Domeena C. Renshaw, MD

Individuals with a past history of chronic psychiatric illness are often given poor prognoses that can limit their therapeutic horizons for further treatment. This pessimism may be misplaced as is demonstrated by the case of Jay, age 71, and Kay, age 65. The couple presented at the Loyola Sexual Dysfunction Clinic in a program consisting of 7 weekly sessions of 5 hours each with 2 trainee therapists.

Jay was born in 1924 in Gary, Indiana, a steel mill town. He was a child during the economic depression of the 1930s during which his father, though never completely unemployed, was reduced to working half time on the railroad. Though hardworking, the family experienced severe poverty. In 1936, when he was 12 years of age, Jay’s mother was institutionalized with a diagnosis of dementia praecox.

In May 1942, with the U.S. involved in World War II, Jay along with 50 of his classmates dropped out of school 2 weeks before graduation in order to have a choice of which branch of service to join. He enlisted in the Air Force and became a flight engineer on a B-24, serving with the 15th Air Force in southern Italy. On a return from a bombing mission over Romania, his bomber lost an engine as a result of being struck by an antiaircraft shell. A Messerschmidt 109 shot down the crippled plane, lagging behind the main formation, over Hungary.

Jay suffered 20 mm shrapnel wounds and was badly burned. Of the 10-man crew, 1 was killed, 1 could not be accounted for, and 1 fell 12,000 feet to his death when his parachute failed to open. The remaining 7 parachuted safely, and after being rescued by Hungarian troops from vengeful peasants, became prisoners of war. Jay spent 6 weeks in a Budapest penitentiary before he and other prisoners were marched off to a prisoner-of-war camp in Poland.

When the Russian army invaded Poland, the German authorities decided to evacuate the prisoners to Germany. Although already at the edge of starvation, Jay spent 3 months on the march, sleeping in fields, ditches, under trees, and in abandoned buildings in conditions of utter privation.

When finally rescued in southern Germany by advancing American troops, Jay weighed 103 pounds (at least 60 pounds under the minimum weight for a man of his size and age) and was not expected to live. Subsequently, Jay experienced recurring nightmares, reliving some of his combat experiences. Upon his recovery and return to civilian life, Jay found employment as an executive with a large national retail chain in California. After a career of 32 years, he retired to his native Indiana.

Jay met Kay at a roller skating rink and began a year-long courtship. He found her to be attractive and down-to-earth, and she saw him as handsome and a good person. They married in 1949 and had 3 sons. Shortly after the wedding, as the only living relative, Jay was expected to assume responsibility for his mother who was being discharged from a mental institution (due to the development of new antipsychotic drugs). Thereupon, his mother came to live with the young couple, an arrangement Kay accepted without complaint for approximately 5 years until he mother-in-law died at the age of 80 years.

In 1980, approximately 15 years prior to presenting at the Loyola sex clinic, Jay suffered a heart attack followed by repair of an aortic aneurysm at the Mayo Clinic. This was understandably a traumatic time for Kay. 

Upon the couple’s presentation at Loyola, Jay was on Inderal (20 mg twice a day) and 1 aspirin daily. He had also undergone knee surgery and had a benign prostate module removed.

Kay had been employed briefly as a bank teller prior to her marriage at age 19. She described her parents as strict, religious, and punitive. Now 65, Kay was physically healthy and kept a good home, but she had a long history of depression dating back to the birth of her third child 39 years before.

The couple’s personal circumstances were further complicated by the treatment of each of their 3 children for acute and chronic depression. Kay described intense guilt whenever she felt sexually aroused by the attractive young men she encountered when shopping. She believed that sexual fantasy was a serious sin and therefore felt guilty. On a number of occasions, she affiliated with and sought advice from a fundamentalist religious group, although she did not divulge her (normal) sexual desires to Jay. He accepted her emotional problems as well as those of his mother, his sons, as well as his own night terrors.

Kay presented at Loyola with a long history of being treated with psychotropic medications and was currently using 6: Eskalith, 450 mg hs; Prozac, 20 mg bid; Mellaril, 50 mg hs; Trazodone, 150 mg hs; Triavil, 425 mg bid (which she had been taking for 20 years); and Xanax, 0.25 mg bid. This polymedication was excessive and blunted her responsiveness. She reported 2 psychiatric hospitalizations-1 postpartum, and the other, at the time of Jay’s aortic valve repair. Several therapists had treated her.

Currently she was being infrequently seen by a psychiatrist to renew her medications. She presented with a pronounced tremor, which suggested Parkinson disease, tardive dyskinesia, or severe anxiety. She complained of increasing memory loss so a CAT scan was done and intracranial pathology was ruled out when this was negative. Her psychiatrist was receptive to our medication reduction proposal.

As mentioned, Jay had a history of nightmares, the most vivid of which was being trapped in a burning aircraft. Kay did not know how to comfort him in these reenactments of his war experience. On retirement, Jay purchased a word processor. In an attempt to deal with his posttraumatic stress disorder (PTSD), he drew upon his diary to author a well-written and detailed autobiography of his World War II experiences (almost to the point of detailing the number of raisins in the Red Cross packages he occasionally received as a prisoner of war).

His nightmares ceased; processing his experiences had permitted him to consign his demons to the written page. His active self-help efforts constituted a strength and an important precedent for both his and her improvement in conjoint sex therapy. Freeing himself was a positive indicator for Kay also.

The therapists began treatment with routine detailed history-taking. Kay disclosed she had never experienced an orgasm; this had gone unmentioned at the initial intake discussion of Jay’s impotence. The 5-hour sessions, part of the normal clinic regimen, fostered an intense dialogue. During the third of 7 weekly sessions, Kay burst into tears and said: “I feel like I have been living in a prison.” The therapists responded that the purpose of the clinic was to assist her in escaping [prison]. 

They noted 2 things: (1) Kay gained new insight into her own situation; and (2) although her medications had remained unchanged, her pronounced tremors had disappeared (eliminating neuroleptic- and/or lithium-induced drug reactions as causative). She was much less anxious after the modified Masters and Johnson touching exercises (part of the Loyola Sexual Dysfunction Clinic routine) that they had been doing at home.

In the fifth session, Kay revealed that she had become orgasmic for the first time (at age 65) with the aid of Jay and a vibrator. Jay was having sustained erections leading to the conclusion that Inderal (Propranolol) was not a factor in his initial complaint. Both were smiling (and the therapists too!). The therapists heard nothing further about Kay’s memory loss or Jay’s impotence. They had successful intercourse. Subsequently, under medical supervision and in cooperation with her psychiatrist, a 4-week plan was initiated to reduce gradually and eliminate slowly all but 1 of her medications. This resulted in a marked improvement in Kay’s alertness and mood.

In the seventh and final week, Jay reported that he had recently returned home to find Kay engaged in an animated telephone conversation with 1 of her relatives. He noted, “We have been married 47, years and I have never seen her like that.” When Kay was queried about her reaction to encountering attractive young men while shopping, she laughed and replied, “When that happens, I go home.” When asked whether she then “took it out on the old man,” she blushed but did not answer (and he made no complaint!) The observed improvement was confirmed upon a single subsequent follow-up visit 3 weeks later.




–Dialogue can be powerful and effective.

 In a true dialogue, none of the committed participants has control of the process that takes a direction of its own
–Relatively open-ended, 4-hour marathons sessions permit complete and uninterrupted exploration of important issues to a final resolution in the absence of deadline pressures imposed by 20-, 40-, or 50-minute sessions. As long as patients are committed to engaging in meaningful dialogue, there is always the possibility of clarifying issues, resolving conflict, or gaining insight.
–Basing an initial prognosis on the patient’s previous diagnosis of chronic depression is inadvisable. With the exception of organic pathology or delusional states, there is a reasonable chance of sexual symptom reversal (or alleviation of other symptoms), regardless of a couple’s previous psychiatric history.
–There is a problem of over-prescription of combinations of tranquilizers and antidepressant drugs (possibly maintained for years after the depression has lifted). In this instance, “dialogue” proved to be the more effective treatment modality.
–Written autobiographical accounts of stressful experiences (self-dialogue) proved to be a valuable method for Jay in dealing with his PTSD. He concluded his story by describing his stable work and family history, a positive ending. This suggests that having a patient provide a written account of his nightmares-with the inclusion of an ending of his own choosing-may have a healing effect (something known from other contexts).
–Resolution of one problem often makes the resolution of other problems easier. Kay’s observation of Jay’s attempts to resolve his problems set the stage for her to resolve her own (suggesting that therapists should follow the line of least resistance in dealing with various problems presented by patients).

The therapists at Loyola took particular satisfaction in the successful outcome of this case. After Jay’s long early struggles and suffering from childhood to marriage, their combined years of care for his mother, depression in Kay and their 3 sons-both deserved a loving and happy retirement together. Basic discussion between 4 persons made personal and sexual healing possible, even at their advanced age.

Dialogue works-and there are times when it may work better than anything else.




1. Renshaw, DC. Seven Weeks to Better Sex. New York: Random House; 1995.

Articles

Individuals with a past history of chronic psychiatric illness are often given poor prognoses that can limit their therapeutic horizons for further treatment. This pessimism may be misplaced as is demonstrated by the case of Jay, age 71, and Kay, age 65. The couple presented at the Loyola Sexual Dysfunction Clinic in a program consisting of 7 weekly sessions of 5 hours each with 2 trainee therapists.

Can Dialogue Cure? A Couple's Therapeutic Journey

Commercially available telephone sex with women has been available at all hours of the day or night for over 25 years to anyone who pays the fee. Explicit sex on screen or interactively in chat rooms is available 24 hours a day, 7 days a week through the Internet. In the 1970s, arrests of voyeurs decreased in Scandinavia when cheap, 5-minute, explicit sex videos could be bought in pornography shops (personal observation, 1981). However, obscene phone callers have not become extinct.

Police often consider obscene call complaints as trivial and a nuisance. They are not easy to trace, so very few obscene callers are actually apprehended. Phone companies report that 20% of all complaints they receive are from women reporting obscene calls from men. Women may make obscene calls or direct solicitations for “business” to men. However, men very rarely report these to the phone company or police because they tend to be amused rather than upset by such calls.

Making an obscene call is a criminal sex offense just as is public display of the genitals (exhibitionism). In fact, scatologia is considered verbal exhibitionism. Explicit sexual conversation with an unwilling listener is illegal-it is an act of public indecency that can result in arrest, a fine, or a jail sentence in the United States.

What kind of man makes an obscene call? The caller may be a teenager, a brain-damaged or mentally retarded person, or a very bright adult con artist. He may be a juvenile or a married father; someone with manic depression or schizophrenia; he may be intoxicated with alcohol or drugs; or an anxious, shy, lonely man afraid of rejection and unable to make a close personal relationship. The range of possible perpetrators is wide. If caught, each will require a careful psychiatric evaluation to answer the question, “What kind of man is this obscene caller?”

What purpose is served by the obscene call? Sexual arousal is the usual goal. There is also anonymity while the caller attains something forbidden-ie, a girl or woman’s ear for his sexual thoughts. An insensitive teen prankster may think it funny to show off and laugh and huddle around a cellular phone with buddies while he makes an obscene call to a girl he knows by name, inconsiderate of her reaction. One such prank call does not qualify for a paraphilic diagnosis (302.9 telephone scatologia, obscene phone calls).

 The behavior must recur for at least 6 months; there must also be an intense preoccupation about talking on the phone about sex explicitly, while the caller becomes aroused, masturbates, and attains orgasm.

There may be comorbid exhibitionism or pedophilia. Direct inquiry is essential. The recipient’s reaction of surprise, fear, upset, and anger may provide the caller with a sense of power and masculinity. Obscene callers describe a strong or intense time-consuming, obsessive preoccupation about making the call. They know it is wrong and possibly legally dangerous. Some callers risk re-arrest for the sake of brief moments of sexual excitement. Evidently, the anticipation is arousing.

An obscene caller may be taking medications, or he may be in therapy. Yet he may feel compelled to repeat the illegal act. On each visit, therefore, the therapist must ask, “Have you made any sex calls since your last visit? When? Do you keep a list?”

Many obscene callers are under a court order to complete a year of psychotherapy. Thus, many callers are not willing patients. A caller may also not show up at therapy until shortly before his court date. Medication (such as an SSRI) can reduce his intense drive for repetition but will not cure his need to make repeat calls. At every visit, the caller should be clearly told this.

Police and the scant scientific literature report that most obscene callers are troubled, immature men who are not dangerous. But how does a victim know that the perpetrator is not dangerous? There is no way to tell. The woman’s first reaction is most often, “Why me?” It may be reassuring for her to realize that the call is incidental or random.

However, if the caller uses her name or address, the recipient has reason for caution. With this indication that the call is not random and that she is not anonymous, the context has changed. If the caller is psychotic, he may be unpredictable. She will worry. Is it her ex-husband, an old boyfriend, someone from work, or a stalker on a car phone outside her home? Did the caller threaten injury to her, a family member, or her property? Was there a demand or blackmail? Should the police be called immediately?

Fortunately, the great majority of obscene calls are made to anonymous recipients. Obviously, the recipient should not give her name or make conversation. She must hang up quietly and expect an immediate repeat call. She should quietly hang up again and again. She could call the phone company’s business office to report the obscene call and request observation and tracing of the originating phone to make a detailed police report.

Volunteers at suicide hotlines are specifically trained to deal with obscene callers because while on duty they frequently receive an obscene call from a masturbator seeking a random female voice/ear. The volunteers are instructed to say, “Please get professional help” and to give their clinic’s office hours because some obscene callers are psychiatric patients who need to resume their medications.

A woman who receives recurrent obscene calls could ask a male relative or friend to record her answering machine message, so that a “random” obscene caller will not hear a woman’s voice. She could also change her phone number or use caller ID, which may solve the problem.

New technology brings new problems. Each person seeks to minimize the negative impact of an unwanted obscene sexual caller on everyday life. A few individuals may benefit from brief counseling as a safe place to discuss fears which may have been triggered by an old remembered horror movie. Medication may be used temporarily to reduce anxiety and restore calm and confidence.

				1. Pakhomou SM. Methodological aspects of telephone scatologia: a case study. Int J Law Psychiatry. 2006;29:176-185.
				2. Price M, Kafka M, Commons ML, et al. Telephone scatologia. Comorbidity with other paraphilias and paraphilia-related disorders. Int J Law Psychiatry. 2002;25:37-49.
				3. Saunders EB, Awad GA. Male adolescent sexual offenders: exhibitionism and obscene phone calls. Child Psychiatry Hum Dev. 1991;21:169-178.


Commercially available telephone sex with women has been available at all hours of the day or night for over 25 years to anyone who pays the fee.

Coping With Obscene Phone Calls

In the 19th and 20th centuries, due to courageous scientific researchers, medicine gradually emerged from total illiteracy about human sexuality. Sir Richard F. Burton, Havelock Ellis, M.D., Sigmund Freud, Robert L. Dickinson, M.D., Alfred C. Kinsey, Sc.D., and William H. Masters, M.D., are but a few who risked much personally and professionally to pursue sexual research. The mysteries and mystique of sexuality gave way to knowledge about the sexual biology and behavior of men, women, children and seniors in health and in illness. The 21st century has brought with it an information age with an abundance and variety of ways in which sexual problems present for solutions.

In this issue we cover a wide range of topics related to sexuality and psychiatry. Some of them are original research resonating with current times. For instance, Melissa Farley, Ph.D., reminds us that we do not need to go to a war zone to find, or prevent, extreme violence. In her article on prostitution and sexual violence she focuses on the plight of women working in the sex industry. This economically disadvantaged, often homeless female population is subjected to a range of abuse, from harassment to battery, rape and torture. Treated like commodities, these women experience devastating outcomes, such as posttraumatic stress disorder, increased risk of suicide, affective and anxiety disorders, substance abuse, sexually transmitted diseases, and traumatic brain injury.

In their article on hypersexuality in children with mania, Barbara Geller, M.D., and Rebecca Tillman, M.S., address a very sensitive and clinically relevant topic: Can an often missed symptom be a cardinal manifestation of prepubertal and early adolescent bipolar disorder? Further, they discuss the issue of validating the diagnosis of mania in children and differentiation from attention-deficit/hyperactivity disorder and other psychopathologies.

Jack Drescher, M.D., focuses on issues relevant for gay, lesbian and bisexual adults, and uncovers from a psychodynamic perspective the struggle homosexual people face while "coming out of the closet." In an attempt to integrate formerly dissociated aspects of the self and fit into their community, these individuals often face homophobia, moral condemnation and antigay violence.

Robert H. Remien, Ph.D., and Jeffrey G. Johnson, Ph.D., in their article on psychiatric disorders and high-risk sexual behavior, highlight the reciprocal relationship between substance abuse, disruptive and personality disorders, and risky sexual behavior. The high rates of sexually transmitted diseases and HIV seen as a result of such behavior are placed in psychosocial context with clear treatment implications.

David L. Rowland, Ph.D., writing about premature ejaculation (PE), underscores the prevalence and broad range of dysfunction associated with PE and provides guidelines for behavioral, psychological and pharmacologic treatment.

Despite such advances in understanding, much remains to be discovered in sexual medicine, which today spans specialties from embryology to pharmacology. Sexual research is still an orphan as far as recognition and funding. It also remains a target for the ignorant to accuse researchers of prurience and oppose their sexual research projects. Child sexual offenders receive lengthy prison sentences, yet there is little scientific understanding or study of their brain function. Should the underlying cause be elucidated using functional magnetic resonance imaging, this may lead to increased protection for society and better treatment of pedophiles.

We are at the frontiers of knowledge. To the ignorant, sex is sex, with no further need to learn and teach. To the wise in society, sexuality can markedly improve the quality of each individual's life. Currently, those with sexual problems struggle to find trained physicians who will assist them. Sexual health remains in the psychiatrist's domain in this millennium and beyond.

acknowledges Drs. Maletic and Renshaw for their assistance in planning and reviewing the Sex & Sexuality Bonus Edition.

Is sexual research still an orphan as far as recognition and funding? Yes. Yet sex and sexuality issues affect the quality of each person's life. As the articles in this Sex & Sexuality bonus issue show, sexual health remains in the physician's domain in this millennium and beyond.

Sexuality and Psychiatry in the 21st Century

Parenthood for father and mother is both a transition and a transformation, although many factors alter the roles themselves (Benedek, 1959; Lamb, 1975). As education, technology, society and the definition of family change--especially with the high divorce rate in the West--fathers in the 21st century are less assured of their impact on the lives of their children.

However, appropriate preparation for fatherhood has the potential to enhance maternal, child and family health (Gage and Kirk, 2002). Emotional and psychological obstacles can be worked through to enhance the father-child relationship. This article will examine the father's changing role in Western society and resources that can help prepare fathers to fill that role.

Throughout human history, war and the abandonment of pregnant women have left children fatherless. Before World War II, the single mother remained within her family circle, where a grandfather or uncle could become a substitute father. Today, the multigenerational family in the affluent West is rare.

A surprise result in a 1999 poll taken in the United States by The National Center for Fathering revealed that 72.2% of respondents saw fatherlessness as the most significant social problem facing America. A 1997 Gallup Poll had shown that 24.7 million children (36.3%) lived without a father. It was estimated that in 1954, 80% of children in the United States lived with both biological parents whereas in 1997 only 50% had intact families. Data from 1997 also show that approximately 58% of black children, 32% of Hispanic children and 21% of white children lived with a single mother.

Obstacles to responsible fatherhood include lack of education, training and jobs needed to provide for children (Lurie, 1992). Aside from programs that provide low-income fathers with the education and work opportunities needed to become consistent providers, to become good fathers, many men require guidance in dealing with feelings of anger or low self-esteem. Support groups can address such issues as child rearing, male-female relationships, decision making, anger control and taking responsibility for one's life (Lurie, 1992).

Another critical factor in a father's involvement with his child is the quality of his attachment to the child's mother (United States Office of Personnel Management, 2000). Lack of attachment and the emotional throes of divorce can upset the father-child relationship. Similarly, in a study of African-American fathers' involvement with their infants, fathers who reported a more satisfying relationship were more involved with their infants (The Fragile Families and Child Well-Being Study, 2004). In addition, adolescent parenthood has been associated with long-term outcomes of greater depression compared to men who became parents during their 20s (Heath et al., 1995). Treatment of anger and depression can help guide men to becoming good fathers.

warned that there were problems with the "privileges" of being a man. He believed it was a form of discrimination that a pregnant woman had the total say about an unexpected pregnancy--the father could not insist on an abortion nor that she not abort. The law protected only her decision, not his. He also felt that many men stayed trapped in a difficult marriage and encouraged them to put themselves first. He devoted a chapter to 19 impossible binds in which a man was "damned," regardless of the choice he made. Goldberg felt social pressures were contradictory to a man's inner needs.

Feminine rearing of boys who were later expected to be tough men was a particular issue. The task of dis-identifying from mother is a developmental task for every boy (Greenson, 1968). Fathering, therefore, remains a key issue for single mothers and in divorced families. Male teachers, ministers, sports heroes and even gangs play a role in providing substitute father figures, for better or for worse.

Since the early 1950s affordable single-family homes, distance from traditional multigenerational families and reliable daytime child care have allowed both parents to work outside the home. As a result, many working parents also took turns to watch their children. Fathers found they could become competent nurturers who could feed, burp, bathe, soothe and diaper their little ones and, in return, discovered unconditional love and smiles. For the long hours and hard work there was gratifying adoration of "Daddy." Patience, protection and persistence are learned parenting qualities, essential and reinforced daily (Benedek, 1959).

Society today has given fathers confusing expectations: Be a good provider; be an aggressive workplace competitor; be a fearless protector; be wise, gentle and sensitive in difficult times; plus, be a considerate lover to your children's mother. For many, parenting is the emotional birth of responsibility for the survival of an important other beyond the self.

How similar are the parenting skills between mother and father? Some have said that after delivery the only real mothering and fathering difference is breast-feeding. Many will list patience, endurance, tolerating sleep deprivation, acute hearing to wake up for a crying baby, coping with messy secretions, laundry, food preparation and other details as mother's tasks. By trial and necessity, these can be learned--usually the hard way. Once mastered, a routine makes domestic tasks much easier or even a challenge for a caretaker father if easier or quicker ways are discovered.

The difference for today's fathers is a new awareness of all the stages of fatherhood. Reading materials are always of value. The Internet has abundant articles and resources (See Table).

The role of the father is rarely consciously taught from father to son. Modeling requires side-by-side daily living and observation of positive or negative behavior. A few contemporary fathers have a new appreciation of fatherhood and have written to encourage and assist fathers about the pitfalls and growth potential (Downey, 2000; Hass, 1994).

Because the mother carries the baby, the mother-child bond is usually more binding than for the father. The father-child attachment bond has been neglected, understudied and often undervalued. In the 1970s, Michael Lamb's research on how fathers contribute to their children's development showed significant positives to daughters' achievements, as well as to sons' (Lamb, 1975).

Many men say, "I am trying to be for my children the father I never had, the father I wish I had when I was growing up." Fantasy is powerful, so the idea of a dream dad may frequently be the opposite of the drunk, absent or divorced father.

When past childhood resentments surface about how an individual suffered due to a neglectful, absent, mean or cruel parent, there is a useful technique to examine retrospective details of what was experienced. The exercise, a copy of which can be found online at www.psychiatrictimes.com/fathering2.html, asks the patient to recall what they liked most then least about their mother and father, then write it down. Perspective is vital for healing through understanding how current behavior may actually repeat the past, so that change and growth can proceed.

Reflex erections or sudden arousal may occur in a care-taking parent quite normally. These must be recognized, controlled instantly and expressed later alone or with the appropriate peer partner. Incest is a criminal offense, harmful to a child and also to the parent who neglects the protective parent role (Renshaw, 1982).

Making peace with one's parents for perceived neglect, oversights, unfairness, abuse and even exploitation means understanding and forgiveness for being who they were--products of their own rearing and personal weaknesses. Love is earned by each person, but forgiveness will bring peace to the individual who had a difficult or negative parent.

Today we recognize a variety of fathers: traditional married father; adolescent father; single father; at-home father; homosexual father; divorced (part-time) father; bootcamp new fathers who decide to have a "great baby race"! The father-child attachment bond must form and will vary with individual differences between parent and child. It takes years to build trust and love. Parent-child differences, conflict and hostility should be expected and may endure for years despite underlying loyalty and care. Self-help resources and professional intervention can better prepare fathers emotionally and psychologically to be effective parents.

 Benedek T (1959), Parenthood as a developmental phase; a contribution to the libido theory. J Am Psychoanal Assoc 7(3):389-417.
 

 Downey P (2000), So You're Going To Be a Dad. Tucson, Ariz.: Fisher Books.
 

 The Fragile Family and Child Well-Being Study (2004), Unmarried African-American fathers' involvement with their infants: the role of couple relationships. Fragile Familes Research Brief No. 21.
 

 Gage JD, Kirk R (2002), First-time fathers: perceptions of preparedness for fatherhood. Can J Nurs Res 34(4):15-24.
 

 Goldberg H (1976), The Hazards of Being Male: Surviving the Myth of Masculine Privilege. New York: Nash Publications.
 

 Greenson RR (1968), Dis-identifying from mother: its special importance for the boy. Int J Psychoanal 49(2):370-374.
 

 Hass A (1994), The Gift of Fatherhood: How Men's Lives Are Transformed by Their Children. New York: Simon & Schuster.
 

 Heath DT, Mckenry PC, Leigh GK (1995), The consequences of adolescent parenthood on men's depression, parental satisfaction, and fertility in adulthood. J Soc Serv Res 20(3-4):127-148.
 

 Lamb ME (1975), Fathers: forgotten contributors to child development. Hum Dev 18(4):245-266.
 

 Lurie T (1992), Fathers and families: forging ties that bind. Ford Found Rep 23(3):3-8.
 

 Renshaw DC (1982), Incest: Understanding and Treatment. Boston: Little, Brown & Co.
 

 United States Office of Personnel Management (2000), OPM's Third Annual Conference on Fatherhood: Multiple initiatives help men to be better fathers. Focus on Federal Employee Health and Assistance Programs 11(2):1-2,8.

As society and the definition of family in the West changes, fathers in the 21st century face emotional and psychological obstacles to a healthy parent-child relationship. This article examines professional interventions and other resources that can help prepare fathers to be effective parents.

Fathering

"The Internet is like being in another world- you can pretend to be everything you ever wanted to be. There are no rules and no sense of time. In one hour you can tell each other all about yourselves. It's so interactive- question and answer and so quickly. No limits." Exhilaration was the expression of a 49-year-old divorced male gynecologist with the password "lady's doc."

"It's so safe. In my own den, without dressing up or driving, I chatted for hours to so many women. We laughed, told jokes, shared fantasies and had fun. No one was trying to get laid, but there were lots of sexual comments. I never could talk to my wife. Here we each took turns listening to the other- funny saying listen when it's reading. I couldn't believe it was 2 a.m. when I checked my watch- four hours on-line." 

His new computer toy delighted him. It is "the best dating tool ever. Believe me, in three years I've tried many ads, clubs, groups." He found that four of the many "chat room" women he contacted lived within a few miles. He met with each. "They all fizzled." Why? "Two were much older than they sounded. One was a huge lady, twice my height and size. The fourth was obnoxious; I couldn't wait to leave, I faked a beeper call." But he still thought it was all highly entertaining, even six months later. The novelty and frequency of use later lessened, "like my CB and cellular phone."

 Some psychologists are studying teens and how they use the Internet. Sherry Turkle, for 

, interviewed 300 teens, most of whom said they knew much more about the Internet than either of their parents. Some teens realize they need to be "cybersmart" since exploitation, taunting, teasing and put-downs are all possible. "I was called 'chicken' and 'dud' when I did not give my phone number or address." 

Other teens totally deny danger: "You can't get pregnant on the Net or catch AIDS or get raped or killed." Another said, "The language is awful, but it's kind of exciting to see such a lot of it and to write smut. I hear obscenities at school all the time, kids think it's cool or big stuff. I feel scared, yet weird to write bad words, or sexy talk. It's sort of dangerous. I'd never do it face-to-face, but I can get away with it because I'm sort of invisible. Then I worry whether they can trace me. I know enough not to give out my password, my phone number or my address. That would be dumb." For this 14-year-old girl, cybersex was fun.

An anxious mother called me. Her 13-year-old had been "chatting" to a man in jail several times, mostly about sex and love, pretending she was 18. She had given him their home address and phone number. An adult male voice called the home that morning for Belinda (the 13-year-old, who was at school) to say their friendship on the Net was great, could she visit him? Her mother was upset and had called the police, who told her they could do nothing. It was not a crime to telephone. The prisoner had told Belinda the truth about being jailed, and that he was due for parole within six months. The parents were concerned he might come to their home. Would a VChip or Parental Control insert have prevented this? Probably not. 

Human impulsivity, youthful ignorance, adventure search, learning the limits of this new medium are all variables as yet to be considered. Could he be dangerous? No one can answer that question yet. The parent must educate Belinda about truth, the consequences of lying, why people go to jail, about potential harm to herself, family or the home. 

An 8-year-old boy in a Chicago classroom downloaded hard-core explicit pictures on his computer to the teacher's horror and the giggling of some of his classmates who all wanted to know how he did it so they could do the same. The teacher insists it was not an accident as he claims. The principal agrees. So far the boy has not repeated the feat.

A 15-year-old girl from the suburbs, on the Dean's list, stable, hardworking, with a steady boyfriend, received a dozen roses "from your Boston lover." Within days she told her parents she would sleep over with a girlfriend but instead met a 21-year-old woman at an airport hotel. The next day she returned home from school to say she had broken up with her boyfriend and has elected to become a lesbian activist. Both parents insisted on counseling. The Internet friendship continued. 

The mother called, upset because the selected social worker therapist for the teen considered her daughter to have a "definite homosexual identity" and will not discuss any therapy details with her. Mother was advised to request some parent conjoint (family) sessions with the same therapist to improve parent-child understanding. Impulsive experimentation or lifelong commitment? In 1996 some parents are adding Web worries to their list of potential dangers to their children.

 A 57-year-old female woman going through a difficult divorce met "the love of [her] life" on the Internet. He is a 52-year-old government scientist living in New Mexico, a divorced father of two adult college-age children. They chatted about astronomy for three months and then sent e-mail daily. She was no longer anxious, angry or depressed about her derisive husband. The screen messages were uplifting. She flew West for a weekend. 

"We clicked. It's too good to be true; we have communicated for so many hours, we know each so well..." That she is wealthy, emotionally vulnerable and sexually adventurous were issues raised in therapy but dismissed by the patient, who had come for a termination session. "I'm on cloud nine for the first time in years. I don't need treatment now. He's invited me to a function in D.C. where he will lecture. He didn't offer the airfare, he knows I can afford it." 

This lady in the short term has found delight and joy on the Internet. She has blinded herself to realities such as financial exploitation and a possible breakup later. Denial is powerful. With adolescent abandon she has seized the moment. Her lawyer husband has all along deliberately delayed divorce cooperation, unaware of this affair. This fact no longer distresses her. "Life is too short to worry." Love is both blind and deaf for her for now.

New technology has offered an exciting arena of communication, not only for the business world but for every person able to use a computer and rent Internet time. Anyone, even a child, can access an enormous variety of material. Medical data, Disney stories, or vivid, violent sex can be viewed from Russia to Rhode Island. Words and pictures may be downloaded and printed for entertainment, learning, business or for copycat trial. For most users there will be amusement but sensible caution. 

For the lonely, the impulsive, the troubled or the exploiters, the Internet can become the Singles Bar of the 1990s. Both parties may lie about age, looks, etc. Privacy may be invaded, combining persuasion and inexperience as with the 13-year-old who gave her phone and address to a man in jail without realizing consequences. There was secrecy, pleasure and power felt by this minor and the one who received flowers and a visit from Boston. Yet these feelings were duplicated by the 57-year-old lady who flew West to meet her chat-lover. Who said common sense was common? 

 Sometimes laws are passed to protect citizens from themselves. Recently, Congress did not succeed in censorship of the Internet (through the Communications Decency Act passed on Feb. 8, 1996, but overturned on June 12). The constitutional right to free speech on this vital new interactive medium was given priority since other laws existed regarding child abuse and pornography. The justices stated that children must actually know how to access graphic sex so it is still up to parents (not the courts) to shield minors. 

It may not yet be the legal end of the debate, because the Supreme Court may still have to examine the new technology, the perceptions and the realities of danger on the Internet. At this time the value of access to commercial and educational material has taken precedence. The market has rapidly offered a variety of "screening devices" such as Surfwatch, Cyber Patrol and Net Nanny to assist parents. Basically it is old-fashioned discipline that must limit the child's on-line time by saying no if the family values or budget cannot accept the child's Internet involvement at the time, and provide alternative programs for the children.

 It will probably be two years before psychiatric literature reflects case studies of Internet impact on persons of all ages. Already fax and e-mail have been helpful links between patient and physician. It is possible that for shy, anxious, lonely patients the treating psychiatrist might recommend classes on how to use the Internet. It may expand their interactive skills, allow them some pleasurable interactions so they can learn to dialogue (to listen and to reply), to focus and to concentrate, to tease and to laugh. These would be gains and even growth. 

Risks must also be discussed with each patient when the suggestion is made, as with any social support group or lifestyle change. 

Therapists must evaluate this new frontier of interaction as it presents in today's practice. Printouts can be brought in for discussion in therapy. Will therapy become obsolete? No. Will therapists use the Internet to do therapy? Not soon, since managed care providers will have to have strategic planning meetings to calculate how many minutes will be approved per session! 

Author | Domeena C. Renshaw, MD

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