, many women reported that they still didn't feel turned on.

Indeed, many psychologists and sex therapists believe that most patients with HSD have sound bodies and troubled relationships. The clinical experience of Gerald Weeks has shown that two factors identified in a relationship can, over time, devastate the sex drive: chronically suppressed anger toward the partner and a lack, or loss, of control over the relationship. And once these issues threaten a healthy sex drive, lack of intimacy can aggravate the problems further. Without help, these issues can balloon until the relationship itself is seriously damaged. And, consequently, HSD becomes further entrenched.
Lacking The Desire For Desire

Although HSD is one of the most difficult to address of all sexual problems, it can be treated successfully. The key is to find a highly qualified sex and marital therapist who has experience in dealing with it. Unfortunately, while HSD is the most common problem that sex therapists see, millions of cases go untreated.

Some people who lack desire are just too embarrassed to seek help, especially men. Others are so focused on immediate concerns—such as a stressful job or a family crisis, that they put off dealing with the loss of a healthy libido. Still others have become so used to having no sex drive that they no longer miss it; they lack the desire for desire. These people represent the most severe cases, the hardest to treat.

Some people who don't get treatment find ways to adjust. "Thank goodness my husband is so patient and caring," Pam says. "He tries to spark interest, but when it is not ignited he'll settle for cuddling and caressing."

Other relationships can't survive the strain. After a year, Kelly and her boyfriend broke up. "I couldn't convince him that it was a problem," she says, "but it was."