Dr. C.R. Chandrashekhar
The most common sexual inadequacies for which people seek treatment are:
Premature ejaculation – among males
Poor or no erection – among males
Decreased sexual desire or not able to meet the demands of the husband regarding the frequency of sexual act – among females
Aversion to sexual act – among females
These individuals do not present their problem straight away because of hesitation and stigma. They may seek help with general complaints like weakness, easy fatiguability, headache, aches and pains in the body, insomnia etc. When they talk about their sexual inadequacies, they feel very
Uncomfortable and guilty because they attribute these problems to
- Masturbation
- Semen loss
- Sexual fantasies
- Pre or extramarital sexual experiences
- Imagined or actual sexually transmitted diseases
- Irregular or improper food habits
- Immoral and unethical lifestyle
They believe that their sexual inadequacies are self-made and it is an insult for them to have such problems.
A case story
22 years old adult hesitates to sit in the client’s chair. He is sweating, looks apologetically at the doctor and says ‘Give me a good and strong tonic Sir’.
‘Why do you need a tonic, what is bothering you?’ … I have become very weak … My private part is extremely weak … it is very small … I discharge very quickly …’ he pulls his head down.
‘Your problem is sexual weakness… since when you are having this problem? Are you married?
‘I am not married. My family members are looking for the bride. I may have to get married soon’.
‘But how do you know that you are unable to perform the sexual act. Did you have any sexual intercourse with a woman?’
… No Sir … Yes Sir… 3 months back, I visited a married woman. I could not perform. Before I could enter her, I discharged…’
‘This is the only occasion, you had or were there many more?’
‘I tried to do with my girlfriend. Then also I failed’.
‘Do you get a normal erection, when you have sexual fantasies?’
‘Yes sir … but off late. I discharge too early’
‘What do you think are the reasons for this type of weakness?’
“The bad habit of masturbation, which I started at the age of 14 years because of some bad friends.” I used to do it almost daily, I have lost a lot of semen. I tried to stop it but could not. I am a weak-minded person”
‘Who has told you that masturbation and semen loss is the cause of a small penis, poor erection and early ejaculation?’
‘It is written in a book on‘Brahmacharya’. Now I am the example. Please look at my organ. It is so small and weak’.
‘But you are getting an adequate erection when you have sexual fantasies’.
‘Yes but… when I tried to have sexual intercourse with that woman and my girlfriend … I failed … later I tried again with no success.’
‘That is because of anxiety and fear. Tell me were you comfortable when you went to this women… was she a known person to you…?
‘No sir, my friend introduced me to her, she was elder to me … I was bit scared … it was the first encounter…’
‘See you were scared. You had a lot of doubts in your mind. You had this belief that masturbation and semen loss were harmful. You thought that you may not be able to do well, you were new to this act. But that lady was not; she might have accepted to have sex with you for money or some other benefit. There is no wonder when you failed. This can happen to anyone’.
‘You are right sir. I was dam scared on that day. Was it the cause of my failure?’
‘Yes, it was the cause of your failure. Our sexual apparatus and system are not under our direct control. They are under the control of the autonomic or involuntary nervous system of the brain. If you are relaxed, if you are comfortable, if there are adequate sexual stimulations the apparatus gets charged and you will be able to perform. But if you are tense, worried, have doubts, the system remains frozen’.
‘I was worried about contracting the sexual disease from her…’
‘That’s right. All these factors made you fail’.
‘But, why I failed with my girlfriend? She loves me. I have her too’.
‘You had this bad past experience. Both of you, though love each other, you are not married. Were you not anxious about having sex before marriage?’
‘She was very anxious. She said that it was not safe and good to have a sexual experience before marriage. But she agreed to have it when I pleaded with her. We were together when there was nobody in the house. But we were worried about somebody coming. We tried to it in a burry’.
‘Do you know that sexual activity has four stages and unless you give attention to them the act may not be complete and you may not enjoy it’.
‘I do not know; neither my girlfriend knows’
‘Tell me the steps you followed while during the act’
‘… I do not remember… Wait, sir, I feel shy, is it necessary to tell you…
‘Yes, it is necessary. If there are mistakes I will tell you what are they and you can avoid them.’
‘I kissed her… I fondled her breasts.
I asked her to touch my organ but she refused… I removed her undergarments. My organ touched her private part …I discharged. I lost my erection I felt very bad’.
‘How much time it took?’
‘Hardly 2 minutes sir. I felt like committing suicide. But she consoled me’
‘See sexual act has 4 stages. The first stage is the “stage of prerequisite or preparation’. You and your partner have to be ready and mentally get prepared for the act. The environment should be convenient and stimulating. Then only, your body will be able to show appropriate responses. The second stage is ‘foreplay’ which is very important for adequate genital responses. Both the partners have to use their fingers, lips and tongue to stimulate each other. The gentle touch, caressing and fondling give immense pleasure, bring intimacy, relieve their anxiety and prepare the genitals for the sexual act. Full erection of the penis and vaginal secretions are signs of adequate genital response. The couple should spend as much as time possible in foreplay. The third stage is ‘coitus’. Penis enters the vagina and there is seminal discharge. Male gets peak pleasure. But a woman may take a few more minutes to get this experience. That is why ‘after play’, the fourth stage is important for a wife. If couples do not know these things, they fail to enjoy sexual activity. You could not enjoy the sexual activity with that woman and your girlfriend because you were in a hurry. One failure arouses frustration and fear which may lead to another failure. Are you following what I am saying…?’
‘Yes sir, I am ignorant and my girlfriend is equally ignorant… Are you sure that I do not have any physical weakness, do I need medicine or tonic to improve my sex power?’
‘You do not have any physical weakness. The very fact that you get a normal erection during sexual fantasy is a testimony for your adequate sexual ability…
‘I cannot believe that fear is the cause of myself losing erection and early ejaculation…’
‘When you have fear, doubt, anger, sadness, you secrete more adrenaline in the body. Because of this hormone, the blood in the penis moves out as more blood flows towards hands and legs. Penis loses its erection. When you are calm and comfortable, the reverse happens. I will give you a book on ‘sexual responses: role of body and mind’. Read the book, let your girlfriend also read it. Then both of you come and discuss your doubts with me’.
‘Yes sir, now I am relieved. If you assure me that I do not have any physical weakness and my problem is very temporary in nature, I will be very happy. I will come along with my girlfriend. Let her also know that I am not sexually weak’
‘That is fine. You will improve. Stop worrying’.
Steps involved in counselling
In the above case study, you have seen how the individual approaches the doctor and how the interview progress. These things may take place in one session or in more than one session.
I Step:
Encourage the person to give details of the problem, its onset and degree of inadequacy, his and his partner’s reactions, their attributions. Listen to him/her carefully. Make him/her comfortable, remove the feelings of frustration, guilt, shame, and anger. Keep reassuring that they can solve this problem. Get the spouse and interview him or her also.
II Step
Educate to remove the various misconceptions, wrong beliefs and practices.
Provide knowledge regarding normal and healthy, sexual life. Use the available scientific sex literature. Ask the couple to study this literature. Many times, this itself will help the person to come out of his/her inadequacy. The clients should know that knowledge, the right attitude and adequate skills are essential for happy sex.
III Step
Co-morbidity
The individual may have physical and/or mental disorders which may contribute to sexual inadequacy. These disorders have to be identified and managed. If necessary, concerned expert’s opinion and help have to be sought. The most common disorders are:
Depression
This can be a cause or result of sexual problem, sad mood, lack of interest, inability to enjoy, negative attitude, poor self-esteem, hopelessness, helplessness and guilt appetite and sleep disturbances aches and pains, death wish and suicidal ideas are symptoms of depression. Loss (of money, materials, people love, recognition, status and health) is the root cause of depression. Antidepressant drugs and counselling are the treatment for depression.
Anxiety
Unexplained fear, apprehension, poor concentration, confusion, inability to think and make the right decision, sleep and appetite disturbances, palpitation, tremors, headache, fatigue are the common symptoms. Presence or perception of danger is the root cause of anxiety. Anxiolytics and counselling are treatment.
Severe mental disorders
like Schizophrenia, affective disorder, alcohol and drug dependence, organic brain syndrome have to be identified and referred to psychiatrists.
Diabetes Mellitus
Arteritis and peripheral neuropathy which are associated with Diabetes mellitus may be the cause for poor erection in man.
Peripheral neuropathy due to nutritional causes and Leprosy has to be identified and treated.
Vascular causes of inadequate blood supply to the penis have to be investigated.
IV Step:
No coitus for 4 weeks. Advice the couple to avoid coitus for 4 to 6 weeks. This will take away the performance anxiety on the part of the male. Otherwise every night, he thinks that he should perform the act and prove his maleness. Tell the couple to look into the pre-requisites and type of foreplay they enjoy. In a comfortable and relaxed state of mind, they should start exploring their sexual needs and responses of body and mind. They should learn to prepare their genitals for the coitus and discuss it among themselves.
V Step:
Specific techniques have to be taught. The couple is taught specific techniques like ‘Stop and start technique and squeeze technique’ for premature ejaculation; sensate focus technique for the poor erection or for vaginismus.
VI Step:
Reassurance and positive feedback: In counselling, the couples have to be reassured regarding their ability to overcome the sexual inadequacies and to enjoy sexual life. Small improvements and progress have to be identified and highlighted. There should be positive feedback among themselves and they should feel hopeful all the time.
Classification of sexual disorders
Those individuals who are unable to participate in a sexual relationship and carry out the sexual activity to their and their partners’ satisfaction, those who lack interest in the heterosexual act and fail to have normal psychophysiological responses necessary for sexual interaction and fail to experience orgasm are said to be suffering from ‘Sexual Disorders’. These disorders are:
Sexual dysfunctions
Lack or loss of sexual desire. In women, it is known as ‘Frigidity’.
Sexual aversion and lack of sexual enjoyment.
Failure of genital response
In men: Erectile dysfunction- difficulty in developing and maintaining an erection required for coitus.
In female: Vaginal dryness.
Orgasmic Dysfunction
Premature ejaculation: Inability to control ejaculation.
Vaginismus: Spasm of the muscles surrounding the vagina leading to difficulties in the coitus.
Dyspareunia: Pain during sexual intercourse.
Excessive Sexual desire
Gender identity disorders
Trans-sexualism: Desire to live and be accepted as a member of the opposite sex. They ask for ‘Sex change operation’.
Transvestism: Wearing clothes of the opposite sex and enjoy being a member of the opposite sex for short periods.
Disorders of sexual preference
Fetishism: Getting sexual arousal and satisfaction with articles like clothes, shoes of the opposite sex.
Exhibitionism: Exposing genitalia to the members of the opposite sex and getting sexual satisfaction.
Voyeurism: Getting sexual satisfaction by looking at people engaging in sexual activity.
Paedophilia: Sexual preference for children.
Sadomasochism: Sexual preference for infliction of pain during sexual activity.
Homosexuality: Preference for a member of the same sex for sexual activity and gratification.
Dhat Syndrome (Culture-Bound Syndrome)
This is specific to the Indian subcontinent. As people wrongly believe that masturbation is bad and leads to sexual weakness, loss of semen leads to sexual weakness as well as sterility; they start worrying about masturbation and semen loss. They develop multiple somatic complaints like general weakness, easy fatiguability, decreased concentration, memory, black rings around the eyes, loss of hairs or greying of hairs, premature ejaculation, erectile dysfunction, fear of being sterile and attribute these symptoms to
- Masturbation
- Nocturnal emission
- Sexual fantasies
- Passing semen in urine
- Frequent sexual intercourse
They have to be reassured and educated to remove these beliefs.
Common misconceptions regarding sex
- Masturbation leads to impotence
- Semen loss leads to impotence and sterility.
- One drop of semen=40 drops of blood.
- Thick hairs on the face/chest – sign of virility.
- Bigger, harder the penis – better is the maleness. Women like a big and hard penis.
- Bigger the breasts, better is the sexual attraction.
- Hypersexual females are dangerous.
- Sexual intercourse makes a person weak.
- Brahmacharya (Avoiding sex) increases life span, increases the body and mental strength of males. Sexual intercourse should be done only for procreation.
- Small testes lead to impotence/sterility.
- Thin, watery semen means sterility. Thick and honey-like semen means high productivity.
- Irregular menstrual cycle and obesity lead to sterility.
- Physical contact with a menstruating woman leads to much illness. Sexual intercourse with that woman leads to impotence, blindness or madness.
- Menstrual blood is poison. It is used to prepare slow poison or black magic.
- Pre-marital sexual experience is necessary for males.
- Prostitutes are better sex-partners and help in developing sexual skills.
- An intact hymen is a sign of virginity.
- Women are usually sexier and look for sexual gratification outside the wedlock. They should be watched and controlled.
- Sexual intercourse is a must on the first night. More the number of intercourse and longer the intercourse proves the maleness of the husband.
- Everyday intercourse/many intercourses a day = proof of maleness.
- Oral sex is bad and dangerous.
- Many foods like onion, garlic, spices, meat, genital parts of animals increase sex power. Less of these food items decrease sexual desire.
- Sexual intercourse during day times is bad, leads to sexual weakness.
- Alcohol increases sex power and orgasm.
- Reading sex literature is a sign of increased sexual drive. It is bad for young people.
- Taking sex hormone injection or tablets increases sexual power.
- Sexual intercourse with children, animals cures V.D.
- After menopause, a woman cannot take part in sexual intercourse.
- Female spirits possess young males, suck their semen and make them impotent.
- Female spirits appear in dreams and cause the nocturnal discharge of semen.
- Persons with a weak heart may die during sexual intercourse.
- Sexual intercourse with a mad person can cause impotence/madness.
- To satisfy a woman in the sexual act is difficult. Women like rough sex.
- A general doctor cannot treat sexual dysfunctions.
- It is a shame to have sexual dysfunctions.
- A man should be the leader in the sexual act.
- Losing one’s potency is equal to death.
- Excess sex/unsatisfactory sex lead to mental illness.
- Sex is an instinct, nobody needs sex education, sex education leads to promiscuity.
The author is Professor, Dept. of Psychiatry, NIMHANS, Bangalore.
