Questions about love and sexual attraction, libido, pleasure, and performance

Have a question for Dr. Pezzi? He will be happy to answer it in this forum for free.
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No liability is assumed with respect to the use of the information herein or otherwise provided. Medicine is an ever-changing science. The information presented is based upon my assessment of the current body of knowledge, but this base of information will change in the future. Hence, before instituting any of the measures presented you should consult with, and obtain the approval of, your physician for the most current recommendations. No material intended for the general population can attempt to treat specific individuals, and no material in this site or otherwise transmitted to you should be construed as offering individual medical advice. Given the innate variability of people, it is critical that your physician approves the adoption of any information as being safe and effective for you. A physician's circumspection is his—and your—greatest asset.

Note: I have all this material on a separate web site ( www.sexualtips.net ) that is more extensive and more visually appealing — and the pages load much faster! :-)

Exercise + breast discharge = ?

Q: I'm a 29-year-old healthy woman who began jogging five months ago. Since I began jogging, I've noticed that my libido has diminished and occasionally my breasts have a slight milky discharge. Does this make any sense to you? I thought exercise was supposed to increase libido, if anything. My doctor is stumped. I'd be very grateful if you can help me. Thanks, Melissa.

A: It sounds as if you're suffering from a condition called benign galactorrhea. I will explain this so that it is easy to understand, so don't be fazed by the big medical words. Galactorrhea just refers to a condition in which breasts make and discharge milk at a time not associated with either childbirth or the nursing of an infant. Benign, of course, simply means that it isn't dangerous. However, it is a good idea for anyone with this problem to see a doctor for testing because certain medical conditions can predispose people to galactorrhea, and these conditions should be excluded before one assumes the condition is benign.

Your galactorrhea is probably induced by the nipple stimulation that results from the to and fro motion of your breasts rubbing against your bra. As I mentioned in The Science of Sex, nipple stimulation in both women and men increases the production of prolactin, a hormone that stimulates lactation (milk production). One of the side effects of prolactin is its ability to impair libido even if its concentration is not high enough to induce lactation. Therefore, even people without lactation may be suffering from the libido-suppressing effects of prolactin. Obviously, for some people nipple stimulation increases libido instead of decreasing it. The reason for this is because breast stimulation also increases the release of oxytocin, a hormone that improves sex in many ways. I'll discuss oxytocin in more detail at the end of this topic.

It is interesting to look at the connection between nipple stimulation and libido suppression from a teleological perspective. In other words, did Mother Nature or God have some logical reason for suppressing libido after childbirth? Of course! Pregnancy can be very hard on women, and that was probably more true eons ago before the advent of modern medicine and an assured food supply. If a woman with marginal deficiencies of some nutrients became pregnant, the fetus would further sap her. After pregnancy came lactation (no formula in the Stone Age, obviously), which really drains energy and nutrients from women. After that, another pregnancy following shortly thereafter could have been fatal, for the mother, her fetus, and her infant. Since there weren't any doctors around in those days to warn women of this serious risk, Mother Nature stepped in and shut down libido. In case an amorous caveman was able to seduce a woman who was still breastfeeding, the chance of conception was rather low because the hormonal changes associated with breastfeeding reduce the risk of pregnancy.

There are numerous causes of hyperprolactinemia (increased blood prolactin) besides jogging and breastfeeding, including eating, stress, strenuous exercise of any sort, alcohol consumption, exposure to xenoestrogens (man-made chemicals that mimic natural estrogens), certain drugs (oral contraceptives, estrogen, Aldomet^®, opiates, tricyclic antidepressants, phenothiazines, Reglan^®, Compazine^®, Phenergan^®, Tagamet^®, Prozac^®, and Haldol^®), hypoglycemia, primary hypothyroidism, and sexual intercourse (in women). Apparently bizarre causes of hyperprolactinemia are certain chest wall lesions, including neoplasms of the chest wall, herpes zoster (shingles), and surgical scars or trauma affecting the chest wall. Since prolactin serves to switch off sexual excitement after orgasm, anyone who wishes to maximize their potential for multiple orgasms should keep these factors in mind.

Prolactin output is normally held in check by dopamine, a neurotransmitter that often declines with aging. Hence, prolactin secretion tends to increase with age. Lindsey Berkson, an expert on endocrine-disrupting chemicals, stated in her book Hormone Deception that certain chemicals may either mimic or indirectly affect prolactin. Incidentally, prolactin can contribute to obesity since it can stimulate appetite and promote fat storage.

OK, what can you do about this problem?

• Switch to a different form of exercise (e.g., swimming).
• Use a sports bra that minimizes breast motion. It may also be a good idea to place a large Band-Aid^® over each of your nipples before donning the bra.
• Consider taking an herb, vitamin, or medicine. Here are some things that help:

Bromocriptine (Parlodel^®): Bromocriptine is a drug that can reduce prolactin secretion. Bromocriptine can improve libido, especially in people with high prolactin levels, and it may increase sexual pleasure, too. One of the unique properties of bromocriptine is its ability to increase sexual desire while postponing ejaculation. Interestingly, since bromocriptine can reduce prolactin secretion, it can therefore promote fat loss. However, that should be viewed as an ancillary benefit and not a primary indication for use of bromocriptine.

Ginseng: Ginseng's reputed aphrodisiac effect has a scientific basis because ginseng can depress blood prolactin levels. This effect is more pronounced with repeated use.

Vitamin B₆: High doses of vitamin B₆ can improve libido by reducing prolactin secretion in both sexes. B₆ can also improve the quality and intensity of sexual pleasure in some people who have poor genital sensation. Vitamin B₆ is excreted within 8 hours after absorption, and thus should be supplied at least every 8 hours. An average dose for these conditions would be 50 mg three times daily. Taking too much B₆ can result in too vivid dream recall. Doses over 200 mg daily can result in neurological disorders if taken for several months.

Those are some of the specific therapies for combating the libido-suppressing effects of prolactin. There are many other general ways of heightening libido, as I discuss in The Science of Sex.

More on oxytocin

Oxytocin is a hormone that promotes contractions of the uterus during childbirth, but it is produced at other times as well. Its secretion increases during sex and breast stimulation, and it is triggered by certain emotional stimuli. It has been termed the "cuddle chemical" because it promotes snuggling, pair-bonding, and the desire to please others. This may explain why women are more likely to want to cuddle after sex. Thus, there is some truth in the phrase "making love." Oxytocin stimulates erection, enhances vaginal and uterine contractions during intercourse, and increases sexual sensation before and during orgasm.

Oxytocin was available by prescription as a nasal spray (Syntocinon^®), intended to assist initial postpartum milk ejection from a woman's breasts after childbirth, but at the time of this writing it is not available; perhaps a generic version will be offered in the future. Oxytocin has been used cosmetically, too. Apparently unaware of the fact that application of a vacuum could achieve the same effect, some Las Vegas showgirls used to sniff Syntocinon to make their nipples more prominent.

Estrogen enhances sensitivity to oxytocin, and thus women with more estrogen are more likely to experience the positive effects of oxytocin—and perhaps its negative effects, too. According to Theresa Crenshaw, MD, author of The Alchemy of Love and Lust, oxytocin diminishes the capacity to think, reason, and remember.

Breast stimulation increases oxytocin in both women and men, and this is therefore a more readily available means of sexual enhancement than the administration of Syntocinon. The amount of oxytocin produced by breast stimulation in men and nonpregnant women is less than that which can be administered by a Syntocinon nasal spray, but you will not find many doctors willing to prescribe Syntocinon simply to enhance your sexual pleasure. However, since breast stimulation can also increase prolactin (which suppresses libido), relying upon breast stimulation to enhance sex is problematic. Since the ratio of oxytocin to prolactin produced as a result of breast stimulation is individually variable, breast stimulation is not a surefire catalyst for sexual pleasure.

Premenopausal women sometimes become attached to a man with whom they have had sex, even if the man isn't good for them, because the sexually induced secretion of oxytocin encourages this binding. After menopause, intercourse does not result in an oxytocin surge, thus permitting women to make a more rationale, and less instinctive, choice. Premenopausal women who wish to avoid being hormonally blinded should know that alcohol suppresses, and heat increases, oxytocin release. To put this into proper perspective, let's look at some real-world examples.

In women, alcohol temporarily increases testosterone and, hence, libido. However, since alcohol also suppresses oxytocin, women who consume it are more likely to engage in sex, but less likely to feel good about it afterwards. They're also less apt to feel attached to the man, and less likely to feel as if they're falling in love. Physiologically-hip, conniving men can to some degree circumvent this stumbling block by remembering the effect of heat. Lounging in a hot tub, and then cuddling in a warm bed—or, better yet, vacationing on a warm, exotic island . . . they don't have anything to do with romance and love, do they? Yes, they do, and I think that most people have an intuitive understanding of this.

Women often assume that men desire sex just for the physical pleasure it provides. No doubt, that's sometimes all the man is after. However, I think that many men realize that intercourse can make the woman feel attached to the man. Longing for love, men may desire sex as a means of fostering a romantic bond.

Situational beauty phenomenon

Q: I'm not having much luck attracting men. I keep myself in good shape, but I wasn't born with good looks. I'm not a dog, either, but I'm evidently not what men are looking for. Short of plastic surgery or new clothes (I've tried the latter, with no success), what can I do? Thanks for any help you can give me! Terri.

A: In The Science of Sex , I devoted one chapter to the enhancement of intersexual attraction. I put a couple of my tips elsewhere on my web site, so I won't repeat that info here but I'll provide a link to that page. One thing that I didn't mention in my book or on that other web page is that you can enhance your desirability by taking advantage of the situational beauty phenomenon. I'll illustrate that by the following story.

A few years ago my brother Ray and I were snowmobiling in Michigan's Upper Peninsula, and we stopped into a restaurant to get a hot chocolate. A few minutes later a woman who'd been snowmobiling entered the restaurant, and we both opined that she was quite attractive. Musing about this over the next few days, I questioned why we thought that woman was so attractive. She was slim, but otherwise possessed no extraordinary physical traits. Moreover, had I passed by her in a mall or in a restaurant in a non-snowmobiling area, I wouldn't have given her a second look. So what was it about her that elevated my perception of her attractiveness? The fact that she was a female snowmobiler. While women who snowmobile aren't quite as rare as a dodo bird, they're rare enough to stand out in a crowd. I suppose it is also human nature to reflexively like people who share your interests.

Besides snowmobiling, another activity you might want to try is target shooting at a shooting range. (Before you non-shooters start guffawing, I should mention that I took a woman friend of mine to a shooting range and in the course of a few hours her opinion changed from "I hate guns" to enjoying that activity so much she didn't want to leave the shooting range.) A single woman who shows up at a shooting range is bound to attract a lot of attention from men, and if you try that on a Saturday afternoon and don't have a date for that evening . . . well, then you do need plastic surgery!

If shooting doesn't rate high enough on your PC scale for you to give it a try, consider golfing, fishing, boating, camping, or any other activity that draws men. Yes, some women engage in those activities, but they're usually tagging along with a man. Try doing it stag and you're bound to attract attention.

Does size matter?

Q: I've heard a number of opinions on the topic of whether or not penis size makes a difference. Does it? Thanks, Tom.

A: Yes, it does matter. However, before you jump to any conclusions, bigger is not necessarily better. "Big" or even "average" may be too large, while "small" may be just right for some women. In my experience as a doctor I've noticed that vaginal size varies greatly — far more than penile size. Considering only adult non-virginal women, some vaginas were so small that they'd provide a snug fit for a pencil, while others were so loose that the thick end of a baseball bat would easily fit inside. Yes, penile size varies, but not to that degree. Therefore, for any given couple, the size of the man's penis is less important than the size of the woman's vagina. This fact is typically given short shrift in our culture. Whenever the topic of "size" is broached, it is tacitly assumed that the only size which matters is penile size, while vaginal size is ignored. If it is politically correct to discuss penile size, it should be acceptable to consider vaginal size, too. However, while I frequently hear many direct and indirect discussions of penile size from sex experts, comedians, ad copy writers, and even on a daytime court TV program, there doesn't seem to be any commensurate mention of vaginal size. Again, since size does matter and vaginal size is the greatest variable, it only makes sense to consider the woman's contribution, too.

Here is another reason to focus more upon vaginal size than penile size: women have more control over the tightness of their vaginas than men do over the size of their penises. While penis size can be increased (especially on a short-term basis, as I explain in my book), vaginal tightness can be dramatically altered on a long-term basis by doing Kegel's exercises. In women, one of the greatest benefits of Kegel's exercises — and one that is rarely mentioned — is that the depth of the outer "tight zone" of the vagina can be increased. I've never met a man whose eyes didn't glaze over at the thought of a tight vagina, but such an improvement can benefit women, too. When this zone of the outer vagina is not just tight, but tight and deep, the penis is better able to stimulate the sensitive outer third of the vagina and the G-spot.

Kegel's exercises are able to increase the depth of the tight zone by causing hypertrophy (thickening) of the pubococcygeal muscles, as depicted in the following diagrams:

The diagram on the left is from a woman with a poorly developed pubococcygeal muscle, and the diagram on the right is from a woman with a well-developed pubococcygeal muscle.

What's the average size of an adult penis? And why is it less than what it once was?

Q: Dr. Pezzi, it's Tom again. Thanks for answering my other question. I showed your answer to my girlfriend, and she now realizes that "my" problem is "our" problem, and probably even more "her" problem. But, she's working on it. My question today is, what is the average size of a penis?

A: The length of an average erect penis in adults is 5.72 inches* (or, if you believe the latest study, 5.1 inches). Years ago, the average length of an erect penis (measured on the dorsal, or top, surface) was 6½ inches. Later on, it was 6¼ inches, then 6 inches . . . now 5.72 or—gulp—5.1? What's going on here? I hate to tell you this, men, but you are not quite the man your grandfather was; the average penile length is shrinking. Why? There are a number of estrogens (phytoestrogens, xenoestrogens, and exogenous estrogens**) to which men are now exposed. Furthermore, the estrogen level in men can be increased by a number of factors (which I discuss in my book in the section on the testosterone to estrogen ratio). Too much estrogen, and the penis either shrinks or fails to grow as much as it should. Not good. If you're interested, in my book I discuss dozens of environmental factors under your control that affect penile size.

* As the automobile companies equivocate, your mileage may vary. By random chance, some women have had nothing but large partners, so they may think that a guy with an average-sized penis is small; other women, having only been with men with small penises, may think that an average man is well-endowed. It's all relative. The average erect penis is 1.62 inches wide, and 4.5 inches in circumference. Most men have a penis measuring 4.6 to 6.25 inches long, but 12% of men have larger penises and 12% have smaller penises. Incidentally, the length of a fully stretched flaccid penis is virtually the same as that of a fully erect penis.

** Phytoestrogens are chemicals with estrogen activity that occur naturally in a variety of plants such as soybeans.
Xenoestrogens are man-made chemicals that mimic natural estrogens.
Exogenous estrogens are estrogens unintentionally introduced into people from ingestion of food or water containing estrogens from animals, humans, or pharmaceuticals.

Why did my penis shrink? What can I do about it?
How to trigger a "second puberty" of penile growth

Q: I am writing to you because my doctor is an idiot. I'll explain why in a minute. I am 47 years old, healthy, have usually one beer each evening, never use drugs, don't smoke, and I haven't gained any weight. I see my doctor once yearly for an annual checkup. So far, so good, except for one thing. My penis is shrinking. It doesn't look as big, or feel as large when I grasp it with my hand, even when it is fully erect. I mentioned this to my doc, and he told me that penises don't shrink. Well, mine did. It's about ¾ inch shorter, and ½ inch less in circumference. My doctor thought I measured wrong. No way. I work as a machinist, and routinely measure things to an accuracy of less than one-thousandth of an inch. There is no way that my measurements are wrong. I must have measured my penis at least a dozen times when I was a teenager, and I've checked it several times in the past few months. There has been a definite size decrease, so I know my doctor is just plain wrong about his statement that penises don't shrink.

My questions are: 1) Why did my penis shrink? 2) What can I do about it? 3) Why do doctors say that penises don't shrink, when they clearly do? I assume I am not the only man who has experienced this problem.

A: You are not alone. I'll tell you about a 62-year-old patient I saw in the ER years ago. As I prepared to insert a catheter into his penis, I asked his daughter to step out of the room. He said, "That's all right, doc. She can stay in here. There isn't much left to see. It used to be large, and now it's just a shriveled up noodle. But I'm proud of what it did. It gave me two beautiful children." This revelation about the shrinkage piqued my curiosity, and I would sometimes ask other patients if they had the same problem. Amongst older men, this was surprisingly common. This caused me to wonder why so many doctors cling to the belief that penis size is fixed at the end of puberty. I know of a few cases in which there has been a documented size increase (I discuss why in my book), and many more cases of shrinkage. Tissue shrinkage is actually a very common accompaniment of aging. Breasts shrink, the vagina shrinks (unless estrogen is given after menopause), the brain shrinks, skin and bones thin, muscles atrophy, lips shrink, testicles shrink, we become shorter, and so on. In spite of this, physicians routinely maintain that penis size does not change. The penis of an average 88-year-old man is just as large as it was on his 18th birthday? Hogwash. Doctors are wrong. Don't be too surprised, though. This isn't the first medical myth to crumble under the weight of objective scrutiny. For example, there is the myth that the average body temperature is 98.6° F. That is not true, but many docs are seemingly ignorant of circadian temperature variation and research which indicates that the average body temperature is not 98.6° F. If doctors can be deceived by the body temperature myth, it is not surprising that they can be duped in regard to age-related changes in penile size — a far more esoteric subject.

Doctors routinely see men in their flaccid state, rarely inquire into their erect size, and almost never discuss if there's been any change in size. With this in mind, I have a difficult time understanding why physicians feel qualified to make a sweeping generalization that penis size is immutable. They believe that to be true because they heard it from another doctor, who just passed on what he heard from another doctor who also didn't know the truth because he was just relaying a myth that he'd heard or read from someone similarly uninformed. Is this any way for learned professionals to behave?

Why did your penis shrink? That could result from decreased testosterone and especially dihydrotestosterone (DHT), which is derived from testosterone. DHT is known to be the primary catalyst for penile growth. Physicians are taught in medical school that this is important only before the end of puberty; once the penis develops, it'll maintain that size forever. I know that is wrong, and it frankly doesn't make any physiological sense to me. As I discuss in my book, the body continuously rebuilds itself. If your house could do the same thing, it could tear off an old shingle and replace it with a new one. In time, your house would replace all of its shingles, and you'd have a new roof. Your body does a fairly good job of renewing itself until you hit middle age, at which time tissue regeneration begins to sputter. After a few more decades, this process slows even more. Wounds heal more slowly, and muscles take longer to regenerate after exercise.

If the cells and molecules in your body were not broken down, you could live off sugar water. You wouldn't need protein. But you do require dietary protein and other nutrients because tissue destruction and regeneration constantly occur. This process is more rapid than you might imagine, because your body recycles some of its building blocks. Only a fraction of the recycled material is lost in the urine or feces.

The bottom line is that the vast majority of the molecules in your body weren't there a year ago. The old ones are gone, and new ones have taken their place. Even bone, which may seem as active as a fossil, is torn down and rebuilt. The penis is no exception. Let's think about this logically. If DHT is critical for stimulating penile growth (and it is), why would this matter only before the end of puberty? Isn't there still a receptor for DHT after puberty? Yes, of course. Once DHT binds to the receptor, doesn't it affect DNA transcription, as it does before puberty ends? Yes, of course. However, physicians who contend that penis size is fixed after puberty would have you believe that it doesn't matter if your DHT level is zero, or if you have DHT bubbling out your ears. Can you think of any other example in which the level of a hormone is totally immaterial to its target tissue? I can't. I graduated in the top 1% of my class in medical school, so I am not ignorant about how the body works. Hormones exist for one reason: to influence their target tissues.

In reality, the penis becomes less sensitive to DHT after puberty, but the sensitivity is not zero. Thus, the DHT level can influence penile size, but to a much smaller degree than it could before the end of puberty, when the penis was still very sensitive to DHT. As I mentioned before, I don't think the DHT level matters after puberty in regard to penis size, I know it. (If any physician or scientist doubts this, put your money where your mouth is. Let's wager a million dollars. You'll lose.)

After reading all this, you might think that increasing the DHT level is the way to go. It may help a wee bit, but there is a much better secret that I accidentally discovered. I discuss this topic in The Science of Sex. Using this method, your penis won't just be larger, it will be exquisitely sensitive, and sex will feel much better. Your libido will increase to the point that you would be called a nymphomaniac, if you were a woman.

Besides DHT, other factors influence penile size. Genetics obviously matters, but it is pointless to discuss them because this is not under your control. In terms of what you can influence, DHT is the most important factor, but there are others. I won't reiterate everything I said in my book, but I will briefly mention other things that make a difference: other hormones, hormone transport proteins such as sex hormone binding globulin (SHBG) and albumin, cadmium, zinc, antiandrogens, phytoestrogens, exogenous estrogens, endogenous estrogens, xenoestrogens, obesity, numerous drugs and chemicals, collagen, elastin, and a dozen other factors.

Why does sexual pleasure vary so much from one woman to the next?

Q: I'd like your medical opinion on something. I've had sex with over 60 women and I've noticed that there is a huge difference in the pleasure I feel during sex with different women. With most of the women it's very pleasurable, with a few it's so little pleasure it's barely worth doing, and with some others it is so pleasurable it's off-the-scale, out-of-this-world, mind-blowing pleasure. Why is that? I used to think that tightness was the only thing that made any difference, but there's more to it than that. I don't think that this variation is attributable to how horny I am because some women are consistently duds and others are consistently extraordinary. Plus, on a few occasions I've had sex with two women, changing partners every few minutes, and I know there can be a significant difference. Why? Another thing I wonder about is why sex feels so different even amongst women who are extraordinary. I don't know how to explain this other than to compare it to eating pizza and eating steak. I love both equally well, but they taste entirely different. So can you see what I'm trying to say? When I think about the two women who've given me the most sexual pleasure, the sensations I got from each women was noticeably different. This really has me stumped. I know there must be some factors that make one vagina better than another, but how can two vaginas feel equally fantastic but yet very different? Thanks, Phil

A: You're correct, there is a significant difference. I've noticed it, and other men have reported to me that they've noticed it, too. There are many factors that underlie this difference, and I discussed them in a chapter in The Science of Sex. One of the reasons why I explained this so extensively is because men sometimes dump women who are "duds," as you termed them. What's important for women to realize is that many of the factors that influence this variation in pleasure are things they can influence.

I don't intend to minimize the importance of love in a relationship, but the fact is that an average couple in the United States begins having sex after three dates. I think it is safe to assume that most men are not truly in love after three dates, so if they don't obtain the pleasure they're seeking they don't feel compelled to stick with that woman. I've heard many women wondering aloud, "Why did he dump me right after we slept together?" Well, it's not because your bedroom was messy, trust me. Maybe the guy suddenly realized he needed to spend more time mowing his lawn . . . or maybe he's been spoiled by sleeping with women who gave him substantially more pleasure. Such pleasure is addicting, and once a man has experienced it, he will often turn up his nose at women who have less to offer in the bedroom. My message to women is this: you can't change the expectations of men, but you don't have to be snubbed. If what you have isn't good enough for the men in your life, you can make it better. I'd like for all women to be superstars in that department, because that would force men to choose partners for more substantial reasons. As a doctor, I've witnessed the pain experienced by women who are repeatedly rejected after The Night. Again, women are dumped for other reasons, but this is one, so why ignore it?

To answer your question about why sexual pleasure can be quantitatively the same but qualitatively different (i.e., both are equally pleasurable but in different ways), the primary reason for this is because there are so many factors that account for the differences in sensation amongst women. As an analogy, consider the three basic colors (red, blue, and green) that are combined to produce the spectrum of colors on your computer monitor or television set. Those three colors can combine to produce equally beautiful but substantially different colors. Or imagine the different flavors produced by cooks who combine flour, sugar, butter, and eggs in different ways to produce entirely different foods. The ingredients may be the same, but when the proportions are varied the end result can be quite different.

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Q: While browsing at the bookstore, I came across a book which proclaimed that the cul-de sac is the "ultimate pleasure spot." First, what is the cul-de-sac? Second, is it really the ultimate pleasure spot?

A: The cul-de-sac (also known as the rectouterine pouch or the pouch of Douglas) is a space above the vaginal apex, above the posterior uterus, and in front of the rectum (see diagram).

In reality, there is no direct way to stimulate the cul-de-sac during sexual activity. It can be indirectly stimulated by stimulation of the cervix or posterior fornix. The cervix projects down into the vagina near its apex, leaving a circular recess around it called the vaginal fornix.

So why did that author say that the cul-de-sac is the ultimate pleasure spot? Probably because cul-de-sac is a sexier and more euphonious term than posterior fornix. Aside from that minor point, is that area some sort of magical hot button? Yes and no. I hate to equivocate, but there's no simple answer. Here are the facts:

• Some women do obtain extra pleasure from cervical stimulation during coitus. If the penis thrusts deep enough to contact the area around the posterior fornix and cul-de-sac, it will inevitably contact the cervix, too. Since these structures are in a small area and they're attached to each other, stimulating one will stimulate the others. Hence, it's a moot point whether one area is the "pleasure spot."

• Calling it the ultimate pleasure spot is a bit of an overstatement. Most women think that the ultimate pleasure spot is the clitoris, especially when the clitoris is stimulated along with the outer vagina and G-spot. Think of that as the South Pole of Pleasure, and the cervix, posterior fornix, and cul-de-sac as the North Pole of Pleasure. Which is the ultimate pleasure spot? 99% of women would choose the South Pole any day — or night.

• For some women, the North Pole isn't the ultimate pleasure spot, it is the ultimate pain spot. If a woman has endometriosis* or an infection of her cervix or tubes, deep thrusting can be uncomfortable or even exquisitely painful.

* A condition in which functional endometrial tissue is present outside the uterus (the endometrium is the lining of the uterus).

Do I have a fornix?

Q: Hi Dr. Pezzi. I've just discovered your question & answer page and have found the reading very interesting. I was doing a search trying to find a diagram of the cul-de-sac after reading about it in a book entitled Super Sexual Orgasm. I found your diagram and description, however now I'm concerned that I may not even have a posterior fornix after a total hysterectomy. Am I correct in assuming this? Thanks for your information, Alexandra.

A: By definition, the vaginal fornix is the recess or arch (fornix is a Latin word that means "arch") formed between the vaginal wall and the part of the cervix that projects into the vagina. If you've had a total hysterectomy that removed your cervix, you do not have a posterior fornix (or an anterior fornix, for that matter). I wouldn't fret over this for a couple of reasons. First, some of the tissue that once formed your fornices (plural of fornix) is likely still present, but instead of reflecting or looping into an arch-like structure, it is just sewn together into what is sometimes termed a "blind pouch" that forms the end of your vagina. Secondly, I don't know of any evidence which suggests that the fornix tissue possesses any special sexual properties. Some of the magic attributed to it is instead due to the cervix. However, as I've pointed out before, not all women think that cervical stimulation is pleasurable. Some love it, some think it feels "weird," while others think it is downright painful (although these latter women usually have some sort of pelvic pathology).

Doctors are now — thank God — less cavalier about hysterectomies than they once were, so if your doctor removed your uterus and its cervix, he likely had a good reason for doing that and you are probably better off without them.

"I don't get horny any more"
Doctors think that "OK is good enough," but patients don't

Q: I'm a 36-year-old married man with a problem. I'm healthy and I don't smoke or use drugs, and I rarely drink. I'm happy, except for one thing. I don't get horny any more. I still have sex, but that's primarily because I want to please my wife. I never have that burning desire for sex that I once had. When I do have sex, it feels OK, but it's not as intensely pleasurable as it once was. I saw my doctor about this, and since I can still get an erection, have sex and an orgasm, he didn't see what the problem is. He just doesn't get it. Is there hope for me, or should I just give up? Steve

A: Yes, there is hope for you. First, let me tell you a little secret about doctors and their modus operandi when confronted with a problem for which they're clueless. Doctors don't like to concede a lack of knowledge, so rather than admit that they cannot solve a problem, they'll trivialize it. If the problem is sufficiently minimized, there's no problem to be solved (at least in their minds), so this mitigates their anxiety about not knowing the answer to the problem. This psychological defense mechanism doesn't just afflict quacks who work in seedy offices; I know physicians who are members of the faculty at the most prestigious medical schools in the world, and they do it, too. When they don't have an answer, they pull this dismissive stunt. Furthermore, in subsequent private conversations with their colleagues, they'll often denigrate both the problem and the patient.

That's enough psychological dissection of doctors and how they respond to a potential threat to their egos. Now, on to your problem. I'm amazed that so many doctors simplistically assume that erection and orgasm are evidence that everything is A-OK in that department. There are erections, and there are rock-hard, fully inflated erections. In terms of preorgasmic and orgasmic sexual pleasure, there is pleasure, and there is pleasurable that is indescribably intense. The realization that pleasure varies so much was one of the primary factors that spurred my interest in researching sex, because this topic has been given short shrift by the medical profession. Ask a typical gynecologist or urologist why some women can give men more sexual pleasure during intercourse. The traditional medical view is that this is explained by one variable, vaginal tightness. If you want to be entertained, you might try this some time: press the doc for more reasons why this variation exists. Most likely, he will hem and haw, say "um," scratch his head, and look befuddled. Ask him to enumerate a half-dozen reasons, and he'd be utterly stumped. This is one of the central flaws of medicine. Doctors assume that the absence of disease is health, and pleasure is pleasure. Obviously, things aren't so black and white. People don't just want to be free from disease, they want to have radiant health and feel great. They don't want just so-so sexual pleasure, they want intense sexual pleasure. However, physicians possess a different mindset, and they think that "OK is good enough." This conviction pervades most specialties within medicine (with the notable exception of plastic surgery, where there is a relentless pursuit of "even better").

Hence, I am not surprised by the apathy evinced by your physician when you discussed your problem with him. The good news for you is that there are many causes of diminished libido and sexual pleasure that are easily treatable. I can't discuss every possible cause in this space, but here are a few that I will briefly mention. Your testosterone level may be low, or your estrogen level may be too high, thus depressing your testosterone-to-estrogen ratio. You may have too much SHBG (sex hormone binding globulin), a blood protein that gloms onto testosterone to transport it, but in the process makes the testosterone inactive. You may have another hormonal imbalance, even endocrine problems that seemingly have nothing to do with sex. You may be deficient in some nutrient, or you may be suffering from an exposure to some chemical in the environment. Surprisingly, common chemicals that people are exposed to every day have the potential to rob them of sexual gratification. As strange as this may sound, the problem may not be you, but your wife. Apart from the obvious (e.g., is your wife still attractive and loving?), there are several physiological reasons why your libido hinges not just on you, but also what goes on in your wife's body. I explain all these things, and many more, in my book.

Accutane causing vaginal pain and fragility

Q: When I took my second course of Accutane I developed severe vaginal pain during intercourse. For two days following intercourse, my vaginal lining would slough and during this period of time it was extremely sore. No tampons could be inserted and certainly no penises either! I saw several doctors through Kaiser Permanente, but none knew why it happened. Not one of them linked it to Accutane. It became almost impossible for me to have sex. I could still do it for a minute or two with a bearable amount of pain, but that too became rare. It has gotten to where I cannot have intercourse at all as insertion of anything feels like I am being stuffed with an extra large sandpaper dildo. Of course, this reduced my appetite for sex. I was a beautiful, flirtatious young lady with a steady boyfriend when this happened to me and suddenly my hopes for a healthy sex life or even a marriage were more or less destroyed.

Have you read about the researcher who worked for Roche who claims that Roche ordered him to destroy research documents on Accutane? I may have a copy of his story if you're interested. Niki

A: Yes, I am very interested, and I'd greatly appreciate that.

I think I will be able to help you overcome your problem, or at least minimize it. First, some background information. Accutane is known to cause skin fragility and dryness. It can also cause dryness of the mouth, lips, eyes, and nose. It can cause peeling of the palms and soles. It can induce eyelid inflammation and conjunctivitis, which is inflammation of the conjunctiva (the mucous membrane lining of the inner surface of the eyelid and the exposed whitish surface of the eyeball). It increases the probability of epistaxis (nosebleed). It can trigger keratitis (inflammation of the cornea). It can cause inflammatory bowel disease. It can also cause bleeding and inflammation of the gums (an interesting aside that is tangentially related to Accutane: researchers discovered that gums undergo cyclic hormonal changes during the menstrual cycle, which led them to theorize that oral tissues, like the vagina, possess hormone receptors). Considering the foregoing, I am not surprised when I've heard women report problems similar to yours. Accutane causes many problems other than the ones listed above, but one of its characteristic effects is to cause abnormalities with skin and mucous membranes (a.k.a., mucosa). The vaginal mucosa is not an exception, as you know.

In the Physicians' Desk Reference, Roche admits that the "exact mechanism of action of Accutane is unknown." Hence, it is not surprising that they do not understand the causation of Accutane's side effects. I think some of Accutane's effects result from it interfering with the action of certain hormones. This plausibly explains why Accutane can decimate libido and sexual pleasure, and why it can lead to vaginal problems such as yours (fragility and pain) that are typically seen only in hormonally deficient postmenopausal women. Hence, one logical therapeutic option is to use supplementary hormones. The mechanisms by which hormones act are very complex. Many doctors oversimplify this subject and think, or act, as if hormone levels were the only important key. In reality, they are just one link in the chain that begins with the body trying to do something and ends with the body accomplishing that task. Hormonal effects can be blocked by competitive inhibition (which I explain in The Science of Sex), various nutritional deficiencies, genetic problems, and exposure to certain chemicals — including Accutane, in my opinion.

I will give you an analogy to help illustrate why measuring hormone levels will not necessarily ensure that your hormonal effects are OK. To clarify this, I'll put the analogy equivalents in parentheses. Let's say that someone (a patient) has difficulty hearing sound (achieving a hormonal effect) from his AM radio (body). He consults an engineer (doctor), who uses a signal strength meter (a lab test) to determine the strength of the radio waves (the hormone level) in that area (in that patient). If you're knowledgeable about electronics, you know that the engineer could not possibly declare that everything was OK just because the signal strength was fine. Perhaps the radio receiver (the hormone receptor) was defective or blocked. Do you see what I'm getting at? Hormones do nothing by themselves. They're just messengers the body uses to signal desired effects. Just because the signal is OK does not mean the effect is OK. Inexplicably and perversely, many physicians ignore this fact. Whenever they wish to gauge action of a hormone, they do a lab test to measure its level. If engineers were that illogical, they would measure AM radio sound levels by testing radio wave signal strength. If you found an engineer that daffy, you'd fire him and find someone else.

I am not opposed to measuring hormone levels, but it is important to remember that hormone levels are just one link in the chain, so to speak. It is also important to assess the hormonal effects. If I were your doctor, I would evaluate the adequacy of your hormonal effects by looking at the hormonally responsive tissues of the body. Some of this investigation would involve visual clinical judgments, while other facets of the evaluation would involve biometric assessments and microscopic evaluations of hormone-responsive tissues (such as vaginal cells). I'd also use various clues (e.g., old photos and your self-assessments, pre- and post-Accutane) to help determine if Accutane is indeed blocking some of your hormonal effects. I'd then consider the totality of the evidence from your history, physical, and lab tests to assess whether or not your body's hormonal messages are "getting through," so to speak. I would not tell you that everything was hunky-dory just because your hormone levels were OK. If your hormonal effect deficits were confined to your vagina, you and I would consider using a topical vaginal cream to supplement the local hormonal effects. If your problems were more widespread, we might opt for oral or transdermal hormonal supplements.

But what if hormonal effects were not the root cause of your problem? Some of Accutane's adverse effects have no clear-cut connection with hormones. If that were true in your case, I'd offer you an invention I conceived while reading your question. This would enable you to experience pleasure with intercourse, instead of pain, and it would also be pleasurable for your partner. I assume that simple measures, such as sexual lubricants, were not adequately helpful.

If you want to read my book The Science of Sex, let me know and I will give you a free e-book copy of it. In any event, let's keep in touch and solve your problem.

The next two Q&A topics generated some heated debate from people who mistakenly assumed that I said it is impossible to contract an HIV infection through vaginal intercourse. I never said that. I have no doubt that it can spread that way because cuts, tears, and abrasions may develop in the vagina. A man may develop similar epithelial defects, or also pass HIV through his semen. While it is possible to transmit HIV via vaginal intercourse, I think the risk of this has been overemphasized in the press, and the risk of dying from other diseases has been underemphasized.

To illustrate this, let’s look at data from the CDC’s National Vital Statistics Reports. For 1999, the most recent year for which final data are available (I have no idea why the government takes so long to finalize their data), death from HIV is not even in the top ten list for all races, sexes, and ages. What is in that list? Heart disease, malignant neoplasms, cerebrovascular diseases, chronic lower respiratory diseases, accidents (unintentional injuries), diabetes mellitus, influenza and pneumonia, Alzheimer’s disease, nephritis, nephrotic syndrome, nephrosis, and septicemia. Have you ever heard the general press discuss nephritis, the nephrotic syndrome, or nephrosis? Have you ever heard a scary public service message about these diseases? (Do you even know what they are?) Do somber Hollywood celebrities ever give you stern warnings about them? Or what about septicemia? I’ve never heard any such message, yet I’ve heard thousands about HIV. Now can you understand why I used the words overemphasized and underemphasized?

HIV shows up in the top ten lists only when deaths are categorized by age. Even then, the statistics show results that may surprise you if you obtain your information from the mainstream media. People in the 20 to 24 age group were 83 times less likely to die from HIV than from greater threats (accidents, assaults, suicide, malignant neoplasms, heart disease, congenital malformations, and chromosomal abnormalities). People in the 25 to 34 age group were over 10 times less likely to die from HIV than from greater threats (accidents, suicide, assault, malignant neoplasms, and heart disease). Imagine that! Even in such young people, cancer and heart disease (often thought to be primarily diseases of the elderly) are bigger killers than HIV. People in the 35 to 44 age group were over 8 times less likely to die from HIV than from greater threats (malignant neoplasms, accidents, heart disease, and suicide). People in the 45 to 54 age group were almost 30 times less likely to die from HIV than from greater threats (malignant neoplasms, heart disease, accidents, chronic liver disease and cirrhosis, cerebrovascular diseases, suicide, and diabetes mellitus). In other age groups, HIV did not make the top ten lists. Combining data for people aged 20 to 54 reveals an interesting statistic: those people are 16 times less likely to die from HIV than from another cause — some of which you may never have heard of. Furthermore, this group includes homosexuals, drug abusers, and heterosexuals who engage in anal intercourse. It also includes countless heterosexuals who don’t use drugs or have anal sex, but aren’t very choosy about selecting sexual partners.

There is no doubt that HIV stirs up quite an emotional reaction in some people, but for a moment I’d like to ask you to dispassionately consider this matter. If you do that, you cannot help but face the fact that you’re far less likely to die of HIV than you are of something else. This is true even if you bend over backwards to look at the most gloomy statistics and consider only the high-risk age groups and don’t separate out homosexuals, drug abusers, or heterosexuals who engage in risky behavior (anal sex, or being cavalier in regard to partner selection). If you do omit those groups, the risk is considerably less.

I’ve read all sorts of statistical analyses of the death risk for heterosexuals who don’t abuse drugs, don’t have anal sex, and are prudent in partner selection. The figures show that those folks are hundreds to thousands of times less likely to die of HIV than from other causes. Even if you insist on looking at only the highest-risk age groups and don’t omit the people who engage in risky behavior, the risk of death from something other than HIV is about 94%. From this, I think that any fair-minded person would have to conclude that HIV has indeed been overemphasized. Thousands of public service commercials about HIV and none about some diseases that are bigger killers, yet are unknown to the average American? Is this balanced? Obviously not.

Should heterosexuals worry about AIDS? Why did the media lie about this?
(If you haven't already read the above text in the yellow box, please do so now.)

Q: I just heard an interview with Bernard Goldberg, a respected journalist who had a long career with CBS. He wrote a book entitled Bias: A CBS Insider Exposes How the Media Distorts the News. In this interview he said that the media distorted the facts about AIDS as it pertains to heterosexuals. Basically, he said that the media made it seem like any heterosexual could get AIDS from regular (vaginal) sex, but that AIDS was really only a problem for gay men and heterosexuals who injected drugs. Tell me, Dr. Pezzi, did the media lie to us? Have they wrongly instilled a fear in us heterosexuals who don't use drugs? Why did it take so long to expose this myth? Thank you for your time, Jeff.

A: Yes, Bernard Goldberg is correct: the media lied about this. Why did it take so long for the truth to come out? I've been writing about this for years, and some doctors who are far better known than I am have said the same thing. However, if the media disagrees with either your message, its implications, or how it is presented, they will quash your message. The media love things that are politically correct whether or not they ARE correct. Regarding the notion that heterosexuals should be shaking in their boots about AIDS, some people speculated that the media spread this myth to curry favor with homosexuals, or perhaps because the media seem to have taken it upon themselves to sanctify and champion the causes of anything dealing with homosexuality, homelessness, minorities, and women's rights. Homosexual men, of course, have good reason to fear AIDS. They also have good reason to make us believe that we're all at risk for this disease. Why? Because it makes it so much easier for them to get funding to support AIDS research.

I know we like to think we live in a time in which such a propagandized distortion of the truth doesn't occur, but unfortunately we often can't get our facts straight even when they're not laden with deep sociological implications. Take something as simple as body temperature. Ask doctors what is normal, and 99% will answer, "98.6° F." You've probably heard that a million times, too. There's just one problem: this number is based on research done in the early 1800's, and was passed from generation to generation with few people questioning its validity. The actual average body temperature is about 97.6°. In the morning, it's about a degree lower, and later in the day it's usually a degree (or more) higher, depending upon activity level and other factors. I don't intend to turn this into a treatise on body temperature; I just want to point out how we're so susceptible to believing things if we hear them often enough.

In the case of the myth about how heterosexuals should fear AIDS even if they don't abuse injectable drugs or engage in anal intercourse, there is more to how this myth gained credence than mere repetition. During my years of training, I'll never forget the subtle but unmistakable brainwashing I and my colleagues were subjected to regarding this matter. I could spend hours writing about that experience, but the bottom line is that we were pressurized into adopting certain attitudes toward homosexuals and their — oops, OUR — disease: AIDS. I don't favor ignoring AIDS research just because it will likely be of tangible benefit only to gay men and drug-abusing heterosexuals, because I think every taxpayer is justified in wanting more federal dollars to fight "his" disease. Michael J. Fox wants money for research on Parkinson's disease, Mary Tyler Moore wants more diabetes research, and on and on. We all have our pet projects and interests, and just because someone has a vested interest in funneling more dollars to something that threatens him doesn't make that cause any less worthy. Hence, I don't object to the fact that gay men want more money to research AIDS. Instead, what galls me is the ease with which the truth of this matter has been trampled. Unfortunately, this deliberate distortion of the truth has left in its wake a lot of collateral damage. I've seen heterosexual patients in the ER sobbing uncontrollably, worried that they may have contracted an HIV infection just because they had vaginal intercourse. What used to be one of life's greatest pleasures is now something that we often fear more than Russian roulette. The needless hand-wringing engendered by this pervasive myth about how HIV is spread has damaged many lives, causing people to fret about an unfounded fear. We all have enough real fears to conquer without losing sleep over things that aren't worth worrying about. How much time do you spend worrying about whether you will die in a car accident? Do you stop driving and huddle under your bed just because many people die in car crashes? No, because automobile transportation is too vital to life. Well, sexual pleasure is one of the foremost things that makes life worth living. It is prudent to be cautious, but don’t let fear rule your life.

I discussed this subject in more detail elsewhere on my web site. You may also wish to read The Myth of Heterosexual AIDS by Michael Fumento. Yes, heterosexuals can contract an HIV infection, but if heterosexuals don't use contaminated needles or engage in homosexuality, their risk of acquiring AIDS is vanishingly small. In fact, one state that once required HIV testing before issuing a marriage license ended that requirement when so few positives appeared — remember, those people may not have acquired HIV via heterosexual means, but rather by drug abuse or sporadic homosexuality.

Let's put this risk into perspective. I've seen several people killed during traffic accidents while on dates. I've seen people who died while engaging in sporting activities. I've seen men who died at work. I've seen people who died from a faulty furnace. As a former ER doc, I've seen people die in just about every way possible, yet I've never seen a non-drug-using heterosexual die of AIDS. But do people worry about dying in traffic accidents on dates? Or do they worry about dropping dead while playing sports? Or at work? Or sleeping at home? No. Virtually no one worries about such things, although those and dozens of other seemingly innocuous events are far more likely to kill than vaginal intercourse. Do you see how the media have twisted the facts? Heterosexuals now think of sex as a potentially lethal event that is one of their gravest threats. Does this make any sense to you? Virtually every heterosexual who isn't an IV drug user dies of something besides AIDS, but the media do not harp about this — they rant about HIV as if we had good reason to make this our supreme fear.

The HIV virus has been so politicized that it will be years, if ever, before people put this into proper perspective. As a doctor, I'm flummoxed by the fact that people are usually oblivious to infectious agents and diseases that are far more of a threat to them than is the HIV virus. I am not encouraging people to take unnecessary risks with their health, but only to spend more time worrying about their greatest threats and less time fretting over less likely dangers (see the following question). Let's face it — no one has enough time to worry about every risk we face, because everything we do carries some risk. I could be killed while snowmobiling, because there are plenty of kooks in that sport who drive at grossly excessive speeds on the trails. Or I could be killed while mowing my lawn. It's hilly, and riding lawn mowers occasionally tip over and crush their riders. Or I could drown, be hit by lightning, or be crushed by a falling tree while logging. After three close calls, I invented a way to cut down trees from a safe distance. This is the correct way to deal with risk: identify what is most likely to kill you, then think of a way to reduce that danger. Incidentally, I also invented various ways to reduce the risk of STD transmission, and I'll announce these in future editions of my book.

Dismantling a common myth about the transmission of STDs
(If you haven't already read the text in the yellow box that preceded the above topic, please do so now.)

Q: You've answered somewhat similar questions on your excellent web site, so I thought I'd write to you for advice. My college prof assigned us to write a paper on a sexual misconception. Anything come to mind?

A: Yes. I've received so many requests from college students asking for help with their papers that I've begun to wonder if I should offer a service writing term papers for a fee. :-)

There are countless sexual misconceptions, but since you're in college, I presume your teacher is not interested in shattering myths that prevail only amongst teenagers and the proletariat. To impress your professor, you need a myth that even an intellectual might fall for. OK, here goes.

Nowadays, people usually interrogate prospective sexual partners before sleeping together. The tacit message I've seen in innumerable sources is this: your risk is decreased if your partner has had few sexual partners. This seems so intuitively obvious that you may wonder why I am discussing it. Why? Because it is misleading. Let's analyze this. This simplistic assumption would be true if disease transmission were 100% per sexual experience, but it is not. For example, from one act of intercourse, the risk of female-to-male transmission of herpes is 0.05%; male-to-female spread occurs 0.2% of the time (you might hear somewhat different statistics from various sources). While the odds are worse for gonorrhea (female-to-male, 20%; male-to-female, 70%), gonorrhea is easily cured. The risk of HIV transmission varies with type of intercourse (vaginal versus anal) and presence of lesions, like herpes, that break down the vaginal lining or penile skin. If those lesions are not present, some docs think that vaginal intercourse is very unlikely to spread HIV. Some physicians and scientists say the risk is zero, or close to it. I doubt the risk is zero, because virtually everything carries some risk — even drinking water.

For the record, I've had more patients die from using a blow dryer than from AIDS if they were heterosexuals who never used drugs or engaged in anal intercourse. I've also had more patients succumb from welding, chainsaw or mower injuries, snowmobiling, hunting, jogging, alcohol abuse, drug abuse, overeating, smoking, driving to school or church, drowning, climbing in trees, or stupidity (like touching live electrical wires while standing in a pool of water). A few years ago, Americans were treated to a spate of brief public service commercials in which somber Hollywood celebrities gave us condescending short speeches about AIDS. Ask yourself this question: if prevention of death is the goal, why have I seen a thousand commercials about AIDS and none about chainsaws, obesity, or the hazards of electricity? Hmmm? I suppose those celebrities get their information from biased sources that give them a skewed perspective. I obtained my information firsthand. When a man was cooked by electricity, flattened in a car accident, or died in any one of numerous other obvious ways, I did not need a pathologist or medical examiner to tell me why he died. Nor did I need some politically motivated statistician or spokesperson to tell me what is killing 99.9% of Americans. I've seen tens of thousands of patients, so my sample is large enough to be statistically valid. From this, I know that heterosexuals spend their time worrying about the wrong things. Instead of worrying about AIDS, it would be far more logical to worry about dying from food that your spouse cooks for you. Remember Poppin' Fresh^TM, the adorable little Pillsbury Doughboy^TM? Or Betty Crocker^®, Mrs. Butterworth’s^®, and similar icons? The processed foods they represent have contributed to the death of more heterosexuals in the United States than has the HIV virus. This is probably true even when heterosexuals are not excluded because of shooting drugs or engaging in anal intercourse, and it is undoubtedly true when these risky subgroups are omitted. Obesity, heart attacks, diabetes, strokes, cancer — those are the big killers that people should worry about. Dr. Dean Edell recently reported a study that suggested the high rate of heterosexual transmission of AIDS in Africa is not due to sexual intercourse (as had long been presumed) spreading a different subtype of HIV than is prevalent in the US, but is instead due to unsafe medical practices such as using dirty needles. Interesting.

The bottom line from the preceding discussion is that the risk of acquiring some sexually transmitted disease from one episode of intercourse is less than 100%, and very low for the incurable diseases that concern most people. Thus, what matters more is not how many people you've slept with, but how many times you've slept with them. I've been exceptionally careful about who I sleep with, and my precoital interrogatory/investigation is probably more thorough than that of just about anyone else. However, most people are not so careful, and they gloss over subtle hints that would be red flags for me. If they're horny, they jump into bed. Thus, the risk these people assume is unknown to them. What difference does it make to switch from Partner #1 with an unknown risk to Partner #2 with an unknown risk?

I will illustrate this by looking at a hypothetical example. For the sake of simplicity, assume the risk of spreading a disease is 1% per sexual encounter. Assume that Person A had sex with eight partners, and Person B had sex with four partners. Who has a higher risk of acquiring the disease? That's right, you cannot determine risk based on number of partners, so I will give you more data. Person A slept with each partner twice, and Person B slept with each partner 20 times. We should also know the prevalence of the disease. Let's say that is 1%. Now who is more likely to acquire the disease? Let's do the math:

Person A
8 partners x 1% prevalence = 8% chance of encountering a partner with the disease
8 partners x 2 sexual encounters per partner = 16 episodes of sex
16 episodes of sex x 1% chance of transmitting the disease per encounter if the disease is present x 8% chance of encountering a partner with the disease = .0128 = 1.28% chance of acquiring the disease

Person B
4 partners x 1% prevalence = 4% chance of encountering a partner with the disease
4 partners x 20 sexual encounters per partner = 80 episodes of sex
80 episodes of sex x 1% chance of transmitting the disease per encounter if the disease is present x 4% chance of encountering a partner with the disease = .032 = 3.2% chance of acquiring the disease

Therefore, although Person B slept with half as many partners as Person A, Person B is over twice as likely to have acquired the disease. Thus, the most important factor isn't number of partners, it is the total number of sexual encounters. If Hollywood folks are smart enough to lecture us about staying safe, why don't they give us the real story? Don't they teach math at Hollywood High?

A very pretty virgin is falling for a man who had 350 partners

Q: Dear Dr. Pezzi: I am a 30-year-old woman and will be having sex for the first time in a couple of weeks. The reasons why I waited so long vary. I wanted to be in love with my "first" and I haven't been in love since college (he was actually sleeping with one of my friends while we were dating; I found out right before the big event and broke up with him). I have also been very focused on my career and let my personal life slide. The person that I am dating now is someone that I have known for years. We have always had "feelings" for each other, we have great intellectual chemistry, and our physical chemistry (thus far) has been very good. We didn't date before this because he was also very focused on his career and wanted to sleep around as much as possible before we tried dating. He (and I) always felt that once we took that step, that would be it, for both of us. He has slept around a lot (in the hundreds), and although we have maintained a very close friendship over the past couple of years I have not told him of my virginal status, nor does he suspect that I am still a virgin. At the risk of sounding conceited, I am very pretty, in great physical shape, and very well "put together." Men constantly approach me (even a couple of his friends, who I frequently run into at restaurants and at the gym). So he has no reason to suspect, nor am I going to tell. This is the problem: as I mentioned he has had many partners and I know he likes it "wild" (hair pulling, etc.) . . . and I suspect I would as well. However, my conception of wild may be very different from his, although I am not sure how. We recently saw a movie together (before we started dating) that involved quite a bit of spanking. He asked me what I thought about that and I told him that it looked like a lot of fun. Honestly, I was thoroughly excited.

I want this to be great for him. I know it will be great for me no matter what, because I am wildly attracted to him and very close to being in love with him. I also know him well enough to know he feels the same way. I have a couple of weeks to "prepare" (I am going out of town on business for three weeks in a couple of days and we decided to wait until I came back). Do you have any suggestions? Thank you, Clarissa

A: Yes I do, but before I delve into that, I want to address another issue, namely "He has slept around a lot (in the hundreds) . . ." I assume you mean that he has had hundreds of partners, correct? (Not one or two partners hundreds of times.)

Q: Dear Kevin: Thank you for responding to my e-mail. Regarding "I assume you mean that he has had hundreds of partners, correct? (Not one or two partners hundreds of times.)": Both. He has had hundreds of partners — probably around 350 over the past nine years, twelve of whom he slept with hundreds of times ("friends"), maybe 150 "one nighters." The remaining: sexual interaction occurred between 8 and 25 times with each partner. For example, until recently he was sleeping with a woman who lives in his apartment building. They weren't dating, they would just get together twice a week and have sex (for the past three years), but he was also dating and sleeping with other women (most of his dating relationships would fizzle out around the 6th date).

Regarding the possibility of contracting an STD: he uses condoms, and always has, except several times about 9 years ago (he was dating someone for about two years, they were monogamous, and they didn't use them a couple of times. He has always told me that he is very careful, always examines the "area," and he never touches himself with the hand that has touched her. He is also a surgeon and has a blood test every couple of months. However, he has not been careful in respect to oral sex. He is quite comfortable with performing cunnilingus, even on a complete stranger — which obviously possesses (albeit a small) theoretical and demonstrated risk of STD transmission.

At this point, I am more concerned with his inability/unwillingness to have established or maintained an emotional relationship with any of these women. He always said I was the standard by which he measured all women and they always fell short. The more realistic explanation is, aside from enjoying/appreciating the same things, we have incredible intellectual chemistry. Most of his female companions are not intelligent. The intelligent professional women that he dated are either un-cultured or unattractive (by his standards). But still, 9 years of meaningless, emotionless sex . . . is it possible he is addicted?

A: The short answer: yes. The long answer: You're obviously an intelligent woman, so why can't you see that you're about to make a major mistake? He has "DANGER" written all over him. Let's analyze this in detail.

First, it is helpful to enumerate why people have sex. This may seem overly simplistic, but I think this is the best way to make one of my points. People have sex for procreation, to help cement a relationship, to give and receive love, and simply for sexual gratification. Your prospective partner (let's call him Bill) obviously is not having sex for the first three reasons. You might think that his sexual appetite is fueled by the latter urge, but I disagree. If sexual release was Bill's motivating factor, why is he evidently perpetually on the prowl for someone new? Why isn't the woman he had sex with last night good enough? Or the woman he slept with last week? Or if finding a quality partner is so difficult for him, why doesn't he just masturbate like the rest of us do? Why is he on a crusade to boink enough women to fill a small town? Do women mean anything to him other than giving him an opportunity to carve another notch in his bedpost?

Oh, I get it . . . Bill's quest for new flesh will end the day you sleep with him. A switch will flip in his mind, and he will become monogamous. A cozy home in the suburbs, a white picket fence, just you and him forever. Does that strike you as plausible? It strikes me as wishful thinking and a fanciful dismissal of the evidence. Ask a man to walk on the moon? No problem. Ask him to change? Don't hold your breath.

You're probably thinking that things will be different with you and Bill because you're hot enough to make him put down roots. Do you honestly believe that Bill is so skilled at finding duds that he found hundreds of them who were such losers that they deserved to be dumped once he had his jollies? Do you think that Bill found 350 women who just wanted a fling? In my experience, it is a rare woman who wants sex but not a relationship. Do you think that Bill possesses some phenomenal ability to ferret out likeminded people? I don't. I think that many, if not most, of his conquests believed that they were special, too, and that they had a future with him. Marrying a surgeon? Gee whiz, that is almost as desirable as bagging a rock star. Bill is obviously attractive, charming, and successful . . . and you think that he found countless women who just wanted an affair and nothing more? It is a safe bet that this isn't true, and he knew it. Nevertheless, he was slick enough to make them believe otherwise. He's undoubtedly suave and skilled at making women presume that sleeping with him is a worthwhile investment. You think so, too, don't you?

Some of the most charming and irresistible people in history were psychopaths. Contrary to popular opinion, psychopaths are not twisted in every way at all times. They don't reek of being aberrant 24/7/365. They can have facets of utter normalcy, which gives them the ability to coexist with less extreme people and not stick out like a sore thumb . . . except when they choose to unfurl their tantalizing spells. After my training in psychiatry and exposure to many thousands of patients in a variety of clinical situations, and after I've pondered why people are spellbound by political leaders who are clearly nuts, it is obvious to me that people are often magnetically drawn to individuals who know how to exploit their unorthodox tendencies. They know that many folks are just sheep who are eager to follow "the man with something extra." The man who does everything by the book and abides by the rules the rest of us follow — well, that man has "plain vanilla" stamped all over him. We crave leaders who believe, and act, as if they are genuinely endowed with singular powers.

I am not necessarily saying that Bill has psychopathic tendencies, but to bed 350 or so women requires a special "gift" that is worthy of an honorable mention in The Guinness Book of Records. An average man has to work overtime to sleep with ten partners, which is fairly typical. Yet your Bill, in spite of the arduous years of medical school and residency, managed to have sex with 35 times as many partners? Aren't you alarmed by such off-the-scale behavior? Had he not been sidetracked by the nuisance of his medical education, do you think that he would have stopped at a mere 350? He is indisputably an avid believer in the notion that "more is better." In fact, that seems to be his guiding light. Without that bothersome diversion of med school and residency, he'd likely had given free rein to his impulses and slept with enough women to erase your hope that his sexual appetite is not incorrigible. Don't comfort yourself thinking that this is water under the bridge. In the years to come after residency, he will have much more time to pursue his personal interests. Don't believe me? Just wait.

On to the next major obstacle standing between you and Bill and happiness forever. If you read the topic about Why does sexual pleasure vary so much from one woman to the next? (presented earlier on this page), you know that the sexual pleasure men receive from sleeping with women varies greatly — probably much more than the pleasure variation women receive from different men, thus making it difficult for women to comprehend this. After sleeping with hundreds of women, Bill is sure to have found a few sexual superstars. If you aren't one, keeping Bill on his leash is just a pipe dream.

Perhaps you think that sexual compatibility (e.g., the spanking you mentioned) will suffice to keep Bill content. One might logically wonder how unusual his sexual tastes are if he has yet to find a good match after 350 candidates have not passed muster. Trust me, he's already slept with sexually compatible women, and dumped them. Probably dozens of times.

On to the topic you knew I would discuss, so you preemptively attempted to dismiss my concerns about it: disease. I will begin by stating the obvious: Bill has not been too careful about choosing his partners, and you don't need an MD degree to know that a quick visual check of the vulva is not sufficient to exclude transmissible diseases. Next point: the protection that condoms provide is far from absolute, and I've read convincing statistical analyses by Ph.D.s who asseverated that partner selection is more important than condom usage. Again, partner selection is Bill's Achilles' heel.

By "blood test," I assume you mean testing for HIV and perhaps hepatitis. But what about the other diseases? And what about your real danger, which is that he's disease-free now, but may not be next Tuesday? I am not as confident as you are that your intellectual and physical chemistry will reform his ingrained behavior. He's had physical chemistry with others. And surely in his storied past were at least a few women who were bright, interesting, and vivacious. And what are they now? History.

I am alarmed by your statement about "Most of his female companions are not intelligent." Does he purposely choose dingbats? Or is it so tough to find 350 bed buddies that he is willing to scrape the bottom of the barrel? Or does he somehow prefer to sleep with intellectually vacuous women, saving you — The Prize, The Catch, The Complete Package — for long-term asexual idolization? This is bizarre. If I were attracted to you and we really hit it off (as you seem to have done with him), I'd want to sleep with you, not a multitude of other women. If he were as fond about you as you are for him, he would not have embarked on his jihad to sleep with every willing woman. Some premarital sexual exploration is normal . . . but three hundred and fifty? Does. Not. Compute.

I was also alarmed when you said, "The intelligent professional women that he dated are either un-cultured or unattractive (by his standards)." When 99.9% of men meet women they find unattractive, they don't sleep with them. Makes sense, doesn't it? What is it that compels Bill to buck this commonsense tenet?

Back to the discourse on disease. The fact that he ends up twixt the sheets with women who usually aren't brainy is something that heightens his STD risk. Some things are too politically incorrect to be mentioned in the mainstream press, so you may not be aware of the fact that the prevalence of STD's in dumb people is much greater than it is in intelligent people. By definition, dumb people do dumb things — one of which is to fail to exercise proper precaution in the selection of sexual partners. Oh, the stories I could tell you about this subject! I'll save those tantalizing true tales for another book and just give you one of the lessons that I, as an experienced doctor, learned in dealing with patients who saw me because they were concerned after having sex with a new partner. The intelligent people, whose circumspection made them wary, rarely acquired diseases. The dumbbells? They'd be whimpering "Why did this happen to me?" as I explained the results of their examination and tests and thought, "Because you slept with the wrong guy." It's not that I am not sympathetic. I am. It's just that there is no substitute for prudent avoidance.

All of which brings me back to you. You might not contract anything from him initially, and he might remain forever faithful, although the chance of that is slim. The one thing you cannot avoid is that having 350 partners is a very bad sign. Please tell me that you are intelligent enough for this to dissuade you from making a mistake that you may forever lament.

I've met docs like Bill before. One of them lost his medical license after he had sex with a patient in the hospital chapel and videotaped it. Ripley was right: truth is stranger than fiction. I am afraid that years of "way beyond the norm" behavior have imbued Bill with the idea that he can do just about anything. He might cool his jets for a while, but when the 7-year itch hits (or for him, 7 months, if you're lucky), he'll revert to his old habits. You might very well regret passing up better, more stable opportunities by devoting yourself to him.

I'm sure you've heard that saying about, "Those who do not learn from history are doomed to repeat it." Many of Bill's partners probably felt used by him, and now regret sleeping with him. One of the advantages of reading history and reading about others is that we can learn from their mistakes. Wouldn't life be unbearably tough if we had to personally learn everything the hard way? You have the luxury of having 350 women attest that Bill uses women and discards them. And you want to be #351?

Sea-going husband suggests that his wife fornicate while he is gone; she fell in love

Q: I am married to a wonderful man who happens to be out at sea. While he was out he said I could have a partner. I decided a threesome would be fun. So my co-worker and her fiancé of five years decided to get together with me. It has been three months now and things have been great until my friend's fiancé told me that he thought he was in love with both she and I. And I felt the same, but remember my husband who I also love is still out to sea. Now, my husband knows about the threesome and when he gets home we are planning to include him in the fun. I guess my question to you is this, can a person be truly in love with two people at the same time? Or is there another explanation for both his and my feelings towards each other and our spouses? Thanks, Erica

A: Is there another explanation? Yes. You're lonely. And him? Well, he is obviously not lonely.

Is he genuinely in love with you? I can't give you a definite answer based on the limited information I have about your relationship, but there is a good chance that he is confusing lust with love. Or perhaps you've both succumbed to the pair-bonding effect of oxytocin (discussed earlier).

Is it possible to love two people simultaneously? Absolutely. We're generally conditioned in our culture to confine ourselves to one romantic partner at a time for pragmatic reasons, but consider this: is love rational and based on definable reasons, or it is irrational and based on nebulous and ethereal whims? People usually fall in love for identifiable reasons: physical attraction, shared interests and beliefs, commonality of intellect and sense of humor, complementary goals and personalities, mutual admiration and respect, and yes, great sex. So if you love your husband because he possesses certain attributes, why wouldn't you be very fond of someone who was endowed with the same or substantially similar attributes? The notion that "there is just one perfect mate for me" is sappy hogwash. If love were predicated on this "one perfect match" nonsense, humans would have gone extinct eons ago. Prior to the advent of motorized transportation, people usually fell in love with others who were within walking distance.

Although we all have countless potential partners who would be good love matches for us, we typically suppress those feelings — sometimes unconsciously and sometimes with a great deal of conscious struggle. Loving more than one person at a time is easy, but it is difficult for most people to accept that they are not the sole love interest of their partners. To keep this from being a source of friction, we usually nix the love for others . . . or try to act as if that love never existed or was erased. Things are obviously different in your little enclave. If your husband is so devoid of the usual male jealousy that compels most men to throw a conniption fit when confronted with infidelity, then he may also accept the fact that you love someone besides him. Given that he is the one who suggested that some man pinch-hit for him in his absence, he would be on shaky ground by proposing your extramarital affair but bristling at the feelings of love that might foreseeably result from it. That would be like suggesting that you strike a match, but complaining that a flame resulted.

What does sex feel like for the opposite sex?

Q: I'm curious as to what sex feels like for women. As a man, I know just what sex feels like for me, but I doubt that it feels the same for women because of differences in anatomy. I've asked my girlfriend to explain what it's like for her, but she isn't telling me much by saying it feels really good. As a doctor, I'm sure you have a much better understanding of the differences in sensation between the sexes, and you can probably offer a much better explanation. Thanks for solving this mystery, doc. Ben

A: Here is an excerpt from The Science of Sex:

Sooner or later, most people wonder what people of the opposite sex experience during sexual stimulation. To understand this, you need to have at least a rudimentary comprehension of the development of genitalia before birth. Early in development, the sexes are anatomically indistinguishable. From this identical base, hormonal and other factors mold the genitalia into either the male or female form. The important point to grasp from this is that male structures have an analogous female counterpart in terms of origin, and vice versa. That is, the same tissue is sculpted into structurally different forms. While it may appear different, the innervation — the way the nerves "hook up" — is essentially identical. From a purely mechanistic point of view in terms of sensation, the genitalia are nothing more than devices that stimulate the sexual nerves. Given that the nerves are identical, it is not surprising that the sensations experienced by the sexes are similar. Anatomical differences account for some minor disparity in sensation, but the overall experience is much the same. For example, when a man touches his scrotum, he feels what a woman experiences when she touches her labia majora (the hair-covered outer lips). Penile sensation is analogous to that of the clitoris, vagina, and labia minora (inner lips) combined. Just as a woman experiences different sensations when stimulation is alternated between the clitoris, vagina, and labia minora, a man will also experience different sensations when different areas of his penis are touched.

Having said this, it is important to note that there are differences in the sensations experienced by the sexes during intercourse. This disparity in sensation is attributable to two factors: anatomic and tactile variation. The first results from the indirect stimulation of the glans clitoris during intercourse, as contrasted with the direct stimulation of the penis. The second factor, which is just as important, results from a variation in perceived sensation due to tactile (touch) dissimilarities between the penis and the vagina. Obviously, a penis does not feel the same as a vagina. Ergo, they cannot impart the same sensations during intercourse, even if the nerves supplying them are identical. For example, when a penis is touched by hand, and then by a vagina, the sensation is greatly different. Because the texture of a vagina differs from that of ordinary skin, the nerves are stimulated in a different manner. This difference in nerve stimulation results in a different nerve impulse, or signal, being conducted to the brain. The brain then interprets the variation in signals as variations in texture.

While the sensations during intercourse may differ, a very close appreciation of the sensations experienced by the opposite sex can be approximated when provision is made for the tactile variation of the penis and the vagina. Given the similarity in feel between the tongue and the lips (especially their inner lining, or mucosa) and that of the vagina, the sensations experienced by a woman when she is orally stimulated (cunnilingus) is quite similar to what a man experiences during intercourse, assuming that her labia minora and clitoral glans are stimulated. The sensations experienced by a woman during intercourse can be approximated in a man when he is orally stimulated by the moistened outer lips of the mouth on the dorsal (bottom) aspect of his penis, but there is no direct stimulation of the penile glans.

Weight gain after marriage and pregnancy: is it inevitable?

Q: I hate to admit this, but after my wife gave birth I am no longer attracted to her. She had a good figure before pregnancy, but now she's overweight. I've tried to get her to exercise or diet, but she won't even try. Her doctor says her thyroid is fine, so that's not the problem. I've noticed that many other women seem to permanently gain weight after pregnancy. Is this something that is inevitable and men just need to accept? Eric

A: It's not inevitable. The incidence of obesity in this country has skyrocketed in the past few decades. Obesity is itself a disease as well as being one of the primary contributing factors to heart disease, diabetes, cancer, stroke, and arthritis. Therefore, obesity is not just a cosmetic problem. Yet in spite of the fact that it is a serious and alarmingly prevalent disease, it has become somewhat politically incorrect to think of this as a problem. Instead, we're pressurized to accept obesity as being almost inescapable. Men are made to feel guilty for desiring a svelte wife, and we're told that we're putting unreasonable pressures on women by expecting them to look like an actress, model, or Barbie doll. OK, it IS unreasonable to expect every woman to be as thin as a stick, but is it really too much to ask for today's women to have the same amount of body fat as women did a few generations ago? In view of the fact that it used to be considered unladylike for women to sweat, whereas exercise is now culturally acceptable, you might think that today's women should be in even better shape. And with the countless numbers of diet pills, diet supplements, fat-free foods, weight loss books and clinics and whatnot, you might think that women should be as thin as Barbie. Instead, we now have more women than ever who weigh more than their husbands. The question is: why?

Before I answer that question, I should point out that I'm not gratuitously slamming women. I used to be fat myself and I know how easy it is to gain weight. However, I also know that anyone who wants to lose weight can succeed. When I got out of my residency program I was so fat I couldn't see my feet when I stood up. Now, even though I'm 14 years older, I have a better body than most teenagers. I'm not mentioning this to brag; I'm mentioning this to demonstrate that obesity is not some sort of inevitable plague.

I will not address all of the explanations for obesity since many of them are well-known and there are enough of them to fill a book. Instead, I'll focus upon why women, more than men, are gaining weight.

First, let's discuss the "ripcord phenomenon." I don't know if women discuss this amongst themselves, but every man I've known seems to know about it — and fear it. In case you're not familiar with the term, the ripcord phenomenon refers to the sudden ballooning of women after they feel they've hooked a man . . . say, by getting a wedding ring or, for the ultimate hook, by giving birth. Go ahead and scream about how politically incorrect I am for discussing this, but remember that men were derisively discussing this before I hit puberty and cared about what women looked like. I'm the messenger, not the source of the message. The message is that men like attractive women — surprise! — and that we're a bit miffed when the women in our lives think so little of us that they give up trying to be attractive. This stings all the more when men think that woman don't try to lose weight because, thanks to the wedding ring or children, they no longer need to even try. The hooks are sunk, so why lift a finger?

Instead of pouting year after year about why men are so commitment-phobic, magazines like Cosmopolitan could do their readers a favor by forthrightly addressing some of the reasons why men are reluctant to tie the knot — and one of these reasons is the fear of the ripcord phenomenon. Or the editors of Cosmo might want to buy my $10 book (free if you buy my sex book) in which I explain how it is possible to lose weight without dieting, drugs, herbs, exercise, or surgery. That might seem as plausible as a perpetual motion machine or time travel, but it works and the science behind it is basic physiology and physics. Not voodoo. Not diets that only work for Hollywood celebrities. The problem is that hucksters have promised us weight loss miracles for decades, and 99.99% of those claims are either overhyped nonsense or a rehash of an old idea. Consequently, it is natural that people are skeptical of weight loss claims — especially ones that seem too good to be true. Alarmingly, the Federal Trade Commission is trying to pressure the media into not accepting weight loss ads that make "too good to be true" claims. The problem with stifling free speech in this manner is that it presupposes that no miraculous breakthroughs will ever occur — some of which may at first seem too good to be true. So should physicians and scientists stop thinking and innovating, fearing that a government bureaucrat with a room-temperature IQ could quash their ideas even if they're legitimate breakthroughs? Haven't we been down this road before? People who once suggested that the earth is round were lambasted by the folks who "knew" the obvious, what they could see with their own eyes: the earth was flat. And then there was the obviously premature idea circulating around 1900 in which people suggested stopping research in physics, since everything about physics was known. The atom bomb blew that supposition apart.

Why do today's women seem to care less about their figures than women once did? The answer is simple: because more women than ever work, they don't need men. Collectively, enough women gained weight so that the overall "mark" against which women are judged was lowered a notch or two. After all, women use their looks (and other attributes, of course) to compete for the best possible man. If enough women gain weight — and this is just what happened — then what passes for an average woman is quite a bit chubbier than before. If a man wants to get married, he often must settle for a woman who is fatter than he'd prefer.

Interestingly, this ripcord phenomenon has not yet pervaded every part of the United States, and certainly not every part of the world. Two summers ago my friend Tracey and her husband, who live in southern Florida, came up to Michigan, my home state. Tracey was flabbergasted and commented, "What the hell is wrong with these women in Michigan? Almost all of them are fat!"

One of the most common explanations for why there are so many obese women in northern Michigan is that it's cold up here, so women bundle up. Since layers of clothes can camouflage fat, the main theory is that this reduces the incentive to diet and exercise. That isn't the sole explanation. It's even colder in Minnesota, but the prevalence of obesity in that state is much less. Go figure. Or consider women in Russia, many parts of which are far colder than Minnesota. Women who place personals ads in Russia typically describe their physiques as average when they weigh 100 to 110 pounds. In contrast, women in the United States (and especially regions like northern Michigan) evidently think that 150 to 170 pounds is average. That's even more frightening than what it may seem at first. Since the weight of most non-fat tissue in the body (brain, blood vessels, liver, kidneys, pancreas, bones, muscles, etc.) doesn't vary by much, a typical Russian woman might have 20 pounds of fat while her "average" counterpart in the United States may carry around 80 pounds of fat. What really matters isn't body weight, it is body fat percentage. With rare exceptions, men think that women with body fat percentages of 18% look yummy, while women who are 47% fat by weight . . . well, not so yummy. Appearance aside, that extra 60 pounds of fat can cause a number of health problems.

Obesity is not inevitable. I beat it, and I know women who, even after marriage and childbirth, have better bodies than most models. I have other friends, too, like Karen, who are mothers yet have such stunning bodies they'd make any man drool. Therefore, obesity after marriage or childbirth is not certain. From reading your question, Eric, it seems clear to me that your wife pulled the ripcord and doesn't feel the slightest bit guilty about it. Is there a reason for this? Are you obese? Is there a reason why your wife doesn't give a hoot?

Two years later I received this response from Eric's wife, Julie:

"Eric showed me your answer, and at first I wanted to strangle you. You were right and I knew it, but rather than blame myself, it was so much easier to blame you. However, deep down I knew that I had stopped trying to keep myself attractive to Eric. Almost all of my friends are overweight, and to tell you the truth that lowered the expectations I had for myself. However, I guess I never really thought about how this might affect Eric's feelings toward me. Anyway, I eventually faced up to the facts. I was overweight, and I had a husband who didn't like my body. I began dieting and exercising, and I regained my old figure. You're correct, it can be done. Now our marriage is much better. Eric treats me like he used to before we were married, and that of course just fuels my desire to please him more. The passion had gone out of our relationship, but now it's back. Thanks, Dr. Pezzi."

While it's politically incorrect and almost taboo to assail some of the "games people play" in regard to obesity, I will discuss it because I don't think that sweeping this problem under the rug is helping anyone. Obese people often claim they do everything they can to lose weight even when they know that's simply not true. Here's an example. I once met an overweight woman with a number of good qualities. She was very interested in dating me, but I was frank and explained that I am not attracted to obese women. She promised to lose weight, so I continued to see her, thinking that we could develop a friendship and perhaps more if she succeeded in losing weight. To make a long story short, she put on a great show of trying to lose weight. Whenever I saw her eat, she would either nibble at her food as if her stomach were the size of a thimble, or she'd eat some atrocious homemade concoction like seaweed soup, whose smell was reminiscent of feces. She told me that her workouts were exhausting, but I didn't see any progress after this went on for months. Had she ate as little, and exercised as much, as she claimed, after months of such an arduous regimen she would have lost weight unless her body knew how to suspend the laws of physics. I told her that I did not believe her, but she swore up and down that she was doing everything she said. This protestation did nothing to dispel my incredulity. No, really, she said. I'm trying, really trying, really, really, really trying. Yeah, right. Sorry, I said, I still don't believe you. Then she tried to persuade me using anger and a guilt trip. I didn't budge. Finally, she sent me an e-mail in which she admitted that once she began seeing me, she no longer felt an impetus to lose weight. Just what I'd suspected. Between her periods of rigorously dieting, she'd binge enough to make up for the earlier caloric deprivation. Finally, the truth.

Back in the days when I was fat, I could honestly say that I always starved myself between meals. I pretended to be into health food. I could conjure up all sorts of excuses as to why women should like me even though I was chubby. I would focus on my good qualities, and ignore the reflection I saw in the mirror after getting out of the shower. Self-deception and excuses became familiar. Sound familiar?

As a resident working 110 hours per week, with no time to exercise, and with food being the only pleasure in my life, I didn't even try