Dr. Shashank Samak
From psychoanalysis to implant surgery to gene therapy, the treatment of Impotence, the commonest sex problem, has come a long way. Hence the future of the ‘Impotence therapy’ is changing hands from psychologists, sexologists and andrologists to the new breed of gene-therapists. Dr Robert Krane, the president of the International Society for Impotence Research (I.S.I.R), concluded the Seventh World Meeting on Impotence in San Francisco in Nov. 1996.
The futuristic gene-therapy is the latest tool of Man to conquer his problem of Impotence where genes encouraging the release of erection-enzymes can be administered locally into the ‘sick’ penis. The new medical field of Sexology is progressing by leaps and bounds, was amply evident from the above statements of the noted Urologist of the United States of America.
I had the opportunity to attend this World Conference. Being the only Sexologist invited from India, to present my work on the medical application of the ancient Indian Kama Shastra (Science of Sex) in this meeting of Urologists and Andrologists, I was amused by the above statements. Since my roots are from the land of ‘Kama Sutra’ and ‘Khajuraho’, I could feel the inadequacy in the above comment. ‘Instant therapies’ may suit the lifestyle and attitudes of the western world but they do not impart sexual fitness and pleasure as taught by the ancient Indians.
‘It’s all in the Head’, a Freudian scientist said at the beginning of the 20th Century regarding Sexuality. ‘It’s all in the defective Penis’ a molecular biologist is viewing sexuality at the turn of the 20th century. From ‘Kinsey’s Report’ in 1953 till the ‘Gene Therapy’ of 1996, the researchers enabled the world to look at sexuality in a logical way rather than in a purely judgemental way. Their efforts put sexuality on the map of the medical world.
From ‘psychopathy to organopathy’ the western world has seen the two extremes in the development of medical science of sexuality. Psychopathy assumed that almost every sexual problem especially Impotence, reflects deeply repressed and unresolved, unconscious conflicts acquired in childhood. Hence it was assumed that recognition and resolution of these conflicts through psychoanalysis was necessary to establish the normal sexual function which implies that all individuals would be equally capable of sexual response if their early experience had been uniform. Immediate situation and stimuli were ignored. Study of physical sexual response was not thought to be essential. Later, sex researcher, Dr. Alfred Kinsey lamented strongly on this approach towards sexuality.
No evidence shows that discovery and resolution of such conflicts if any do improve erectile dysfunction suo moto. Also, the training in assertive sexual behaviour with the aim to relax and to get desensitized may help to solve some of the Impotence cases. But the fact that it bypasses the inter-personal interaction for sexual arousal makes the therapy incomplete.
Then came the epoch-making ‘Kinsey Report’ in 1953, which studied sexual behaviour in the human female. Dr Alfred Kinsey, an entomologist, took a mission of fact-finding, which began in 1938. This was ‘to inform, to enlighten and to guide the people in an area where knowledge and understanding may affect the very existence of the genus homo, hoped Robert Yerkes and George Corner, the chairmen of the Committee for Research in Problems of Sex, supporting Kinsey’s Sex Research. They also expressed ‘large faith in the values of knowledge, little faith in ignorance.’
‘Atomism of Behaviour’ commented strongly Dr Sol W. Ginsburg, a prominent New York psychiatrist. Kinsey’s approach to defining ‘normalcy in sex’ and to reduce ‘psychology of sex’ to simple elements fitted in the frame of ‘statistics’ was condemned by him. He questioned the feasibility of the study ‘to estimate the normality of such a complicated set of variables as is subsumed under ‘sexual behaviour’. But Kinsey accused this psychoanalyst by saying that ‘they minimize the significance of the stimuli in the immediate situation.’ Hence he proposed three groups of factors which were imperative to understand Sexuality, ‘the stimuli, the capacity of the responding individual and the nature and extent of the individual’s previous experience.’
The ‘Kinsey Report’ based on the personal interview of nearly 8000 women and gynaecological examination of more than 800 women, was a pioneering work had laid a foundation on which the epic of ‘Dr. William Masters and Mrs Virginia Johnson’ couple created in the 1960s, who conducted the laboratory research in ‘Human Sexual Response and Human Sexual Inadequacy. They formulated the sexual response in four phases and suggested the need for techniques of Foreplay fondly called by them the Sensate Focus’.
First time in the history of Dr William Masters, a gynaecologist with his wife and former assistant Mrs Virginia Johnson, created special packages of training for various sexual problems. They devised special residential programs and put sexuality on the map of the scientific community of the medicine. Western Sexology never really came out of the shadow of this research until the 1980s.
Rejecting the pre-existing psychopathology and considering ‘Performance anxiety’ as the major cause in most of the Impotence cases, Dr Masters and Johnson integrated behavioural training and psycho-education. They also included interpersonal communication with an initial ban on intercourse. Apart from being expensive, partnerless individuals were unable to undergo this therapy. Moreover, two therapists were required to deal with the couple. The initial two-week residential program was replaced later by home assignments. But even the modified therapy was also quite time-consuming. Hence the couple can get bored especially with the long-term ban on intercourse. Due to lack of user-friendliness, the dropout rate is high.
Last two decades of the 20th century were phenomenal in the field of science of Sexuality. Neurobiology of sexuality flourished and the forum of urologists pounced on the most common male problem of sex namely ‘Impotence’ which had miserable outcome from the psychological fraternity. Right or wrong, the seized opportunity by urologists, in reality, helped the development of ‘instant genital therapy’ by penile injections and implants for the dysfunctional men.
First time in the history Dr William Masters, a gynaecologist with his wife and former assistant Mrs Virginia Johnson, created special packages of training for various sexual problems.
The penis contains three tubes having a spongy tissue in them. There are a lot of small blood vessels also. On getting sexually stimulated, these blood vessels pour their blood into the cavities of the spongy tissue. Thus that tissue expands inside the tubes of the penis. This results in the elongation and stiffness of the penis. The fully blood-filled penile tubes give full rigid erection of the penis. Thus the erection of the penis is a result of the healthy nerves and blood vessels of the penis. But it also depends on the expansive ability of the spongy tissue.
The sex hormone, testosterone, is also essential to generate sexual desire at the brain centre as well as to help expand spongy tissue of the penis. For the common people, this desire or instinct is related to the mind. But in fact, this Mind is nothing but the part of the brain where certain chemical reactions involving neurochemicals like dopamine, oxytocin, endorphins, adrenaline, norepinephrine etc. occur. The arousal or pleasure is the interpretation of these reactions. Thus the mind is that part of the brain which deals with a set of such perceptions and interpretations of organic reactions. The only thing is that the concerned part of the brain may change from time to time with different desires and instincts. Therefore the Mind cannot be pinpointed to one particular area of the brain in general but is to be considered as per the instinct or desire. The areas mostly involved are related to the core and the limbic part of the brain. In short, the mind is also organic.
Any problem at the desire or the mind level or at the penis level is obviously responsible for the problem of erection called Impotence. In most cases, the instinct or sexual desire is always there but the satisfactory reaction of the penis is not there. That is why the person seeks medical advice. In short, the ‘Mind’ is at no fault.
Once the sexual desire is present, there are two important factors responsible for the erection of the penis namely, neuro-vascular or the hormonal mechanisms of the penis. With the help of modern technology, it has been shown that dysfunctioning of these two important dimensions of Erection are the main causes of Impotence. Sexual desire is usually present in most of the long-standing cases of Impotence. And the relational and other psychological causes contribute to a minor percentage (10 to 20). Moreover, the relational impotence cannot be considered as a permanent problem as it gets solved with the improved relation or a changed relation.
The concept to treat a sexual problem was in itself a revolutionary idea in the 1960s when Dr Masters and Johnson offered such a therapy. By now the sex therapies have been evolved into three major approaches. The psychological approach aims at resolving the psychosexual conflicts and improving the marital relationship. The behavioural approach teaches sexual pleasuring techniques. Physical therapies for impotence include the use of non-invasive vacuum devices, invasive and painful penile injection therapy of vasodilator drugs as well as surgeries on the penis – vascular and implant. Oral or trans-urethral (through urine tract) medications are still under trial and no ideal drug has been found till date.
Since the local factors, the two dimensions, are responsible for many cases of Impotence, the approach in treating Impotence has become penis-oriented. Hence the urologists thought to treat Impotence with the help of their knife or injection of drugs in the penis. The cost of such andrological therapies ranges from Rs. 150 or more per injection of the cheaper option of vasodilator drug of papaverine to very costly imported vasodilators like prostaglandin EI. Apart from the pain, the complication of the stagnated blood in the penis may need its emergency removal by a qualified specialist. Repeated injections may pose the danger of fibrosis and permanent damage to the penis.
Penile implants are put inside the penis by permanently the tubes by cutting them open and taking out their natural sponge. The cost of goods imported high-quality latest malleable penile implants is prohibitory to many as the operative cost may run into lakhs of rupees. Cheaper Indian alternative of implants may cost the operation in good hands anywhere from Rs.25, 000 onwards. Complications like perforation of the penis in a later period also loom large. These are invasive, painful procedures for seeking the pleasure of sexual relation.
Neuro-biological development helped the understanding of sexual response at its molecular level. The discovery of the enzymes like ‘Nitric Oxide Synthase’ and other related to erection response in Man was revolutionary. The new drug called ‘Sildenafil’ (Viagra) is getting projected as a magic cure. But realizing the limitations of the medicine, the medical field should not venture to say so. Because it may only act chemically at the level of the penis in some cases but has no action what so ever on the ‘sex counter’ in the brain. So inducing or enhancing the ‘libido’ is not the function of the drug. Moreover, Sildenafil is not at all a sex tonic.
Sex is not only a dynamic process; it is also an intimate relational bond. Sex problem involves mind, body and intellect of the individual. It deals with both psychologies as well as physiology and techniques of Sexuality. Sexuality should be studied at all levels mind, body and intellect of the concerned individual. The mind creates ideas, the body tries to execute them and the intellect decides the appropriateness of the action. Thus sex is not just all in the mind.
There is more to sexual problems than just a disturbed psyche or dysfunctional genes. It is not only psychology but the sexual fitness and behavioural application of the techniques of Sex, which are important in Human Sexuality, insist ancient Indian scientists of Sex. Sex is an instinctual expression involving a physical relation and is technical and not mechanical; the erectile dysfunction should not be just ‘treated’.
The cause of every case of Impotence should not be considered either an organic disease or a psychogenic disorder. But it should be treated as a problem that of a Sexual Fitness. Apart from the neuro-vascular and hormonal factors responsible for the Male Erection, I have proposed in the 6th biennial Asia Pacific meeting congress on impotence, in 1997, that there is the Third Dimension to erectile dysfunction. It is weak or dysfunctional sexual muscles. This important factor is responsible for the lack of sexual fitness and majority cases of Impotence. This should change the customary outlook towards the causative aspects of Impotence. This ‘Muscular Factor’ is physical but in most cases of non-pathological nature.
I have found in the common causes of erectile dysfunction, the under-exercised or dysfunctional sexual muscles, are responsible for the ‘Decay Phenomenon’ of the physiological erectile reflex in man. The correction of this dysfunctional ‘Muscular Factor’ needs a specially designed training. This new sex therapy, which I have devised, is a direct physical, natural and non-invasive nature based on the techniques of ancient Indian science of Tantra and Kama Shastra. It is a total training in sexual fitness.
The techniques rejuvenate the erectile reflex and also improve the blood circulation in the penis non-invasively by the compression of the erectile tissue of the penis, the deep dorsal vein of the penis and the pre-prostatic venous plexus. This enhances penile erection. As a mark of respect to our ancient sexological heritage of Tantra, I have labelled proudly this scientific program of sexual therapy as ‘Dr. Samak’s Tantric Sex Therapy’. It now finds its mention in various international medical journals of Impotence and Sexology.
It is one of the most basic instincts, yet approaching 21st century understanding of Sexuality still remains shrouded in mystery and myth. Sexuality is not just related to psychiatry or to neurosurgery. It is nothing but a very special branch of modern medicine. The problem of today’s sexologist imparting such knowledge is not what people do not know about sexuality, but the problem is what they think they do know about it is true knowledge. Sexual therapy is still made difficult by the conventional assumptions regarding sexuality that people developed over years of sexual practices other than the Art and Science of ‘Quality Sex’. The lost glory of the land of the ‘Kamasutra’, ‘Tantra’ and ‘Khajuraho’ should be regained and India should lead the world in the field of sexuality even in this modern era of AIDS.
The author is an internationally renowned sexologist practising in Pune.
