I slam the locker and dial Security.
Across the hall, fifty beds bulge
with the high tide of labor.
Grandmothers with boom-boxes
boogie in the aisles
and sponge breasts of girls
who cry 

.
At any moment one will rise,
heave and stumble
past students and ultrasounds
to the corridor called Labor Line.
Babies burst out before their time
and midwives catch them above the slop
of blood and stool and amniotic fluid,
medical students thrilled by a footling breech,
a four-fingered hand, the drama of hemorrhage,
clamps, forceps and suture dancing
as child-mothers moan 

.
Cleaned and toweled, we give up
babies to grandmothers who live the struggles
of milk and blood on barren streets,
a cradle lined with broken glass and gunfire.
And after legions of new lives have wailed
into this world, I wait for Security's safe delivery
to the parking lot, where the city heaves
its great contractions, and night labors hard
toward morning.
© CME LLC
3/01

Articles

Obstetrics Ward, County Hospital - Poetry of the Times

Obstetrics Ward, County Hospital

(This is the third part of a series on the 2000 New Clinical Drug Evaluation Unit [NCDEU] meeting, held May 30 through June 2 in Boca Raton, Fla. Part I appeared in the September issue of 

Evaluations of new drugs, new dosage formulations and new applications for currently approved drugs were a substantial portion of the scientific program at the 40th annual NCDEU meeting, which is sponsored by the National Institute of Mental Health.

Extrapolating from the long half-life of fluoxetine (Prozac) and its major active metabolite, norfluoxetine, Eli Lilly and Company researchers reported successfully developing a modified-release, enteric-coated 90 mg formulation for treating depression with a once-weekly administration. An application for the novel formulation was submitted to the U.S. Food and Drug Administration in March.

The effectiveness of the weekly dose for antidepressant maintenance was compared to fluoxetine 20 mg/day in patients with major depression who had improved in a 13-week open trial with the daily regimen. Mark Schmidt, M.D., and colleagues at Lilly continued 189 patients on daily fluoxetine. They converted 190 patients to the weekly formulation and 122 to placebo for 25 weeks in randomized, double-blind fashion. The active treatments were found to be similar in effectiveness and were associated with significantly lower relapse rate than placebo.

In a separate study with Lilly researchers in the United Kingdom, patient compliance with the weekly enteric-coated formulation was compared in 56 patients to compliance with daily fluoxetine in 53 patients over a 12-week study period. In comparison to the 83.2% baseline compliance over a four-week, open-label treatment with daily fluoxetine, the patients converted to weekly dosing were rated 85.9+21.4% compliant, while those continuing with daily dosing decreased to 79.4+16% compliance with their regimen.

An investigational transdermal delivery system for selegiline (Eldepryl), a selective monoamine (MAO)-B inhibitor approved for treatment of Parkinson's disease, was assessed for possible benefit of patients with major depression by Jay Amsterdam, M.D., and Alexander Bodkin, M.D. At six sites, 177 patients with a score of at least 20 on the Hamilton Rating Scale for Depression (HAM-D-17) were randomized in double-blind, parallel-groups to receive either the transdermal system (89 patients), which delivered 20 mg selegiline daily, or a placebo patch.

The investigators reported that their criteria for response of at least 50% reduction in HAM-D score was met in 37% of those receiving medication, compared with 24% of those on placebo. Response on the Clinical Global Impression (CGI) scale was found in 42% of medicated patients and 28% of those on placebo. The statistical separation of drug and placebo was apparent by week 1 on the Montgomery-Asberg Depression Rating Scale (MADRS).

Except for a local application-site rash with the medication patch, there were no differences in adverse reactions between groups. The investigators found that their data, albeit preliminary, suggest that the transdermal delivery of selegiline may be a safe and effective treatment for patients with major depression, and it may have a relatively rapid onset of action.

The kinetics and safety of a new intramuscular (IM) depot formulation of risperidone (Risperdal) were reported by Marielle Eerdekens, M.D., and colleagues at the Janssen Research Foundation. The investigators tapered the oral risperidone regimen of stabilized patients with schizophrenia, while providing depot doses at two-week intervals. They found oral and depot dosing to be equivalent in the total amount of active drug available within the respective dosing periods. As expected, however, peak plasma concentrations were significantly lower with depot injection than after oral dosage. In addition to being bioequivalent to oral dosing, the IM depot was well tolerated.

Several studies with the selective norepinephrine reuptake inhibitor antidepressant reboxetine (Vestra) were presented. The agent is used clinically in Europe and is pending regulatory approval in Canada and the United States. Maurizio Fava, M.D., and Patrick McGrath, M.D., collaborated with Pharmacia & Upjohn Corp. (now Pharmacia Corp.) researchers in evaluating the efficacy and safety of reboxetine in patients with major depression. These patients had failed to respond to at least six weeks of fluoxetine treatment, with 40 mg daily given for the last three weeks of treatment.

At the time of their report to the NCDEU, the researchers had enrolled 80 outpatients in the study. The patients were started on reboxetine 4 mg twice daily without a washout period and were treated for a total of eight weeks, with option to increase daily dosage to 10 mg after four weeks. Patients were then randomized to a 24-week, placebo-controlled discontinuation phase. The investigators indicated that patients tolerated the switch from fluoxetine to reboxetine, although they experienced more adverse events during the first four weeks than in the second. Preliminary results indicate a statistically significant reduction in the HAM-D-25 scores from the fluoxetine-treatment baseline at both four weeks and end of treatment.

James Ferguson, M.D., and colleagues described changes in suicidal ideation in trials with reboxetine from a review they conducted. Ferguson indicated that they had consistently found significant decreased scores in the suicidal-ideation item 3 and depressed-mood item 1 on the HAM-D from baseline to each assessment, with the depressed mood item score reduction evident in some cases in the second week of treatment.

Intramuscular ziprasidone (Zeldox), an investigational antipsychotic formulated in both a rapid-acting IM and oral dosage form, was evaluated in two 24-hour, double-blind trials in 20 mg, 10 mg and 2 mg for acute agitation and psychosis; and in two open-label, seven-day trials in comparison with IM haloperidol (Haldol), in fixed and flexible dosage.

Dan Zimbroff, M.D., and colleagues reported that IM ziprasidone in 10 mg and 20 mg produced rapid, significant, dose-related reductions in symptoms of agitation, while the 2 mg dose was ineffective. In comparison to IM haloperidol, ziprasidone evidenced significantly greater reduction in the Brief Psychiatric Rating Scale (BPRS) scores, and it was associated with a substantially lower incidence of movement disorders.

Several reports were also presented from an evaluation of oral dosage ziprasidone treatment of patients who had not tolerated, or adequately responded to, either conventional neuroleptics (93 patients), olanzapine (Zyprexa) (88 patients) or risperidone (41 patients). In three separate six-week, multicenter, open-label trials, these patients were randomized to ziprasidone in a variety of dosing schedules from 40 mg/day to 160 mg/day.

Nina Schooler, Ph.D., and Cynthia Siu, Ph.D., of Pfizer Inc., examined the changes in the Positive and Negative Symptom Scale (PANSS) anxiety item score for these patients to ascertain any anxiolytic effect of ziprasidone. They posited that the agent's unique pharmacological profile, which includes serotonin and norepinephrine reuptake inhibition and serotonin 5-HT1A receptor agonism, might have antianxiety properties.

Significant improvement in the PANSS anxiety item score was found to occur with ziprasidone treatment in patients with at least minimal baseline anxiety. This improvement appeared independent of changes in depressive symptoms or somatic concerns. The investigators called for further study of the agent's possible anxiolytic activity, in view of the prevalence of anxiety symptoms in schizophrenia.

New Products, Applications Assessed at NCDEU

(The following are highlights of new research presented at the 2000 American Psychiatric Association Annual Meeting. Additional highlights can be found in "APA Meeting Highlights New Research," in the February issue of 

Bupropion Sustained Release in the Treatment of Dysthymic Disorder

This study was conducted to evaluate the efficacy of bupropion (Wellbutrin) sustained release (SR) in treating dysthymic disorder. Subjects meeting 

 criteria for dysthymic disorder were enrolled in this eight-week, open-label study. Bupropion SR was initiated with 150 qd and increased to a maximum of 200 mg bid for 21 patients.

Of the 21 subjects, 15 were treatment responders, with response defined as 50% drop in Hamilton Rating Scale for Depression (HAM-D) score. Patients with a diagnosis of past alcohol or chemical abuse were significantly less likely to respond to bupropion SR.  Minor side effects were reported. Neither sexual dysfunction nor weight gain was reported. The findings suggested that bupropion SR was not only effective in treating dysthymic disorder but also highly tolerable among patients (Hellerstein DJ et al., NR702).

Prevalence and Assessment of Antidepressant-Induced Sexual Dysfunction

Antidepressant-induced sexual dysfunction (AISD) has become an important clinical side effect since the advent of selective serotonin reuptake inhibitors and the newer generation of antidepressants. Each of the major classes of antidepressants is associated with variable rates of sexual dysfunction. The early data in package inserts regarding AISD's prevalence are grossly underestimated because studies used-by default-a "don't ask, don't tell" methodology. In head-to-head studies using established rating scales to measure sexual functioning before and after treatment, findings indicated that bupropion, nefazodone (Serzone) and mirtazapine (Remeron) are associated with the least incidence of AISD. On the other hand, fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa) (the SSRIs) and venlafaxine (Effexor) are associated with substantial rates of AISD. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) have a long history of AISD as well, but the rates are less clear because of methodological limitations (Nierenburg AA, Symposium 2B).

Smoking, Smoking Cessation and Antidepressants

Researchers have reported that smokers with a history of depression who succeed in smoking cessation are at risk for new episodes of depression. As one might assume, this has serious ramifications for patients who smoke. New episodes occur not only in the immediate withdrawal period but also for months after cessation.

Antidepressants, bupropion in particular, have effectively aided smoking cessation, whether or not the patient is depressed. There is also evidence that the TCA nortriptyline (Pamelor) may be useful. No study has shown SSRIs to be beneficial (Glassman AH, Symposium 6B).

Weight Changes Associated With Long-Term Antidepressant Therapy

Short-term effects of antidepressant drugs on body weight may be different from those seen during chronic therapy. Early in treatment, SSRIs typically produce weight loss, but during ongoing therapy some patients gain substantial weight. This is a common occurrence according to anecdotal and non-placebo-controlled studies. Mirtazapine causes significant weight gain early in treatment, but patients lose the added weight over time. Nefazodone appears to be weight neutral, and bupropion can actually cause weight loss (Sussman N, Symposium 14B).

Sexual Dysfunction Associated With Treatment of Major Depression

Both depression and pharmacologic treatment of depression are associated with sexual dysfunction. Most patients (70% to 80%) with major depressive disorder (MDD) experience decreased libido. To improve their quality of life, several strategies are available to manage the medication-induced sexual dysfunction. One such strategy is switching to an antidepressant with minimal effects on sexual functioning, such as bupropion, mirtazapine or nefazodone. In fact, substituting an SSRI with bupropion SR is an effective alternative in at least 55% of patients. Other strategies include waiting for spontaneous remission, decreasing the antidepressant dose, prescribing drug holidays and adding a pharmacologic antidote for sexual dysfunction (Clayton ALH et al., Symposium 14A).

While there are currently no reliable methods for determining which antidepressant is most likely to benefit an individual depressed patient, there are some inferences that offer helpful guidelines: 1) serotonergics may be more beneficial in anxious, angry, irritable and impulsive (demodulated) states; 2) catecholaminergics may be more effective in apathetic and fatigued (deactivated) states; and 3) dual-mechanism medications may be more efficacious in melancholic and other mixed states.

To test such targeted treatment and improve results in practice, for the past decade, private outpatients suffering from MDD have been managed by giving SSRIs to patients in demodulated states, catecholaminergics (such as bupropion) to those in deactivated states, and venlafaxine or dual-mechanism combinations (such as fluoxetine and bupropion) to patients in mixed states. In comparing the randomly selected charts of 100 recent targeted-treatment cases with those of a similar group in the 1980s whose treatment was not targeted in this way, researchers found that 95% of patients globally improved in the targeted group compared to 65% in the non-targeted group (Metzner RJ, Symposium 35D). 

Quetiapine in Psychotic Patients With Parkinson's Disease

A recent study assessed the effectiveness and tolerability of the atypical agent quetiapine (Seroquel) in patients with Parkinson's disease (PD) and psychosis who are particularly susceptible to the extrapyramidal symptoms (EPS) and anticholinergic side effects associated with other atypical antipsychotic agents. 

In a 24-week, open-label trial, 29 patients (mean age 73 years) received quetiapine up to 400 mg/day. According to the Brief Psychiatric Rating Scale (BPRS), the Clinical Global Impression (CGI) Severity of Illness Scale and Neuropsychiatric Inventory (NPI), patients responded well, with scores decreasing significantly. Scores on the Unified Parkinson's Disease Rating Scale (UPDRS) remained stable. No important effects were observed on mean vital signs, weight gain, laboratory tests or electrocardiograms. The results showed that quetiapine is effective and well-tolerated in patients with PD. (Juncos JL et al., NR687).

Bupropion SR for SSRI-Resistant Major Depression

This study was conducted to determine whether bupropion SR would be beneficial for patients with MDD who failed to respond to fluoxetine. In this trial, 28 subjects who were resistant to fluoxetine were switched to bupropion SR 150 mg bid without a washout period. Because of adverse effects, 21% of the 28 subjects dropped out of the study. Of these 28 patients, 35% were considered responders and six were considered partial responders. (Responders were those with a 50% decrease in baseline HAM-D score.) 

Despite the adverse effects experienced by some of the subjects, preliminary results suggested that bupropion SR treatment is well-tolerated in fluoxetine nonresponders without a washout and may be effective for some SSRI nonresponders. Of the 22 patients who completed eight weeks of therapy, 45% of them were considered responders and 27% were considered partial responders (McGrath PJ et al., NR707).

An Overview of the Efficacy and Safety of Rapid-Acting Intramuscular Ziprasidone

Because patients with psychosis and acute agitation often need treatment with intramuscular (IM) conventional neuroleptics such as haloperidol (Haldol) and sedatives, they experience debilitating side effects, such as EPS and profound sedation. Ziprasidone (Zeldox) IM, however, has a unique receptor profile, making it effective in relieving the symptoms of agitation in patients with an acute exacerbation of schizophrenia. It is the first novel antipsychotic to enter late-stage clinical development as a rapid-acting IM formulation.

To further assess the efficacy of ziprasidone, several clinical trials were conducted. Two, 24-hour, randomized, double-blind trials compared ziprasidone IM 10 mg and 20 mg to respective 2 mg dose groups with acute agitation and psychosis. Then there were two open-label, seven-day trials with fixed- and flexible-dose ziprasidone IM and haloperidol IM.

Researchers concluded that ziprasidone IM is a considerable advancement in therapy for the acute control of agitated patients. It acts rapidly and is effective in reducing acute agitation. In addition, it offers tolerability advantages over haloperidol IM, particularly with regard to movement disorders. Doses of 5 mg, 10 mg and 20 mg up to qid for <3 days were well-tolerated (Zimbroff DL et al., NR365).

Antidepressants: Mechanism of Action and Clinical Response

The 21 drugs currently marketed in the United States for the treatment of depression can be divided into four categories based upon their acute pharmacologic actions: 1) selective enhancers of noradrenergic transmission (e.g., desipramine [Norpramin], reboxetine [Vestra]); 2) selective enhancers of serotonergic transmission (e.g., fluoxetine, citalopram); 3) nonselective enhancers of both noradrenergic and serotonergic transmission (e.g., phenelzine [Nardil], amitriptyline, mirtazapine); and 4) no known potent pharmacologic effects to enhance either noradrenergic or serotonergic function (e.g., bupropion, nefazodone). Keep in mind that the third category is not homogeneous, as drugs may be efficacious by inhibiting monamine oxidase, by inhibiting the reuptake of both norepinephrine and serotonin, or by being antagonists of a-adrenoceptors.

In nonselected depressed patients, there does not seem to be any difference in efficacy among drugs with different mechanisms of action. This may not be true for different subgroups of depressed patients. As doctors consider the best drug for a depressed patient, they should also consider the side-effect profiles, which vary greatly among these drugs (Frazer A, Symposium 18A).

Co-Occurrent Anxiety and Depression: Pharmacotherapy

Depression and anxiety occur together more than they occur individually. While this may be because both disorders are prevalent in the general population, there is also evidence that a number of neurobiologic abnormalities may be common denominators for mixed anxiety and depression. For example, early life stress can cause permanent neurobiological changes-one of which is an increase in the activity of systems mediated by corticotropin-releasing factor (CRF). Elevated in humans diagnosed with depression and several anxiety disorders, CRF both influences and is regulated by the serotonin (5-HT) and noradrenergic neurotransmitter systems.

So what medications should be used to treat the co-occurrence of anxiety and depression? It appears that medications which downregulate the activity of the brain's main noradrenergic center and locus ceruleus and increase overall brain 5-HT activity, may decrease fear-induced increases in CRF release also. Therefore, drugs that modulate either serotonergic or noradrenergic systems, or both, are the best treatments for this comorbid situation (Gorman JM, Symposium 18b).

Long-Term Treatment of Depression With Bupropion SR 

The safety and efficacy of bupropion SR for the long-term treatment of depression were evaluated in approximately 800 subjects with moderate recurrent depression. They were treated with bupropion SR (300 mg/day) during an eight-week, open-label phase trial. Of these subjects, 52% responded to the treatment (CGI Scale of Improvement of 1 or 2 for the three weeks prior to randomization), thus qualifying them to enter a 44-week, randomized, placebo-controlled, double-blind phase. 

The results indicated that long-term treatment with bupropion SR is well-tolerated. Adverse events accounted for 9% and 2% of discontinuation from the open-label and double-blind phases, respectively (Weihs KL et al., NR507).

Bupropion SR for SSRI-Induced Sexual Dysfunction

Sexual dysfunction affects 60% of patients taking SSRIs. In this randomized, double-blind, placebo-controlled study, 30 euthymic patients experiencing sexual dysfunction, as determined by the Arizona Sexual Experience Scale (ASEX), were randomized to either bupropion SR 150 mg/day or placebo for three weeks.

The outcome showed that there were no significant differences between the bupropion SR and placebo groups, as measured by side effects or change in ASEX or HAM-D scores (Ashton AK et al., NR684).

(The following are highlights of new research presented at the 2000 American Psychiatric Association Annual Meeting. Additional highlights can be found in "APA Meeting Highlights New Research," in the February issue of Psychiatric Times, p23-Ed.)

APA Annual Meeting Highlights New Research

One of the long-standing myths about sexual coercion is that a woman cannot make a man have sex with her. Prevailing stereotypes about women's physical weakness, disinterest in sex, sex-role passiveness and gentle nature lead many people to assume that women are not capable of such an act (Anderson and Struckman-Johnson, 1998). In reality, research has shown that substantial numbers of men are subjected to the sexually aggressive behavior of female strangers, acquaintances and lovers.

Over a decade ago, we found that 16% of a sample of 268 men at a small Midwestern university reported that they had been forced to have sexual intercourse on a date (Struckman-Johnson, 1988.) A few years later, we documented that 30% of a sample of 204 college men had experienced an incident of pressured or forced sexual contact with a female perpetrator. For 20% of the men, the incident resulted in sexual intercourse (Struckman-Johnson and Struckman-Johnson, 1994). In a replication of this survey, 43% of 318 men reported having had at least one coercive sexual experience with a woman since the age of 16. The incident culminated in sexual intercourse for 27% of the men (Anderson and Struckman-Johnson, 1998).

Other researchers have reported similar findings. Lottes (1991) reported that 24% of 171 men at an Eastern college had been coerced into sexual intercourse. Fiebert and Tucci (1998) found that 24% of a sample of 182 college men in California had unwanted sex with an insistent woman in the past five years. In a survey of two Canadian universities, O'Sullivan et al. (1998) reported that 24% of 156 men had experienced some type of sexual coercion in heterosexual dating. Larimer et al. (1999) found that 21% of a sample of 165 fraternity men at a Western college experienced unwanted sexual contact. Going beyond the college campus, Isely and Gehrenbeck-Shim (1999) documented that 6% of 3,635 male rape victims requesting assistance at 172 agencies had been assaulted by a woman.

How does a woman accomplish sexual coercion of an adolescent or adult male? Our research suggests that women are most likely to use psychological pressure such as verbal pleading and arguments, emotional blackmail, and deception. Another common approach of sexually aggressive women is to take advantage of a man's intoxicated state. A typical scenario, according to male victims, involves a predatory woman who encounters an inebriated man (or contributes to his drinking) and pursues him until he falls asleep or passes out. The woman then manually or orally stimulates him to erection and mounts him for sexual intercourse.

Sexually aggressive women only occasionally resort to force tactics, which we define as intimidation with size, threats of harm including blackmail, physical restraint, physical harm or use of a weapon. In our surveys, about 12% or less of male victims reported that a woman used force against them, but in most cases, the force was not extreme. Women locked men into cars, blocked their retreat from a room, grabbed at them, threw them down on beds and floors, sat on them, and tied them up. In some instances, women pinched, slapped and hit men who tried to stop their advances. A few men reported that women blackmailed them into having sex by threatening to divulge damaging information to parents, employers or girlfriends.

Men's strong negative reactions to sexual coercion by another man have been well documented (Myers, 1989; Scarce, 1997). Several researchers have described men's reactions to sexual assault by perpetrators who included both men and women (King and Woollett, 1997; Sorenson and Siegel, 1992).

Only a few studies have exclusively examined the effects of female sexual coercion of adult men. The classic work is that of Sarrel and Masters (1982) who discussed the emotional impact on 11 men who had been sexually molested by females. In the course of counseling for sexual problems, the men revealed recent and past incidents of forcible rape, abuse by a baby-sitter, incest and assault by a dominant woman. The authors documented a posttraumatic reaction involving depression and sexual aversion and dysfunction.

Most of the information about male reactions to female sexual coercion comes from surveys of college men. Larimer et al. (1999) discovered that fraternity men who had experienced sexual coercion had more depressive symptoms, more alcohol use and more alcohol-related problems than fraternity men who had not been sexually coerced. It was not known whether these states were caused by the coercion experience. O'Sullivan et al. (1998) found that male victims had a range of positive to negative reactions to unwanted sexual contact at the time it happened. Nearly 40% of male victims reported being not at all upset, whereas 17% were extremely upset at the time of the incident. One-fifth of the men indicated that the incident decreased their involvement in social activities, and 19% had impairment of academic functioning.

Our research also revealed that college men have mixed reactions to female sexual coercion. In the 1988 study, 21 male victims were asked to categorize how they felt about being forced to have sexual intercourse at the time it happened (Struckman-Johnson, 1988). Twenty-five percent said they felt good, 50% felt neutral and 25% felt bad. One-fifth of the victims reported that long-term effects had occurred. In our 1994 study, almost half of the male victims rated the incident as having no negative impact, whereas 23% rated the negative impact in the moderate to severe range (Struckman-Johnson and Struckman-Johnson, 1994). We found no differences in sexual self-esteem between men with and without coercion experience. In a similar survey in 1998, we determined that 33% of male victims rated the incident as having no effect, 30% were mildly to moderately upset, and 14% had a severe negative effect (Anderson and Struckman-Johnson, 1998). Our general conclusion is that at least one out of five men has a strong negative reaction to sexual coercion from a woman.

We speculate that many men are not upset by female sexual coercion because the event is "sex-role congruent." According to cultural scripts, men are expected to initiate and to pursue ever-increasing levels of sexual intimacy with female partners. Therefore, when a man is confronted with a sexually aggressive woman, he is likely to view it as a positive opportunity to have sex, not a violation of will (Struckman-Johnson and Struckman-Johnson, 1996). O'Sullivan et al. (1998) suggested that female sexual coercion may even enhance a man's reputation and thus prevent negative effects. Zweig et al. (1997) added that a man's sexual script may protect him from feeling negatively about himself because he had sex. Another protective factor is men's size and physical strength-they may feel that they have little to fear from a smaller, weaker female perpetrator. It is also possible that men deny or minimize their victimization because of masculine standards to be self-reliant (Struckman-Johnson, 1991).

In what situations, then, are men distressed by female sexual coercion? Foremost, we have found that a man is likely to be greatly upset when a woman uses physical restraint against him. Even if the man knows that he can escape, he is still likely to feel shocked, confused and possibly frightened by a woman's use of force. Men are also likely to have a strong negative reaction when they are exploited by a woman while they are intoxicated, especially if the woman is unattractive. Dozens of men in this situation have told us how upsetting it was to be unable to physically stop the sexual interaction. Others resented the woman for taking away their right to choose who they would have sex with.

A third distressing circumstance is when a young man with conservative sexual standards loses his virginity to a sexually coercive woman, who is usually older. Numerous young men in our surveys have reported that this type of incident prevented them from having their "first time" with a partner who was specially chosen and well-loved. Another upsetting circumstance is one in which a sexually aggressive woman causes a man to betray another woman in his life.

Finally, men tend to be negatively affected when the female perpetrator is a powerful authority figure. For example, in a recent study, we found that some men in prison were profoundly upset when female staff coerced them into sexual activity (Struckman-Johnson and Struckman-Johnson, 2000).

In our research, we have not systematically assessed the nature of psychological trauma experienced by male victims. Through written survey comments and interviews, however, we have found that men who are very upset by an incident of female sexual coercion are likely to experience subsequent distrust and wariness around women and to have relationship difficulties.

Much research suggests that men who are sexually coerced by either a woman or a man are unlikely to report the incident to the police, tend not to reveal the sexual incident if they seek medical treatment, and are unlikely to seek psychological support or therapy for subsequent emotional problems (Pino and Meier, 1999; Sorenson and Siegel, 1992.) Psychiatric and medical professionals are encouraged to address this hidden victimization by asking their male clients if sexual assault has occurred in their past and, if so, to provide or refer them to appropriate treatment.

Anderson PB, Struckman-Johnson C (1998), Sexually Aggressive Women: Current Perspectives and Controversies, Anderson PB, Struckman-Johnson C, eds. New York: Guilford.


Fiebert MS, Tucci LM (1998), Sexual coercion: men victimized by women. Journal of Men's Studies 6(2):127-133.


Isely PJ, Gehrenbeck-Shim D (1997), Sexual assault of men in the community. Journal of Community Psychology 25(2):159-166.


King M, Woollett E (1997), Sexual-assaulted males: 115 men consulting a counseling service. Arch Sex Behav 26(6):579-588.


Larimer ME, Lydum AR, Anderson BK, Turner AP (1999), Male and female recipients of unwanted sexual contact in a college students sample: prevalence rates, alcohol use, and depression symptoms. Sex Roles 40(3-4):295-308.


Lottes IL (1991), The relationship between nontraditional gender roles and sexual coercion. Journal of Psychology and Human Sexuality 4(4)89-109.


Myers MF (1989), Men sexually assaulted as adults and sexually abused as boys. Arch Sex Behav 18(3):203-215.


O'Sullivan LF, Byers ES, Finkelman L (1998), A comparison of male and female college students' experiences of sexual coercion. Psychology of Women Quarterly 22:177-195.


Pino NW, Meier RF (1999), Gender differences in rape reporting. Sex Roles 40(11-12):970-990.


Sarrel PM, Masters WH (1982), Sexual molestation of men by women. Arch Sex Behav 11(2):117-131.


Scarce M (1997), Male on Male Rape: The Hidden Toll of Stigma and Shame. New York: Plenum Press.


Sorenson SB, Siegel JM (1992), Gender, ethnicity, and sexual assault: findings from a Los Angeles study. Journal of Social Issues 48(1):93-104.


Struckman-Johnson CJ (1991), Male victims of acquaintance rape. In: Acquaintance Rape: The Hidden Crime, Parrot AL, Bechhofer L, eds. New York: Wiley, pp192-214.


Struckman-Johnson CJ (1988), Forced sex on dates: it happens to men, too. Journal of Sex Research 24:234-240.


Struckman-Johnson C, Struckman-Johnson D (2000), Sexual coercion rates in seven Midwestern prison facilities for men. Prison Journal 80:379-390.


Struckman-Johnson D, Struckman-Johnson C (1996), College men's reactions to hypothetical forceful sexual advances from women. In: Sexual Coercion in Dating Relationships, Byers ES, O'Sullivan LF, eds. New York: Haworth Press, pp93-105.


Struckman-Johnson C, Struckman-Johnson D (1994), Men pressured and forced into sexual experience. Arch Sex Behav 23(1):93-114.


Zweig JM, Barber BL, Eccles JS (1997), Sexual coercion and well-being in young adulthood: comparisons by gender and college status. Journal of Interpersonal Violence 12(2)291-308.

Men's Reactions to Female Sexual Coercion

I heard something like a whisper once
in grade school, a boy's blood


 they said
as we stared at his empty seat.

When the first glass syringe
stuck to my father's arm
like an engorged tick
he smiled his lie: 

Then bitter grandmother, diabetic blood
so sweet, lost a little toe,
a foot, her leg, until she groaned,


Or that first week in medical school,
the man my age, wheezing gray bones,
wife and kids holding wasted hands,


And we touched, inevitable as lovers,
my finger in a latex glove
deep inside, rubbing over and over
something hard and common as a garden stone.

Now a friend loses her glorious hair,
my mother moans without a breast,
and my hands search hidden places
something dark might live

 but feel only cold through thin sheets,
a familiar whisper on my skin.

Psychiatric Times Vol 17 No 3

Obstetrics Ward, County Hospital

New Products, Applications Assessed at NCDEU

APA Annual Meeting Highlights New Research

Men's Reactions to Female Sexual Coercion

Places We Have Met