The Joy of Sex

RJ

Human sexuality has interested scientists and

ordinary people for centuries

Havelock Ellis wrote on Psychology of Sex in

1910, probably the first scientific account on
sex

Kinsey did a survey in America involving more

than 5000 men and women and wrote two
books Sexual Behaviour of the Human Male in
1948 and in 1953 about the Human Female

In 1960s William Masters, a Professor of

Gynaecology and Virginia Johnson, a Clinical
Psychologist studied people having sex and
other sex acts and contributed immensely
to our knowledge by writing the book
Human Sexual Response

They then did research on sexual problems

and how to treat them and wrote the book
Human Sexual Inadequacy in 1970

Research done by Masters and Johnson was a

milestone at the time

Later other researchers added more knowledge

after Masters and Johnson

Their treatment methods are still used but have

been modified with new knowledge

New medications have been added to methods

of treatment

Sexuality and its problems

Sexual response in the human male
and
Sexual response in the human female
(will be discussed in an SGD)

So we go straight to sexual problems

Homosexuality

What do you know of homosexuality?

Is it legal or illegal in Sri Lanka?

Is it a disease? Do people suffer from

homosexuality? Can it be cured?

1% of males in a population is said to be

exclusively homosexual

0.25% of females are said to be exclusively

homosexual

So in Sri Lanka, there should be about

100,000 male homosexuals and 25,000
female homosexuals

Are they accepted in Sri Lankan society?

Is there discrimination against them?

What is the position in other countries?

Do they have problems? What are the

problems?

Can we help them?

What are the attitudes of major religions/so

called current religious leaders to
homosexuality?

What is the attitude of modern psychiatry to

homosexuality?

What is meant by sexual deviation?

Deviation is- deviation from what is

considered acceptable behaviour

Acceptable behaviour depends on cultural

factors, society, period of time etc., e.g. in
Greco-Roman period in the history of the
world, homosexuality appears to have been
quite acceptable

Sexual deviation is no longer an accepted

concept in psychiatry/medicine

What was earlier considered sexual

deviation is now called :

Disorders of sexual preference

They are sometimes called paraphilias

Disorders of sexual preference

Abnormalities of the sexual object

Sexual fetishism
Transvestism
Paedophilia
Abnormalities of the sexual act
Exhibitionism
Voyeurism
Sexual sadism
Sexual masochism

Paedophilia

Recurrent sexual urges towards or aroused

by pre-pubertal children over a period of six
months or more

This topic is in the news frequently these

days in Sri Lanka and the world

Who are the perpetrators?

Priests, teachers, sports coaches, managers

of childrens homes, recently in UK TV
celebrities who worked with children over
the years have been charged

In the modern computer age what do the

people who are interested in this do?

They visit web-sites which carry pictures and

videos and download them (child pornography)

In the developed countries these people are

hunted down and taken into custody and
charged

In child sex tourism, paedophiles come to Asia

especially South Asia and SE Asia for their
activities as these countries are lax in their
legal actions and there is corruption

When caught, most get imprisonment in

developed countries

They are at severe risk of assault and even

murder in the prison by other prisoners and
have to be protected from them

Fetishism

An inanimate object like rubber garments,

underwear, shoes are the preferred or only
means of sexual arousal

Some buy them and others steal them and may

get caught

In Sri Lanka, teenagers get caught stealing

knickers, what is the story, why do they ?

Transvestism

cross dressing to get sexually aroused

Usually in private, single garment of the

opposite sex, occasionally complex set of
clothes

Disorders of the preference of the sexual

act

Exhibitionism

Sexual arousal is obtained by repeatedly

exposing ones genitals to an unprepared
stranger

Where do you find them in Sri Lanka?

Are exhibitionists dangerous?

There are two types i) those who expose a

flaccid penis and ii) those who expose an erect
penis and masturbate

They expect a reaction from the victim, disgust

or fear

The type two exhibitionists could be dangerous

For some, the act is a compulsive one

They are driven to do it in spite of getting

caught and in spite of punishment

They are charged with the offence of indecent

exposure

If the exhibitionism starts in late life, organic

brain disease, depression or alcoholism has to
be considered

Voyeurism

Their preferred way of getting sexually

aroused is by spying on people having sex
and women undressing (peeping toms)

Sexual sadomasochism

In sadism, preference is for inflicting pain to

get sexual satisfaction

In masochism, preference is to receive such

pain to get sexual satisfaction

What is necrophilia?

What is bestiality?

What sort of people engage in them?

In the newspapers these days you get news

items that 70 yr old 80 yr old women have
been raped, what are your views?

Sexual dysfunctions

Some people present directly with their sexual

problems to doctors

Some others will offer symptoms like backache,

lower abdominal pain, weakness of body etc., so
it is important to ask about their sexual
functioning when taking a general history

Some people will present with a physical

symptom and come back another day and say
their real problem is a sexual one

How do you take a sexual history? How do

you ask about a patients sexual
functioning?

So what are the sexual dysfunctions that we

see?

Low sexual desire

Commoner in women who attend a sex clinic

Could be Primary : a biological variation

Or secondary : due to
problems in the relationship
physical disorders/ drugs
psychiatric disorders esp. depression

Can not be increased by hormones (unless low hormone

level have been detected)

Male erectile dysfunction

Inability to get an erection or sustain it long

enough for satisfactory coitus

Commonest presentation for males to sex

clinic

Could be primary or secondary

Causes of erectile dysfunction

Anxiety about sexual performance

Side-effects of drugs
antihypertensives
beta- blockers
diuretics
cimetidine
psychiatric drugs

Alcohol abuse / ?cigarettes

Diabetes
Arteriosclerosis
Age related - longer time
to get an erection

Treatment

Hormones have no place in treatment unless there

is a primary hormonal disorder

Sex therapy techniques like sensate focus are used

Anxiolytics may be useful in patients with performance

anxiety

Medications like sildenafil are useful in some patients

Other methods like cavernosal injections are available

but not popular

Orgasmic dysfunction

Premature ejaculation

Habitual ejaculation before penetration or

shortly afterwards
Common in young men during first sexual
encounters
Usually improves with sexual experience

Treatment

Stop- start technique

Squeeze technique

Now the treatment of choice is small dose

of antidepressant clomipramine, which
retards ejaculation as a side effect (12.5 mg
25 mg)

Retarded ejaculation

No ejaculation or takes a long time

dry orgasm feels the sensation of orgasm but

no ejaculation of semen

Commonly due to drugs, SSRIs, antipsychotics

Could also be due to general psychological

inhibition about relations with women

Inhibited female orgasm

Common

Female orgasm not absolutely essential for successful

sexual relationship with partner

May be due to male partners inability to arouse the

female

Tiredness, depression, physical illness, drugs could

cause this

Sex therapy is indicated in sexual dysfunction

What are the components?

Communication

Relaxed relationship with partner

Sensate focus exercises (Masters and Johnson)

Conditions causing pain or discomfort on

sexual intercourse

Mainly in women

Vaginismus

Dysparaeunia

Vaginismus

Painful spasm of vaginal muscles during

intercourse

Occurs when man tries to penetrate

Even a PV examination cannot be done

May be due to aversion to sexual

intercourse

Painful scarring after episiotomy or other

surgical procedures also can cause it

Made worse by an inconsiderate or

inexperienced partner

May lead to non-consummation of the

marriage

Treatment is by:

Relaxation exercises and gradual

introduction of tip of finger, then finger, two
fingers

Dilators can be used with relaxation

exercises

Dysparaeunia

Pain on intercourse

May be due to:

Painful scarring e.g. after episiotomy

Endometriosis
Pelvic inflammations
Pelvic cysts or tumours

In men, it is painful ejaculation which may

be due to:

Urethritis
Prostatitis

Disorders of gender identity: transsexualism

Rare disorder

The person believes that they should really be the opposite

sex occurs mostly in men

They want to live like a woman

May request sex reassignment surgery

They dress as women but unlike transvestites do not get

sexual arousal from such dressing

Do people change their sex spontaneously?

What about stories in the press of sex

change like Somapala has become
Somawathie in some village?